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Lo JH, Agarwal R, Goff LW, Heumann TR. Immunotherapy in Biliary Tract Cancers: Current Standard-of-Care and Emerging Strategies. Cancers (Basel) 2023; 15:3312. [PMID: 37444422 PMCID: PMC10340362 DOI: 10.3390/cancers15133312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/15/2023] Open
Abstract
Biliary tract cancers (BTCs), comprising intrahepatic, perihilar, and distal cholangiocarcinoma as well as gallbladder adenocarcinoma, continue to be challenging to manage. Conventional chemotherapy regimens for advanced disease are limited in both options and benefits, and more effective perioperative regimens are also needed. Over the last decade, immunotherapy has had a profound impact on the management of many solid tumor types, particularly in using immune checkpoint inhibition to enable a tumor-directed T cell response. Immunotherapy administered on its own has had limited utility in BTCs, in part due to a hostile immune microenvironment and the relative infrequency of biomarker-based tumor-agnostic indications for immunotherapy. However, immunotherapy in conjunction with chemotherapy, molecularly targeted therapies, and/or anti-angiogenic therapies has gained traction, supported by evidence that these agents can impart favorable immunomodulatory effects on the tumor microenvironment. The TOPAZ-1 trial led to the first BTC-specific immunotherapy approval, establishing the combination of durvalumab with gemcitabine and cisplatin as the preferred first-line treatment for advanced or metastatic disease. Recently, the KEYNOTE-966 trial showed positive results for the combination of pembrolizumab with gemcitabine and cisplatin in the same setting, adding further evidence for the addition of immune checkpoint inhibition to the standard chemotherapy backbone. Meanwhile, advances in the molecular profiling of BTCs has contributed to the recent proliferation of molecularly targeted therapeutics for the subset of BTCs harboring alterations in IDH1, FGFR2, MAP kinase signaling, HER2, and beyond, and there has been great interest in investigating combinations of these agents with immunotherapy. Emerging immunotherapy strategies beyond immune checkpoint inhibition are also being studied in BTCs, and these include immunostimulatory receptor agonists, Wnt signaling modulators, adoptive cell therapy, and cancer vaccines. A large number of trials are underway to explore promising new combinations and immune-targeted strategies, offering opportunities to expand the role of immunotherapy in BTC management in the near future.
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Affiliation(s)
| | | | | | - Thatcher R. Heumann
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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Karasic TB, Eads JR, Goyal L. Precision Medicine and Immunotherapy Have Arrived for Cholangiocarcinoma: An Overview of Recent Approvals and Ongoing Clinical Trials. JCO Precis Oncol 2023; 7:e2200573. [PMID: 37053534 PMCID: PMC10309532 DOI: 10.1200/po.22.00573] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/31/2023] [Indexed: 04/15/2023] Open
Affiliation(s)
- Thomas B. Karasic
- Division of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA
| | - Jennifer R. Eads
- Division of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA
| | - Lipika Goyal
- Department of Medicine, Division of Hematology and Oncology, Stanford Cancer Center, Palo Alto, CA
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Ruff SM, Shannon AH, Pawlik TM. Advances in Targeted Immunotherapy for Hepatobiliary Cancers. Int J Mol Sci 2022; 23:ijms232213961. [PMID: 36430440 PMCID: PMC9698563 DOI: 10.3390/ijms232213961] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Cancer of the hepatobiliary system can be divided into primary liver cancer and biliary tract cancer (BTC), which includes hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), and gallbladder cancer (GBC). These aggressive cancers often present at an advanced stage or among patients with poorly preserved liver function. The primary treatment for HCC and BTC when diagnosed early is surgical resection, but given the high rate of recurrence and often advanced stage at diagnosis, many patients will require systemic therapy. Unfortunately, even with systemic therapy, long-term survival is poor. The immune system plays an important role in preventing cancer progression. The unique immune environment of the liver and subsequent alterations to the immune microenvironment by tumor cells to create a favorable microenvironment plays a key role in the progression of HCC and BTC. Due to the paucity of effective systemic therapies and distinctive immune environment of the liver, research and clinical trials are investigating the use of immunotherapy in HCC and BTC. This review will focus on current immunotherapies and emerging data for the treatment of HCC and BTC.
