EASL-ILCA Clinical Practice Guidelines on the management of intrahepatic cholangiocarcinoma

From PD-1/PD-L1 to tertiary lymphoid structures: Paving the way for precision immunotherapy in cholangiocarcinoma treatment

Cholangiocarcinoma (CCA) is a highly malignant hepatobiliary tumor characterized by limited treatment options and poor prognosis. The recent rise of immunotherapy has significantly influenced research in this field. This study presents a bibliometric analysis of 416 articles retrieved from the WOSCC, Wan fang Data, CNKI and VIP databases, spanning contributions from 32 countries, 589 institutions and 3,200 authors. The analysis identified "PD-L1," "PD-1" and "pembrolizumab" as central research foci, while "immune checkpoint inhibitors," "tumor immune microenvironment," "tertiary lymphoid structures" and "durvalumab" emerged as key areas of interest. These findings emphasize the pivotal role of immunotherapy in improving survival outcomes for CCA, and they highlight the significance of tertiary lymphoid structures within the tumor microenvironment as a promising target for future research. This study offers a strategic overview of the evolving landscape of CCA immunotherapy, providing valuable insights to guide future scientific endeavors in this domain.

Classification of intrahepatic cholangiocarcinoma

Cholangiocarcinoma is a heterogenous malignancy with various classifications based on location, morphological features, histological features, and actionable genetic mutations. Intrahepatic cholangiocarcinoma (ICC), which arises in and proximal to second order bile ducts, is the second most common primary liver malignancy after hepatocellular carcinoma. In this review, we will discuss ICC risk factors, precursor lesions, various growth, anatomic, morphologic, and histologic classifications, rare variants, and differential diagnoses.

Biliary tract cancer

BACKGROUND

Biliary tract cancers comprise a heterogeneous collection of malignancies usually described as cholangiocarcinoma of the intra- or extrahepatic bile duct, including perihilar cholangiocarcinoma and gallbladder cancer.

METHODS

A review of pertinent parts of the ESSO core curriculum for the UEMS diploma targets (Fellowships exam, EBSQ), based on updated and available guidelines for diagnosis, surgical treatment and oncological management of cholangiocarcinoma.

RESULTS

Following the outline from the ESSO core curriculum we present the epidemiology and risk factors for cholangiocarcinoma, as well as the rationale for the current diagnosis, staging, (neo-)adjuvant treatment, surgical management, and short- and long-term outcomes. The available guidelines and consensus reports (i.e. NCCN, BGS and ESMO guidelines) are referred to. Recognition of biliary tract cancers as separate entities of the intrahepatic biliary ducts, the perihilar and distal bile duct as well as the gallbladder is important for proper management, as they each provide distinct clinical, molecular and treatment profiles to consider.

CONCLUSION

Core competencies in knowledge to the diagnosis, management and outcomes of biliary tract cancers are presented.

Cholangiocarcinoma cells direct fatty acids to support membrane synthesis and modulate macrophage phenotype

BACKGROUND AND AIMS

Cholangiocarcinoma (CCA) is a globally rare, increasingly incident cancer. Metabolic reprogramming is common in cancer cells, and altered lipid homeostasis favors tumor development and progression. Previous studies have described lipid deregulation in HCC cells, while in CCA, the lipidome profile is still poorly characterized.

METHODS

We used liquid chromatography-tandem mass spectrometry to examine the lipid level profile of intrahepatic CCA (iCCA) and non-tumor surrounding tissue from patients, as well as in patients' and healthy controls' sera.

RESULTS

All lipid classes were upregulated in tumor specimens and iCCA-derived sera. Newly synthesized fatty acids (FAs) accumulated in iCCA and were only marginally directed to mitochondrial β-oxidation and scarcely folded in lipid droplets as neutral species. Metabolic flux assay showed that FAs were instead redirected toward plasma membrane formation and remodeling, being incorporated into phospholipids and sphingomyelin. A distinct lipid droplet and macrophage distribution was revealed by immunohistochemistry and Imaging Mass Cytometry. Lipid droplets were fewer in iCCA than in normal tissue and present mainly in the intratumoral fibrous septa and in M2 macrophages. Monocytes modified their lipid content and phenotype in the presence of iCCA cells, and the same effect could be recapitulated by FA supplementation.

CONCLUSIONS

Our results reveal a profound alteration in the lipid content of iCCA tissues and demonstrate that FA accumulation prompts iCCA aggressiveness by supporting membrane biogenesis, generating bioactive lipids that boost proliferation, and by modifying macrophage phenotype.

The present and the future of immunotherapy in hepatocellular carcinoma and biliary tract cancers

Hepatobiliary malignancies encompass a spectrum of invasive carcinomas arising in the liver [hepatocellular carcinoma (HCC), bile ducts [intrahepatic cholangiocarcinoma (ICC), and extrahepatic cholangiocarcinoma (EHC)] and the gallbladder. These malignancies represent a growing global health burden, with rising incidence and mortality rates and their overall prognosis remains poor because many patients present with advanced unresectable disease at diagnosis. In recent years, significant advancements in understanding HCC immunogenicity have reshaped the therapeutic scenario of advanced HCC with the immunotherapy revolutionizing the current HCC treatment landscape and patients' prognosis. Moreover, the addition of immunotherapy to chemotherapy has recently established a new standard of care first-line treatment for patients with biliary tract cancers (BTCs) who had historically few therapeutic options. Currently, immunotherapy and immune checkpoint inhibitor (ICI)-based regimens stand as a valuable and practice-changing options in both HCC and BTC management. The mounting recent evidence supporting immunotherapy's survival benefit demands clinicians to stay updated with a rapidly evolving treatment landscape as well as gain knowledge about patient selection, response rate compared with other systemic treatments and immune-mediated adverse events (imAEs) management. A panel of international Experts, comprising hepatologists and oncologists, gathered to explore the challenges in effectively integrating immunotherapy in routine clinical practice. The aim of this review is to present the Experts' insights to inform treatment choice in HCC and BTC with a special emphasis on the role of currently available ICI-based therapies in shifting treatment paradigms and potentially reversing the natural course of these two deadly malignancies.

Progress in the application of fludeoxyglucose positron emission tomography computed tomography in biliary tract cancer

Biliary tract cancer (BTC) is a group of heterogeneous sporadic diseases, including intrahepatic, hilar, and distal cholangiocarcinoma, as well as gallbladder cancer. BTC is characterized by high invasiveness and extremely poor prognosis, with a global increased incidence due to intrahepatic cholangiocarcinoma (ICC). The 18F-fludeoxyglucose positron emission tomography (PET) computed tomography (18F-FDG PET/CT) combines glucose metabolic information (reflecting the glycolytic activity of tumor cells) with anatomical structure to assess tumor metabolic heterogeneity, systemic metastasis, and molecular characteristics noninvasively, overcoming the limitations of traditional imaging in the detection of micrometastases and recurrent lesions. 18F-FDG PET/CT offers critical insights in clinical staging, therapeutic evaluation, and prognostic prediction of BTC. This article reviews research progress in this field over the past decade, with a particular focus on the advances made in the last 3 years, which have not been adequately summarized and recognized. The research paradigm in this field is shifting from qualitative to quantitative studies, and there have been significant breakthroughs in using 18F-FDG PET/CT metabolic information to predict gene expression in ICC. Radiomics and deep learning techniques have been applied to ICC for prognostic prediction and differential diagnosis. Additionally, PET/magnetic resonance imaging is increasingly demonstrating its value in this field.

Prognostic significance of the number of hepatic lesions in multifocal intrahepatic cholangiocarcinoma after radical resection: an IPTW propensity-score analysis

BACKGROUND

Multifocal hepatic lesions represent a distinctive subgroup within intrahepatic cholangiocarcinoma(iCCA), the management of these patients remains controversial. This study aimed to compare the survival of intrahepatic cholangiocarcinoma (iCCA) with different numbers of hepatic lesions and select patients benefiting most from surgery in multifocal iCCA.

