Biliary tract cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up

Circular RNAs in gynecological cancer: From molecular mechanisms to clinical applications (Review)

Circular RNAs (circRNAs) have emerged as promising biomarkers and therapeutic targets in gynecological cancer. The present review explored developments in circRNA research in ovarian, endometrial and cervical cancer. circRNA biogenesis, functions and roles in cancer pathogenesis have been discussed, focusing on their potential as diagnostic and prognostic markers. Furthermore, circRNAs mechanisms of action, including miRNA sponging, protein scaffolding and peptide encoding were examined, highlighting specific circRNAs implicated in each cancer type and their clinical significance. The unique properties of circRNAs, such as stability and tissue-specific expression, make them ideal candidates for biomarker development. By synthesizing the currently available literature and identifying future research directions, the present review underscored circRNAs potential to improve gynecological cancer management through novel diagnostic tools, prognostic markers and targeted therapies.

Association of preablation tumor biopsy and long-term outcomes of colorectal liver oligometastases

OBJECTIVE

To explore the association of preablation liver biopsy and long-term oncological outcomes in colorectal liver oligometastases (CLOM) (lesions, ≤5; diameter, <5cm).

MATERIALS AND METHODS

This retrospective study included 149 patients who underwent percutaneous liver biopsy before microwave ablation and 259 patients who did not receive preablation biopsy between September 2009 and June 2023 from two tertiary hospitals. Primary outcome, intrahepatic recurrence-free survival (IRFS), and secondary outcomes, disease-free survival (DFS) and overall survival (OS) were analyzed using Cox regression and Kaplan-Meier methods. Propensity score matching (PSM) and four sensitivity analyses were performed to mitigate confounding. Multivariable analyses and adjusted subgroup analyses were performed to assess the correlation of intrahepatic recurrence with preablation biopsy.

RESULTS

408 patients were analyzed, with 149 patients (mean age, 58 years ± 10, 105 men [70.5 %]) in the biopsy group and 259 patients (mean age, 58 years ±± 11, 186 men [71.8 %]) in the non-biopsy group. There were no statistically significant differences for 5-years IRFS (HR = 1.14 [95 % CI: 0.82-1.58]; P = 0.450), 5-years DFS (HR = 1.23 [95 % CI: 0.93-1.62]; P = 0.147), and 5-years OS (HR = 1.45 [95 % CI 0.97-2.16]; P = 0.071) between groups after PSM (n = 100). The above results were consistent with those before PSM and four sensitivity analyses. For IRFS, multivariable analyses identified that preablation liver biopsy was not an independent risk factor and did not increase the risk of intrahepatic recurrence in any subgroup based on adjusted subgroup analyses.

CONCLUSION

Preablation liver biopsy has no significant adverse effects on intrahepatic recurrence, disease progression, or patient survival in colorectal liver oligometastases, regardless of covariate adjustments. Our study provides evidence-based guidelines for the diagnosis and management of CLOM; liver biopsy should not be banned without consideration in the era of precision medicine.

Distinct chromosome abnormality patterns for differential diagnosis of hepatocellular carcinoma and cholangiocarcinoma

Hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA) are primary liver cancers with overlapping histopathological features, making accurate diagnosis challenging. This study aimed to identify chromosomal abnormalities that could aid in differentiating these cancers using chromosome microarray analysis (CMA). We analyzed ten frozen tumor tissues each of HCC and CCA, identifying distinct patterns of chromosomal gains and losses. HCC exhibited gains in regions 1p36.32, 1q23.3-q24.1, 3q21.3, 4p16.1, 5q31.1, and 11p15.5, and losses in 2p15, 3p11.1-q11.1, 4q12, 5p12-q11.1, 7q11.23, 14q23.2, 17p11.2, 17p13.3, 22q12.1, 22q12.2-q12.3, and 22q13.2. In contrast, CCA showed gains in 5p13.2, 5p14.1, 8p12-p11.23, 8p22, and 19p13.2, and losses in 1q31.1, 1q42.13, 3p25.3, 6p12.1, 6p25.3, and 17q21.33. Heatmap analysis revealed 17 distinct chromosomal regions between the two groups including 2q14.2, 4p16.3, 5q32, 7p14.3, 7p22.1, 7q11.21, 7q11.23, 7q21.3, 7q22.1, 10q21.3, 18q23, 19p13.2, 19q13.2, 21q21.3, 21q22.13, 22q11.21, and 22q12.2. Among these 1p36.32, 19p13.2, and 19q13.2 emerged as potential biomarkers for differential diagnosis. These findings may aid in confirming cases with overlapping histopathological features contribute to the development of diagnostic tools and improved targeted therapies for HCC and CCA.

Adjuvant chemotherapy compared to observation in resected biliary tract cancers: Survival meta-analysis of phase-III randomized controlled trials

BACKGROUND

A limited number of randomized controlled trials (RCTs) investigated adjuvant chemotherapy in biliary tract cancers (BTCs). Recurrences and deaths are common in the first 2 years and survival remains poor despite adjuvant treatment.

METHODS

Phase-III RCTs were included comparing adjuvant chemotherapy and observation in resected BTCs. The primary endpoints were recurrence-free (RFS) and overall survival (OS). Proportional hazard results were used for trial-based analyses. Patient data was curated from published Kaplan-Meier curves to analyze short-term (2-year) hazards. The Parmar and generic inverse variance methods were used.

RESULTS

1308 patients in 4 trials (BILCAP, ASCOT, BCAT, PRODIGE-12) were included. Capecitabine (BILCAP) and S-1 (ASCOT) were grouped as 5-FU-based, gemcitabine (BCAT) and gemcitabine-oxaliplatin (PRODIGE-12) were grouped as gemcitabine-based chemotherapy. Adjuvant 5FU-based chemotherapy improved RFS [HR: 0.80 (95 % CI:0.68-0.95), p = 0.012] and OS [HR: 0.78 (95 % CI:0.65-0.94), p = 0.009]. However, gemcitabine-based chemotherapy did not provide benefit in RFS [HR: 0.90 (95 % CI:0.70-1.15), p = 0.428] and OS [HR: 1.03 (95 % CI:0.78-1.36), p = 0.794]. The benefit of 5-FU-based chemotherapy was more apparent in the short-term (2-year hazards) (RFS: [HR: 0.67 (95 %CI:57-0.79), p < 0.001] and OS: [HR: 0.61 (95 % CI:59-0.64), p < 0.001]). However, gemcitabine-based chemotherapy did not provide RFS benefit in the short term either [HR: 0.80 (95 % CI:0.64-0.1.01), p = 0.067] and seemed to be even detrimental for OS [HR: 1.22 (95 % CI:1.14-1.31), p < 0.001] in the first 2 years.

CONCLUSION

This study confirms using 5FU-based monotherapy in the adjuvant treatment of resected BTCs. The more prominent benefit in the first 2 years emphasizes that more effective adjuvant treatments with sustained long-term benefits are needed. Two-year proportional hazards OS and RFS are proposed here as an additional secondary end-point to consider in future clinical trials. in this setting. Registration ID (PROSPERO): CRD42024614444.

Revisiting resectability of biliary tract cancers, in the triplet drug therapy era with immune checkpoint inhibitors

Biliary tract cancers (BTCs) include intrahepatic, perihilar, distal cholangiocarcinoma, gallbladder cancer, and sometimes papillary Vater cancer. The incidence of BTCs varies worldwide (0.3-85.0/100,000 population). In Japan, the incidence is lowest, but it is increasing (22,000 cases/ year). The 5-year overall survival (OS) in patients with localized BTC is approximately 60%, which is better than that in liver or pancreatic cancer, but is < 5% in patients with metastatic cancers. Surgery requires liver and pancreas surgery with vascular reconstruction, and is associated with a high perioperative mortality rate (> 2%) relative to other cancer surgeries (< 1%). As an adjuvant therapy, fluorouracil prodrugs are effective for improving OS (hazard ratio [HR] 0.69-0.81); however, in patients who receive major hepatectomy, the completion rate is reportedly low (60%). Since 2010, gemcitabine + cisplatin (GC) has become the first-line therapy for unresectable lesions. Subsequently, in 2023-2024 three triplet regimens were reported: GC + S-1(tegafur-gimeracil-oteracil), GC + durvalumab (an anti-PD-L1 antibody), and GC + pembrolizumab (an anti-PD-1 antibody). HRs for OS were 0.79-0.83, objective response rates were 27-42% (GC, 15-29%), and tumor control rates were 75-85% (GC, 62-83%) with small increases in adverse events. In this review, considering the eligibility criteria of currently ongoing neoadjuvant studies, we report two borderline resectable cases with a discussion on resectability. Owing to the high-risk nature of the surgery and to avoid early recurrence due to subclinical metastasis during postoperative recovery, these three triplet regimens for unresectable tumors may change the concept of resectability in BTC.

Global trends and disparities in gallbladder and biliary tract cancers: insights from the global burden of disease study 2021

BACKGROUND

Gallbladder and biliary tract cancers (GBC and BTC) are highly malignant, with poor prognoses and substantial regional variability in the disease burden. Although advances in medical science have improved outcomes in high-income regions, low- and middle-income regions continue to face rising incidence and mortality rates owing to delayed detection and treatment. Understanding the global trends and risk factors of GBC and BTC is essential for targeted interventions to reduce disease burden.

METHODS

A retrospective analysis of GBC and BTC was conducted using the 2021 Global Burden of Disease study. Data from 204 countries and territories between 1990 and 2021 were analyzed for incidence, mortality, and disability-adjusted life years stratified by age, sex, and sociodemographic index (SDI). Trends were quantified using age-standardized rates and estimated annual percentage changes.

