Gemcitabine and S-1 versus gemcitabine and cisplatin treatment in patients with advanced biliary tract cancer: a multicenter retrospective study

Body mass index and survival among patients with advanced biliary tract cancer: a single-institutional study with nationwide data-based validation

BACKGROUND

Excess body weight may modulate the progression of various cancer types. The prognostic relevance of body mass index (BMI) has not been fully examined in patients with biliary tract cancer.

METHODS

Using a single-institutional cohort of 360 patients receiving gemcitabine-based chemotherapy for advanced biliary tract cancer, we examined the association of BMI with overall survival (OS). Using the Cox regression model with adjustment for potential confounders, we calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for OS according to BMI. The findings were validated using a Japanese nationwide inpatient database including 8324 patients treated at 201 hospitals.

RESULTS

In the clinical cohort, BMI was not associated with OS (Ptrend = 0.34). Compared to patients with BMI = 18.5-24.9 kg/m2, patients with BMI < 18.5 kg/m2 and ≥ 25.0 kg/m2 had adjusted HRs for OS of 1.06 (95% CI, 0.78-1.45) and 1.01 (95% CI, 0.74-1.39), respectively. There was no evidence on a non-linear relationship between BMI and OS (Pnonlinearity = 0.63). In the nationwide cohort, the null findings were validated (Ptrend = 0.18) with adjusted HRs of 1.07 (95% CI, 0.98-1.18) for BMI < 18.5 kg/m2 and 1.05 (95% CI, 0.96-1.14) for BMI ≥ 25.0 kg/m2 (vs. BMI = 18.5-24.9 kg/m2). In the clinical cohort, BMI was not associated with progression-free survival (Ptrend = 0.81).

CONCLUSIONS

BMI was not associated with survival outcomes of patients with advanced biliary tract cancer. Further research is warranted incorporating more detailed body composition metrics to explore the prognostic role of adiposity in biliary tract cancer.

Development of a model based on the age-adjusted Charlson comorbidity index to predict survival for resected perihilar cholangiocarcinoma

BACKGROUND

Perihilar cholangiocarcinoma (pCCA) has a poor prognosis and urgently needs a better predictive method. The predictive value of the age-adjusted Charlson comorbidity index (ACCI) for the long-term prognosis of patients with multiple malignancies was recently reported. However, pCCA is one of the most surgically difficult gastrointestinal tumors with the poorest prognosis, and the value of the ACCI for the prognosis of pCCA patients after curative resection is unclear.

AIM

To evaluate the prognostic value of the ACCI and to design an online clinical model for pCCA patients.

METHODS

Consecutive pCCA patients after curative resection between 2010 and 2019 were enrolled from a multicenter database. The patients were randomly assigned 3:1 to training and validation cohorts. In the training and validation cohorts, all patients were divided into low-, moderate-, and high-ACCI groups. Kaplan-Meier curves were used to determine the impact of the ACCI on overall survival (OS) for pCCA patients, and multivariate Cox regression analysis was used to determine the independent risk factors affecting OS. An online clinical model based on the ACCI was developed and validated. The concordance index (C-index), calibration curve, and receiver operating characteristic (ROC) curve were used to evaluate the predictive performance and fit of this model.

RESULTS

A total of 325 patients were included. There were 244 patients in the training cohort and 81 patients in the validation cohort. In the training cohort, 116, 91 and 37 patients were classified into the low-, moderate- and high-ACCI groups. The Kaplan-Meier curves showed that patients in the moderate- and high-ACCI groups had worse survival rates than those in the low-ACCI group. Multivariable analysis revealed that moderate and high ACCI scores were independently associated with OS in pCCA patients after curative resection. In addition, an online clinical model was developed that had ideal C-indexes of 0.725 and 0.675 for predicting OS in the training and validation cohorts. The calibration curve and ROC curve indicated that the model had a good fit and prediction performance.

