Pembrolizumab in combination with gemcitabine and cisplatin compared with gemcitabine and cisplatin alone for patients with advanced biliary tract cancer (KEYNOTE-966): a randomised, double-blind, placebo-controlled, phase 3 trial

Liver Transplantation for Non-hepatocellular Carcinoma: The Role of Immune Checkpoint Inhibitors

Colorectal cancer (CRC), gastroenteropancreatic neuroendocrine neoplasm (GEP-NEN), and cholangiocarcinoma (CCA) exhibit high rates of morbidity and mortality once metastasized to the liver. Liver transplantation (LT) is a viable therapeutic approach for these cancers in highly selected patients; however, their invasive nature at late stages causes many patients to be delisted from transplantation or to require further downstaging. Immunotherapy with immune checkpoint modulators has revolutionized cancer research. Immune checkpoint inhibitors (ICI) leverage the chronic inflammatory state and the overexpression of cytotoxic T lymphocyte antigen 4 (CTLA-4) and programmed cell death protein 1 (PD-1)/programmed cell death-ligand 1 (PD-L1) by malignant cells and regulatory T cells, to block immune checkpoints and counteract tumor's ability to evade the immune system. However, the interaction between allograft PD-L1 and PD-1 on infiltrating T cells functions as a means of graft tolerance in cases of LT. Therefore, the application of ICIs might block this protective effect and induce graft rejection, a phenomenon particularly observed in PD-1/PD-L1 inhibiting ICIs. The risk of post-LT graft rejection can be mitigated by applying advanced biomarkers and specifying certain mutations that enhance patient selection criteria for pre-LT ICI use. Furthermore, the determination of optimal intervals of ICI administration pre- and post-LT, identification of ICI indications in de novo malignancies occurring after LT, and investigation of biomarkers for early rejection detection, pave the way for more promising LT outcomes in patients with CRC, GEP-NEN, or CCA. Therefore, this review aims to illustrate a comprehensive overview of the role of ICI therapy in the management of non-hepatocellular carcinoma transplant oncology cancers by demonstrating the potential for its application in both pre-and post-LT states, and pathways to reduce or timely detect ICI-associated graft rejection.

Intrahepatic cholangiocarcinoma: Insights on molecular testing, targeted therapies, and future directions from a multidisciplinary panel

Biliary tract cancers (BTCs) are a histologically and molecularly diverse group of malignancies arising from the gallbladder and the ductal epithelium of the biliary tree. Intrahepatic cholangiocarcinoma (iCCA) is the second most common primary liver malignancy in the United States. Surgical resection with negative margins is the only recognized curative treatment option for iCCA; however, most patients will present with advanced or unresectable disease. The clinical presentation is largely non-specific, with the characteristic symptoms of biliary malignancies being less frequent than extrahepatic cholangiocarcinoma. Clinical management in iCCA is heavily influenced by the molecular profile of individual tumors. Hence, pathologists must exercise caution to prevent tissue exhaustion during the diagnostic workup of iCCA and ensure the availability of tissue samples for molecular testing. Establishing standardized procedures for obtaining adequate tissue and using molecular testing is vital. Circulating tumor DNA (ctDNA) offers a potential alternative to tissue-based analysis, especially in cases with insufficient tissue samples. Drugs targeting alterations in NTRK, IDH1, BRAF, FGFR2, and HER2 are commonly utilized. Targeting the MDM2-p53 pathway represents an avenue for future investigations in advanced BTCs. Liver transplantation and locoregional therapies are treatment modalities that may represent curative intent treatments for patients with unresectable disease, and larger explorations are warranted. Akin to HCC, a multidisciplinary team-based approach is essential for patients with BTCs. Through this narrative review of literature, we provide an overview of the current management of iCCA with perspectives regarding future directions in the clinical management of iCCA. We also present patient perspectives regarding the importance of patient advocacy and access to advances in clinical research for patients with BTCs.