RESULTS

In 2021, 216,768 new cases and 171,961 deaths were reported globally, with age-standardized incidence and mortality rates of 2.6 and 2.0 per 100,000, respectively. The high-income Asia-Pacific and Latin American regions exhibited the highest disease burdens. While global age-standardized rates declined estimated annual percentage changes for incidence: -0.44; mortality: -0.97), low-SDI regions experienced increases. High BMI emerged as the leading risk factor, contributing to 12% of the disability-adjusted life years. Projections indicate a stable incidence but rising mortality by 2036.

CONCLUSION

Although the global age-standardized rates of GBC and BTC are decreasing, disparities persist, with low-SDI regions experiencing increasing burdens. Targeted interventions addressing modifiable risk factors such as obesity, along with improved healthcare infrastructure and early detection, are critical for mitigating this global health challenge.

FAPI radiopharmaceuticals in nuclear oncology and theranostics of solid tumours: are we nearer to surrounding the hallmarks of cancer?

[18F]FDG PET/CT is the most widely used PET radiopharmaceutical in oncology, but it is not exempt of diagnostic limitations. FAPI have emerged as a great tool in the management of several different solid tumours in which [18F]FDG is not able to provide enough information. The aim of this work was to evaluate the available evidence on diagnostic and therapeutic applications of PET/CT with FAPI radiopharmaceuticals. We underwent a non-systematic review focusing in the utility of FAPI radiopharmaceuticals in PET/CT diagnosis and in the treatment of several malignancies. FAPI radiopharmaceuticals present characteristics that can potentially overcome some known diagnostic limitations of [18F]FDG. FAPI radiopharmaceuticals present a high target-to-background ratio (TBR) in many solid tumours such as oesophageal cancer, gastric cancer, pancreatic cancer, hepatic cancer, colorectal cancer, breast cancer, ovarian, cervical cancer, and head and neck cancer. Available evidence suggests the high TBR improves sensitivity and specificity compared to [18F]FDG, especially for the detection of lymphadenopathies and peritoneal metastases, and may improve patient management and radiation treatment planning. Moreover, it is important to underline the potential theranostic application of FAPI radiopharmaceuticals.

Pharmacologic features, clinical applications, and drug safety evaluation of futibatinib in the treatment of biliary tract cancer (BTC)

INTRODUCTION

Futibatinib is a small, potent, covalent, irreversible fibroblast growth factor receptor (FGFR) 1-4 inhibitor that has been added as a new standard of care for previously treated unresectable and/or advanced FGFR2 fusion/rearrangement-positive BTC. FGFR2 fusions/rearrangements play a key role in BTC survival, proliferation, invasion, and development of distant metastasis. The inhibition of this pathway is an important target in the treatment of BTC.

AREAS COVERED

The article covers the development of futibatinib for the treatment of refractory unresectable/advanced BTC, its mechanism of action, and key pharmacodynamic/pharmacokinetic data with a focus on the safety profile. Data are based on published clinical trials, pooled analysis, and retrospective studies indexed in PubMed (2010-2024).

EXPERT OPINION

Futibatinib is an FDA and EMA approved FGFR2 inhibitor for the treatment of patients with refractory BTC with FGFR2 fusions/rearrangements. Ongoing drug development strategies are centered on designing new FGFR2 fusion inhibitors able to overcome on-target and off-target resistances coupled with a high target selectivity to spare the most common treatment-related adverse events (hyperphosphatemia, stomatitis, alopecia, nail toxicity, skin reactions, eye toxicity).

Precision oncology in biliary tract cancer: the emerging role of liquid biopsy

Liquid biopsy has already proven effective in aiding diagnosis, risk stratification and treatment personalization in several malignancies, and it could represent a practice-changing tool also in biliary tract cancer, even though clinical applications are currently still limited. It is promising for early diagnosis, especially in high-risk populations, and several studies on circulating free DNA (cfDNA), circulating tumour cells and differential microRNA (miRNA) profiles in this setting are ongoing. Circulating tumour DNA (ctDNA) also appears as a feasible noninvasive biomarker in the curative setting, in detecting minimal residual disease after resection and in monitoring disease recurrence. As of today, it can be particularly valuable in biliary tract cancer for genomic profiling, with a good concordance with tissue samples for most molecular alterations. CtDNA analysis may especially be considered in clinical practice when the tumour tissue is not sufficient for next-generation sequencing, or when urgent therapeutic decisions are needed. Moreover, it offers the possibility of providing a real-time picture to monitor treatment response and dynamically identify resistance mutations, potentially representing a way to optimize treatment strategies.

Genomic landscape of biliary tract cancer and corresponding targeted treatment strategies

Biliary tract cancers (BTCs) are classified on the basis of their anatomical origin, and the feasibility of surgical resection depends on the tumor location and extent of progression. However, for unresectable BTCs, systemic therapy has been uniformly applied. Gemcitabine and cisplatin (GC) therapy and GC-based therapies were established as the first-line standard BTC treatment. However, no highly effective second-line therapy has been established, and the prognosis remains poor, highlighting the need for further therapeutic advancements. Meanwhile, the era of precision medicine has expanded the use of genetic testing, leading to the identification of actionable molecular targets in BTC. Several targeted therapies, including FGFR inhibitors and IDH1 inhibitors, have been developed, offering new second-line treatment options and the potential for first-line use in appropriate cases. Notably, the frequency of these genetic alterations varies depending on the tumor location, demonstrating the molecular heterogeneity of BTC. Therefore, it has been recognized that a tailored treatment approach for each BTC patient may be more effective than uniform systemic therapy. Consequently, although routine genetic testing before initiating systemic treatment is currently limited by the medical environment (e.g., cost, accessibility, regional differences), it is recommended in ESMO guideline and might be increasingly advocated. However, BTC harbors a wide range of genetic alterations, and numerous targeted therapies are being developed accordingly. This review provides an overview of the reported genetic alterations in BTC, the frequencies of these alterations, and the corresponding targeted therapies, emphasizing the evolving role of precision medicine in BTC treatment.

Conversion treatment for advanced intrahepatic cholangiocarcinoma: Opportunities and challenges

The prevalence of intrahepatic cholangiocarcinoma (ICC) is increasing globally. Despite advancements in comprehending this intricate malignancy and formulating novel therapeutic approaches over the past few decades, the prognosis for ICC remains poor. Owing to the high degree of malignancy and insidious onset of ICC, numerous cases are detected at intermediate or advanced stages of the disease, hence eliminating the chance for surgical intervention. Moreover, because of the highly invasive characteristics of ICC, recurrence and metastasis postresection are prevalent, leading to a 5-year survival rate of only 20%-35% following surgery. In the past decade, different methods of treatment have been investigated, including transarterial chemoembolization, transarterial radioembolization, radiotherapy, systemic therapy, and combination therapies. For certain patients with advanced ICC, conversion treatment may be utilized to facilitate surgical resection and manage disease progression. This review summarizes the definition of downstaging conversion treatment and presents the clinical experience and evidence concerning conversion treatment for advanced ICC.

Real-world efficacy of zanidatamab in patients with HER2 positive advanced biliary tract cancers

INTRODUCTION

In the HERIZON BTC 01 trial for patients with HER2-positive biliary tract cancer (BTC) previously treated with systemic therapy, zanidatamab improved the objective response rate, disease control rate (DCR), progression-free survival (PFS), and overall survival (OS). However, real-world data are needed to assess its efficacy and safety outside clinical trials.

PATIENTS & METHODS

We conducted an investigator initiated national multicenter retrospective study of most patients with BTC treated with zanidatamab in France as part of a compassionate access. The primary endpoint was PFS.

RESULTS

Our study included 20 patients with metastatic BTC enrolled between September 2022 and November 2024. The median age at diagnosis was 61.5 (interquartile range: 55-69) years and the majority of patients had gallbladder cancer (n = 12, 60 %). After a median follow-up of 8.5 (95 % confidence interval [CI]: 3.3-11.8) months, the median PFS was 6.7 (95 % CI 1.3-11.8) months, with an estimated OS at 1 year of 79.1 % (95 % CI: 53.2-91.6 %). The DCR was 65 %, with 40 % confirmed partial responses and a median duration of response of 7.3 (95 % CI: 2.06-16) months. Patients with immunohistochemistry (IHC) 3 + HER2 scores had a better PFS [8 (95 % CI: 1.5-18.4) months] than those with 2 + HER2 scores obtained by IHC followed by fluorescence in situ hybridization amplification or next-generation sequencing [1.4 (95 % CI: 1.1-6.8) months] (P = 0.02). No statistical difference in 1-year estimated OS rates was observed (P = 0.39). There were no grade 3 or 4 treatment-related adverse events or cardiac toxicities.

CONCLUSION

The benefits of in patients with HER2-positive BTC were confirmed. Zanidatamab should be considered for patients with this condition.

Treating intrahepatic cholangiocarcinoma with pemigatinib: two case reports of Nordic patients

BACKGROUND

Cholangiocarcinoma (CCA) is a diverse group of aggressive liver tumors with up to 20% being intrahepatic CCA (iCCA). Up to 15% of patients with iCCA have fibroblast growth factor receptor 2 (FGFR2) fusions or rearrangements. Here we evaluated iCCA treatment with pemigatinib, a selective inhibitor of FGFR1-3, in two patients from Denmark and Finland.

PATIENTS

We identified a total of two Nordic patients with iCCA in our clinics, who received first-line cisplatin/gemcitabine before initiating pemigatinib.

RESULTS

Case 1 was a 34-year-old woman with aggressive, metastatic iCCA upon presentation, who progressed on cisplatin/gemcitabine. Pemigatinib was initiated after FGFR2 fusion detection by genomic testing. She had a partial response after three cycles (9 weeks) of pemigatinib but experienced disease progression after three more pemigatinib cycles. Adverse events were primarily managed by supportive care and dose reduction, except hyperphosphatemia, which was complicated by food allergies and required medication. She received subsequent chemotherapy but deteriorated rapidly and died 1 month later. Case 2 was an 81-year-old man with unresectable iCCA who achieved stable disease with first-line chemotherapy. He switched to pemigatinib after FGFR2 fusion detection by next-generation sequencing. The tumor shrank by 20% after three pemigatinib cycles and completely calcified with continued treatment. Adverse events were managed by two dose adjustments. Treatment has continued for 57 months and is ongoing.