METHODS

A cohort of 354 consecutive iCCA patients were included. Based on the number of hepatic lesions, patients were classified as follows: solitary tumors (type I), 2 or 3 hepatic lesions in the same-sided hepatic lobe (type II), and more than three hepatic lesions in the same-sided hepatic lobe (type III). Stabilized inverse probability treatment weighting (IPTW) was conducted for accurate prognosis comparisons. Furthermore, the long-term prognosis was compared between different American Joint Committee on Cancer.

RESULTS

Among all patients, multifocal iCCA presented significantly worse overall survival (OS) and recurrence-free survival (RFS) than solitary tumor (p < 0.001 and p < 0.001), 11.9% (n = 42), and 14.4% (n = 51) patients were classified into type II, and type III, respectively. After IPTW, type II exhibited similar while type III exhibited worse RFS and OS to type I cohort (solitary tumors) (p < 0.001and p < 0.001). Multivariable Cox analysis also identified type III tumors as an independent risk factor for OS (HR 1.95, 95% CI:1.33-2.87, p < 0.001). Among AJCC stage II (T2N0M0) patients, multifocal iCCA presented significantly worse OS than solitary tumors (vascular invasion) (p = 0.018), and type II exhibited similar while type III exhibited worse OS than solitary tumors (p = 0.500 and p = 0.040). Compared with stage III patients, type II exhibited better while type III exhibited similar OS (p < 0.001 and p = 0.300).

CONCLUSIONS

Multifocal iCCA presented a significantly worse prognosis, the number of hepatic lesions significantly influenced the prognosis of multifocal iCCA. Patients with type II tumors may derive comparable oncological benefits from surgery compared with solitary tumors, radical surgery still be strongly recommended as the preferred treatment.

Deep Learning to Enhance Diagnosis and Management of Intrahepatic Cholangiocarcinoma

Intrahepatic cholangiocarcinoma (iCCA) is associated with a poor prognosis and necessitates a multimodal, multidisciplinary approach from diagnosis to treatment to achieve optimal outcomes. A noninvasive preoperative diagnosis using abdominal imaging techniques can represent a clinical challenge. Given the differential response of iCCA to localized and systemic therapies compared with hepatocellular carcinoma and secondary hepatic malignancies, an accurate diagnosis is crucial. Deep learning (DL) models for image analysis have emerged as a promising adjunct for the abdominal radiologist, potentially enhancing the accurate detection and diagnosis of iCCA. Over the last five years, several reports have proposed robust DL models, which demonstrate a diagnostic accuracy that is either comparable to or surpasses that of radiologists with varying levels of experience. Recent studies have expanded DL applications into other aspects of iCCA management, including histopathologic diagnosis, the prediction of histopathological features, the preoperative prediction of survival, and the pretreatment prediction of responses to systemic therapy. We herein critically evaluate the expanding body of research on DL applications in the diagnosis and management of iCCA, providing insights into the current progress and future research directions. We comprehensively synthesize the performance and limitations of DL models in iCCA research, identifying key challenges that serve as a translational reference for clinicians.

EASL Clinical Practice Guidelines on extrahepatic abdominal surgery in patients with cirrhosis and advanced chronic liver disease

Extrahepatic surgery in patients with cirrhosis of the liver represents a growing clinical challenge due to the increasing prevalence of chronic liver disease and improved long-term survival of these patients. The presence of cirrhosis significantly increases the risk of perioperative morbidity and mortality following abdominal surgery. Advances in preoperative risk stratification, surgical techniques, and perioperative care have led to better outcomes, yet integration of these improvements into routine clinical practice is needed. These clinical practice guidelines provide comprehensive recommendations for the assessment and perioperative management of patients with cirrhosis undergoing extrahepatic surgery. An individualised patient-centred risk assessment by a multidisciplinary team including hepatologists, surgeons, anaesthesiologists, and other support teams is essential.

Liver transplantation as a treatment for cancer: comprehensive review

BACKGROUND

Liver transplantation for cancer indications has gained momentum in recent years. This review is intended to optimize the care setting of liver transplant candidates by highlighting current indications, technical aspects and barriers with available solutions to facilitate the guidance of available strategies for healthcare professionals in specialized centres.

METHODS

A review of the most recent relevant literature was conducted for all the cancer indications of liver transplantation including colorectal cancer liver metastases, hilar cholangiocarcinoma, intrahepatic cholangiocarcinoma, neuroendocrine tumours, hepatocellular carcinoma and hepatic epitheloid haemangioendothelioma.

RESULTS

Transplant benefit from the best available evidence, including SECA I, SECA II, TRANSMET studies for colorectal liver metastases, various preoperative protocols for cholangiocarcinoma patients, standard, extended selection criteria for hepatocellular carcinoma and neuroendocrine tumours, are discussed. Innovative approaches to deal with organ shortages, including machine-perfused deceased grafts, living donor liver transplantation and RAPID procedures, are also explored.

CONCLUSION

Cancer indications for liver transplantation are here to stay, and the selection criteria among all cancer groups are likely to evolve further with improved prognostication of tumour biology using adjuncts such as radiomics, cancer genomics, and circulating DNA and RNA status. International prospective registry-based studies could overcome the limitations of smaller patient cohorts and lack of level 1 evidence.

External validation of plasma CSF1 as a preoperative prognostic marker in patients with resectable intrahepatic cholangiocarcinoma

INTRODUCTION

Long-term prognosis after resection for intrahepatic cholangiocarcinoma (iCCA) remains poor and the preoperative oncological risk assessment is difficult. Two immune system-related plasma proteins, colony stimulating factor 1 (CSF1) and TNF-related apoptosis-inducing ligand (TRAIL), were previously indicated as prognostic factors in iCCA. This study aimed to externally validate CSF1 and TRAIL as preoperative prognostic markers for patients with resectable iCCA.

MATERIALS AND METHODS

Preoperative plasma CSF1 and TRAIL concentrations (pg/mL) were determined from prospectively collected biobank samples by multiplex immunoanalysis, for patients with resectable iCCA operated at two tertiary referral centers. Primary outcome was overall survival (OS), analyzed by Kaplan-Meier method and Cox regression. Secondary outcome was disease-free survival (DFS). Discrimination was evaluated with concordance indices (C-index) and prognostic performance assessed with calibration curves.

RESULTS

Sixty-one patients with resection for iCCA were included. CSF1 was associated with both OS (hazard ratio [HR] 1.03, 95 % confidence interval [CI] 1.01-1.05) and DFS (HR 1.02, 95 % CI 1.00-1.04). Median OS was eight months for patients with CSF1 levels in the upper quartile (≥158 pg/mL), compared to the overall median OS of 47 months. While TRAIL was not significantly associated with OS (P = 0.216), levels in the lower quartile (≤256 pg/mL) were associated with short DFS (P = 0.004). The C-index of CSF1 for OS was 0.70, with excellent calibration for three- and five-year OS.

CONCLUSIONS

Preoperative plasma CSF1 was validated as a novel, well-calibrated predictor of poor survival in resectable iCCA, which could assist the preoperative risk assessment. Low plasma TRAIL was associated with early recurrence.

Single-Cell Transcriptomic Analysis Reveals an Aggressive Basal-Like Tumor Cell Subpopulation Associated With Poor Prognosis in Intrahepatic Cholangiocarcinoma

BACKGROUND AND AIM

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver cancer whose incidence is increasing globally. However, the high tumor heterogeneity of ICC restricts the efficacy of available systematic therapies. We aim to dissect the tumor heterogeneity of ICC utilizing high-resolution single-cell RNA sequencing to identify novel therapeutic targets.

METHODS

We performed single-cell RNA sequencing (scRNA-seq) of 26 tumor samples from 23 ICC patients and spatial transcriptomic sequencing of six tumor sections from six ICC patients. Bulk RNA-seq data from two public datasets were used for validation. Additionally, immunohistochemical staining and multiplex immunofluorescence staining were conducted to validate the infiltration and distribution of cells in the tumor microenvironment.

