Sorafenib Induced Autophagy Using Hydroxychloroquine in Hepatocellular Cancer

Phase 2 study with two cohorts:

Cohort 1: As second-line treatment, we will add HCQ to SOR dose the patient was tolerating at
the time of progression.

Cohort 2: SOR-naïve patients receive SOR 400 mg by PO twice daily on Cycle1 Day1 (C1D1). On
Cycle 1 Day 15, HCQ 400 mg PO daily will be started. In clinical practice, dose reduction of
SOR may be required. On C1D15 SOR maybe kept as starting dose or reduced for toxicity. On
Cycle 2 Day 1 of toxicity of HCQ and SOR will be assessed.

Each cycle is 28 days.

Blood samples will be collected at Cycle 1 Day 1, Cycle 1 Day 15 and Cycle 2 Day 1 to assess
for biomarkers.

Disease evaluation every 2 cycles.

Dose reductions due to adverse events are allowed for both sorafenib per standard of care
and/or HCQ for grade 3 or more adverse event was related to study medication. Dose reductions
are also permitted based on investigator clinical decision.

Inclusion Criteria:

- Cytologically or histologically confirmed advanced or metastatic HCC. If no
histological diagnosis, patient must have imaging studies compatible with HCC.

- Age 18 years and above

- ECOG performance status of 0 or 1

- Not a candidate for curative treatments (i.e., resection, transplantation)

- Child-Pugh class A or B7 liver function

- Measurable disease as defined by RECIST 1.1

- Patients who received prior local therapy (e.g., TACE) are eligible.

- Documented virology status of hepatitis, as confirmed by screening HBsAg, anti-HBc,
and/or anti-HCV

- Life expectancy> 3 months

- For women who are not postmenopausal (12 months of amenorrhea) or surgically sterile
(absence of ovaries and/or uterus): agreement to use two adequate methods of
contraception. For men: agreement to use a barrier method of contraception during the
treatment period

- Hematologic, Biochemical, and Organ Function within 7 days prior to Cycle 1 Day 1:
Granulocyte count > 1500/mm3, Platelet count > 75,000/ mm3, Hemoglobin > 8 g/dL; Total
bilirubin < 2.0; Albumin > 2.8g/dl; AST (SGOT) and ALT (SGPT) < 5 x ULN; Serum
creatinine< 1.5 x ULN

- Cohort 1 (with sorafenib): No previous systemic therapy including sorafenib or
chemotherapy treatment. Previous TACE and local treatments are permitted.

- Cohort 2 (on progression of sorafenib): Patients who have received prior sorafenib
therapy for at least 4 weeks and has confirmation of disease progression on CT/MRI.
Prior surgery or local therapy within 4 weeks prior to Cycle 1 Day 1, with the
exception of palliative radiation therapy to the bone

Exclusion Criteria:

- Patients receiving prior therapy with HCQ.

- Patients with uncontrolled brain metastases. Patients with brain metastases must be
asymptomatic and off corticosteroids for at least one week.

- Due to risk of disease exacerbation, patients with psoriasis are ineligible unless the
disease is well controlled, and they are under the care of a specialist for the
disorder who agrees to monitor the patient for exacerbations.

- Patients with previously documented macular degeneration or or untreated diabetic
retinopathy (stable retinopathy is allowed).

- Patients may not be receiving any other investigational agents.

- History of allergic reactions attributed to compounds of similar chemical or biologic
composition to HCQ.

- Patients requiring the use of enzyme-inducing anti-epileptic medication (phenytoin,
carbamazepine, phenobarbital, primidone or oxcarbazepine) are not eligible for entry
into the study.

- Uncontrolled intercurrent illness including, but not limited to, ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, or psychiatric illness/social situations that would limit compliance with
study requirements

- QTc > 500 milliseconds (ms) at baseline.

- Gastrointestinal tract disease resulting in an inability to take oral medication or a
requirement for IV alimentation, prior surgical procedures affecting absorption, or
active peptic ulcer disease. Patients with NG-tube, J-tube, or G-tube will not be
allowed to participate.

- Pregnant women are excluded from this study because sorafenib has the potential for
teratogenic or abortifacient effects. For this reason, women of childbearing potential
and men must also agree to use adequate contraception (hormonal or barrier method of
birth control) prior to study entry and for the duration of study participation.

- Should a woman become pregnant or suspect she is pregnant while participating in this
study, she should inform her treating physician immediately. Because there is an
unknown but potential risk for adverse events in nursing infants secondary to
treatment of the mother with sorafenib, breastfeeding should be discontinued.

- Informed Consent - No study specific procedures will be performed without a written
and signed informed consent document. Patients who do not demonstrate the ability to
understand or the willingness to sign the written informed consent document will be
excluded from study entry.