CONCLUSION

A high ACCI score may predict poor long-term survival in pCCA patients after curative resection. High-risk patients screened by the ACCI-based model should be given more clinical attention in terms of the management of comorbidities and postoperative follow-up.

Prevalence of acute oral mucosal damage secondary to the use of systemic antineoplastics: A systematic review and meta-analysis

OBJECTIVE

The aim of this study was to determine the prevalence of acute oral mucosal toxicities in non-irradiated patients treated with systemic antineoplastics agents. The secondary objective was to find out differences in its prevalence among the different types of systemic antineoplastics.

STUDY DESIGN

A systematic review and meta-analysis was performed. Articles from 2010 to July 2022 were retrieved and included if patients were adults undergoing oral assessment after administration of commercially available systemic antineoplastics. Data was extracted and pooled proportions were estimated using random-effect model method (Der Simonian and Lair).

RESULTS

Eighty-two articles were included in the study. The overall prevalence of acute oral mucosal damage across studies was 38.2% (95% CI: 33.1%-43.3%). The prevalence was 42.9% (95% CI: 32.8%-53%) in patients treated with chemotherapy alone, 38% (95% CI: 29.1%-47%) in patients treated with a combination of chemotherapy and targeted therapies, and 32.1% (95% CI: 26.8%-37.5%) in targeted therapies alone-treated patients. No statistically significant differences were found in the prevalence of oral mucosal toxicities between the different types of systemic antineoplastic treatments.

CONCLUSIONS

Oral mucosal toxicity is a major side effect in non-irradiated cancer patients undergoing systemic antineoplastics.

A prospective multicenter phase II study of FOLFIRINOX as a first-line treatment for patients with advanced and recurrent biliary tract cancer

Given the promising activity and tolerability of FOLFIRINOX as a second-line treatment for advanced biliary tract cancer (BTC), it can be an attractive first-line treatment option as well. This is a single-arm, open-label, multicenter phase II study to evaluate the safety and efficacy of FOLFIRINOX as a first-line treatment for patients with advanced BTC. Primary endpoint was progression-free survival (PFS), and the secondary endpoints included overall survival (OS), tumor response and safety. This study defined primary endpoint might be met when the lower limit value of 80% confidence interval [CI] of the median PFS ≥ 6.0 months. Between June 2016 and March 2020, 35 BTC patients (21 intrahepatic, 10 extrahepatic, 2 gallbladder, 2 ampulla) including 26 unresectable and 9 recurrent disease were enrolled. After a median follow-up of 13.9 months, the median PFS and OS were 7.4 (80% CI, 5.5-7.5) and 14.7 (80% CI, 11.8-15.7) months, respectively. Complete response was achieved in 1 (2.9%) and partial response in 10 (28.6%), giving an objective response rate of 31.4% and disease control rate of 74.3%. Major grade 3-4 adverse events included neutropenia (54.3%), leukopenia (34.4%), febrile neutropenia (17.1%), thrombocytopenia (8.6%), cholangitis (8.6%), anemia, nausea, diarrhea, and peripheral sensory neuropathy (2.9% each). FOLFIRINOX was well tolerable in patients with advanced BTC, however, this study did not meet the primary endpoint to conduct a phase III trial. Thus, further explorations are required to find a subset of patients and/or certain clinical scenario which might be beneficial from FOLFIRINOX.

Survival Outcomes of Gemcitabine Plus S-1 Adjuvant Chemotherapy after Surgical Resection for Advanced Biliary Tract Cancer

INTRODUCTION

The usefulness of adjuvant chemotherapy in biliary tract cancer (BTC) is poorly reported. This study aimed to evaluate the effectiveness and safety of adjuvant gemcitabine plus S-1 (GS) chemotherapy after curative surgical resection for BTC.