INTERPRETATION

CCA is an aggressive disease that requires early molecular testing of abundant biopsy tissue so not to delay second-line therapies, such as pemigatinib. Variability in treatment outcomes is expected.

Idarubicin-transarterial chemoembolization combined with gemcitabine plus cisplatin for unresectable intrahepatic cholangiocarcinoma

BACKGROUND

Intrahepatic cholangiocarcinoma (iCCA) is the second most common liver malignancy with poor prognosis and limited treatment options.

AIM

To identify the most effective drug for transarterial chemoembolization (TACE) in cholangiocarcinoma and evaluate the efficacy and safety of combining it with gemcitabine and cisplatin (GemCis) for unresectable iCCA.

METHODS

Cholangiocarcinoma cell lines (RBE, HuCC-T1) were treated with 10 chemotherapeutic drugs, and cytotoxicity was assessed by cell counting kit-8 assays. Tumor-bearing nude mice were treated with idarubicin or GemCis, and tumor growth was monitored. Clinical data from 85 iCCA patients were analyzed to evaluate the efficacy and safety of idarubicin-TACE combined with GemCis.

RESULTS

Idarubicin demonstrated the highest cytotoxicity, significantly outperforming GemCis, the standard first-line therapies. In tumor-bearing mouse models, idarubicin and GemCis treatments significantly slowed tumor growth, with idarubicin showing particularly pronounced effects on days 12 and 15 (P < 0.05). In retrospective analysis, the median overall survival (OS) and progression-free survival (PFS) in the combination therapy group were significantly longer than those in the GemCis alone group (median OS, 16.23 months vs 10.07 months, P = 0.042; median PFS, 7.73 months vs 6.30 months, P = 0.023). Additionally, major grade 3/4 adverse events (AEs) in the combination therapy group were abdominal pain (26.3% vs 6.5%, P = 0.049) and elevated transaminases (42.1% vs 12.9%, P = 0.038). Most AEs were mild to moderate and manageable.

CONCLUSION

Idarubicin demonstrated higher cytotoxicity than GemCis, significantly inhibiting tumor growth in tumor-bearing mouse models. Preliminary clinical results suggest that local idarubicin-TACE combined with GemCis may offer improved survival outcomes for iCCA patients with a manageable safety profile.

Impact of Tumor Size on the Survival Benefit of Anatomic Versus Non-Anatomic Resection for Intrahepatic Cholangiocarcinoma

BACKGROUND

The role of anatomic resection (AR) versus non-anatomic resection (NAR) for intrahepatic cholangiocarcinoma (ICC) has not been thoroughly investigated. This study sought to define the impact of tumor size on the relative therapeutic benefit of AR versus NAR for ICC. Specifically, the study aimed to identify a threshold tumor size to define when AR rather than NAR may be warranted to achieve better survival outcomes for patients undergoing resection of ICC.

METHODS

Patients who underwent liver resection for ICC were identified from an international multi-institutional database. A multivariable Cox model with an interaction term was used to assess the relationship between tumor size and the survival impact of AR.

RESULTS

Among 969 patients, 506 (72.9 %) underwent AR, whereas 263 (27.1 %) had an NAR. Multivariable analysis demonstrated an interaction between tumor size and AR (hazard ratio [HR], 0.94; 95 % confidence interval [CI], 0.88-1.00; p = 0.045). A plot of the interaction demonstrated that AR was associated with improved outcomes for tumors size ≥4 cm. Among 257 (26.5 %) patients with tumors smaller than 4 cm, recurrence-free survival (RFS) did not differ between NAR and AR (3-year RFS: 65.2 % [95 % CI, 55.7-76.2] vs 58.1 % [95 % CI, 49.2-68.5]; p = 0.720). In contrast, among 712 (73.4 %) patients with tumors size ≥4 cm, AR was associated with improved RFS (3-year RFS: 34.7 % [95 % CI, 27.5-43.8] vs 44.9 % [95 % CI, 40.4-50.0]; p = 0.018).

CONCLUSIONS

Anatomic resection was associated with improved RFS for ICC patients with tumors size ≥4 cm, indicating that tumor size may be a valuable criterion to determine the extent of liver resection for resectable ICC patients.

Efficacy and Toxicity of Pemigatinib in Advanced Cholangiocarcinoma Harboring FGFR Fusions or Rearrangements: A Systematic Review and Meta-analysis

BACKGROUND

The efficacy and safety of pemigatinib in advanced cholangiocarcinoma (aCCA) were presented in phase I-II trials and retrospective reports, with small sample sizes and variable results.

METHODS

A systematic literature search included studies investigating the efficacy/safety of pemigatinib in aCCA harboring FGFR fusions/rearrangements. Primary outcomes were objective response rate (ORR) and treatment-related adverse events (AEs). A pooled proportion meta-analysis was performed.

RESULTS

Three hundred and twenty-seven patients in eight studies were included (three phase-II, one phase-I/II, two phase-I, and two retrospective). In the pooled analyses, the median age was 58.9 years (95% confidence interval (CI): 51.9-65.8); 33.4% (95% CI: 28.1-39.0) were male. Pemigatinib was the second-line treatment in 58.5% (95% CI: 52.7-64.1) and was beyond second-line in the remaining. ORR was 42.2% (95% CI: 35.9-48.7) (I2:48.4%) and disease control rate (DCR) was 86.5% (95% CI: 81.6-90.5) (I2: 58.8%). Median progression-free survival (PFS) was 7.8 months (95% CI: 6.2-9.4) (I2: 11.6%). Two studies reported overall survival (OS) (median 17.5 and 17.1 months). The most common AEs (any grade) were hyperphosphatemia (46%), dysgeusia (33.2%), alopecia (31.4%), fatigue (30.9%), stomatitis (28.5%), and diarrhea (27.5%). Cumulative eye and nail toxicities were observed in 32.5% and 40.9%, and retinal detachment in 5.5%.

CONCLUSION

This analysis emphasizes the FGFR alteration testing and pemigatinib use in the second-line and beyond treatment of aCCA.

REGISTRATION ID (PROSPERO)

CRD42024627459.

First-Line Genomic Profiling in Previously Untreated Advanced Solid Tumors: 1-Year Follow-Up of the FIRST-Dx Study

The FIRST-Dx study prospectively evaluated the clinical utility of the comprehensive genomic profiling (CGP) test (FoundationOne CDx) in the first-line setting for patients with chemotherapy-naïve advanced solid tumors (gastrointestinal, biliary, pancreatic, lung, breast, gynecologic, melanoma) in six hospitals in Japan. Here, we report the results of the 1-year interim analysis of the follow-up study about the clinical benefits provided by the upfront CGP test. The primary endpoint was overall survival (OS), and secondary endpoints were the proportion of patients who actually received molecular-based recommended therapy (MBRT) determined by the molecular tumor board, best overall response rate (ORR) in each line of therapy, and progression-free survival (PFS) ratio (PFS on MBRT/PFS on the first-line therapy). Data from 172 patients with a median follow-up of 15.1 months (range: 0.1-21.5 months) were available. The median OS was not reached. Thirty-nine patients (22.7%) received MBRT during this follow-up period. ORR in first-line therapy was 56.3% in the MBRT group (n = 16) vs. 42.3% in the non-MBRT group (n = 137), and in the second-line was 26.3% in the MBRT group (n = 19) vs. 17.1% in the non-MBRT group (n = 82). Regarding the PFS ratio of second-line MBRT (n = 12), the median PFS ratio was 1.1, and four patients (33.3%) had a ratio ≥ 1.3, indicating that MBRT might be effective in changing the clinical outcome. The findings of this study imply that CGP testing before the standard of care for patients with advanced solid tumors could prove to be a clinically beneficial strategy for guiding subsequent precision anticancer treatments. Trial Registration: Japan Registry of Clinical Trials (jRCT) ID: jRCT1050220041.

Claudin 18.2: a promising actionable target in biliary tract cancers

BACKGROUND AND PURPOSE

Anti-claudin 18.2 (anti-CLDN18.2) therapy has been approved for patients with CLDN18-positive gastric and gastroesophageal junction adenocarcinomas. The current study aims at evaluating the expression of CLDN18 in a large cohort of pathologically characterized biliary tract cancers (BTCs).

MATERIALS AND METHODS

A series of 237 BTCs were collected and reviewed under the BITCOIN protocol. All samples were assessed for CLDN18 status using immunohistochemistry (clone 43-14A). Tumor positivity for CLDN18 was determined if ≥75% of tumor cells exhibited moderate-to-strong membranous staining.

RESULTS

CLDN18 expression was found in 29.5% of BTCs (70/237), with the highest rates in gallbladder carcinoma (GBC; 62.5%; 20/32) and extrahepatic cholangiocarcinoma (eCCA; 53.4%; 31/58), compared with intrahepatic cholangiocarcinoma (iCCA; 12.9%; 19/147) (P < 0.0001). CLDN18 positivity was detected in 5.5% of cases (13/237), most common in GBC (15.6%; 5/32), followed by eCCAs (8.6%; 5/58) and iCCAs (2.0%; 3/147) (P = 0.0045). Most CLDN18-positive samples (10/13) exhibited a heterogenous staining pattern. In iCCAs, large duct subtypes had higher CLDN18 expression [33.3% (10/30) versus 7.7% (9/117), P = 0.0002] and positivity [6.7% (2/30) versus 0.9% (1/117), P = 0.106] than small duct iCCAs. No significant differences were observed across GBC and eCCA histotypes, and CLDN18 was not associated with IDH1 or FGFR2 status in iCCAs.

