Clinical feasibility of curative surgery after nab-paclitaxel plus gemcitabine-cisplatin chemotherapy in patients with locally advanced cholangiocarcinoma

Survival benefit of conversion surgery for initially unresectable biliary tract cancer: a systematic review and meta-analysis

PURPOSE

Combination of gemcitabine and cisplatin (GemCis) is the current first-line treatment for unresectable biliary tract cancer (UR-BTC), but it confers a median overall survival (OS) of less than one year. This study aimed to evaluate the survival benefit of conversion surgery for initially UR-BTC.

METHODS

Eligible studies published between January 2000 and May 2024 were identified via an electronic search of PubMed and Web of Science databases. The primary endpoint was OS.

RESULTS

Included in this study were 96 observational studies involving 466 patients with 231 cases (49.6%) of intrahepatic cholangiocarcinoma, 131 cases of (28.1%) extrahepatic cholangiocarcinoma, and 104 cases (22.3%) of gallbladder cancer. The 90-day mortality rate was 4.3%, and the median survival duration was 36.8 (17.9-57.6) months, with a 1-, 3- and 5-year OS rate of 86% (74-95.9%), 59.9% (32.3-78.7%), and 41.1% (24-58.5%) respectively. Meta-analysis showed that survival in patients who underwent conversion surgery was significantly higher than that in those who received non-surgical treatment (hazard ratio [HR] 0.39, P < 0.001) and comparable to that in those who underwent up-front surgery for resectable cancer (HR 1.02, P = 0.43). Pooled analysis of 149 individual participant data showed that male gender (HR 20.649, P = 0.014) and lymph node metastasis (HR 14.671, P = 0.005) were independently associated with reduced OS.

CONCLUSION

Conversion surgery is justified in initially UR-BTC with favorable long-term survival, and may prove to be a promising option for the multimodality treatment of UR-BTC.

Diagnostic cholangioscopy for surgical planning of extrahepatic cholangiocarcinoma

The recent clinical outcomes of multi-regimen chemotherapy included prolonged survival and a high rate of conversion to surgery in Asian patients with advanced biliary tract cancer. The ability of single-operator cholangioscopy (SOC) to detect and stage extrahepatic cholangiocarcinoma (CCC) in intraductal lesions is becoming more important in determining the extent of surgery. The aim of this study was to evaluate the role of SOC in surgical planning for extrahepatic CCC. We reviewed the consecutive data of patients who received nab-paclitaxel plus gemcitabine-cisplatin for the management of extrahepatic CCC and underwent preoperative evaluations between June 2020 and August 2022. SOC was performed to determine the precise extent of the disease in patients with a good response to chemotherapy who were considering surgical treatment. Among the 38 patients included, 30 (79%) were diagnosed with perihilar CCC, six (16%) with distal CCC, and two (5%) with intraductal papillary neoplasm of the bile duct. Intraductal evaluation with SOC altered disease extent defined by previous imaging findings in 14 (37%) patients. In those patients, five (36%) were changed to less extensive surgery, four (29%) to conversion surgery, four (29%) avoided surgery, and one (7%) was changed to more extensive surgery. Among the 38 included patients, 27 (71%) underwent surgery, and the accuracy of the visual impressions was 93%, as confirmed by the surgical pathology report. In conclusion, SOC examination of patients with potentially resectable extrahepatic CCC was more precise than conventional diagnostic evaluations and could help in planning surgical options.

Gemcitabine-cisplatin induction treatment in patients with locally advanced perihilar cholangiocarcinoma (IMPACCA): A prospective registration study

BACKGROUND

Induction treatment may be beneficial in patients with unresectable locally advanced perihilar cholangiocarcinoma (LAPCCA). Prospective studies are currently lacking. This study aimed to assess the feasibility and efficacy of gemcitabine and cisplatin as induction treatment in patients with unresectable LAPCCA.

METHODS

In this prospective single-center registration study, consecutive patients with unresectable LAPCCA who received induction treatment with gemcitabine and cisplatin in an intent to downsize the tumor to allow for resection were included. The primary outcomes were resection rate and overall survival.

RESULTS

Overall, 265 patients with perihilar cholangiocarcinoma were screened between January 2020 and June 2023, of whom 23 patients (9%) with unresectable LAPCCA met the eligibility criteria. Eight patients (35%) became eligible for resection, of whom six ultimately underwent resection (resection rate, 26% (11-42%)). Two out of 23 patients (9%) experienced adverse events grade≥3, forcing one to stop induction treatment. Compared to baseline, CA19.9 levels decreased by 42% (95 % CI, -65 to -5%; P = 0.039) and 8% (-44 to 112%; P = 0.80) at the first and second restaging, respectively. Tumor size did not significantly decrease after chemotherapy. Median overall survival was 27 months (18-36), with 40 (24-56) in the resected and 19 (13-26) in the unresected group (P = 0.127).

CONCLUSION

Patients with LAPCCA frequently tolerate induction gemcitabine-cisplatin, leading to a 26% resection rate with 40 months overall survival. These findings support routine re-staging after three to six cycles of palliative treatment, and lay the groundwork for future prospective trials in this patient group.

Management of distal cholangiocarcinoma with arterial involvement: Systematic review and case series on the role of neoadjuvant therapy

BACKGROUND

The use of neoadjuvant therapy (NAT) in distal cholangiocarcinoma (dCCA) with regional arterial or extensive venous involvement, is not widely accepted and evidence is sparse.

AIM

To synthesise evidence on NAT for dCCA and present the experience of a high-volume tertiary-centre managing dCCA with arterial involvement.