RESULTS

We discovered that malignant cells in ICC samples exhibited a remarkably high degree of tumor heterogeneity. We identified a basal-like tumor cell subpopulation characterized by the expression of basal epithelial related genes including KRT5, KRT6A, and KRT17. The basal-like tumor subpopulation was characterized by activation of MET signaling and extracellular matrix organization associated with tumor invasion and correlated with poor prognosis. Cell-cell communication analysis further showed significant HGF-MET interaction between inflammatory cancer-associated fibroblasts (iCAFs) and basal-like tumor cells. We found that iCAFs were the major source of HGF in tumor environment and contributed to the basal-like phenotype formation of tumor cells by HGF-MET axis.

CONCLUSIONS

We identified an aggressive basal-like tumor cell subpopulation, which correlated with poor prognosis in ICC. The MET pathway contributes to the aggressiveness of basal-like tumor cells and serves as a novel therapeutic target for ICC.

EASL Clinical Practice Guidelines on the management of extrahepatic cholangiocarcinoma

Recent years have witnessed significant advances in the imaging, molecular profiling, and systemic treatment of cholangiocarcinoma (CCA). Despite this progress, the early detection, precise classification, and effective management of CCA remain challenging. Owing to recent developments and the significant differences in CCA subtypes, EASL commissioned a panel of experts to draft evidence-based recommendations on the management of extrahepatic CCA, comprising distal and perihilar CCA. Particular attention is given to the need for accurate classification systems, the integration of emerging molecular insights, and practical strategies for diagnosis and treatment that reflect real-world clinical scenarios.

Use of sintilimab in primary adenosquamous carcinoma of the liver results in pathological complete response: a case report and literature review

Adenosquamous cell carcinoma (ASC) is a rare and aggressive malignant tumor which consists of both adenocarcinoma (AC) and squamous cell carcinoma (SCC) component types. Although ASC can sometimes develop in the stomach, pancreas, gallbladder and thyroid, it rarely occurs in the liver. As such, primary ASC of the liver remains a poorly understood malignancy due to both the paucity of reported cases and scarcity of available published data. As such, while the use of immune checkpoint inhibitors (ICIs), including PD-1 and PD-L1 antagonists, has profoundly changed the treatment paradigm and outcomes in most tumors, there is virtually no previous documentation for the application of ICIs in the treatment of primary hepatic adenosquamous carcinoma. Herein, we report a clinical case of a 54-year-old woman with metachronous double primary tumors, one of which was dMMR ASC of the liver and received 8 cycles of single-agent immunotherapy using sintilimab. The post-treatment response was evaluated as a pathological complete response (pCR).

ESGAR consensus statement on MR imaging in primary sclerosing cholangitis

OBJECTIVES

To provide a consensus statement and recommendations on MR imaging in primary sclerosing cholangitis (PSC).

METHODS

The European Society of Gastrointestinal and Abdominal Radiology (ESGAR) convened a multinational European panel of experts selected based on a literature review and their leadership in the field. A modified Delphi process was adopted to draft a list of statements. For each statement, the panelists indicated the level of agreement using a 5-point Likert scale, where 1 means "no agreement," 2 means "poor agreement," 3 means "slight agreement," 4 means "fair agreement," and 5 means "complete agreement." The median score for each statement was collected. The level of evidence was reported according to the Oxford Centre for Evidence-Based Medicine. Descriptive statistics were used to rate agreement levels and the consensus' internal reliability.

RESULTS

The 12 voting committee members were from Italy (n = 4, 33.4%), Austria (n = 2, 16.7%), Sweden (n = 1, 8.3%), France (n = 1, 8.3%), the United States (n = 1, 8.3%), Switzerland (n = 1, 8.3%), and Belgium (n = 2, 16.7%). The final questionnaire consisted of 55 statements. The agreement reached by the expert panel was complete for 23 statements (41.8%), fair for 16 (29.1%), slight for 15 (27.2%), and poor for 1 (1.9%). Statements that received complete agreement were used to structure a reporting template.

CONCLUSIONS

This statement paper recommends how and when to perform MRI in PSC patients. A structured reporting template has been created to improve quality care and communication among radiologists and clinicians.

KEY POINTS

Question A standard MR protocol and the most common imaging features to be reported are fundamental for the correct evaluation of primary sclerosing cholangitis (PSC) patients. Findings Twelve expert radiologists reported which are the most important imaging features and how and when to perform MR in PSC patients. Clinical relevance The identified statements reported in this paper and the structured reporting template are useful for radiologists and clinicians to help correctly manage PSC patients.

Extended Left Hepatectomy with Inferior Vena Cava Replacement and Right Hepatic Vein Re-implantation Under In Situ Cooling and Venous Bypass for Advanced Intrahepatic Cholangiocarcinoma: H123458-RHV-IVC

BACKGROUND

Resection of intrahepatic cholangiocarcinoma (iCCA) with invasion of major venous structures is controversial because of its significant morbidity and mortality and questionable oncological value.1,2 We report on a case of long-term survival after extreme liver surgery in a patient with advanced iCCA.3 METHODS: A 51-year-old woman was referred for locally advanced, biopsy-proven iCCA. Imaging showed an 8 cm mass involving the inferior vena cava (IVC) and hepatic veins confluence with no evidence of extrahepatic disease. The procedure included an extended left hepatectomy with IVC and right hepatic vein (RHV) resection and reconstruction. The measured future liver remnant was 884 mL.

RESULTS

The procedure began with liver mobilization, hilar dissection, and lymphadectomy. Total vascular exclusion (TVE) was required and an elective venous bypass was created using the femoral and inferior mesenteric veins to the axillary vein. TVE was placed, and liver cooling was performed using 3 L of IGL solution delivered through the left portal vein stump, vented by an opening in the IVC. An extended left hepatectomy with en bloc resection of the retrohepatic IVC and main hepatic veins was performed. At the end of the transection, tumor contact was confirmed at the distal end of the RHV, resulting in an R1 vascular resection. A posterior patch of the RHV, including three constitutive branches, was kept for reconstruction. The IVC was replaced with a 16 Fr polytetrafluoroethylene (PTFE) graft, and an RHV patch was re-implanted on the side of the PTFE graft. The duration of both the surgery and the venous bypass was 560 and 130 min, respectively. The patient developed transient postoperative hepatic failure and was discharged on day 18. The pathology results indicated pT3N0 stage with a focal R1 margin, as seen during surgery. The patient declined adjuvant treatment. Eight years after surgery, the patient is alive and disease-free, with excellent quality of life.

CONCLUSIONS

Extreme surgical approaches can allow for long-term survival and possible cure in selected patients with advanced iCCA. Focal R1 resection may occur in such instances and should be considered on a case-by-case decision.

Defining advanced lymph node metastasis in intrahepatic cholangiocarcinoma: A multicenter study

BACKGROUND

There is no specific boundary for stratifying survival outcomes in patients with node-positive intrahepatic cholangiocarcinoma (ICC). This study aimed to propose advanced nodal status in ICC.

METHODS

Data from patients with pathologically confirmed node-positive ICC who underwent liver resection (LR) with lymph node dissection (LND) from 2000 to 2020 at three tertiary centers were retrospectively analyzed. The boundaries of regions and the yield that stratified overall survival (OS) were evaluated. The lymph node (LN) regions were defined as follows: hepatoduodenal ligament, common hepatic artery, and peripancreatic area (HCP-area), gastrohepatic area (GH-area), and para-aortic area (A-area).

RESULTS

Eighty-four patients with node-positive ICC were enrolled in this study. The median numbers of retrieved LNs and involved LNs (ILNs) were 15 (range: 2-56) and 2 (range: 1-20), respectively. Most patients (96.5%) had ILNs in the HCP-area, whereas only 3 patients (3.5%) had ILNs in other areas without HCP-area involvement. OS of patients with LN metastasis confined to the HCP-area was better than for those beyond this area (median OS: 24.3 vs. 13.3 months, p = 0.047). The best cut-off number of ILNs to stratify OS was 4, and patients with 1-3 ILNs showed better OS than those with ≥ 4 ILNs (25.4 vs. 13.8 months, p = 0.006). Combining distribution and yield showed the best prognostic power compared to using either distribution or yield alone.

CONCLUSION

In patients with node-positive ICC, LN metastasis beyond the HCP-area or ≥ 4 ILNs can be proposed as advanced N disease.

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.