CONCLUSIONS

This study demonstrates that CLDN18 expression is present in a subset of BTCs, with significantly higher positivity rates in GBCs and eCCAs compared with iCCAs. In iCCAs, CLDN18 expression was more frequent in the large duct subtype but was not associated with IDH1 or FGFR2 status. These findings suggest that CLDN18 could be a potential therapeutic target in BTCs, warranting further prospective studies to evaluate its clinical significance and impact on patient outcomes.

Assessment of heterogeneity according to hospital or medical experience factors in outcomes of chemotherapy for advanced biliary tract cancer: a post-hoc analysis of JCOG1113

BACKGROUND

JCOG1113 is a randomized phase III trial that showed non-inferiority of gemcitabine plus S-1 to gemcitabine plus cisplatin in patients with advanced biliary tract cancer. Assessment of inter-institutional heterogeneity in chemotherapy contributes to confirm generalizability and reliability of the study itself. However, there have been no studies conducted to assess the heterogeneity among participating centers in randomized phase III trials for biliary tract cancer.

METHODS

The objective of this post-hoc analysis was to assess the inter-institutional heterogeneity in the overall survival and progression-free survival of patients with advanced biliary tract cancer treated with first-line chemotherapy in the JCOG1113 trial. The heterogeneity in the overall survival and progression-free survival was assessed according to three factors: hospital volume, experience in medical oncology and experience in biliary intervention. A total of 300 advanced biliary tract cancer patients were analyzed. There were no statistically significant trends observed between hospital volume, experience in medical oncology, or experience in biliary intervention and overall survival (hospital volume: adjusted trend P value = 0.6796; experience in medical oncology: adjusted trend P value = 0.4092; experience in biliary intervention: adjusted trend P value = 0.6112). Similarly, no statistically significant trends were observed between these factors and progression-free survival (hospital volume: adjusted trend P value = 0.3000; experience in medical oncology: adjusted trend P value = 0.1108; experience in biliary intervention: adjusted trend P value = 0.2898).

CONCLUSIONS

This study revealed no inter-institutional heterogeneity in the overall survival and progression-free survival in the JCOG1113 study population of advanced biliary tract cancer patients.

Human serum albumin microspheres synchronously loaded with ZIF-8 and triptolide (TP) for the treatment of intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver tumor and remains a fatal malignancy in most patients. Only 20% to 30% of patients can be treated with potentially curative surgical resection. Local therapies such as radioembolization and hepatic arterial perfusion may be a more effective treatment strategy. The active ingredients of natural plants have aroused wide interest in the treatment of tumors. Triptolide shows toxic effects on a variety of epithelioid carcinoma cells. However, there is currently a lack of suitable delivery system for the treatment of ICC. In this study, organometallic framework material ZIF-8 was chosen to load TP, and then encapsuled in HSA micro-nanoparticles for the perfusion treatment of ICC. The results of SEM, XRD, and FTIR showed that ZIF-8 nanoparticles were encapsuled in HSA micro-nanoparticles. ZIF-8 nanoparticles (57.89 ± 12.24%) and TP@ZIF-8/HSA (36.8 ± 4.71%) micro-nanoparticles could significantly inhibited proliferation of RBE cell. Also, TP@ZIF-8/HSA micro-nanoparticles of all groups exhibited favorable cytocompatibility to L929 cells and hemocompatibility. RT-qPCR and western blot showed that ZIF-8 and TP induced apoptosis in cancer cells through mitochondria-related pathways. The results demonstrated that TP@ZIF-8/HSA was a potential chemotherapy candidate for the treatment of ICC.

Second-Line Fluoropyrimidine-Based Chemotherapy in Advanced Biliary Tract Cancer: A Meta-analysis Based on Individual Patient-Level Data of Randomized Trials

PURPOSE

While fluoropyrimidine-based chemotherapy regimens are recommended second-line treatment for patients with advanced biliary tract cancer (BTC), there have been no studies comparing different regimens head-to-head.

MATERIALS AND METHODS

We performed individual patient-level meta-analysis based on data from the intention-to-treat population of the phase 2b NIFTY trial (liposomal irinotecan [nal-IRI] plus fluorouracil and leucovorin [5-FU/LV] vs. 5-FU/LV; NCT03542508) and the phase 2 FIReFOX trial (modified oxaliplatin plus 5-FU/LV [mFOLFOX] vs. modified irinotecan plus 5-FU/LV [mFOLFIRI]; NCT03464968). Pairwise log-rank tests and multivariable analysis using Cox proportional hazards modeling with shared frailty to account for the trial's effect were used to compare overall survival (OS) between regimens.

RESULTS

A total of 277 patients were included. The nal-IRI plus 5-FU/LV group (n=88) showed significantly better OS compared to the mFOLFOX group (n=49, pairwise log-rank, p=0.02), and mFOLFIRI group (n=50, p=0.03). Multivariable analysis showed consistent trends in OS with adjusted hazard ratios of 1.39 (mFOLFOX vs. nal-IRI plus 5-FU/LV: 95% confidence interval [CI], 0.93 to 2.07; p=0.11) and 1.36 (mFOLFIRI vs. nal-IRI plus 5-FU/LV: 95% CI, 0.92 to 2.03; p=0.13), respectively. Compared to the 5-FU/LV group, the mFOLFOX group and the mFOLFIRI group did not show differences in terms of OS (pairwise log-rank p=0.83 and p=0.58, respectively). The nal-IRI plus 5-FU/LV group experienced more frequent diarrhea, while the mFOLFOX group experienced peripheral neuropathy.

CONCLUSION

Nal-IRI plus 5-FU/LV showed favorable survival outcomes compared to mFOLFOX, mFOLFIRI, or 5-FU/LV. The safety profiles of these regimens should be considered along with efficacy.

HER2-targeted therapies: Unraveling their role in biliary tract cancers

Biliary tract cancers (BTCs) constitute a heterogeneous group of malignancies with rising incidence and limited therapeutic options in advanced stages, leading to increased overall mortality. Extensive genomic profiling has identified key oncogenic drivers in BTCs that represent promising therapeutic targets and could change the treatment paradigm. Evidence suggests improved survival outcomes for patients with actionable molecular alterations who received matched targeted therapies. Human epidermal growth factor receptor 2 (HER2) is a receptor tyrosine kinase and proto-oncogene that has been extensively studied as a prognostic biomarker and a therapeutic target in multiple solid organ malignancies. Recent clinical trials on the combination of trastuzumab with tucatinib, FOLFOX, or pertuzumab for previously treated, HER2-positive, advanced BTCs have shown improved outcomes compared to current second-line therapies. Early evidence from observational studies on trastuzumab-containing regimens as first-line suggests promising efficacy. Furthermore, the recent tumor-agnostic approval of trastuzumab deruxtecan for HER2-positive solid tumors has formally introduced HER2-directed agents in the BTC therapeutic arsenal. This review aims to summarize the rapidly evolving landscape of HER2-directed agents for BTCs, highlighting current evidence of survival benefit. Beginning with a concise presentation of the structural and functional aspects of HER2, we detail the frequency and prognostic significance of HER2 alterations in BTCs and discuss all available preclinical and clinical data on anti-HER2 agents tested for BTCs.

Safety and efficacy of living donor liver transplantation for unresectable perihilar cholangiocarcinoma: A single center prospective study

BACKGROUND

The prognosis for unresectable perihilar cholangiocarcinoma (phCCA) is extremely poor. Liver transplantation in combination with neoadjuvant chemoradiation therapy has become the treatment of choice for unresectable phCCA in the USA. In 2018, we launched a prospective study to evaluate the safety and efficacy of living donor liver transplantation (LDLT) for unresectable phCCA.

METHODS

A total of 10 patients were enrolled in this study between 2018 and 2024. Finally, five patients with unresectable phCCA underwent LDLT after neoadjuvant chemotherapy, radiation, and staging laparotomy, while the other five patients dropped out of the protocol.

RESULTS

The median follow-up period was 23.7 months. The overall survival rate for the five patients who underwent LDLT was 100% after one year. Hepatic artery thrombosis and delayed gastric emptying occurred in two and three cases, respectively. The histological efficacy of preoperative treatment was grade IIb and III, according to the Evans classification, in all five patients. All surgical margins and dissected lymph nodes were negative. Four patients were alive with no evidence of disease recurrence while one patient had recurrence 10 months after LDLT.

CONCLUSIONS

LDLT is feasible and may be a last-resort treatment option for unresectable phCCA, although the long-term outcomes need to be carefully monitored.

CLINICAL TRIAL REGISTER AND CLINICAL REGISTRATION NUMBER

The UMIN registration number for this study is 000033348.

The efficacy of second-line chemotherapy for advanced biliary tract cancer: A systematic review and network meta-analysis

BACKGROUND

This network meta-analysis (NMA) aims to provide evidence-based guidance for selecting the second-line chemotherapy for biliary tract cancer (BTC).

METHODS

A comprehensive literature search was conducted on PubMed, Cochrane, and EMBASE through July 2024. Inclusion criteria involved: (1) patients underwent second-line chemotherapy following platinum-based first-line therapy, (2) intervention/comparator groups consisted of various chemotherapeutic agents, and (3) outcomes measured as hazard ratio (HR) of overall survival (OS) and progression-free survival (PFS) in randomized controlled trials (RCTs) and cohort studies.

RESULTS

Outcomes were measured as HR of OS and PFS in RCTs and cohort studies. The eight studies consisting of 1621 patients were selected. In the NMA for OS, 5FU_plus_Plat (fluorouracil plus oxaliplatin or cisplatin; HR 0.52, 95% confidence interval [CI]: 0.30-0.91), nal-IRI_5FU_LV (nano-liposomal irinotecan plus fluorouracil and LV; HR 0.54 [95% CI: 0.32-0.92]), and FOLFOX (fluorouracil plus oxaliplatin; HR 0.69 [95% CI: 0.50-0.96]) demonstrated significant benefits in OS when compared to control. For PFS, nal-IRI_5FU_LV (HR 0.61 [95% CI: 0.44-0.85]) provided a significant advantage over 5FU.