A novel platinum(IV) prodrug, gramine-Pt(IV) enhances chemoimmunotherapy by activating cGAS-STING and modulating TGF-β-MHC-I axis

Platinum(II) (Pt(II)) drugs, such as cisplatin and oxaliplatin, played critical roles in cancer therapy; however, their efficacy is often limited by significant toxicity and the development of drug resistance. Recently, multi-target platinum(IV) (Pt(IV)) complexes, particularly those optimized with axial ligands, have emerged as promising alternatives enhancing tumor selectivity and drug stability. In this study, we synthesized a series of novel platinum(IV) prodrugs, gramine-platinum(IV), by incorporating gramine-a natural indole alkaloid that antagonizes TGF-β receptors I and II to inhibit the TGF-β signaling pathway-as an axial ligand. Among them, compound 8 (referred to as GP) was screened out to have the best antitumor activity. GP not only enhances the therapeutic efficacy of platinum(II) drugs but also targets TGF-β signaling. Our findings demonstrate that GP rapidly enters cells and preferentially accumulates in critical subcellular compartments, such as the nucleus and mitochondria, significantly amplifying its therapeutic impact. Notably, GP exhibits great tumor accumulation compared to cisplatin and oxaliplatin, with minimal uptake in normal tissues, highlighting its superior tumor specificity with reduced systemic toxicity. This unique characteristic enables GP to enhance therapeutic efficiency through multiple modalities, including strengthening DNA damage, reducing mitochondrial membrane potential, promoting apoptosis, and arresting cell cycle in the S phase. Moreover, GP activates the cyclic GMP-AMP synthase (cGAS)-stimulator of interferon genes (STING) signaling (cGAS-STING) pathway, enhancing antigen presentation and fostering robust anti-tumor immune responses. In mouse models of pancreatic and breast cancer, GP significantly inhibits tumor growth and triggers strong innate immune activation. By combining GP with anti-PD-1 therapy, immunotherapy-resistant tumors are rendered responsive, leading to a pronounced suppression of tumor growth. Overall, GP not only amplifies the DNA-damaging effects of platinum(II) drugs but also elicits durable immune responses, establishing itself as a promising chemo-immune-combined strategy for treating pancreatic and breast cancers.

Response to crizotinib in advanced intrahepatic cholangiocarcinoma with ZKSCAN1-MET fusion and MET amplification: case reports and literature review

Intrahepatic cholangiocarcinoma (ICC) is the second most prevalent liver cancer after hepatocellular carcinoma and is characterized by high malignancy and poor prognosis. Gemcitabine combined with cisplatin is the standard first-line therapy for metastatic or unresectable ICC. The combination of immunotherapy and targeted therapy represents a promising new direction for ICC treatment. Common genetic mutations in ICC include those in TP53, FGFR2, IDH1/2, and KRAS. MET alterations such as fusions and amplifications are rare in ICC. However, limited research has been conducted on the efficacy of specific MET inhibitors. We present two cases: the first with refractory ICC treated with a combination of immunotherapy and targeted therapy, harboring a ZKSCAN1-MET fusion and the second with a metastatic ICC with MET amplification. Both patients demonstrated a significant clinical response to crizotinib, a MET-specific tyrosine kinase inhibitor.

Cisplatin and temozolomide combinatorial treatment triggers hypermutability and immune surveillance in experimental cancer models

Hypermutation induced by mismatch repair (MMR) inactivation leads to immune surveillance in colorectal cancer (CRC) and in several other malignancies. We investigated the impact of a rationally designed chemotherapy combination on the generation of hypermutation and immunogenicity in otherwise immune-refractory CRC and breast cancer mouse models. Combinatorial treatment with cisplatin (CDDP) and temozolomide (TMZ) induces an adaptive downregulation of MMR, resulting in chemotherapy-dependent hypermutability and increase in predicted neoantigens. This combination specifically alters the immune fitness of the tumors, ultimately leading to CD8+ T cell-mediated immune surveillance, immunoediting of chemotherapy-induced neoantigens, and durable immunological memory. Treatment with CDDP and TMZ also remodels the innate immune microenvironment and induces long-lasting responses and complete rejections when combined with anti-PD-1 therapy in mice. The same effects are not observed using the clinically approved combination of 5-fluorouracil, oxaliplatin, and irinotecan (FOLFOXIRI). Treatment-induced hypermutation can enhance anti-tumor immune responses, offering additional avenues for cancer treatment.

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

INTRODUCTION

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

PATIENTS & METHODS

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

RESULTS

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

CONCLUSION

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

Single-cell analyses unravel ecosystem dynamics and intercellular crosstalk during gallbladder cancer malignant transformation

BACKGROUND

Gallbladder cancer (GBC) is a rare but aggressive malignancy, often detected late due to early asymptomatic stages. Understanding cellular and molecular changes from normal tissue to high-grade intraepithelial neoplasia (HGIN) and invasive GBC is vital for identifying early biomarkers and therapeutic targets.