METHODS

225 BTC patients who underwent surgical resection between January 2006 and May 2019 were enrolled in this study. Twenty-seven patients received adjuvant chemotherapy with GS (GS group), whereas 67 patients underwent surgery alone (S group). Twenty-three matching pairs were derived through propensity score (PS) matching analysis. Patients received 12 cycles of adjuvant chemotherapy (70 mg/m2 oral S-1 for 7 consecutive days plus intravenous gemcitabine 1,000 mg/m2 on day 7). The primary end point was recurrence-free survival (RFS). The secondary end points were the 1-, 2-, and 3-year RFS and overall survival (OS) rates, tolerability, and frequency of grade 3/4 toxicity.

RESULTS

The completion rate was 81.5%; no treatment-related deaths were observed. Grade 3/4 adverse events were seen in 40.7% of the patients. RFS (3-year RFS rate: 59.3% vs. 39.1%, p = 0.049) and OS (3-year OS rate: 71.7% vs. 53.4%, p = 0.008) were significantly better in the GS group than in the S group among PS-matched pairs.

DISCUSSION/CONCLUSION

GS chemotherapy after curative surgery was well tolerated, showed better clinical benefit in the adjuvant setting, and can effectively reduce BTC recurrence.

The impact of age and comorbidity in advanced or recurrent biliary tract cancer receiving palliative chemotherapy

BACKGROUND AND AIM

Limited data are available on age and comorbidity assessment in patients with biliary tract cancer (BTC). This study aimed to evaluate the association of age and comorbidity burden with clinical outcomes of chemotherapy for BTC.

METHODS

Consecutive 197 BTC patients undergoing first-line chemotherapy between 2007 and 2017 were retrospectively studied. Patients were classified to three groups according to the age-adjusted Charlson comorbidity index (ACCI) excluding the score about BTC and progression-free survival, overall survival (OS), and safety were compared.

RESULTS

Fifty-one patients (26%) were elderly (≥ 75 years), and ACCI was 0-2 in 73 patients (37%), 3-4 in 98 (50%), and ≥ 5 in 26 (13%). ACCI was associated with the administration of first-line combination chemotherapy (89% in 0-2, 80% in 3-4, and 64% in ≥ 5, P < 0.01) and second-line chemotherapy (67% in 0-2, 51% in 3-4, and 35% in ≥ 5, P = 0.01). ACCI was prognostic for OS in addition to performance status, disease status, and CA19-9: The hazard ratios in ACCI of 3-4 and ≥ 5 were 1.39 and 1.79, compared with ACCI of 0-2 (P = 0.04). While overall safety profile did not differ by ACCI, higher ACCI score group developed Grade 3-4 neutropenia more frequently (26% in 0-2, 42% in 3-4, and 46% in ≥ 5, P = 0.04).

CONCLUSION

Age and comorbidity burden did affect OS and safety profile in BTC patients undergoing first-line palliative chemotherapy. ACCI can be a simple and useful tool to evaluate the age and comorbidity burden in these patients.

Gemcitabine Plus Cisplatin Chemotherapy Prolongs the Survival in Advanced Hilar Cholangiocarcinoma: A Large Multicenter Study

OBJECTIVES

Gemcitabine plus cisplatin (GC) is recommended as first-line treatment for advanced cholangiocarcinoma. We investigated the impact of GC in patients with unresectable hilar cholangiocarcinoma (HC) based on the time taken for effective biliary drainage (EBD).

MATERIALS AND METHODS

We retrospectively enrolled 113 patients with unresectable HC. Thirty-nine and 74 patients received GC chemotherapy and best supportive care (BSC), respectively. EBD was defined as a reduction in total bilirubin >50% or to a value <2 mg/dL after the drainage procedure. Early EBD (eEBD) and delayed EBD (dEBD) were separated by 2 weeks. Overall survival (OS) was estimated.