CONCLUSIONS

Second-line chemotherapy for BTC after the failure of gemcitabine plus platinum as first-line therapy, nal-IRI_5FU_LV appears to be the most promising second-line therapy in terms of both OS and PFS.

Evaluation of the validity of pancreatoduodenectomy for octogenarian patients with biliary tract carcinoma from the perspective of recurrence

OBJECTIVE

To clarify the short- and long-term validity of pancreatoduodenectomy in octogenarian patients with biliary tract carcinoma.

METHODS

We compared 23 and 141 patients aged ≥80 and <80 years, who underwent pancreatoduodenectomy for biliary tract carcinoma (distal cholangiocarcinomas and ampullary carcinomas) and evaluated the relationship between age, clinicopathological factors, and surgical and oncological outcomes, especially in terms of recurrence.

RESULTS

Median overall survival time of distal cholangiocarcinoma and ampullary carcinoma was 92 and 109 months (p = 0.13). Postoperative complications, mortality, and adjuvant chemotherapy rates did not differ between the groups. Although the 5-year recurrence-free survival rate was similar, the 5-year disease-specific survival and overall survival rate were significantly shorter in octogenarians (≥80 years: 43.5, 47.1, and 35.3%; <80 years: 54.1, 69.2, and 63.0%; p = 0.41, 0.016, and 0.034, respectively). The median time from recurrence to death for octogenarian patients was significantly shorter than that of younger patients (3.3 vs. 16.1 months, p < 0.001). At recurrence, the serum albumin level, prognostic nutritional index, controlling nutritional status score, and treatment rate for recurrence were lower in octogenarians. The multivariate analysis identified age ≥80 years (hazard ratio: 3.8), low prognostic nutritional index (hazard ratio: 2.9), high serum carbohydrate antigen 19-9 (hazard ratio: 2.6), and failure to implement treatment after recurrence (hazard ratio: 3.0) as independent risk factors for a short time from recurrence to death. Furthermore, age ≥80 years (odds ratio 0.09) was an independent risk factor for treatment implementation after recurrence.

CONCLUSIONS

Octogenarians had a shorter survival time after recurrence, resulting from low nutritional indices and a reduced rate of treatment implementation at the time of recurrence.

Molecular Landscape and Treatment Paradigms of Hepatocellular and Cholangiocarcinoma: A Multinational Review

Hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA) represent the most prevalent primary liver cancers and pose significant challenges in oncology. While their etiology and incidence vary globally, the molecular landscape of these tumors is increasingly understood, offering new opportunities for precision medicine. In this joint multinational review, we present a comprehensive analysis of the key molecular pathways involved in the pathogenesis of HCC and CCA, highlighting actionable targets for emerging therapies. Recent advances in molecular diagnostics have significantly influenced treatment paradigms for both cancers. In HCC, while genetic alterations have not yet led to established diagnostic or therapeutic applications, targeting vascular endothelial growth factor (VEGF), immune checkpoints, and tyrosine kinase pathways has demonstrated considerable therapeutic potential. In CCA, genetic profiling has uncovered actionable alterations, such as FGFR2 fusions and IDH1 mutations, driving the development of targeted therapies. The growing complexity of precision oncology underscores the need for standardized molecular testing and streamlined diagnostic workflows to ensure timely and effective treatment. This review also emphasizes the importance of collaborative efforts between clinicians, pathologists, and oncologists to optimize outcomes. By synthesizing the latest molecular insights and treatment trends, this review provides a valuable resource to guide the personalized management of HCC and CCA.

Efficacy and safety of immune checkpoint inhibitors in advanced biliary tract cancer: a real-world study

Background

Immune checkpoint inhibitors (ICIs) combined with gemcitabine and cisplatin chemotherapy have become the standard first-line treatment for advanced biliary tract cancer (BTC). However, real-world evidence on domestic ICIs widely used in China and the therapeutic outcomes across treatment lines remains limited. This study aimed to assess the real-world effectiveness and safety profiles of ICIs in advanced BTC patients, while concurrently elucidating potential efficacy variations among distinct ICI subtypes.

Methods

We analyzed patients with unresectable, locally advanced, or metastatic BTC treated with ICIs at West China Hospital (January 2019-October 2023). Primary endpoint was overall survival (OS), while secondary endpoints included progression-free survival (PFS), objective response rate (ORR), disease control rate (DCR), and safety. Kaplan-Meier survival curves, propensity score matching (PSM), and Cox proportional hazards regression analyzed treatment efficacy.

Results

A total of 221 advanced BTC patients were enrolled. Among them, 137 patients received ICIs treatment in the first line, while 84 patients in the second or later lines. For patients treated with ICIs as first-line therapy, the median OS was 15.7 months (95% CI: 13.1-19.8) and PFS was 8.4 months (95% CI: 7.6-10.3). In contrast, patients treated in second or later lines had shorter median OS of 9.8 months (95% CI: 8.1-12.3) and median PFS of 5.6 months (95% CI: 4.2-6.8). The reduced efficacy in later-line treatments may reflect prior therapeutic resistance and generally poorer patient conditions compared to first-line recipients. 211 (95.5%) patients experienced at least one adverse event (AE), and 93 (42.1%) of them experienced grade 3 or higher AEs. The incidence of immune-related adverse events (irAEs) was 35.8%, with 8.6% of patients experiencing grade 3-4 irAEs. The most common ICI treatments are with Durvalumab or Sintilimab, which we are interested in comparing. Durvalumab showed numerically superior OS vs Sintilimab (19.3 vs 10.2 months, p<0.001) in unmatched analysis, though significance attenuated after PSM (16.1 vs 13.1 months, p=0.299).

Conclusion

ICIs demonstrate robust efficacy and manageable toxicity in real-world settings, supporting their use in both first- and later-line treatments for advanced BTC. However, whether domestic ICI alternatives remain viable options warranting further validation.

Clinical and dosimetric considerations for yttrium-90 glass microspheres radioembolization of intrahepatic cholangiocarcinoma, metastatic colorectal carcinoma, and metastatic neuroendocrine carcinoma: recommendations from an international multidisciplinary working group

PURPOSE

The TheraSphere Global Steering Committee reconvened to review clinical data and address knowledge gaps related to treatment and dosimetry in non-HCC indications using Yttrium-90 (90Y) glass microspheres.

METHODS

A PubMed search was performed. References were reviewed and adjudicated by the Delphi method. Recommendations were graded according to the degree of recommendation and strength of consensus. Dosimetry focused on a mean dose approach, i.e., aiming for an average dose over either single or multicompartment volumes of interests. Committee discussion and consensus focused on optimal patient selection, disease presentation, liver function, tumour type, tumour vascularity, and curative/palliative treatment intent for intrahepatic cholangiocarcinoma (iCCA) and colorectal and neuroendocrine carcinoma liver metastases (mCRC, mNET).

RESULTS

For all indications, single compartment average perfused volume absorbed dose ≥ 400 Gy is recommended for radiation segmentectomy and 150 Gy for radiation lobectomy. Single compartment 120 Gy for uni- and bilobar treatment reflects current clinical practice, which results in variable tumour and normal tissue absorbed doses. Therefore, multicompartment dosimetry is recommended for uni- and bilobar treatment, aiming for maximum 75 Gy to normal tissue and 150-200 Gy (mCRC, mNET), ≥ 205 (iCCA) tumour absorbed doses. These dose thresholds are preliminary and should be used with caution accounting for patient specific characteristics.

CONCLUSION

Consensus recommendations are provided to guide clinical and dosimetry approaches for 90Y glass microsphere radioembolization in iCCA, mCRC and mNET.

CLINICAL TRIAL NUMBER

not applicable.

Health-related quality of life in participants with advanced biliary tract cancer from the randomized phase III KEYNOTE-966 study

BACKGROUND & AIMS

In the randomized, double-blind, phase 3 KEYNOTE-966 trial, pembrolizumab plus gemcitabine and cisplatin demonstrated a significant improvement in overall survival as first-line therapy for advanced biliary tract cancer (BTC). We present the prespecified health-related quality of life (HRQoL) outcomes from KEYNOTE-966.

METHODS

HRQoL was assessed using the European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30), EORTC QLQ-BIL21, and EuroQoL 5 Dimensions 5 Levels (EQ-5D-5L) questionnaires. Data from the latest time point with ≥60% completion and ≥80% compliance (week 18) were compared to baseline. Least squares means (LSM) for change from baseline to week 18 were compared using a constrained longitudinal analysis model in six prespecified domains: QLQ-C30 global health status/quality of life (GHS/QoL), physical functioning, and role functioning; QLQ-BIL21 pain and jaundice scores, and EQ-5D-5L visual analog score. The analysis population was all treated participants with ≥1 completed HRQoL assessment. Between-arm difference in time to confirmed deterioration (TTD) was assessed using a stratified Cox proportional hazards model with randomization stratification factors.

RESULTS

KEYNOTE-966 randomized 1,069 participants into the study (n=533 pembrolizumab arm; n=536 placebo arm). Questionnaire compliance was >87% from baseline to week 18 in both arms. LSM changes from baseline to week 18 were similar between arms for all prespecified domains. TTD estimates were also similar between arms, including GHS/QoL (median not reached [NR] in the pembrolizumab arm versus 21.2 months in the placebo arm; HR=0.86, 95% CI=0.70-1.07); jaundice (NR versus NR; HR=1.20, 95% CI=0.94-1.54), and pain (NR versus NR; HR=0.79, 95% CI=0.59-1.05).

CONCLUSION

HRQoL was maintained after adding pembrolizumab to gemcitabine and cisplatin, further supporting this regimen as first-line treatment for advanced BTC.