METHODS

We performed single-cell RNA sequencing on 98,113 cells derived from 2 normal adjacent tissues (NAT), 2 HGIN, and 6 GBC samples. The cellular diversity and heterogeneity, particularly within epithelial and immune cell populations in NAT-HGIN-GBC, were investigated utilizing single-cell RNA sequencing, bulk RNA sequencing (bulk RNA-seq), and 10 machine learning methodologies. Furthermore, the intercellular crosstalk between epithelial cells and tumor immune microenvironment cells was examined and validated through multiplex immunofluorescence staining.

RESULTS

The constructed cell atlas elucidated alterations in the immune landscape across various states of NAT-HGIN-GBC, highlighting a more pronounced inhibitory immune microenvironment in GBC. The epithelial subtype TOP2A+ Epi is markedly elevated in GBC and is correlated with a poor prognosis. Key genes associated with this subtype may include GMNN, CYTOR, KLK6, and BIRC5. Similarly, immunosuppressive macrophages, identified as TOP2A+ Macro, also increase along the NAT-HGIN-GBC sequence and are linked to reduced patient survival. Furthermore, TOP2A+ Macro and CD8+ exhausted T cells (CD8+ Tex) engage in intercellular communication with epithelial TOP2A+Epi cells via the TWEAK/FN14 signaling pathway, thereby promoting tumor progression and immune evasion in GBC. The findings were further corroborated through multiplex immunofluorescence staining conducted on specimens from patients.

CONCLUSIONS

This study elucidates significant alteration in the cellular ecosystems and intercellular signaling within the tumor immune microenvironment across the NAT-HGIN-GBC sequence. It identifies TOP2A, TWEAK, and FN14 as potential biomarkers and therapeutic targets for GBC.

Long-Term Outcomes According to Surgical Margin in Mass-Forming Cholangiocarcinoma: The Role of R1vasc

BACKGROUND

R0 resection is the standard for mass-forming cholangiocarcinoma (MFCCC). R1vasc resection (tumor-vessel detachment) yielded results comparable to R0 and superior to parenchymal-tumor exposure (R1par) for hepatocellular carcinoma and colorectal liver metastases. This study aims to clarify R1vasc outcomes for MFCCC.

PATIENTS AND METHODS

Margin status of patients with MFCCC undergoing resection between 2008 and 2022 was assessed to determine the oncological efficacy of R1vasc regarding survival and hepatic recurrence.

RESULTS

The study analyzed 125 patients: 68 (54.4%) R0, 18 (14.4%) R1vasc, 24 (19.2%) R1par, and 15 (12.0%) R1vasc + par. Tumor size was similar between R0 (4.4 cm, range 1.5-19.0) and R1vasc (4.3 cm, range 2.3-14.5, p = 0.754) but larger for R1par (8.2 cm, range 2.5-15.0, p = 0.005) and R1vasc + par (9.0 cm, range 5.0-17.0, p < 0.001). The median overall survival (OS) was comparable for R0 [64.8 months; 95% confidence interval (CI): 50.0-79.6], R1vasc (54.4 months; 95% CI 19.6-89.2; p = 0.932), and R1vasc + par (62.0 months; 95% CI 35.6-88.5; p = 0.989). R1par showed lower OS (26.8 months; 95% CI 16.1-37.6; p = 0.134). Local recurrence was higher for R1par (45.8%, p < 0.0001) compared with R0 (10.3%) and similar for R1vasc (16.6%) and R1vasc + par (20.0%). Survival after hepatic recurrence was higher for R1vasc compared with R1par (p = 0.041).

CONCLUSIONS

R1vasc is a valid option for increasing resectability in patients with MFCCC, with OS being comparable to R0. R1vasc + par may be necessary for larger tumors.

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.

Molecular signatures of intrahepatic cholangiocarcinoma: role in targeted therapy selection

Cholangiocarcinoma is a highly lethal disease with a 5-year overall survival rate of 7-20%. A minority of patients present with resectable disease, and relapse rates remain high. Emerging data from next generation sequencing analysis have identified various actionable mutations which drive the different disease courses opening door to precision medicine and targeted therapies. This review focuses on the clinical significance of genetic alterations as well as the role of systemic therapies, immunotherapy and targeted therapies for intrahepatic cholangiocarcinoma.

Genomic landscape of biliary tract cancer and corresponding targeted treatment strategies

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

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.