Mutant KRAS and CK2 Cooperatively Stimulate SLC16A3 Activity to Drive Intrahepatic Cholangiocarcinoma Progression

Intrahepatic cholangiocarcinoma (iCCA) is a lethal malignancy affecting the liver and biliary system. Enhanced understanding of the pathogenic mechanisms underlying iCCA tumorigenesis and the discovery of appropriate therapeutic targets are imperative to improve patient outcomes. In this study, we investigated the functions and regulations of solute carrier family 16 member 3 (SLC16A3), which has been reported to be a biomarker of poor prognosis in iCCA. High SLC16A3 expression was enriched in KRAS viral oncogene homolog-mutated iCCA tumors, and mutant KRAS elevated SLC16A3 expression via the PI3K-AKT-mTORC1-HIF1α pathway. SLC16A3 not only enhanced glycolysis but also induced epigenetic reprogramming to regulate iCCA progression. Phosphorylation of SLC16A3 at S436 was vital for its oncogenic function and was linked to iCCA progression. Casein kinase 2 (CK2) directly phosphorylated SLC16A3 at S436, and CK2 inhibition with CX-4945 (silmitasertib) reduced the growth of KRAS-mutated iCCA tumor xenografts and patient-derived organoids. Together, this study provides valuable insights into the diverse functions of SLC16A3 in iCCA and comprehensively elucidates the upstream regulatory mechanisms, providing potential therapeutic strategies for patients with iCCA with KRAS mutations. Significance: Characterization of the oncogenic function and regulators of SLC16A3 in intrahepatic cholangiocarcinogenesis revealed the potential of CK2 inhibitors as a promising treatment for KRAS-mutated tumors.

Radiation Segmentectomy and Modified Radiation Lobectomy for Unresectable Early-Stage Intrahepatic Cholangiocarcinoma

PURPOSE

To validate the safety and effectiveness of radiation segmentectomy (RS) and modified radiation lobectomy (mRL) in intrahepatic cholangiocarcinoma (iCCA) and to evaluate long-term outcomes in patients with unresectable, early-stage iCCA.

MATERIALS AND METHODS

A single-institution, retrospective study of patients with unresectable, solitary iCCA without extrahepatic disease or vascular involvement (Stage I) treated with RS and mRL was performed. Fifteen patients met inclusion criteria (median age, 65.5 years), including 11 (73%) with T1a disease and 4 (27%) with T1b disease. Outcomes included biochemical and clinical toxicities, tumor response by Response Evaluation Criteria in Solid Tumors (RECIST), time to progression, and overall survival (OS).

RESULTS

Median treatment dose was 308.2 Gy (range, 194.2-879.3 Gy). There were no cases of periprocedural mortality or hepatic deterioration. Grade 3+ clinical toxicities occurred in 1 patient (7%). The 3-month and best objective response rates by RECIST were 47% and 60%, respectively. Three patients went on to surgery with explant pathology revealing complete pathologic necrosis. Target lesion progression occurred in 4 patients at a median of 43.4 months. Median OS was 72 months. The 1-, 3-, and 5-year OS rates were 100%, 73.3%, and 50.3%, respectively.

CONCLUSIONS

RS and mRL were safe and effective in treating unresectable, early-stage iCCA. Overall progression of 47% and 5-year OS of 50% were comparable with those of surgical resection. RS and mRL may represent viable therapeutic options for patients with early-stage disease deemed surgically unresectable.

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.

Tumour burden predicts outcomes after curative resection of multifocal intrahepatic cholangiocarcinoma

BACKGROUND

Liver resection for multifocal intrahepatic cholangiocarcinoma (ICC) remains controversial due to a poor prognosis, driven by aggressive tumour biology. The aim of this study was to stratify multifocal ICC patients to identify those who are likely to benefit from resection.

METHODS

Patients who underwent upfront curative-intent hepatectomy for ICC were identified from an international multi-institutional database. Among patients with multifocal tumours, overall survival (OS) was analysed using multivariable Cox regression to identify prognostic factors. Tumour burden score (TBS) was used for stratification of multifocal ICC, with the optimal cut-off determined via restricted cubic spline (RCS) analysis.

RESULTS

Of 1502 patients, 208 (13.8%) had multifocal ICC. Among them, independent predictors of prognosis included TBS (HR 1.09), ASA grade >II (HR 1.48), cirrhosis (HR 2.05), periductal infiltrating/mass forming plus periductal infiltrating morphological subtype (HR 1.58), and receipt of adjuvant chemotherapy (HR 0.59). RCS analysis identified a TBS of 7.0 as the optimal cut-off. Notably, multifocal ICC patients with a low TBS (<7.0) demonstrated comparable 3-year OS to solitary ICC patients with AJCC stage II/III. In contrast, patients with a high TBS (≥7.0) and multifocal ICC exhibited the worst prognosis (3-year OS: stage I and solitary 67.1%, stage II/III and solitary 43.2%, low TBS and multifocal 43.4%, and high TBS and multifocal 17.8% (P < 0.001)).

CONCLUSION

Whereas patients with high-TBS multifocal ICC had a poor prognosis, individuals with low-TBS multifocal ICC demonstrated survival outcomes comparable to solitary ICC patients. These findings emphasize the importance of stratifying patients by tumour burden to guide surgical decision-making and optimize treatment strategies for multifocal ICC.

Conversion therapy combined with ALPPS for the treatment of intrahepatic cholangiocarcinoma: a case report

Rationale

Intrahepatic cholangiocarcinoma (ICC) is a highly malignant liver tumor with limited treatment options for advanced cases. Conversion therapy combining immunotherapy, targeted therapy, and chemotherapy offers a promising approach to enable surgical resection, which remains the only curative option.

Patient concerns

A 67-year-old male presented with right upper abdominal pain for two months. Imaging and biopsy confirmed advanced ICC (Stage IV), with a 98 mm tumor, lymphadenopathy, and elevated tumor markers (CA199: 1190.4 U/ml). The disease was deemed unresectable.

Diagnosis

The patient was diagnosed with advanced ICC involving a large hepatic mass, lymph node metastasis, and insufficient liver reserve for conventional resection.

Interventions

The patient received six months of oxaliplatin plus gemcitabine (GEMOX), lenvatinib, and toripalimab, achieving significant tumor regression. A two-step ALPPS procedure was then performed, comprising portal vein ligation and right hepatectomy.

Outcomes

The treatment reduced tumor size (98 mm to 60 mm), normalized tumor markers, and improved liver reserve. Postoperative pathology confirmed >80% tumor remission with negative margins. At 12 months post-surgery, the patient remained disease-free.

Lessons

This case demonstrates that advanced ICC can be downstaged with systemic therapy, enabling resection via ALPPS. The combination of GEMOX, lenvatinib, and toripalimab is an effective and safe conversion therapy regimen. This approach may serve as a model for managing similar advanced cases.

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.

Outcomes and Role of Lymphadenectomy in Hypervascular Intrahepatic Cholangiocarcinoma Based on CT-Vascularity

BACKGROUND

This study aimed to evaluate the outcomes and role of lymphadenectomy in hypervascular intrahepatic cholangiocarcinoma (ICC) quantified using the arterial phase of contrast-enhanced computed tomography (CT).

METHODS

Consecutive patients with mass-forming (MF) or predominantly MF type ICC who underwent surgical resection from 2000 to 2019 were retrospectively analyzed. Using the image of the late arterial phase, CT-vascularity was calculated by dividing the CT value of the tumor (Hounsfield units) with that of the liver parenchyma. According to the CT-vascularity, patients were divided into hypervascular (CT-vascularity > 1) and non-hypervascular (CT-vascularity ≤ 1) groups. Clinicopathologic features and survival outcomes were compared between the two groups. Further, the prognostic impact of lymphadenectomy was assessed in the hypervascular group.

RESULTS

Of the 135 patients with MF-ICC, the hypervascular group, and non-hypervascular group comprised 47 (34.8%) and 88 patients (65.2%), respectively. The hypervascular group displayed clinical features typically associated with hepatocellular carcinoma (HCC) (i.e., viral hepatitis or history of HCC) and less aggressive tumor characteristics such as lower proportions of regional lymph node metastasis. The overall survival (OS) and recurrence-free survival (RFS) of the hypervascular group were significantly better than those of the non-hypervascular group (all, p < 0.001), and these results were retained after adjusting for known prognostic factors. Further, implementation of lymphadenectomy was not associated with benefit for OS and RFS in the hypervascular group (p = 0.819, p = 0.912).