IMPACT AND IMPLICATIONS

Biliary tract cancer (BTC) is often diagnosed at late stages because most patients do not present with disease-specific symptoms. Compared with the general population, patients with advanced BTC report worse physical, emotional, and functional well-being. In KEYNOTE-966, adding the programmed cell death protein 1 (PD-1) inhibitor pembrolizumab to gemcitabine and cisplatin as first-line therapy for participants with advanced BTC produced a statistically significant and clinically meaningful improvement in overall survival. The prespecified patient-reported outcomes results from KEYNOTE-966 presented herein demonstrated that health-related quality of life was maintained after adding pembrolizumab to gemcitabine and cisplatin, further supporting this regimen as first-line treatment for advanced BTC.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, NCT04924062.

Liposomal irinotecan for previously treated patients with biliary tract cancer: A pooled analysis of NIFTY and NALIRICC trials

BACKGROUND & AIMS

Liposomal irinotecan (nal-IRI) combined with fluorouracil (5-FU)/leucovorin (LV) as a second-line treatment for biliary tract cancer (BTC) following progression on gemcitabine-based therapy yielded conflicting outcomes in the Korean NIFTY and German NALIRICC trials. This necessitated a comprehensive pooled analysis to evaluate its efficacy and safety.

METHODS

Individual patient data were pooled from the intention-to-treat populations of the NIFTY and NALIRICC trials. The primary endpoint was progression-free survival (PFS).

RESULTS

A total of 278 patients were included: 137 in the nal-IRI plus 5-FU/LV group and 141 in the 5-FU/LV group. The nal-IRI plus 5-FU/LV group showed significantly longer median PFS (3.6 months [95% CI 2.7-4.4] vs. 1.8 months [95% CI 1.5-2.6]; hazard ratio 0.65, p <0.001). Median overall survival was 8.1 months (95% CI 6.0-8.9) and 6.1 months (95% CI 5.3-7.5), respectively (hazard ratio 0.77, p = 0.051). Objective response rates were also higher in the nal-IRI plus 5-FU/LV group than in the 5-FU/LV group (17.5% vs. 2.8%; p <0.001). Post-study irinotecan-containing therapy was administered in 4 (2.9%) and 21 (15.3%) patients in the nal-IRI plus 5-FU/LV group and 5-FU/LV group, respectively. Adverse events varied by ethnicity, with gastrointestinal toxicities more common in Germans and neutropenia more prevalent in Koreans; treatment discontinuation without disease progression occurred in 31.3% vs. 8.0%, respectively.

CONCLUSION

The addition of nal-IRI to 5-FU/LV significantly improved PFS and objective response rates, supporting its potential as subsequent-line therapy. Differences in safety profiles underscore the relevance of ethnicity for nal-IRI in patients with BTC.

IMPACT AND IMPLICATIONS

Current standard of care for second-line therapy in patients with advanced biliary tract cancer (BTC) is FOLFOX. This study provides robust evidence supporting the potential role of adding liposomal irinotecan (nal-IRI) to fluorouracil and leucovorin (5-FU/LV) as a subsequent therapy for patients with BTC who have progressed on gemcitabine-based regimens. The findings demonstrate significant improvements in progression-free survival and objective response rates in a patient population for whom treatment options are limited. Furthermore, the study underscores the necessity of considering ethnic differences in adverse event profiles to optimize treatment administration and patient outcomes.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03524508 and NCT03043547.

Molecular Testing and Targeted Therapies in Hepatobiliary Cancers: A Review

Importance

Hepatobiliary cancers are heterogeneous and molecularly complex. Recent advances in next-generation sequencing (NGS) have enhanced the understanding of their molecular landscape and enabled deployment of biomarker-based gene- and immune-targeted therapies. This review examines the role of molecular testing and targeted therapies in these malignant neoplasms.

Observations

Patients with hepatobiliary cancers have poor outcomes. Precision oncology studies have shown that while many common molecular alterations are not currently targetable in hepatocellular carcinoma (HCC), a large number of actionable alterations characterize biliary tract cancers (BTCs), with several therapies now approved by the US Food and Drug Administration. Immunotherapy is increasingly adopted in clinical practice, either as monotherapy or combined with cytotoxic chemotherapy, for both HCC and BTCs. Moreover, multiple solid cancer tumor-agnostic therapies are approved (larotrectinib, entrectinib, and repotrectinib for NTRK fusions; selpercatinib for RET fusions; dabrafenib and trametinib combination for BRAF V600E mutations; dostarlimab or pembrolizumab for tumors with high microsatellite instability and pembrolizumab for tumor mutation burden ≥10 mutations/megabase), highlighting the need for NGS as well as ERBB2 (formerly HER2) immunohistochemistry (IHC) (with the recent approval of solid tissue-agnostic deruxtecan trastuzumab for ERBB2-positive [IHC 3+] cancer) across cancers. N-of-1 clinical trials using customized drug combinations matched to the tumor's molecular profile have yielded encouraging results and provide a promising framework for future clinical trial design.

Conclusions and Relevance

Molecular testing and gene- and immune-targeted therapies are transforming hepatobiliary cancer treatment. Tumor-agnostic and N-of-1 clinical trials have challenged traditional clinical trial paradigms and provide the foundation for truly personalized oncology for patients with these aggressive cancers. Further work is needed to determine how to leverage these novel approaches into the management of operable disease.

Global burden of gallbladder cancer in 2022 and predictions to 2042

BACKGROUND & AIMS

This study aims to provide updated estimate on the global burden of Gallbladder cancer (GBC) in 2022 and to predict the trends through the year 2042.

METHODS

Data were extracted from GLOBOCAN 2022 database. Incidence and mortality rates were calculated by sex, country, world region and Human Development Index (HDI). Trends up to the year 2042 were predicted based on global demographic projections by HDI.

RESULTS

Worldwide, there were 122,469 new GBC cases and 89,045 deaths identified in 2022. While the highest absolute number was observed in South Central Asia and Eastern Asia, particularly India and China, countries in South America, particularly Bolivia, showed the highest age-standardised rate. Medium HDI countries showed more than double the incidence and mortality rates compared to low HDI countries. Over half of GBC cases and deaths occurred in individuals aged 50-74 years. Predictions indicate a 65.3 % increase in new cases and a 67.6 % increase in deaths by 2042, with High HDI countries and Low HDI countries experiencing the largest absolute and percentage increases, respectively.

CONCLUSIONS

The global burden of GBC is substantial, especially concentrated in South Central Asia, Eastern Asia and South America. With significant increase of burden over the next 20 years, there is an urgent need for effective cancer control strategies in regions exhibiting great GBC burden.

Efficacy of cisplatin-gemcitabine-durvalumab in patients with advanced biliary tract cancer experiencing early vs late disease relapse after surgery: a large real-life worldwide population

BACKGROUND

In the TOPAZ-1, patients with biliary tract cancers (BTC) and recurrence within 6 months after surgery were excluded, even if this event is frequently observed in clinical practice. Our study aimed to assess if the efficacy of cisplatin-gemcitabine-durvalumab (CGD) in this population is comparable to that reported in the phase 3 trial.

METHODS

The study cohort included patients with BTC who underwent surgery on the primary tumor, experienced disease recurrence occurring ≤6 months or >6 months after surgery or after the end of adjuvant therapy and started CGD. The primary objectives were overall survival (OS) and progression free survival (PFS).

RESULTS

A total of 178 patients were enrolled. No significant differences were observed between early and late relapse groups in OS (23.4 months vs not reached; HR 1.26; 95% CI, 0.67-2.37; P = .45) and PFS [7.0 months vs 9.8 months; HR 1.3(95% CI, 0.9-2.1) P = .13]. Overall response rate and disease control rate (P = .33 and P = .62) were comparable between the 2 groups, as the overall safety profile. In addition, we compared survival outcomes between the selected population and a historical cohort of patients with BTC treated with cisplatin-gemcitabine (CG) and found that despite the absence of statistical significance, CGD showed an outcome trend compared with CG regardless of the time of recurrence after surgery or adjuvant chemotherapy [(CG ≤ 6 vs CGD ≤ 6 months: HR 0.59, 95%CI, 0.35-1.01, P = .05; HR 0.70; 95%CI, 0.46-1.06, P = .09, OS and PFS, respectively) and (CG > 6 vs. CGD > 6 months: HR 0.50; 95%CI, 0.29-0.88, P = 0.0165; HR 0.54; 95%CI, 0.35-0.84, P = .0068, OS and PFS, respectively)].

CONCLUSION

Our analysis suggests that CGD retains its efficacy independently of the timing of relapse after surgery or completion of adjuvant treatment in patients with advanced BTC.

Update for: New developments in systemic therapy for advanced biliary tract cancer

Biliary tract cancer, carcinoma of the extrahepatic bile ducts, carcinoma of the gallbladder, ampullary carcinoma, and intrahepatic cholangiocarcinoma are often identified at advanced stages. The standard therapy for advanced biliary tract cancer has been a combination of cytotoxic agents. Globally, gemcitabine plus cisplatin has been the standard first-line regimen, whereas gemcitabine plus cisplatin plus S-1 and gemcitabine plus S-1 have also been the standard regimens in Japan. Recently, treatment strategies have been updated. As first-line systemic therapy, the addition of an immune checkpoint inhibitor, such as durvalumab or pembrolizumab, to gemcitabine plus cisplatin has been shown to prolong overall survival compared with gemcitabine plus cisplatin. These combined immunotherapies are widely used in clinical practice as internationally standard first-line regimens. Regarding second-line treatment after a gemcitabine-based regimen, fluorouracil and folinic acid plus oxaliplatin have been the standard regimen. Additionally, FGFR2 fusion gene/rearrangement, mutations of IDH1/2, KRAS, and BRAF, and overexpression of HER2 are promising therapeutic targets for which the effectiveness of each targeted therapy has been reported, at this time, as a second-line or later treatment.