RESULTS

The GC group showed a significantly longer median OS than the BSC group (12.8 vs. 6.1 mo; P<0.001). Moreover, the eEBD group experienced a significantly longer OS than the dEBD group (8.2 vs. 4.3 mo; P<0.001). GC led to improved OS in the eEBD (12.8 vs. 6.8 mo; P=0.003) and dEBD (12.2 vs. 3.4 mo; P=0.009) groups. In multivariate analysis, dEBD (adjusted hazard ratio [aHR], 1.785; 95% confidence interval [CI], 1.183-2.691; P=0.006), BSC (aHR, 2.409; 95% CI, 1.579-3.675; P<0.001), and an ECOG status ≥2 (aHR, 3.721; 95% CI, 2.093-6.615; P<0.001) were associated with poor prognosis. In GC group, the older (70 y and above) patients did not have a higher risk of death than younger patients.

CONCLUSIONS

GC prolongs the survival of patients with unresectable HC, even those with dEBD or elderly.

The Efficacy of Different Chemotherapy Regimens for Advanced Biliary Tract Cancer: A Systematic Review and Network Meta-Analysis

Background: Although gemcitabine plus cisplatin (GP) is considered as standard chemotherapy for patients with advanced biliary tract cancer (BTC), the optimal regimen remains unknown.

Methods: Using Network meta-analysis (NMA), a systematic review was conducted to find the most effective chemotherapy regimen for advanced BTC. We searched PubMed, Web of Science, Embase, Scopus and the Cochrane Library for articles published before October 6, 2018. Articles about chemotherapeutic comparisons were included. Hazard ratios (HRs) for overall survival (OS) and progression free survival (PFS) were estimated while odd ratios (ORs) was assessed for objective response rate (ORR).

Results: The NMA included 25 studies and 3,312 individuals. Among all the regimens, Folfox-4 regimen obtained a superior difference in OS (BSC vs. Folfox-4, HR 3.4, 95% CI 1.7-6.7). XP was slightly better than GP in OS and GS approximately obtained the same efficacy to GP (HR for XP vs. GP 0.74, 95% CI 0.51-1.1; HR for GS vs. GP 1.1, 95% CI 0.71-1.5). Most of the targeted therapies included in this study tend to achieve better results in PFS and ORR but failed to improve OS, in which E-GEMOX achieved the best ORR when compared to BSC (OR 0.03, 95% CI 0.00-0.94).

Conclusions: Folfox-4 regimen is likely to be the optimal chemotherapy for patients with advanced BTC and the predominant targeted therapy hasn't achieved significant success currently. XP and GS can be considered as alternatives for advanced BTC.

The Efficacy and Safety of First-line Chemotherapies for Advanced Biliary Tract Cancer: A Network Meta-analysis

Major chemotherapeutic drugs for advanced biliary tract cancer (ABTC) include gemcitabine, fluoropyrimidines and platinum compounds, but the optimum combination of them remains inconclusive. The main objective of this network meta-analysis was to compare the efficacy and safety of first-line chemotherapies for ABTC.

Methods: We searched PubMed, EMBASE, the Cochrane library and Science Direct for relevant controlled trials until May 2017. We estimated the Hazard ratios (HRs) for survival time and odds ratios (ORs) for response rate and toxic effects among different therapies. All data were calculated by Aggregate Data Drug Information System (ADDIS) v2.0 online and STATA software.

Results: 16 trials involving 2245 patients and 10 regimens were included in this study. In terms of the objective response rate, Cap plus CIS (CapC) exhibited better performance than FU (OR 5.46, 95% CI 1.07-56.63). Gem plus S-1 (GS) was superior to Gem (OR 4.72, 95% CI 1.31-17.02) and FU (OR 9.08, 95% CI 1.56-89.20). Also, GS had an overall survival benefit compared to FU and Gem, with a HR of 0.51 (95% CI 0.28-0.96) and 0.43 (95% CI 0.20-0.93), respectively. Compared with FU, Gem plus OXA (Gemox) prolonged the OS (HR 0.57, 95% CI 0.32-0.96). And FU was also inferior to FP (HR 1.88, 95% CI 1.07-3.16). The PFS did not differ between all regiments. The incidence of grade 3 or 4 hematological toxic effects appeared to be higher in the Gem-based chemotherapies. In regard to nonhematological adverse events, grade 3 or 4 diarrhea and stomotitis occurred more frequently in S-1-based groups. In addition, the Cap plus CIS combination (CapC) were more likely to cause vomiting, stomotitis and hand-foot syndrome. As for peripheral neuropathy, Gem plus OXA (Gemox), CapC and GC were associated with higher risk. There was no difference among different treatments with respect to anorexia, fatigue, nausea, pigmentation, renal dysfunction and asthenia.