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Zhou T, Mahn R, Möhring C, Sadeghlar F, Meyer C, Toma M, Kreppel B, Essler M, Glowka T, Matthaei H, Kalff JC, Strassburg CP, Gonzalez-Carmona MA. Case Report: Sustained complete remission on combination therapy with olaparib and pembrolizumab in BRCA2-mutated and PD-L1-positive metastatic cholangiocarcinoma after platinum derivate. Front Oncol 2022; 12:933943. [PMID: 35957899 PMCID: PMC9359099 DOI: 10.3389/fonc.2022.933943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/27/2022] [Indexed: 12/15/2022] Open
Abstract
Cholangiocarcinoma (CCA) still has a poor prognosis and remains a major therapeutic challenge. When curative resection is not possible, palliative systemic chemotherapy with gemcitabine and platinum derivate as first line followed by a 5-FU doublet combination as second line is the standard therapy. Recently, targeted therapy and immunotherapy have rapidly emerged as personalized therapeutic approaches requiring previous tumor sequencing and molecular profiling. BRCA mutations are well-characterized targets for poly (ADP-ribose) polymerase inhibitors (PARPi). However, BRCA gene mutations in CCA are rare and few data of PARPi in the treatment of CCA are available. Immunotherapy with programmed death receptor-1 (PD-1) has been shown to be effective in combination with chemotherapy or in PD-L1-positive CCA. However, data from immunotherapy combined with targeted therapy, including PARPi, are lacking. In this report, we present the case of a male patient with PD-L1-positive and BRCA2-mutated metastatic intrahepatic cholangiocarcinoma, who was treated with a combined therapy with PARP (PARPi), olaparib, and a PD-1 antibody, pembrolizumab, as second-line therapy after gemcitabine/platinum derivate failure. Combined therapy was able to induce a long-lasting complete remission for over 15 months. The combined therapy was feasible and well tolerated. Only mild anemia and immune-related thyroiditis were observed, which were easily manageable and did not result in discontinuation of olaparib and pembrolizumab.
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Affiliation(s)
- Taotao Zhou
- Department of Internal Medicine I, University Hospital of Bonn, Bonn, Germany
- *Correspondence: Taotao Zhou, ; Maria A. Gonzalez-Carmona,
| | - Robert Mahn
- Department of Internal Medicine I, University Hospital of Bonn, Bonn, Germany
| | - Christian Möhring
- Department of Internal Medicine I, University Hospital of Bonn, Bonn, Germany
| | - Farsaneh Sadeghlar
- Department of Internal Medicine I, University Hospital of Bonn, Bonn, Germany
| | - Carsten Meyer
- Department of Radiology, University Hospital of Bonn, Bonn, Germany
| | - Marieta Toma
- Department of Pathology, University Hospital of Bonn, Bonn, Germany
| | - Barbara Kreppel
- Department of Nuclear Medicine, University Hospital of Bonn, Bonn, Germany
| | - Markus Essler
- Department of Nuclear Medicine, University Hospital of Bonn, Bonn, Germany
| | - Tim Glowka
- Department of Visceral Surgery, University Hospital of Bonn, Bonn, Germany
| | - Hanno Matthaei
- Department of Visceral Surgery, University Hospital of Bonn, Bonn, Germany
| | - Jörg C. Kalff
- Department of Visceral Surgery, University Hospital of Bonn, Bonn, Germany
| | | | - Maria A. Gonzalez-Carmona
- Department of Internal Medicine I, University Hospital of Bonn, Bonn, Germany
- *Correspondence: Taotao Zhou, ; Maria A. Gonzalez-Carmona,
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Yin C, Kulasekaran M, Roy T, Decker B, Alexander S, Margolis M, Jha RC, Kupfer GM, He AR. Homologous Recombination Repair in Biliary Tract Cancers: A Prime Target for PARP Inhibition? Cancers (Basel) 2022; 14:2561. [PMID: 35626165 PMCID: PMC9140037 DOI: 10.3390/cancers14102561] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/10/2022] [Accepted: 05/14/2022] [Indexed: 01/27/2023] Open
Abstract
Biliary tract cancers (BTCs) are a heterogeneous group of malignancies that make up ~7% of all gastrointestinal tumors. It is notably aggressive and difficult to treat; in fact, >70% of patients with BTC are diagnosed at an advanced, unresectable stage and are not amenable to curative therapy. For these patients, chemotherapy has been the mainstay treatment, providing an inadequate overall survival of less than one year. Despite the boom in targeted therapies over the past decade, only a few targeted agents have been approved in BTCs (i.e., IDH1 and FGFR inhibitors), perhaps in part due to its relatively low incidence. This review will explore current data on PARP inhibitors (PARPi) used in homologous recombination deficiency (HRD), particularly with respect to BTCs. Greater than 28% of BTC cases harbor mutations in genes involved in homologous recombination repair (HRR). We will summarize the mechanisms for PARPi and its role in synthetic lethality and describe select genes in the HRR pathway contributing to HRD. We will provide our rationale for expanding patient eligibility for PARPi use based on literature and anecdotal evidence pertaining to mutations in HRR genes, such as RAD51C, and the potential use of reliable surrogate markers of HRD.