Perforated Calculous Cholecystitis and Incidental Squamous Cell Carcinoma of the Gallbladder-A Complex Relationship with a Difficult Management in the Acute Setting

The worldwide prevalence of gallstones (GSs) is estimated to be between 10% and 15% in the general population. Gallbladder carcinoma (GBC) is the most common biliary tract neoplasia, and it is characterized by highly aggressive behavior and poor overall prognosis. Long-standing GSs and chronic inflammatory state represent the most common risk factors for GBC, promoting a carcinogenic microenvironment. Long-standing GSs expose patients to potentially severe surgical and oncological complications. A 71-year-old gentleman, who had never experienced biliary symptoms and had diabetes mellitus (DM), presented with severe peritonitis due to perforated acute calculous cholecystitis. The patient underwent an emergent laparotomic cholecystectomy. Histopathology found a rare pT2b poorly differentiated squamocellular carcinoma of the gallbladder. Although more difficult due to the concomitant inflammatory context, it is critical to identify suspicious lesions during preoperative imaging in patients at high risk of malignancy presenting with complex acute gallbladder pathologies. A review of the literature was conducted to gain a deeper insight into the relationship between long-standing GSs and GBC, evaluating also the difficult diagnosis and management of malignancy in the acute setting. Considering the existing literature, the choice to pursue a prophylactic cholecystectomy may be justifiable in selected asymptomatic GS patients at high risk for GBC.

Bintrafusp alfa and chemotherapy as first-line treatment in biliary tract cancer: A randomized phase 2/3 trial

BACKGROUND AND AIMS

We compared the safety and efficacy of bintrafusp alfa (BA) in combination with gemcitabine+cisplatin (GemCis), to those of GemCis alone, in patients with biliary tract cancer.

APPROACH AND RESULTS

This randomized, double-blind, placebo-controlled, adaptive design phase 2/3 trial (NCT04066491) included adults who are treatment-naive with locally advanced/metastatic biliary tract cancer. Patients (N = 297) were randomized to receive an IV infusion of BA (2400 mg once/3 wk) plus GemCis (gemcitabine 1000 mg/m 2 +cisplatin 25 mg/m 2 on days 1 and 8/3 wk; 8 cycles) (BA group, n = 148) or placebo+GemCis (placebo group, n = 149). The primary end point was overall survival (OS). For adaptation analysis (phase 2-phase 3; data cutoff: May 20, 2021), efficacy was assessed in the first 150 patients who were antibiotic-naive when 80 progression-free survival events had occurred and ≥ 19 weeks of follow-up had been completed (BA, n = 73; placebo, n = 77). Median OS (95% CI) for the BA (11.5 mo [9.3-not estimable]) and placebo (11.5 mo [10.0-not estimable]) groups was comparable (hazard ration 1.23 [95% CI 0.66-2.28]; p = 0.7394); OS data maturity was 27.2% (41 events/151 patients). The most common grade ≥3 treatment-related adverse event was anemia (BA, 26.0%; placebo, 22.8%). Bleeding adverse events were reported more frequently in the BA group (28.8%) versus the placebo group (7.4%). Deaths within 60 days of the first dose were reported in 7.5% and 1.3% of patients in the BA and placebo groups, respectively.

CONCLUSIONS

BA+GemCis did not provide a clinically meaningful benefit compared with GemCis alone as first-line treatment for biliary tract cancer, and the study was discontinued early (terminated: August 20, 2021).

New systemic treatment paradigms in advanced biliary tract cancer and variations in patient access across Europe

In recent years, treatment options for patients with advanced biliary tract cancer (BTC) have increased significantly due to the positive results from phase 2/3 clinical trials of immune checkpoint inhibitors, combined with chemotherapy, and molecularly targeted agents. These advances have led to the need for molecular testing to identify actionable alterations and patients amenable to targeted therapies. However, these improvements have brought with them many questions and challenges, including the identification of resistance mechanisms and therapeutic sequences. In this Series paper we aim to provide an overview of the current systemic treatment options for patients with BTC, highlighting disparities in access to innovative treatments and molecular testing across European countries, which lead to inequalities in the possibilities of treating patients with advanced BTC. We also discuss how ongoing European collaborative projects, such as the COST Action Precision-BTC-Network CA22125, supported by COST (European Cooperation in Science and Technology), linked to the European Network for the Study of Cholangiocarcinoma (ENSCCA), can help overcome these disparities and improve the current scenario.

Recent advances in systemic therapy for advanced biliary tract cancer: A systematic review and meta-analysis using reconstructed RCT survival data

Background & Aims

Gemcitabine/cisplatin (GemCis) was the long-standing first-line treatment for advanced biliary tract cancers (BTCs). Following positive results from the TOPAZ-01 and KEYNOTE-966 trials, immune checkpoint inhibitors (ICIs) combined with chemotherapy are now the standard of care. We aim to compare the efficacy of first-line therapies for advanced BTCs.

Methods

Our systematic review included studies from five databases focusing on English-language articles published between January 2010 and June 2024. We included randomized clinical trials (RCTs) that featured GemCis in a treatment arm for treatment-naive adults with advanced BTCs. The primary endpoints were overall survival (OS) and progression-free survival. We conducted a one-stage meta-analysis using reconstructed survival data, Cox-based models, and restricted mean survival time (RMST).

Results

After screening 8,797 studies, 17 RCTs were selected, involving a total of 4,584 patients. Of these, 2,140 (46.7%) received GemCis. The majority (68.9%) were diagnosed with intrahepatic or extrahepatic cholangiocarcinoma, and 80% had metastatic disease at the time of treatment. The pooled median OS in the GemCis group was 11.6 months (95% CI 11.3-12.2 months). GemCis plus pembrolizumab (hazard ratio [HR] 0.99, 95% CI 0.98-0.99; p <0.001), GemCis plus durvalumab (HR 0.98, 95% CI 0.97-0.99; p = 0.015), GemCis plus S-1 (HR 0.97 95% CI 0.95-0.99; p <0.001), and GemCis plus nab-paclitaxel (HR 0.98, 95% CI 0.98-0.99; p <0.001) demonstrated superior OS compared with GemCis alone. These combinations also showed increases in RMST by +1.1, +2.5, +2.8, and +2.1 months, respectively. In terms of progression-free survival, GemCis with ICIs (HR 0.91, 95% CI 0.78-0.94; p <0.001), GemCis plus S-1 (HR 0.98, 95% CI 0.96-0.99; p = 0.003), and GemCis plus nab-paclitaxel (HR 0.98, 95% CI 0.97-0.99; p <0.001) also demonstrated superiority, with corresponding RMST increases of +0.7, +1.9, and +2.5 months, respectively.

Conclusions

Despite incremental advancements, a breakthrough in advanced BTC treatment remains elusive. Further improvements in treatment efficacy may require biomarker identification to optimize combinational therapies for better patient selection.

Impact and implications

This study analyzed recent RCTs, including KEYNOTE-966, TOPAZ-1, NIFE, and SWOG 1815, involving 4,584 patients with advanced biliary tract cancer. A meta-analysis of 17 treatment arms, using reconstructed survival data, confirmed the modest survival benefit of GemCis plus ICIs, supporting its guideline adoption. The findings, however, highlight the need for biomarker identification and better patient selection.

Operative management and outcomes of gallbladder cancer in Australia: a multi-institutional, retrospective, observational cohort analysis

BACKGROUND

Data on optimal extent of resection for various stages of gallbladder cancer are lacking. This study aims to evaluate disease-free (DFS) and overall survival (OS) after simple (SC) versus radical cholecystectomy (RC) for gallbladder cancer in the Australian context, and assesses factors associated with post-operative morbidity.

METHODS

Multi-centre, retrospective cohort analysis including all gallbladder cancer patients who underwent resection across six Australian institutions between January 2010 and January 2020.

RESULTS

Of 63 patients included, 31 underwent SC and 32 had RC. Liver and other organ resection correlated with prolonged median DFS (41.9 vs. 13.1 months, HR 0.492 [95% CI 0.245-0.987], P = 0.042) and OS on univariate analysis of all patients (55.8% survived five years follow-up at study conclusion vs. median 18.4 months, HR 0.66 [95% CI 0.446-0.972], P = 0.036) but failed to demonstrate effect on multivariable analysis (OS HR 0.31 [95% CI 0.09-1.04], P = 0.057). RC was associated with a higher 30-day complication rate (n = 21 [65.6%] vs. n = 15 [48.4%], P = 0.310) compared to SC, although not statistically significant. There was no significant difference in the major morbidity rate (Clavien-Dindo ≥ Grade III) observed after SC (n = 7 [22.6%]) compared with RC (n = 6 [18.7%], P = 0.754). Neoadjuvant therapy was not utilized and adjuvant treatment used infrequently.

CONCLUSION

Extended gallbladder cancer resection was associated with prolonged OS and DFS but also considerable post-operative morbidity. Further studies are warranted to determine the optimal extent of surgical resection by stage of gallbladder cancer.

Focal acute cholecystitis misdiagnosed as gallbladder carcinoma

Thickening of the gallbladder wall is often associated with acute or chronic cholecystitis, adenomyomatosis and gallbladder carcinoma or seen in the context of liver and systemic diseases (acute hepatitis, cirrhosis, sepsis). Here we present a case of a 61 y.o. man with focal thickening of the gallbladder wall, in whom all imaging techniques were inconclusive. Pathological examination of the resected gallbladder revealed acute-on-chronic cholecystitis. We describe focal acute cholecystitis in absence of the classic clinical and imaging findings (Murphy's sign, fever, gallstones, hydrops, pericholecystic fluid) and mimicking a gallbladder carcinoma.

