{
  "abstract": "Introduction Combined vascular endothelial growth factor/programmed death-ligand 1 blockade through atezolizumab/bevacizumab (A/B) is the current standard of care in advanced hepatocellular carcinoma (HCC). A/B substantially improved objective response rates compared with tyrosine kinase inhibitor sorafenib; however, a majority of patients will still not respond to A/B. Strong scientific rationale and emerging clinical data suggest that faecal microbiota transfer (FMT) may improve antitumour immune response on PD-(L)1 blockade. Early trials in melanoma with FMT and reinduction of immune checkpoint blockade (ICI) therapy in patients with anti-PD-1-refractory metastatic melanoma were reported in 2021 and demonstrated reinstatement of response to ICI therapy in many patients. Due to anatomical vicinity and the physiological relevance of the gut-liver axis, we hypothesise HCC to be a particularly attractive cancer entity to further assess a potential benefit of FMT in combination with ICI towards increased antitumour immunity. Additionally, HCC often occurs in patients with liver cirrhosis, where liver function is prognostically relevant. There is evidence that FMT may increase hepatic function and therefore could positively affect outcome in this patient population.Methods and analysis This prospective, multicentre, randomised, placebo-controlled, double-blind phase II clinical trial has been designed to assess immunogenicity and safety of FMT via INTESTIFIX 001 combined with A/B in advanced HCC in comparison to A/B with placebo. Primary endpoints are measured as tumour CD8+ T cell infiltration after 2 cycles of treatment with vancomycin, A/B+INTESTIFIX 001 in comparison to vancomycin-placebo, A/B+INTESTIFIX 001-placebo and safety of the therapeutic combination in advanced HCC. INTESTIFIX 001 is an encapsulated FMT preparation by healthy donors with a high alpha-diversity in their gut microbiome for oral administration, manufactured by the Cologne Microbiota Bank (CMB). Sample size was calculated to achieve a specific expected accuracy for the primary immunological endpoint. 48 subjects will be randomised to reach a goal of 42 usable measurements in the modified intention-to-treat set. Subjects will be randomised in a 2:1 ratio to A/B or placebo (28 A/B, 14 placebo).Ethics and dissemination The study was approved by ethics committee review and the German Federal Ministry of Drugs and Medical Devices. The trial is registered under EU CT no. 2023-506887-15-00. The outcome of the study will be disseminated via peer-reviewed publications and at international conferences.Trial registration number NCT05690048.",
  "authors": [
    {
      "affiliations": [
        "Department of Gastroenterology, Hepatology, Infectious Diseases and Intoxication, University Hospital Heidelberg, Heidelberg, Germany",
        "Liver Cancer Center Heidelberg (LCCH), Heidelberg, Germany"
      ],
      "name": "Conrad Rauber"
    },
    {
      "affiliations": [
        "Clinical Cooperation Unit Applied Tumor Immunity, DKFZ, Heidelberg, Germany",
        "Department of Medical Oncology and Internal Medicine VI, Medical Faculty Heidelberg, University Hospital Heidelberg, Heidelberg, Germany",
        "NCT Heidelberg, a partnership between DKFZ and Heidelberg University Hospital, NCT, Heidelberg, Germany"
      ],
      "name": "Maria Paula Roberti"
    },
    {
      "affiliations": [
        "Department of Internal Medicine, Infectious Diseases, Goethe University Frankfurt, University Hospital Frankfurt, Department of Internal Medicine, Frankfurt, Germany",
        "Partner Site Bonn-Cologne, German Center for Infection Research (DZIF), Cologne, Germany",
        "Department I of Internal Medicine, University Hospital Cologne, Cologne, Germany"
      ],
      "name": "Maria JGT Vehreschild"
    },
    {
      "affiliations": [
        "Department I of Internal Medicine, University of Cologne, Cologne, Germany",
        "German Center for Infection Research, Cologne, Germany"