Pathological complete response following addition of durvalumab to gemcitabine and cisplatin therapy for intrahepatic cholangiocarcinoma with Lynch syndrome-associated mismatch repair deficiency

A 64-year-old man with a history of surgery for rectal cancer and colon cancer was referred for a hepatic mass identified on computed tomography (CT). He was diagnosed with unresectable intrahepatic cholangiocarcinoma (ICC) with perihilar and para-aortic lymph node metastases. After 4 cycles of gemcitabine and cisplatin combination therapy (GC therapy), follow-up CT showed slight enlargement of the primary tumor and a slight increase in carbohydrate antigen (CA) 19-9. Genetic testing was performed during GC therapy based on the strong family history of cancer. Germline pathogenic variant in MLH1 was identified, leading to the diagnosis of Lynch syndrome (LS) with mismatch repair deficiency (dMMR: loss of MLH1/PMS2). Durvalumab was added to GC therapy following regulatory approval in Japan. A significant reduction in tumor size and CA19-9 was observed after only two cycles of GC and durvalumab therapy. Continuous improvement was observed, and conversion surgery involving liver resection, partial inferior vena cava resection, and perihilar and para-aortic lymph nodes dissection was performed with curative intent. No malignant cells were found in any of the resected specimens, consistent with pathological complete response.

Histopathologic Grading of Residual Tumor Predicts Survival of Intrahepatic Cholangiocarcinoma Patients Treated With Neoadjuvant Therapy: Major Pathologic Response and Its Clinical Significance

Neoadjuvant therapy (NAT) is increasingly used to treat patients with initially unresectable intrahepatic cholangiocarcinoma (iCCA). A histopathologic grading system for residual tumors that can predict patient survival is lacking in the literature. This retrospective study enrolled 151 iCCA patients who received NAT. The percentage of residual viable tumor (%RVT) extent was calculated by RVT surface area/total tumor bed area ×100 and scored in 5% increments. Kaplan-Meier and Cox regression analyses were used to investigate its correlations with recurrence-free survival (RFS) and overall survival (OS). Tumor regression grading by the College of American Pathologists (CAP) and MD Anderson (MDA) methodologies were also validated. A 10% RVT-based tumor regression score (TRS) showed a significant correlation with both OS and RFS. TRS and major pathologic response (mPR) were therefore defined as follows: TRS 1/mPR, tumor with 0 to 10% RVT; TRS 2, more than 10% RVT. Patients graded as TRS 1/mPR had superior OS ( P =0.006) and RFS ( P <0.001) compared with those with TRS 2 in univariate analysis. In a multivariate analysis including ypTNM stages, lymphovascular invasion, and perineural invasion, TRS 1/mPR was also found to be an independent prognostic factor for both OS (hazard ratio [HR]: 0.226; 95% CI: 0.053-0.966, P =0.045) and RFS (HR: 0.474; 95% CI: 0.231-0.974, P =0.042). As for the CAP and MDA grading methodologies, they were found to correlate with RFS (CAP: P =0.002; MDA: P =0.001), but not with OS (CAP: P =0.181; MDA: P =0.09). Our study revealed that a TRS of ≤10% RVT significantly correlates with longer OS and RFS and can be suggested as an mPR in iCCA. This indicator is easily applicable, prognostically relevant, and could be further validated in future prospective clinical trials.

Neoadjuvant treatment for incidental gallbladder cancer: A systematic review

Incidental gallbladder cancer (iGBC) diagnosed post-histopathological examination of gallbladders removed assuming benign gallstone disease constitutes a significant proportion of GBC patients. Most iGBC patients present with early-stage disease. The standard care for localized (non-metastatic) iGBC includes a reoperation for complete extended (radical) cholecystectomy involving liver resection and lymphadenectomy, followed by postoperative adjuvant systemic therapy. However, a major drawback of this approach is the high recurrence rate within six months post-radical surgery, which undermines the benefits of the extensive procedure; notably, most recurrences are distant, highlighting the efficacy of systemic therapy. Similar to other gastrointestinal cancers, there appears to be a potential for neoadjuvant systemic therapy (chemotherapy) before reoperative surgery in iGBC cases. The premise that neoadjuvant systemic therapy aids in selecting diseases with more favorable biological characteristics and addresses micro-metastatic disease appears applicable to iGBC as well. This systematic review examines the current evidence supporting or refuting neoadjuvant therapy and discusses criteria for selecting patients who would derive significant benefit, along with proposing an optimal chemotherapy regimen for iGBC patients. Improved outcomes have been reported in patients undergoing reoperation after 4 to 14 weeks following the initial cholecystectomy compared to immediate reoperation. Limited, yet promising, evidence supports the use of 3 to 4 cycles of gemcitabine-based neoadjuvant chemotherapy prior to reoperative surgery in select high-risk iGBC cases.