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Affiliation(s)
- Chao Yin
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20007, USA; (C.Y.); (M.K.); (T.R.)
| | - Monika Kulasekaran
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20007, USA; (C.Y.); (M.K.); (T.R.)
| | - Tina Roy
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20007, USA; (C.Y.); (M.K.); (T.R.)
| | - Brennan Decker
- Foundation Medicine, Cambridge, MA 20007, USA; (B.D.); (S.A.); (M.M.)
| | - Sonja Alexander
- Foundation Medicine, Cambridge, MA 20007, USA; (B.D.); (S.A.); (M.M.)
| | - Mathew Margolis
- Foundation Medicine, Cambridge, MA 20007, USA; (B.D.); (S.A.); (M.M.)
| | - Reena C. Jha
- Department of Radiology, Georgetown University Medical Center, Washington, DC 20007, USA;
| | - Gary M. Kupfer
- Departments of Oncology and Pediatrics, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20007, USA;
| | - Aiwu R. He
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20007, USA; (C.Y.); (M.K.); (T.R.)
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Woods E, Le D, Jakka BK, Manne A. Changing Landscape of Systemic Therapy in Biliary Tract Cancer. Cancers (Basel) 2022; 14:2137. [PMID: 35565266 PMCID: PMC9105885 DOI: 10.3390/cancers14092137] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/17/2022] [Accepted: 04/22/2022] [Indexed: 12/19/2022] Open
Abstract
Biliary tract cancers (BTC) are often diagnosed at advanced stages and have a grave outcome due to limited systemic options. Gemcitabine and cisplatin combination (GC) has been the first-line standard for more than a decade. Second-line chemotherapy (CT) options are limited. Targeted therapy or TT (fibroblast growth factor 2 inhibitors or FGFR2, isocitrate dehydrogenase 1 or IDH-1, and neurotrophic tyrosine receptor kinase or NTRK gene fusions inhibitors) have had reasonable success, but <5% of total BTC patients are eligible for them. The use of immune checkpoint inhibitors (ICI) such as pembrolizumab is restricted to microsatellite instability high (MSI-H) patients in the first line. The success of the TOPAZ-1 trial (GC plus durvalumab) is promising, with numerous trials underway that might soon bring targeted therapy (pemigatinib and infrigatinib) and ICI combinations (with CT or TT in microsatellite stable cancers) in the first line. Newer targets and newer agents for established targets are being investigated, and this may change the BTC management landscape in the coming years from traditional CT to individualized therapy (TT) or ICI-centered combinations. The latter group may occupy major space in BTC management due to the paucity of targetable mutations and a greater toxicity profile.
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Affiliation(s)
- Edward Woods
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH 432120, USA;
| | - Dat Le
- Department of Pharmacy, The Arthur G. James Cancer Hospital and Richard J. Solove Institute at The Ohio State University, 460 W 10th Ave, Columbus, OH 43210, USA;
| | - Bharath Kumar Jakka
- Department of Internal Medicine, Baptist Medical Center South, Montgomery, AL 36116, USA;
| | - Ashish Manne
- Department of Internal Medicine, Division of Medical Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA
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