CONCLUSION

Hypervascular ICC itself represents a favorable prognosis, and there is a possibility of omitting lymphadenectomy in this subgroup.

Survival Outcomes of Radiofrequency Ablation for Intrahepatic Cholangiocarcinoma from the Surveillance, Epidemiology, and End Results (SEER) Database: Comparison with Radiotherapy and Resection

PURPOSE

To determine effectiveness of radiofrequency ablation for treatment of intrahepatic cholangiocarcinoma (iCCA) using a population-based database.

MATERIALS AND METHODS

Data were extracted from Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2020 to include 194 patients who underwent ablation for iCCA. Data on patient demographics, overall survival (OS), and cancer-specific survival were retrieved. Factors associated with survival were evaluated. Comparison between ablation and surgical resection (n = 2,653) or external beam radiotherapy (n = 1,068) was performed.

RESULTS

In the ablation group, patients diagnosed and treated after 2010 demonstrated improved OS than that in the 2000-2009 subgroup (median OS, 32 vs 21 months; hazard ratio, 0.50; 95% CI, 0.33-0.75; P = .001). Additional factors associated with OS included tumor size (≤3 cm vs >3 cm; P = .049) and tumor stage (P < .001). For patients diagnosed after 2010, the 1-, 3-, and 5-year OS were 82.8% (95% CI, 74.8%-88.4%), 43.5% (95% CI, 33.5%-53.1%), and 23.7% (95% CI, 15.3%-33.5%), respectively. Patients with local disease (1-year OS, 87.8%; 95% CI, 78.6%-93.3%) demonstrated improved OS compared with patients with regional (1-year OS, 81.3%; 95% CI, 52.5%-93.5%) and distant disease (50.2%; 95% CI, 34.0%-78.8%; P < .001). For tumors ≤3 cm, ablation and surgical resection offered comparable survival benefits (P = .561), although both were better than radiotherapy (P < .0001).

CONCLUSIONS

Survival of patients with iCCA who underwent thermal ablation has improved over the last 10 years. For tumors ≤3 cm, ablation could be as effective as resection with careful candidate selection, and may be considered front-line compared with radiotherapy in certain patient populations. Patient selection based on tumor size and disease stage could improve survival outcomes.

Care Patterns and Outcomes for Intrahepatic Cholangiocarcinoma by Rurality of Patient Residence in a Midwestern State

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is the second most common malignancy of the liver and has the worst prognosis of any tumor arising from the liver, with a 5-year survival as low as 10%. However, whether the rurality of a patient's residence impacts care received and survival has not been well studied. We aimed to assess differences in care patterns associated with the rurality of patient's residences and their impact on survival outcomes, hypothesizing that patients in rural areas would experience lower survival.

METHODS

Adult patients diagnosed with ICC between 2010 and 2020 were identified in the Iowa Cancer Registry. Chi-square tests were used to compare values categorical variables by rural/urban status. Cox proportional hazards regression was used to determine associations with cancer-specific mortality.

RESULTS

Of 672 patients diagnosed with ICC during the study period, 53%, 27%, and 21% resided in metropolitan, micropolitan, and rural areas, respectively. There were no significant differences in age, sex, stage at diagnosis, the proportion receiving chemotherapy within 12 weeks of diagnosis, and undergoing surgery across all groups. Additionally, the proportion receiving definitive care at a National Cancer Institute (NCI) designated center was comparable across the three groups (37% metro vs. 43% micro vs. 35% rural). However, rural residents had the highest proportion of traveling ≥ 50 miles for definitive care (22% metro vs. 41% micro vs. 56% rural). In multivariable analysis of patients with Stage 1-3 disease, younger age, receipt of chemotherapy, surgery, and definitive care at an NCI center were independently associated with decreased mortality risk. However, rural residence was not significantly associated with survival (HR: 0.64 [95% CI: 0.38-1.06]).

CONCLUSION

Similar to other complex cancer diagnoses, we found that definitive care at an NCI center was associated with decreased mortality risk for patients with ICC. Although rural residence was not independently associated with survival in this cohort, rural residents traveled significantly longer distances to access definitive care. This highlights a crucial need to improve access to specialized centers for complex cancer care.

Morphomolecular Pathology and Genomic Insights into the Cells of Origin of Cholangiocarcinoma and Combined Hepatocellular-Cholangiocarcinoma

Cholangiocarcinomas are a highly heterogeneous group of malignancies that, despite recent progress in the understanding of their molecular pathogenesis and clinical management, continue to pose a major challenge to public health. The traditional view posits that cholangiocarcinomas derive from the neoplastic transformation of cholangiocytes lining the biliary tree. However, increasing genetic and experimental evidence has recently pointed to a more complex, and nuanced, scenario for the potential cell of origin of cholangiocarcinomas. Hepatocytes as well as hepatic stem/progenitor cells are being considered as additional potential sources, depending on microenvironmental contexts, including liver injury. The hypothesis of potentially diverse cells of origin for cholangiocarcinoma, albeit controversial, is certainly not surprising given the plasticity of the cells populating the liver as well as the existence of liver cancer subtypes with mixed histologic and molecular features. This review carefully examines the current pathologic, genomic, and experimental evidence supporting the existence of multiple cells of origin of liver and biliary tract cancers, with particular focus on cholangiocarcinoma and combined hepatocellular-cholangiocarcinoma.

Neoadjuvant pemigatinib as a bridge to living donor liver transplantation for intrahepatic cholangiocarcinoma with FGFR2 gene rearrangement

We report a case of a 55-year-old male with intrahepatic cholangiocarcinoma (iCCA) who underwent living donor liver transplantation (LDLT) after complete radiographic response on second-line pemigatinib. LDLT for iCCA is controversial, but recent reports have cited the potential benefit for patients with unresectable disease, especially those with disease stability after 6 months of systemic therapy. Concomitantly, genomic profiling has identified potentially treatable oncologic targets in iCCA. This patient's tumor genomic profile revealed an FGFR2 rearrangement and was treated with pemigatinib, a competitive inhibitor for fibroblast growth factor receptors 1, 2, and 3. This resulted in a complete radiographic and metabolic response after 2 months of treatment. He was considered eligible for LDLT after 6 months of observation on treatment with a sustained response. He underwent an uncomplicated LDLT (including an uncomplicated donor surgery) and at a 1-year follow-up is without evidence of disease recurrence. We believe this is the first report of LDLT for this indication.

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.

Effectiveness and safety of transarterial chemoembolization combined with PD-1 inhibitors and lenvatinib for unresectable intrahepatic cholangiocarcinoma

BACKGROUND

The objective of this study was to evaluate the therapeutic effectiveness and safety of transarterial chemoembolization (TACE) combined with programmed cell death-1 (PD-1) inhibitors and lenvatinib in the treatment of unresectable intrahepatic cholangiocarcinoma (uICC).

METHODS

This multicenter retrospective study screened patients with uICC who underwent TACE in combination with PD-1 inhibitors and lenvatinib between January 2019 and June 2023. Tislelizumab or camrelizumab (200 mg) was intravenously administered every three weeks. The daily dose of lenvatinib was 8 mg for patients weighing < 60 kg and 12 mg for those weighing ≥ 60 kg. In cases of disease progression, the therapeutic strategy was adjusted based on the clinical condition and individual patient's treatment preferences. Options included transitioning to standard or supportive care or continuing treatment with TACE in combination with PD-1 inhibitors and lenvatinib. The primary outcomes were overall survival (OS) and progression-free survival (PFS), while secondary outcomes included the objective response rate (ORR), disease control rate (DCR), and the incidence of adverse events (AEs).

RESULTS

A total of 59 patients with uICC were included. Over a median follow-up period of 32.3 months, the median OS and PFS were 25.8 months (95% confidence interval [CI]: 17.9-33.7) and 9.5 months (95% CI: 7.9-11.0), respectively. The ORR was 55.9%, and the DCR was 96.6%. Grade 3 or four AEs were observed in 15 of 59 patients (25.4%).

