Change of the scientific and medical context that is no longer favorable to our study. This has resulted in the termination of inclusions.

The aim of this trial is to investigate whether quantitative analysis of the total concentration of circulating free deoxyribonucleic acid (cfDNA) and of the cfDNA integrity index (DII) (Intplex®) may reflect hepatocellular carcinoma (HCC) tumor dynamics or response for patients treated by Sorafenib or Regorafenib and if it could be used as a tool for patient management under targeted therapy.

Circulating free deoxyribonucleic acid (cfDNA) is increasingly used in oncology with the aiml of early diagnosis of the disease, its therapeutic management and monitoring the evolution of the disease. Numerous publications have shown that the cfDNA concentration is correlated with the pathology of cancer. Larger amounts of cfDNA are detected in metastatic patients or patients with advanced cancer. However, the cfDNA concentrations have not yet shown their clinical interest mainly because of the variations in the same individual during the effort or the moment of collection of the blood sample. The concept of the integrity of cfDNA has also been studied as a biomarker in oncology and seems to show an interesting clinical value. The cfDNA is essentially released by cell apoptosis generating 170 bp fragments, corresponding to the size of a nucleosome. Many studies have shown that the integrity of cfDNA increases with the pathology of cancer. Thus, tumor-derived cfDNA is more fragmented than healthy cells with fragments smaller than the size nucleosome.

To date, no predictive biomarker is available for the management of treatment with Sorafenib which is a targeted therapy with a marketing authorization in first-line treatment of HCC (hepatocellular carcinoma) or second line with Regorafenib, treatment having shown a benefit positive on overall survival in the Resorce study. AFP (alpha-foetoprotein) is the only serum marker available with an inconstant increase in patients with HCC in fact only 30 to 40% of patients have abnormal values. In liver cancer, Ono et al showed that serum cfDNA is positively correlated with a larger tumor size.

This study shows that the rate of tumor cfDNA reflects the progression of the disease. Jiang et al showed that cfDNA derived from HCC is more fragmented than that derived from healthy cells, with fragments smaller than the size nucleosome.

These data demonstrate the potential utility of cfDNA amount and integrity as a biomarker for individualized management of hepatocellular carcinoma.

This new marker is expected to be an effective tool to overcome the lack of specificity of the AFP (alpha foetoprotein) assay in this pathology.

The investigator's team developed an Intplex® test that showed significant discrimination between healthy individuals and cancer patients.

The aim of this trial is to investigate whether quantitative analysis of the total concentration of cfDNA and of the cfDNA integrity index (DII) (Intplex®) may reflect HCC tumor dynamics or response for patients treated by Sorafenib or Regorafenib and if it could be used as a tool for patient management under targeted therapy.

Inclusion Criteria:

1. Male or female patients ≥ 18 years of age

2. Histological or cytological documentation of hepatocellular carcinoma (HCC) or non-invasive diagnosis of HCC as per American Association for the Study of Liver Diseases (AASLD) criteria in patients with a confirmed diagnosis of cirrhosis

3. Patient treated for stage B hepatocellular carcinoma (multifocal disease) or stage C (metastatic disease) according to Barcelona Clinic liver cancer, regardless of treatment line, and that cannot benefit from local treatments such as resection, local ablation, chemoembolization

4. At least one uni-dimensional measurable lesion by computed tomography (CT) scan or magnetic resonance imaging (MRI) according to RECIST criteria 1.1 and modified RECIST for HCC

5. Liver function status Child-Pugh Class A

6. Eastern Cooperative Oncology Group (ECOG) Performance Status ≤ 1

7. Adequate bone marrow, liver and renal function as assessed by the following laboratory tests:

   • Hemoglobin > 8.5 g/dL
   • Absolute neutrophil count ≥ 1500/mm3
   • Platelet count ≥ 60,000/ mm3
   • Total bilirubin ≤ 2 mg/dL
   • Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) ≤ 5 x upper limit of normal (ULN)
   • Serum creatinine ≤ 1.5 x Upper limit normal (ULN)
   • Lipase ≤ 2 x ULN
   • Prothrombin time-international normalized ratio (PT-INR) < 2.3 x ULN and partial thromboplastin time (PTT) < 1.5 x ULN
   • Glomerular Filtration Rate (GFR) ≥ 30 mL/min/1.73 m2

8. Life expectancy ≥ 3 months

9. Women of childbearing potential and men must agree to use adequate contraception

10. Patients must be affiliated to a Social Security System

11. Written informed consent signed

    Patients initially treated with Sorafenib, will be switched to Regorafenib if all the above conditions are still met and, in addition:

12. Documented progression under treatment with Sorafenib (defined as documented radiological and/or clinical and/or biological progression)

Exclusion Criteria:

1. Prior liver transplantation or candidates for liver transplantation

2. Hypersensitivity to the active substance or to any of the excipients

3. Patients with large esophageal varices at risk of bleeding that are not being treated with conventional medical intervention

4. Past or concurrent history of neoplasm other than HCC, except for in situ carcinoma of the cervix uteri and/or non-melanoma skin cancer and superficial bladder tumors. Any cancer curatively treated > 3 years prior to study entry is permitted

5. Known history or symptomatic metastatic brain or meningeal tumors

6. Major surgical procedure or significant traumatic injury within 28 days before enrollment

7. Congestive heart failure New York Heart Association (NYHA) ≥ class 2

8. Unstable angina or myocardial infarction within the past 6 months before enrollment

9. Cardiac arrhythmias requiring anti-arrhythmic therapy

10. Uncontrolled hypertension

11. Patients with phaeochromocytoma

12. Uncontrolled ascites

13. Persistent proteinuria of NCI-CTCAE version 4.0 ≥ Grade 3

14. Ongoing infection > Grade 2 according to NCI-CTCAE version 4.0. Hepatitis B is allowed if no active replication is required

15. Clinically significant bleeding NCI-CTCAE version 4.0 ≥ Grade 3 within 30 days before enrollment

16. Arterial or venous thrombotic or embolic events such as cerebrovascular accident, deep vein thrombosis or pulmonary embolism within 6 months before enrollment

17. Any psychological, familial, sociological, geographical or illness or medical condition that could jeopardize the safety of the patient and/or his compliance with the study protocol and follow-up procedure

18. Known history of human immunodeficiency virus (HIV) infection

19. Seizure disorder requiring medication

20. Non-healing wound, ulcer or bone fracture

21. Active autoimmune disease (lupus, sclerodermia, rheumatoid arthritis, …)

22. Any malabsorption condition

23. Breast feeding

24. Pregnancy

25. High performance sport practice

26. Patient unable to swallow oral medication

    Patients who discontinue sorafenib will not be switched to regorafenib if any of the condition listed above occurs and/or the following criteria are met:

27. Prior discontinuation of prior Sorafenib therapy due to Sorafenib-related toxicity

28. Unresolved toxicity (Sorafenib) ≥ NCI-CTCAE version 4.0 Grade 2