PD-1 monoclonal antibody (Tislelizumab)-induced DRESS syndrome in an intrahepatic cholangiocarcinoma patient with FGFR3 mutation and elevated IgG4:A case report

BACKGROUND

Immune-related adverse events (irAEs) include a rare, idiosyncratic but potentially life-threatening drug reaction with eosinophilia and systemic symptoms (DRESS), characterized by exanthem, fever, as well as hematologic and visceral organ involvement.

CASE PRESENTATION

We describe a 54-year-old man under the novel sequential treatment including all-trans retinoic acid (ATRA) and programmed death protein 1(PD-1) antibody (Tislelizumab) for advanced intrahepatic cholangiocarcinoma (iCCA). He was found to have Tislelizumab-induced DRESS syndrome during adjuvant therapy, and also showed the evidence of IgG4-related lymphadenopathy (IgG4-RLAD) as well as Epstein-Barr virus (EBV) infection in the absence of hemophagocytic lymphohistiocytosis (HLH) and T cell lymphoma. The patient's clinical status was successfully ameliorated through the administration of corticosteroids, intravenous immunoglobulin (IVIG), and antiviral agents, demonstrating a positive response to the treatment protocol. He was the first-ever case report of Tislelizumab-induced DRESS syndrome in the context of IgG4-RLAD with an exploration of potential mechanisms. Furthermore, we found that a somatic fibroblast growth factor receptor (FGFR) 3 p.P774L mutation at the frequency of 1.96 % was detected in his iCCA tissue.

CONCLUSION

These findings indicated that this novel therapy, based on ARTA and PD-1 antibody, is more effective and could guide the clinical application of PD-1 antibody in the iCCA patients with elevated IgG4. Human leukocyte antigen (HLA) typing assay might help to screen the potential susceptible individuals to avoid immune checkpoint inhibitors (ICIs)-induced DRESS syndrome.

Efficacy and safety of combining tislelizumab with capecitabine compared to capecitabine alone in the adjuvant treatment of biliary tract cancers: rationale and protocol design for a randomized clinical trial

BACKGROUND

Adjuvant therapy with capecitabine is recommended to improve survival for resectable biliary tract cancers (BTC) patients. Considering that the combination of PD-1/PD-L1 inhibitors with chemotherapy has demonstrated a survival benefit over chemotherapy alone in advanced stage BTC, we aim to evaluate the treatment efficacy and safety of tislelizumab, a PD-1 inhibitor, combined with capecitabine vs. capecitabine alone as an adjuvant treatment in patients with resectable BTC.

METHOD

This multicenter randomized controlled study will include a total of 140 patients who will have undergone curative resection within 4 weeks prior to enrollment and will have been pathologically diagnosed with cholangiocarcinoma (including intrahepatic and extrahepatic cholangiocarcinoma) or muscle-invasive gallbladder carcinoma. Those patients will be randomly assigned 1:1 to tislelizumab combined with capecitabine or capecitabine alone group. The primary endpoint will be recurrence free survival (RFS), the secondary endpoints will be overall survival (OS) and adverse events (AEs). Multi-omics biomarkers will be assessed as exploratory objective.

DISCUSSION

There remains a major unmet need for more effective adjuvant therapies for resectable BTC. If this study demonstrates that adding tislelizumab enhances the therapeutic efficacy of capecitabine, this combined regimen will potentially improve the prognosis of patients with resectable BTC. In addition, we will analyze the relationship between various gene expression profiles and clinical endpoint events to define the ideal patient population receiving adjuvant immunotherapy.

Laparoscopic Extended Segmentectomy 8 with Right Hepatic Vein Resection After Conversion Therapy for Advanced Intrahepatic Cholangiocarcinoma

BACKGROUND

Most patients with intrahepatic cholangiocarcinoma (ICC) are diagnosed at advanced stages and are thus ineligible for surgery. Recently, a combination of immunotherapy, chemotherapy, and lenvatinib has shown promising results for treating advanced ICC.1-3 Laparoscopic anatomical liver resection of segment 8 remains challenging.4,5 We present a case of advanced ICC treated with durvalumab, gemcitabine plus oxaliplatin (GEMOX), and lenvatinib, followed by laparoscopic extended segmentectomy 8 using indocyanine green (ICG) fluorescent staining.