CONCLUSION

TACE combined with PD-1 inhibitors and lenvatinib demonstrated a promising therapeutic potential with a manageable safety profile for patients with uICC.

RELEVANCE STATEMENT

The combination of TACE, PD-1 inhibitors, and lenvatinib represents a novel therapeutic option for patients with uICC.

KEY POINTS

TACE plus PD-1 inhibitors and lenvatinib represent a promising therapeutic strategy for uICC. The safety profile of TACE plus PD-1 inhibitors and lenvatinib was manageable. This study demonstrated improved outcomes compared to prior standard-of-care treatments.

Efficacy and safety of immune checkpoint inhibitors in patients with advanced intrahepatic cholangiocarcinoma

Background

To assess the efficacy and safety of PD-1 and PD-L1 immune checkpoint inhibitors (ICIs) in managing advanced intrahepatic cholangiocarcinoma (ICC).

Methods

A retrospective analysis of treatment data for patients with advanced ICC who received ICIs at the Second Affiliated Hospital of Chongqing Medical University from the inception of the inpatient medical record database until 30 April 2024. The analysis concentrated on the safety and efficacy of the treatment. The primary endpoint was progression-free survival (PFS), while the secondary endpoints included overall survival (OS) and safety. The Kaplan-Meier method was employed to plot survival curves, and differences between groups were assessed using log-rank tests.

Results

96 patients diagnosed with ICC were included, comprising 60 males (62.50%) and 36 females (37.50%). 85 patients exhibited disease progression, 22 patients succumbed, and 38 patients were lost to follow-up finally. Those who initiated immunotherapy promptly following first-line antitumor treatment exhibited a notably prolonged PFS compared to those experiencing tumor progression (5.63 months (95%CI: 3.12~8.14) vs 2.50 months (95%CI: 1.83~3.17), P=0.002). However, no significant disparity in the PFS with immunotherapy in different lines therapy(P=0.406) and the OS was observed between the two groups(P=0.360). 18 patients (18.75%) experienced treatment-emergent adverse events (AEs), with 3 patients encountering AEs of grade ≥3. All patients returned to normal after symptomatic treatment.

Conclusions

In patients with advanced ICC, the timely initiation of ICIs as adjuvant therapy following first-line antitumor treatment can result in favorable efficacy and a good safety profile.

The efficacy of adjuvant chemotherapy for curative resected biliary tract cancers: a systematic review and network meta-analysis of randomized clinical trials

BACKGROUND

Despite complete resection, the recurrence rate of biliary tract cancer (BTC) remains high, leading to poor prognosis. Postoperative adjuvant chemotherapy (ACT) following radical resection may substantially reduce the recurrence risk by eradicating micrometastatic lesions. However, the benefits of postoperative ACT and the optimal ACT strategy are still unclear for BTC. The objectives of this study are to evaluate the prognostic value of ACT and compare the effectiveness of different ACTs among BTC patients after curative resection.

METHODS

A comprehensive literature search was conducted across PubMed, Cochrane Library, Web of Science, and EMBASE databases to identify randomized controlled trials (RCTs) comparing the benefits of ACT versus no intervention or other ACTs in BTC patients after curative resection. A random-effects network meta-analysis was performed to compare overall survival (OS) and relapse-free survival (RFS). The quality of evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation framework.

RESULTS

Eight RCTs comprising 1803 patients were included in the meta-analysis. ACT was associated with significant improvements in 5-year all-cause mortality [four RCTs, hazard rate (HR) 0.93; 95% confidence interval (CI), 0.87-1.00, marginally significant; low-certainty evidence], RFS (five RCTs, HR 0.87; 95% CI, 0.78-0.98; moderate-certainty evidence), and OS (7 studies, HR 0.85; 95% CI, 0.75-0.96; low-certainty evidence) compared with observation. ACT had significantly better survival benefits on patients with negative margins (R0), lymph node-positive (N+), and tumor node metastasis classification (TNM) stage I/II ( P < 0.05). Further network meta-analysis demonstrated that fluorouracil-based ACT was significantly inferior to gemcitabine-based ACT (HR 1.20; 95% CI, 1.10-1.25) in improving RFS. However, both were superior to observation ( P < 0.05). No statistical difference in OS was observed between gemcitabine-based and fluorouracil-based chemotherapy (HR 1.00; 95% CI, 0.86-1.20). In subgroup analysis, fluorouracil-based ACT but not gemcitabine-based ACT achieved significantly better OS benefits on patients with N+ (HR 0.67; 95% CI, 0.52-0.86) and R0 (HR 0.69; 95% CI, 0.54-0.88).

CONCLUSION

Compared with observation, ACT should be routinely recommended to improve survival outcomes in BTC patients after curative resection, especially for those with R0, N+, and TNM stage I/II. Gemcitabine-based ACT performed better than other chemotherapies in improving RFS. This network meta-analysis provides precise information for determining the best adjuvant treatment for resected BTC. Further thorough and high-quality RCTs are needed.

First-line chemotherapy with selective internal radiation therapy for intrahepatic cholangiocarcinoma: The French ACABi GERCOR PRONOBIL cohort

BACKGROUND & AIMS

Selective internal radiation therapy (SIRT) is a promising option for liver-only unresectable intrahepatic cholangiocarcinoma (iCCA). The Real-SIRTCCA study retrospectively assessed the benefit of adding SIRT to chemotherapy in this setting within the French nationwide observational cohort ACABi-GERCOR-PRONOBIL.

METHODS

Inclusion criteria were advanced iCCA with limited or no extrahepatic disease, treated with first-line gemcitabine plus platinum chemotherapy +/- concurrent SIRT. All patients treated with chemotherapy and concurrent SIRT were included. To ensure groups' similarity, a rigorous selection was applied to the chemo-only group, with exclusion of patients with liver involvement >50% and extrahepatic metastases. The primary outcome was progression-free survival (PFS). Secondary outcomes were overall survival (OS), objective response rate (ORR) and tumor resection rate. Propensity score and inverse probability of treatment weighting (IPTW) propensity approaches were used to address confounding factors between groups.

RESULTS

Between July 2007 and December 2023, 277 patients met the Real-SIRTCCA inclusion criteria, with 88 in the chemo-SIRT group and 189 in chemo-only group. Chemo-SIRT was associated with longer PFS (median = 10.8 vs. 5.5 months, hazard ratio [HR] 0.54, 95% CI 0.41-0.71, p <0.0001), a trend for longer OS (median = 22.5 vs. 15.1 months, HR 0.76, 95% CI 0.57-1.01), higher ORR (58.3% vs. 28.5%, odds ratio [OR] 3.51, 95% CI 2.03-6.09, p <0.0001), and resection rate (18.7% vs. 8.8%, p = 0.0279) compared to chemo-alone. After IPTW, the superiority of chemo-SIRT was confirmed with better PFS (HR 0.55, 95% CI 0.45-0.66, p <0,0001), OS (HR 0.70, 95% CI 0.58-0.85, p = 0.0004), ORR (OR 3.17, 95% CI 2.18-4.49, p <0.0001) and resection rate (OR 2.94, 95% CI 1.71-5.03, p <0.0001).

CONCLUSIONS

Adding SIRT to first-line chemotherapy significantly improved survival outcomes, ORR, and secondary tumor resection rates in locally advanced iCCA. Prospective randomized data are needed to confirm these results.

IMPACT AND IMPLICATIONS

Herein, we report the results of the Real-SIRTCCA study, comparing the efficacy of the gemcitabine-platinum systemic first-line chemotherapy with or without selective internal radiation therapy (SIRT) in 277 patients with locally advanced intrahepatic cholangiocarcinoma within the cohort ACABi-PRONOBIL. An improvement of progression-free survival, overall survival, tumor response and secondary surgical resection rate was observed in favor of chemo-SIRT, before adjustment and after inverse probability of treatment weighting propensity score analyses. Even though prospective randomized data would be needed to confirm these findings, we believe that this study constitutes new evidence of the potential benefit of combining SIRT with chemotherapy. The safety and efficacy of this strategy whether as a bridge to intent-to-cure strategies or in a palliative setting, should encourage its adoption in a larger panel of clinical centers, or at very least, prompt clinicians to refer their patients to centers where SIRT is performed.