Global, regional, and national burden of gallbladder and biliary tract cancer, 1990 to 2021 and predictions to 2045: an analysis of the Global Burden of Disease study 2021

BACKGROUND

Identifying past, present, and future temporal trends in gallbladder and biliary tract cancer (GBTC) can increase public awareness and promote changes in prevention and treatment strategies.

METHODS

The incidence and death rates of GBTC between 1990 and 2021 were extracted from the Global Burden of Disease study 2021 and assessed according to country, region, year, age, and sex. Time trends were measured using the average annual percentage change (AAPC) and projections of the burden of disease for 2022 to 2045 were made using the Bayesian age-period-cohort model.

RESULTS

In 2021, there were 216,768.3 new cases (95% uncertainty interval [UI], 181,888.0-245,237.6) and 171,961.2 deaths (95% UI, 142,351.8-194,238.4) in GBTC globally. The increases in incidence and deaths were 101.09% and 74.26%, respectively, compared with 1990. The GBTC burden was higher in females and older adults. However, age-standardized incidence rate (ASIR) and age-standardized death rate (ASDR) trended downward from 1990 to 2021, with AAPC at -0.39 (95% CI, -0.52 to -0.26) and -0.88 (95% CI, -0.96 to -0.79), respectively. Although the ASIR and ASDR for both sexes are projected to decline gradually from 2022 to 2045, the incidence and deaths are expected to increase steadily. In addition, the global proportion of GBTC deaths owing to high body mass index in 2021 was 12.66% for females and 10.48% for males, which did not change significantly from 1990.

CONCLUSION

GBTC is becoming a major global health burden, especially among females and older adults. Given the increasing burden of an aging population, there is a need to reduce the incidence of this disease by adopting effective strategies and measures targeting risk factors.

Mapping the landscape of biliary tract cancer in Europe: challenges and controversies

Biliary tract cancer (BTC) is becoming more common worldwide, with geographic differences in incidence and risk factors. In Europe, BTC may be associated with primary sclerosing cholangitis, lithiasis, and liver cirrhosis, but is more frequently observed as a sporadic disease. BTC increasingly affects patients under 60 years, resulting in a significant social and economic burden. Early diagnosis remains challenging due to vague symptoms in 50% of patients with BTC, and lack of specific biomarkers, resulting in late presentation and poor prognosis. The identification of patients at increased risk and reliable biomarkers require collaborative efforts to make faster progress. This Series paper highlights the disparities in access to diagnostic tools and multidisciplinary care in Europe, particularly in economically disadvantaged regions, while identifying priority areas for improvement. Addressing these inequities requires harmonised guidelines, accelerated pathways to curative treatments, and improved awareness among healthcare professionals and the public. Multidisciplinary teams (MDTs) are crucial for the diagnosis of BTC and for improving patient outcomes, yet inconsistencies exist in their implementation not only between different countries, but also between different centres within a country. Collaboration and standardisation of diagnostic and treatment protocols across Europe are essential to effectively address the management of patients with BTC.

HER2 Pathway in Biliary Tract Cancer: A Snapshot of the Current Understanding and Future Directions

Biliary tract cancers (BTCs) are a wide class of malignancies with dismal prognosis. The therapeutic scenario of metastatic BTCs has profoundly changed during recent years. The combination of cisplatin-gemcitabine plus immunotherapy is currently the gold standard in the first line. The more extensive comprehension of the mechanisms at the basis of BTCs and the identification of several molecular alterations has led to the introduction of target-directed therapies in the second line and beyond that have expanded the therapeutic armamentarium alongside the standard FOLFOX regimen, and for the near future, the results of some trials with targeted therapies in first line are expected. HER2 represents a promising therapeutic target detected in BTCs, being overexpressed in approximately 15-20% of cases, with a strong predilection for gallbladder carcinoma and extrahepatic cholangiocarcinoma, although a small proportion of HER2 overexpression can be detected even in intrahepatic cholangiocarcinoma. The efficacy and safety of different HER2 inhibitors have been investigated in several studies in the second line and beyond with encouraging results. This comprehensive review is intended to provide a summary of existing evidence and future perspectives on HER2 altered BTCs.

Propensity score analysis of adjuvant therapy in radically resected gallbladder cancers: A real world experience from a regional cancer center

Backgrounds/Aims

Given the high mortality associated with gallbladder cancer (GBC), the efficacy of adjuvant therapy (AT) remains controversial. We audited our data over an 11-year period to assess the impact of AT.

Methods

This study included all patients who underwent curative resection for GBC from 2007 to 2017. Analyses were conducted of clinicopathological characteristics, surgical details, and postoperative therapeutic records. The benefits of adjuvant chemotherapy (CT) or chemoradiotherapy (CTRT) were evaluated against surgery alone using SPSS version 20 for statistical analysis.

Results

The median age of patients (n = 142) was 50 years. The median overall survival (OS) was 93, 34, and 30 months with CT, CTRT, and surgery alone respectively (p = 0.612). Multivariate analysis indicated that only disease stage and microscopically involved margins significantly impacted OS and disease-free survival (DFS). CT showed increased effectiveness across all prognostic subsets, except for stage 4 and margin-positive resections. Following propensity score matching, median DFS and OS were higher in the CT group than in the CTRT group, although the differences were not statistically significant (p > 0.05).

Conclusions

Radically resected GBC patients appear to benefit more from adjuvant CT, while CTRT should be reserved for cases with high-risk features.

Evaluation of an IDH1/2 Mutation FastTrack Assay for Patients with Cholangiocarcinoma

BACKGROUND

Cholangiocarcinoma, a malignancy originating from the bile ducts, poses significant treatment challenges due to its typically late diagnosis and limited therapeutic options. However, recent advances in molecular genetics enable more personalized treatment approaches. A notable breakthrough in this context is the identification of isocitrate dehydrogenase (IDH) mutations, particularly IDH1 and IDH2, which occur in a subset of cholangiocarcinoma patients. Those with IDH1/2 mutations may benefit from targeted therapies. For instance, Ivosidenib, an IDH1 inhibitor, has shown efficacy in clinical trials, offering a new therapeutic option for patients with IDH1-mutant cholangiocarcinoma. Developing and implementing standardized protocols for testing and reporting mutation status are crucial for consistency and accuracy in clinical practice. Both the Idylla™ IDH1-2 Mutation Assay Kit as a FastTrack method and Next-Generation Sequencing (NGS) panels play critical roles in molecular characterization of cholangiocarcinoma.

METHODS

Under this aspect, a set of cholangiocarcinomas was tested using the Idylla™ platform regarding the respective recommended guidelines and standards of DIN EN ISO:17020 and DIN EN ISO:15198.

RESULTS

Overall, 25 clinically diagnosed intrahepatic cholangiocarcinomas or Adeno-CUPs were analyzed. IDH1/2 mutations were identified in 68% (17/25) of cases using both methods, with high concordance between NGS and Idylla™ results. Discrepancies were observed in two samples, where Idylla™ detected no mutations, but NGS reported IDH1 and IDH2 mutations, respectively.

CONCLUSIONS

IdyllaTM offers a rapid, user-friendly, and specific method for detecting IDH1/2 mutations, ideal for immediate clinical needs. NGS, while more time-consuming and costly, provides comprehensive genetic profiles valuable for personalized medicine and research. The choice between these methods should be guided by the clinical context, resource availability, and individual patient needs. For routine diagnostics, we recommend an algorithmic approach starting with the FastTrack method followed by NGS for wildtype cases.

Open versus laparoscopic oncologic resection for gallbladder cancer after index cholecystectomy: international multicenter comparative study

BACKGROUND

Liver resection and lymphadenectomy is a standard procedure in patients with incidental gallbladder cancer. Data regarding laparoscopic approach in this setting are scarce. The aim of this study was to compare laparoscopic and open approach in this population.

METHODS

This was a multicenter retrospective study including 177 patients. The primary outcome measure was overall survival (OS). The secondary outcomes measures were recurrence-free survival (RFS), lymph node yield, operative time, postoperative complications and length of hospital stay.

RESULTS

Surgery was laparoscopic in 60 (33.9%), including 18 conversions (30.0%). By intention to treat analysis, 3 and 5 year OS were 72.1% and 51.8% after laparoscopic surgery compared to 62.8% and 36.2% after open surgery (p = 0.201). 3- and 5-year RFS were 29.1% and 19.4% after laparoscopic surgery and 28.7% and 19.1% after open surgery (p = 0.697). Severe (grade ≥ 3 ) complications (p = 0.032) and Comprehensive Complication Index (CCI; p = 0.027) were both significantly higher after laparoscopic surgery (p = 0.032), although length of hospital stay was significantly shorter after laparoscopic procedures both on intention-to-treat (median 6 vs. 8 days; p = 0.004) and per protocol analysis (median 6 vs. 8 days; p = 0.004).

CONCLUSIONS

Laparoscopic approach is feasible in patients with gallbladder cancer and may shorten the duration of hospital stay.

SYNOPSIS

This retrospective cohort study suggests that laparoscopic liver resection is feasible in patients with gallbladder cancer and may shorten the duration of hospital stay. Minimally invasive procedures should be performed by surgeons experienced in laparoscopic liver surgery.

Molecular subtypes of intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (iCCA) presents in two clinically distinct subtypes: large duct (LD-iCCA) and small duct (SD-iCCA). These subtypes exhibit significant molecular, genetic, and histopathological differences that impact patient prognosis and treatment responsiveness. This review advocates for a subtype-specific approach to iCCA research and clinical management, including tailored therapeutic strategies that consider distinct genetic profiles and tumor microenvironments. Current therapeutic approaches hold promise, yet efficacy varies by subtype. Additionally, subtype-specific molecular diagnostics, including DNA methylation-based classifiers and transcriptomic sequencing, have shown potential in refining iCCA subclassification, thereby guiding precision medicine efforts. This article outlines existing clinical trials, key research trajectories, and future directions for developing more effective subtype-adapted therapies for iCCA.