Conclusion: Physicians should discuss with the patients the different options outlining potential benefit and toxicity since no clear evidence of an approach of choice can be produced.

Second-line chemotherapy in patients with advanced or recurrent biliary tract cancer: a single center, retrospective analysis of 294 cases

Purpose The survival benefit of first-line chemotherapy (CT1) for biliary tract cancer (BTC) is now established but the role of second-line chemotherapy (CT2) has not been fully elucidated yet. Methods Consecutive advanced BTC patients receiving CT1 between 2000 and 2016 were retrospectively studied. We investigated the safety and efficacy of CT2, prognostic factors for residual survival after CT1, and explored subgroups who would benefit from CT2. Results Among 294 patients receiving CT1 for advanced BTC, CT2 was given in 139 patients (47%). CT2 provided a response rate of 4%, a disease control rate of 52%, a median progression-free survival of 2.8 and overall survival of 7.7 months, respectively. CT2 was associated with longer residual survival after CT1 (hazard ratio [HR] 0.61, p < 0.01), as well as PS of 0-1 (HR 0.53, p < 0.01), best response to CT1 of PD (HR 1.46, p = 0.01), and CEA ≥5.0 ng/mL (HR 1.69, p < 0.01). The effects of CT2 were homogeneous across almost all subgroups but were more prominent in patients with age ≥ 70 years (HR 0.32, p for interaction =0.02), CA19-9 ≥ 200 IU/mL (HR 0.41, p for interaction = 0.08) and CEA ≥5.0 ng/mL (HR 0.41, p for interaction = 0.06). Conclusions The introduction rate of CT2 was 47%. Although the efficacy of CT2 was modest in terms of tumor response, it was associated with better survival. Further investigations are necessary both to develop more effective regimens and to select patients who will benefit from CT2.

CA19-9 kinetics during systemic chemotherapy in patients with advanced or recurrent biliary tract cancer

PURPOSE

The role of carbohydrate antigen 19-9 (CA19-9) kinetics in patients with biliary tract cancer (BTC) receiving chemotherapy remains to be elucidated.

METHODS

A total of 185 advanced or recurrent BTC patients receiving a first line chemotherapy between January 2006 and March 2016, were retrospectively studied. Serum CA19-9 was measured at baseline and after two cycles of chemotherapy, and patients were categorized based on CA19-9 response: CA19-9 decrease group (≥ 30% decrease), stable group (< 30% decrease and < 20% increase) and increase group (≥ 20% increase). The associations of CA19-9 response with radiological tumor response, progression-free survival (PFS) and overall survival (OS) were investigated.

RESULTS

There was a statistically significant association between CA19-9 response and radiological tumor responses (p < 0.001). The median PFS and OS were significantly different among three groups according to CA19-9 response: PFS of 8.0, 5.7 and 3.5 months in CA19-9 decrease, stable and increase groups (p < 0.001) and OS of 18.8, 16.0 and 7.5 months in CA19-9 decrease, stable and increase groups, respectively (p < 0.001). Multivariate analyses showed that CA19-9 response was prognostic both of OS and PFS in addition, to CA19-9 at baseline, and performance status.

CONCLUSION

CA19-9 kinetics after the first two cycles of a first line chemotherapy was a prognostic factor for OS and PFS in patients with advanced and recurrent BTC.