CLINICAL TRIAL NUMBER

NCT04935853.

Surgical management, including the role of transplantation, for intrahepatic and peri-hilar cholangiocarcinoma

Intrahepatic and peri-hilar cholangiocarcinoma are life threatening disease with poor outcomes despite optimal treatment currently available (5-year overall survival following resection 20-35%, and <10% cured at 10-years post resection). The insidious onset makes diagnosis difficult, the majority do not have a resection option and the high recurrence rate post-resection suggests that occult metastatic disease is frequently present. Advances in perioperative management, such as ipsilateral portal vein (and hepatic vein) embolisation methods to increase the future liver remnant volume, genomic profiling, and (neo)adjuvant therapies demonstrate great potential in improving outcomes. However multiple areas of controversy exist. Surgical resection rate and outcomes vary between centres with no global consensus on how 'resectable' disease is defined - molecular profiling and genomic analysis could potentially identify patients unlikely to benefit from resection or likely to benefit from targeted therapies. FDG-PET scanning has also improved the ability to detect metastatic disease preoperatively and avoid futile resection. However tumours frequently invade major vasculo-biliary structures, with resection and reconstruction associated with significant morbidity and mortality even in specialist centres. Liver transplantation has been investigated for very selected patients for the last decade and yet the selection algorithm, surgical approach and both value of both neoadjuvant and adjuvant therapies remain to be clarified. In this review, we discuss the contemporary management of intrahepatic and peri-hilar cholangiocarcinoma.

Epidemiology of cholangiocarcinoma

Cholangiocarcinoma (CCA) represents a heterogenous set of malignancies arising from the biliary tract. Classification of CCA subdivides tumours into intrahepatic (iCCA) and extrahepatic (eCCA), with eCCA further categorised as perihilar (pCCA) and distal (dCCA) lesions. Tumour subtypes show distinct epidemiological, genetic and clinical characteristics. Global incidence and mortality are rising, with the highest rates seen in Asian populations compared to the West. There has been a divergence in recent mortality trends observed between CCA subtypes, with rising rates of iCCA seen compared with eCCA. There are several drivers for these differing trends, including specific risk factors, misclassification of CCA subtypes and variation in diagnosis and surveillance. Risk factors for CCA can be divided into hepatobiliary, extra-hepatic and environmental, with hepatobiliary diseases conferring the largest risk. Surgery represents the only curative treatment for CCA, but can only be offered to early-stage candidates who are otherwise fit; the majority of patients are therefore treated with chemotherapy and, recently, immunotherapy. Due to late-stage presentation of disease, prognosis is poor, with 5-year survival <20%.

Advancements in Locoregional Therapies for Unresectable Intrahepatic Cholangiocarcinoma

Intrahepatic cholangiocarcinoma is an aggressive malignancy with rising incidence and poor outcomes. This review examines recent advancements in locoregional therapies for unresectable intrahepatic cholangiocarcinoma, focusing on external beam radiotherapy, transarterial radioembolization (TARE), hepatic artery infusion pump (HAIP) chemotherapy, and liver transplantation. Stereotactic body radiation therapy and proton beam therapy have shown promise in achieving local control and improving survival. TARE, with personalized dosimetry, has demonstrated encouraging results in select patient populations. HAIP chemotherapy, primarily studied using floxuridine, has yielded impressive survival outcomes in phase II trials. Liver transplantation, once contraindicated, is now being reconsidered for carefully selected patients with localized disease. While these locoregional approaches show potential, randomized controlled trials comparing them to standard systemic therapy are lacking. Patient selection remains crucial, with factors such as liver function, tumor burden, and molecular profile influencing treatment decisions. Ongoing research aims to optimize treatment sequencing, explore combination strategies with systemic therapies, and refine phenotype identification and patient selection criteria. As the landscape of intrahepatic cholangiocarcinoma management evolves, a multidisciplinary approach is essential to tailor treatment strategies and improve outcomes for patients with this challenging disease.

Management of intrahepatic cholangiocarcinoma: a review for clinicians

Intrahepatic cholangiocarcinoma (iCCA) is an aggressive liver malignancy that arises from second-order biliary epithelial cells. Its incidence is gradually increasing worldwide. Well-known risk factors have been described, although in many cases, they are not identifiable. Treatment options are continuously expanding, but the prognosis of iCCA remains dismal. R0 liver resection remains the only curative treatment, but only a limited number of patients can benefit from it. Frequently, major hepatectomies are needed to completely remove the tumour. This could contraindicate surgery or increase postoperative morbidity in patients with chronic liver disease and small remnant liver volume. In cases of anticipated inadequate future liver remnant, regenerative techniques may be used to expand resectability. The role and extent of lymphadenectomy in iCCA are still matters of debate. Improvements in iCCA diagnosis and better understanding of genetic profiles might lead to optimized surgical approaches and drug therapies. The role of neoadjuvant and adjuvant therapies is broadening, gaining more and more acceptance in clinical practice. Combining surgery with locoregional therapies and novel drugs, such as checkpoint-inhibitors and molecular-targeted molecules, might improve treatment options and survival rates. Liver transplantation, after very poor initial results, is now receiving attention for the treatment of patients with unresectable very early iCCA (i.e. <2 cm) in cirrhotic livers, showing survival outcomes comparable to those of hepatocellular carcinoma. Ongoing prospective protocols are testing the efficacy of liver transplantation for patients with unresectable, advanced tumours confined to the liver, with sustained response to neoadjuvant treatment. In such a continuously changing landscape, the aim of our work is to review the state-of-the-art in the surgical and medical treatment of iCCA.

Application value of 18F-FDG PET/CT in soft tissue metastasis of intrahepatic cholangiocarcinoma: a case report and literature review

Intrahepatic cholangiocarcinoma (ICC)originates from the epithelial cells of the intrahepatic bile ducts, with insidious onset and strong invasiveness, and most of the cases are found in the advanced stage, with extremely poor prognosis. In advanced stages, distant metastases to the lungs, bones, and brain are common, but distant soft tissue (subcutaneous and skeletal muscle) and breast metastases are rare, and simultaneous metastases to all three rare sites had not been reported. We report a 69-year-old woman with right upper abdominal pain who underwent a plain and enhanced CT scan of the upper abdomen, which revealed an intrahepatic space-occupying lesion, as well as subcutaneous and peritoneal nodules in the abdomen. To further evaluate the presence of other metastases, an 18F-FDG PET/CT scan was performed, which showed abnormal FDG uptake in the liver, peritoneum, left upper femur, right breast, subcutaneous tissues of the thoracic and abdominal regions, and skeletal muscle, while the corresponding CT densities of part of the skeletal muscle and the left upper femur did not show any significant abnormality. Pathologic confirmation of ICC with multiple metastases was obtained by puncture biopsy of the liver and subcutaneous nodes. This case demonstrates the advantages of 18F-FDG PET/CT in comprehensively evaluating systemic metastasis of ICC and detecting occult metastases, which is of great significance in its clinical diagnosis and staging.

First-line systemic therapy and sequencing options in advanced biliary tract cancer: A systematic review and network meta-analysis

The current state of systemic therapy for advanced biliary tract cancer (BTC) has undergone significant changes. Currently, there are no clinical trials directly comparing various first-line systemic therapy regimens to each other, and these trials are unlikely to be conducted in the future. In this systematic review, after various abstracts and full-text articles published from the establishment of the database until October 2024 were searched, we included and analysed phase 3 clinical trials to evaluate the efficacy of different first-line systemic treatment regimens in advanced BTC. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines and a random effects model to pool the overall effects. Finally, seven low-risk-of-bias trials (with all of the trials representing first-line trials) were included. A total of 4033 patients were included in seven first-line trials. In terms of progression-free survival (PFS), network meta-analysis revealed that durvalumab + gemcitabine + cisplatin (GemCis) triple therapy, S-1 + GemCis triple therapy, and pembrolizumab + GemCis triple therapy were superior to GemCis. In terms of overall survival (OS), network meta-analysis revealed that durvalumab + GemCis triple therapy and pembrolizumab + GemCis triple therapy outperformed GemCis. According to the ranking of the P scores, durvalumab + GemCis triple therapy ranked first in PFS and second in OS. Therefore, the advantages of molecular immunotherapy have gradually become known, which suggests that future trials should focus on other potential combinations and molecular immunotargeted therapies.