      ],
      "name": "Anastasia Tsakmaklis"
    },
    {
      "affiliations": [
        "Liver Cancer Center Heidelberg (LCCH), Heidelberg, Germany",
        "Department of Medical Oncology and Internal Medicine VI, Medical Faculty Heidelberg, University Hospital Heidelberg, Heidelberg, Germany",
        "NCT Heidelberg, a partnership between DKFZ and Heidelberg University Hospital, NCT, Heidelberg, Germany"
      ],
      "name": "Christoph Springfeld"
    },
    {
      "affiliations": [
        "Liver Cancer Center Heidelberg (LCCH), Heidelberg, Germany",
        "Department of Medicine II, Heidelberg University Medical Faculty Mannheim, Mannheim, Germany"
      ],
      "name": "Andreas Teufel"
    },
    {
      "affiliations": [
        "Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany"
      ],
      "name": "Thomas Ettrich"
    },
    {
      "affiliations": [
        "Department of Gastroenterology, Hepatology and Transplant Medicine, University of Duisburg-Essen, Duisburg, Germany"
      ],
      "name": "Leonie Jochheim"
    },
    {
      "affiliations": [
        "Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany"
      ],
      "name": "Arne Kandulski"
    },
    {
      "affiliations": [
        "Department of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany"
      ],
      "name": "Pavlos Missios"
    },
    {
      "affiliations": [
        "Department of Hepatology and Gastroenterology, Charité - UniversitätsmedizinBerlin, Campus Virchow Klinikum (CVK) and Campus Charité Mitte (CCM), Charite Universitatsmedizin Berlin, Berlin, Germany"
      ],
      "name": "Raphael Mohr"
    },
    {
      "affiliations": [
        "Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany"
      ],
      "name": "Alexander Reichart"
    },
    {
      "affiliations": [
        "Department for Gastroenterology and Hepatology, University Hospital Cologne, Cologne, Germany"
      ],
      "name": "Dirk T Waldschmidt"
    },
    {
      "affiliations": [
        "Institute of Medical Biometry (IMBI), Heidelberg University, Heidelberg, Germany"
      ],
      "name": "Lukas D Sauer"
    },
    {
      "affiliations": [
        "Institute of Medical Biometry (IMBI), Heidelberg University, Heidelberg, Germany"
      ],
      "name": "Anja Sander"
    },
    {
      "affiliations": [
        "Liver Cancer Center Heidelberg (LCCH), Heidelberg, Germany",
        "Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany"
      ],
      "name": "Peter Schirmacher"
    },
    {
      "affiliations": [
        "Clinical Cooperation Unit Applied Tumor Immunity, DKFZ, Heidelberg, Germany",
        "Department of Medical Oncology and Internal Medicine VI, Medical Faculty Heidelberg, University Hospital Heidelberg, Heidelberg, Germany",
        "NCT Heidelberg, a partnership between DKFZ and Heidelberg University Hospital, NCT, Heidelberg, Germany"
      ],
      "name": "Dirk Jäger"
    },
    {
      "affiliations": [
        "Department of Gastroenterology, Hepatology, Infectious Diseases and Intoxication, University Hospital Heidelberg, Heidelberg, Germany",
        "Liver Cancer Center Heidelberg (LCCH), Heidelberg, Germany"
      ],
      "name": "Patrick Michl"
    },
    {
      "affiliations": [
        "Department of Gastroenterology, Hepatology, Infectious Diseases and Intoxication, University Hospital Heidelberg, Heidelberg, Germany",
        "Liver Cancer Center Heidelberg (LCCH), Heidelberg, Germany",
        "NCT Heidelberg, a partnership between DKFZ and Heidelberg University Hospital, NCT, Heidelberg, Germany",
        "Research Group Experimental Hepatology, Inflammation and Cancer, DKFZ, Heidelberg, Germany"
      ],
      "name": "Michael T Dill"
    }
  ],
  "title": "Protocol: Faecal microbiota transfer in liver cancer to overcome resistance to atezolizumab/bevacizumab – a multicentre, randomised, placebo-controlled, double-blind phase II trial (the FLORA trial)",
  "uid": "6bbc01b4-2e1b-568f-892b-fb23b90a41b8"
}