METHODS

A systematic review was performed according to PRISMA guidance to identify all studies reporting outcomes of patients with dCCA who received NAT. All patients from 2017 to 2022 who were referred for NAT for dCCA at our centre were retrospectively collected from a prospectively maintained database. Baseline characteristics, NAT type, progression to surgery and oncological outcomes were collected.

RESULTS

Twelve studies were included. The definition of "unresectable" locally advanced dCCA was heterogenous. Four studies reported outcomes for 9 patients who received NAT for dCCA with extensive vascular involvement. R0 resection rate ranged between 0 and 100% but without survival benefit in most cases. Remaining studies considered either NAT in resectable dCCA or inclusive with extrahepatic CCA. The presented case series includes 9 patients (median age 67, IQR 56-74 years, male:female 5:4) referred for NAT for borderline resectable or locally advanced disease. Three patients progressed to surgery and 2 were resected. One patient died at 14 months with evidence of recurrence at 6 months and the other died at 51 months following recurrence 6 months post-operatively.

CONCLUSION

Evidence for benefit of NAT is limited. Consensus on criteria for uniform definition of resectability for dCCA is required. We propose using the established National-Comprehensive-Cancer-Network® criteria for pancreatic ductal adenocarcinoma.

Efficacy and biomarker analysis of second-line nab-paclitaxel plus sintilimab in patients with advanced biliary tract cancer

Biliary tract cancer (BTC) is a highly aggressive malignancy with limited second-line therapy. We conducted this phase 2 trial to evaluate the efficacy and safety of second-line nab-paclitaxel plus sintilimab in advanced BTC. Histologically confirmed advanced BTC patients with documented disease progression after first-line chemotherapy were enrolled. Subjects received nab-paclitaxel 125 mg/m2 on days 1 and 8 plus sintilimab 200 mg on day 1, administered every 3 weeks. The primary end point was the objective response rate (ORR). The secondary end points were progression-free survival (PFS), overall survival (OS), and adverse reactions. Simultaneously, next-generation sequencing, programmed cell death ligand 1 immunohistochemistry and multiplex immunofluorescence of tumor-infiltrating lymphocytes were applied to explore potential biomarkers. Twenty-six subjects were consecutively enrolled. The ORR was 26.9% (7/26), including two complete responses and five partial responses, which met the primary end point. The disease control rate was 61.5% (16/26). The median PFS was 169 days (about 5.6 months, 95% confidence interval [CI] 60-278 days). The median OS was 442 days (about 14.7 months, 95% CI 298-586 days). Grade 3 treatment-related adverse events (TRAEs) were mainly anemia (27%), leukopenia (23%), neutropenia (19%), and peripheral sensory neuropathy (8%). No grade 4 or 5 TRAEs occurred. Biomarker analysis suggested that positive PD-L1 and high proportions of CD8+ T-cell infiltration were correlated with improved clinical outcome. Nab-paclitaxel plus sintilimab is a potentially effective and tolerable second-line regimen for advanced BTC that deserves to be studied in large-scale trials. PD-L1 status and CD8+ T cell infiltration might be promising biomarkers for efficacy prediction.

A phase II/III randomized clinical trial of CisPlatin plUs Gemcitabine and Nabpaclitaxel (GAP) as pReoperative chemotherapy versus immediate resection in patIents with resecTable BiliarY Tract Cancers (BTC) at high risk for recurrence: PURITY study

BACKGROUND

Biliary tract cancers (BTCs) are rare and lethal cancers, with a 5-year survival inferior to 20%(1-3). The only potential curative treatment is surgical resection. However, despite complex surgical procedures that have a remarkable risk of postoperative morbidity and mortality, the 5-year survival rate after radical surgery (R0) is 20-40% and recurrence rates are up to ~ 75%(4-6). Up to ~ 40% of patients relapse within 12 months after resection, and half of these patient will recur systemically(4-6). There is no standard of care for neoadjuvant chemotherapy (NAC) in resectable BTC, but retrospective reports suggest its potential benefit (7, 8).

METHODS

PURITY is a no-profit, multicentre, randomized phase II/III trial aimed at evaluating the efficacy of the combination of gemcitabine, cisplatin and nabpaclitaxel (GAP) as neoadjuvant treatment in patients with resectable BTC at high risk for recurrence. Primary objective of this study is to evaluate the efficacy of neoadjuvant GAP followed by surgery as compared to upfront surgery, in terms of 12-month progression-free survival for the phase II part and of progression free survival (PFS) for the phase III study. Key Secondary objectives are event free survival (EFS), relapse-free survival, (RFS), overall survival (OS), R0/R1/R2 resection rate, quality of life (QoL), overall response rate (ORR), resectability. Safety analyses will include toxicity rate and perioperative morbidity and mortality rate. Exploratory studies including Next-Generation Sequencing (NGS) in archival tumor tissues and longitudinal ctDNA analysis are planned to identify potential biomarkers of primary resistance and prognosis.

DISCUSSION

Considering the poor prognosis of resected BTC experiencing early tumor recurrence and the negative prognostic impact of R1/R2 resections, PURITY study is based on the rationale that NAC may improve R0 resection rates and ultimately patients' outcomes. Furthermore, NAC should allow early eradication of microscopic distant metastases, undetectable by imaging but already present at the time of diagnosis and avoid mortality and morbidity associated with resection for patients with rapid progression or worsening general condition during neoadjuvant therapy. The randomized PURITY study will evaluate whether patients affected by BTC at high risk from recurrence benefit from a neoadjuvant therapy with GAP regimen as compared to immediate surgery.

TRIAL REGISTRATION

PURITY is registered at ClinicalTrials.gov (NCT06037980) and EuCT(2023-503295-25-00).