Preoperative prediction of lymph node metastasis in intrahepatic cholangiocarcinoma: an integrative approach combining ultrasound-based radiomics and inflammation-related markers

OBJECTIVES

To develop ultrasound-based radiomics models and a clinical model associated with inflammatory markers for predicting intrahepatic cholangiocarcinoma (ICC) lymph node (LN) metastasis. Both are integrated for enhanced preoperative prediction.

METHODS

This study retrospectively enrolled 156 surgically diagnosed ICC patients. A region of interest (ROI) was manually identified on the ultrasound image of the tumor to extract radiomics features. In the training cohort, we performed a Wilcoxon test to screen for differentially expressed features, and then we used 12 machine learning algorithms to develop 107 models within the cross-validation framework and determine the optimal radiomics model through receiver operating characteristic (ROC) curve analysis. Multivariable logistic regression analysis was used to identify independent risk factors to construct a clinical model. The combined model was established by combining ultrasound-based radiomics and clinical parameters. The Delong test and decision curve analysis (DCA) were used to compare the diagnostic efficacy and clinical utility of different models.

RESULTS

A total of 1239 radiomics features were extracted from the ROIs of tumors. Among the 107 prediction models, the model (Stepglm + LASSO) utilizing 10 radiomics features ultimately yielded the highest average area under the receiver operating characteristic curve (AUC) of 0.872, with an AUC of 0.916 in the training cohort and 0.827 in the validation cohort. The combined model, which incorporates the optimal radiomics score, clinical N stage, and platelet-to-lymphocyte ratio (PLR), achieved an AUC of 0.882 in the validation cohort, significantly outperforming the clinical model with an AUC of 0.687 (P = 0.009). According to the DCA analysis, the combined model also showed better clinical benefits.

CONCLUSIONS

The combined model incorporating ultrasound-based radiomics features and the PLR marker offers an effective, noninvasive intelligence-assisted tool for preoperative LN metastasis prediction in ICC patients.

CLINICAL TRIAL NUMBER

Not applicable.

Prognostic Significance of Lymphocyte-to-Monocyte Ratio in Patients With Unresectable Biliary Tract Cancer Undergoing Systemic Chemotherapy

Background/Aim

The incidence of biliary tract cancers (BTC), including cholangiocarcinoma and gallbladder cancer, has been increasing worldwide. Approximately 70% of BTC patients have advanced disease at diagnosis, leading to a poor survival rate. Recent clinical trials have demonstrated that the addition of immune checkpoint inhibitors, such as durvalumab or pembrolizumab, to gemcitabine plus cisplatin chemotherapy significantly improves survival rates, making triple therapy the current standard for first-line treatment of BTC. Few models with predictive value exist for BTC. Lymphocyte-to-monocyte ratio (LMR) is a relatively new inflammation-related score and translational biomarker and has prognostic value for survival of patients with other cancers. This study assessed the prognostic value of LMR in patients with advanced BTC and analyzed the risk factors associated with overall survival (OS).

Patients and Methods

This prospective study enrolled 75 patients with advanced BTC who were treated with gemcitabine-based chemotherapies at Aso Iizuka Hospital, Japan. The cutoff value of LMR for predicting 6-month survival was 3.27.

Results

OS was longer for patients with high LMR compared with low LMR (median 32.4 months and 8.6 months, respectively; p=0.0069). Multivariate analysis identified LMR >3.27 [hazard ratio (HR)=0.427, p=0.0339] and objective response rate (HR=0.210, p=0.0116) as independent factors associated with OS.

Conclusion

Despite some limitations, such as the single-center design and small sample size, the results of this study suggest a potential role for LMR in predicting survival outcomes for BTC patients treated with gemcitabine-based chemotherapies.

[Cholangiocarcinomas]

The term cholangiocarcinoma (CCA) includes a group of malignant tumors that develop in the efferent bile ducts and are characterized by a high degree of heterogeneity. These differences between intrahepatic, perihilar and distal CCAs run through all aspects of the disease including the etiology, pathogenesis, symptoms, diagnostics and treatment. This review article presents the current developments in this field of diseases. We highlight surgical innovations in the clinical routine and the application of new systemic forms of treatment to augment the oncological radicality of surgery.

Surgical interpretation of the WHO subclassification of intrahepatic cholangiocarcinoma: a narrative review

Intrahepatic cholangiocarcinoma (iCCA) has been subclassified by its gross morphology into the mass-forming (MF), periductal-infiltrating (PI), and intraductal growth (IG) types and their combinations. This classification correlates well with clinical features; for example, MF-iCCA has less lymph-node metastasis and a better prognosis than PI-iCCA. According to the recently accumulated evidence from histological investigations, the WHO classification endorsed a subclassification scheme in which iCCA cases are classified into small- and large-duct types. Small-duct iCCA is considered to originate from septal or smaller bile ducts and is characterized by less frequent lymph-node metastasis, a favorable prognosis, and an MF appearance. Large-duct iCCA arises around the second branch of the biliary tree and has more aggressive biology and distinct genetic abnormalities. According to the practice guidelines for iCCA from the Liver Cancer Study Group of Japan and the National Comprehensive Cancer Network, upfront surgery is recommended for iCCA without distant metastasis regardless of the morphological subtype, based on clinical experience. In consideration of the biological heterogeneity of iCCA, the treatment strategy for iCCA needs to be reconsidered based on the WHO subtypes.

Developing a Prognostic Model for Intrahepatic Cholangiocarcinoma Patients With Elevated Preoperative Carbohydrate Antigen 19-9 Levels: Volume-Adjusted CA19-9 (VACA) as a Novel Biomarker

PURPOSE

The predictive sensitivity of carbohydrate antigen 19-9 (CA19-9) in assessing the prognosis of intrahepatic cholangiocarcinoma (ICC) remains inadequate. Integrating CA19-9 with tumor volume offers a potentially viable strategy for improving prognostic accuracy. This study aimed to develop a prognostic model utilizing volume-adjusted CA19-9 (VACA) for ICC patients.

PATIENTS AND METHODS

A retrospective analysis was conducted on data from 436 ICC patients. These patients from two centers were divided into the training (n = 291, Center 1) and validation (n = 145, Center 2) cohorts. Using the training cohort, univariate and multivariable Cox regression analyses were employed to identify clinicopathological characteristics significantly associated with overall survival (OS) and recurrence-free survival (RFS), which enabled the construction of prognostic nomograms both with and without VACA. The nomograms' discriminatory and calibration abilities were assessed using receiver operating characteristic (ROC) curves, decision curve analysis (DCA) curves, and calibration curves, applying both training and validation cohorts.

RESULTS

VACA emerged as an independent variable that significantly correlated with prognosis. The nomogram incorporating VACA demonstrated superior accuracy in predicting OS and RFS rates compared to the model without VACA. In the validation cohort, the nomogram with VACA yielded area under the ROC curve (AUC) values of 0.695 (95% CI = 0.597∼0.793) and 0.666 (95% CI = 0.559∼0.773) (1- year), 0.662 (95% CI = 0.518∼0.806) and 0.651 (95% CI = 0.446∼0.857) (3- years), and 0.701 (95% CI = 0.486∼0.916) and 0.703 (95% CI = 0.428∼0.978) (5- years) for OS and RFS, respectively, along with improved calibration and DCA curves.

CONCLUSIONS

VACA, formed by integrating tumor volume with CA19-9, exhibits promising prognostic capabilities. The nomogram incorporating data from two centers and utilizing VACA demonstrates robust prognostic performance and holds clinical utility.

CONDENSED ABSTRACT

Combining CA19-9 with tumor volume presents a potentially viable strategy for improving prognostic accuracy. The nomogram incorporating VACA demonstrates robust prognostic performance and holds clinical utility.