METHODS

A 54-year-old patient was found to have a hepatic tumor in segment 8, with invasion into the right hepatic vein and multiple enlarged lymph nodes, confirmed by abdominal computed tomography (CT). After six cycles of conversion therapy, partial response was achieved. The patient then underwent laparoscopic extended segmentectomy 8 and right hepatic vein resection. Preoperative planning with three-dimensional (3D) reconstruction, along with intraoperative ultrasonography and ICG-guided fluorescent staining, greatly enhanced the precision and success of the surgery.

RESULTS

The operation lasted 220 min with an estimated blood loss of 800 mL. The Pringle maneuver was performed intermittently six times for a total of 85 min. The patient was discharged on the 12th postoperative day without complications. Postoperatively, the patient received adjuvant therapy with durvalumab and capecitabine, 6 achieving recurrence-free survival for over 6 months.

CONCLUSIONS

Cases of patients with advanced ICC undergoing surgical resection after immunotherapy and chemotherapy are rare. The combination of GEMOX, durvalumab, and lenvatinib showed promising antitumor efficacy and safety, suggesting its potential as a feasible and safe conversion therapy for advanced ICC.

Targeting GPX4 to Induce Ferroptosis Overcomes Chemoresistance Mediated by the PAX8-AS1/GPX4 Axis in Intrahepatic Cholangiocarcinoma

The standard regimen of gemcitabine combined with cisplatin offers limited clinical benefits in the treatment of advanced intrahepatic cholangiocarcinoma (ICC) due to intrinsic or acquired resistance. Currently, effective biomarkers to predict and improve chemotherapy resistance in ICC are lacking. Here, it is reported that a long non-coding RNA (lncRNA), PAX8-AS1, reduces the efficacy of standard chemotherapeutic drugs. Mechanistically, PAX8-AS1 activates NRF2 by binding to p62, thereby promoting GPX4 transcription, and stabilizes GPX4 mRNA through interaction with IGF2BP3. The PAX8-AS1/GPX4 axis inhibits ferroptosis and promotes resistance to gemcitabine and cisplatin. In preclinical models, the combination of the GPX4 inhibitor JKE-1674 with gemcitabine and cisplatin exhibits superior antitumor efficacy. These findings suggest a promising therapeutic strategy to improve chemotherapy efficacy in advanced ICC.

Hepatic arterial infusion chemotherapy (HAIC) plus Lenvatinib and PD-1 inhibitors versus systemic chemotherapy for unresectable intrahepatic cholangiocarcinoma

BACKGROUND

Unresectable intrahepatic cholangiocarcinoma (iCCA) is characterized with dismal prognosis. Here, this study aimed to compare the efficacy and safety of hepatic arterial infusion chemotherapy (HAIC) combined with lenvatinib and PD-1 inhibitors versus systemic chemotherapy (SC) for unresectable iCCA.

METHODS

Patients with histologically confirmed unresectable iCCA from January 2020 to December 2022 at our center were retrospectively enrolled. Propensity score matching (PSM) method was used to balance clinicopathological information between two groups. The primary endpoints were overall survival (OS), progression-free survival (PFS), whereas the secondary endpoints included objective response rate (ORR), disease-control rate (DCR) and safety profiles. Factors affecting the survival were identified through univariate and multivariate analyses.

RESULTS

Eighty-six cases were included in this study. After PSM, there were 30 patients in each group. Compared to SC group, HAIC + Len + PD-1 inhibitor exhibited significantly improved OS (16.91 [95%CI: 11.6-28.4] months vs. 11.06 months [95%CI: 7.8-14.6 months], p = 0.011), PFS (11.17 months [95%CI: 7.0, 26.7] vs. 5.55 months [95%CI: 3.8, NA], p = 0.004), better ORR (56.7% vs. 23.3%, p = 0.008) and DCR (93.3% vs. 70.0%, p = 0.019). Multivariate analysis indicated that treatment arm of SC was a risk factor of worse OS and PFS, while uni-lobe tumor distribution, AST ≤ 40, CA19-9 level ≤ 39 were protective factors of worse OS. All adverse events were comparable and controllable between two groups.

CONCLUSIONS

In conclusion, HAIC combined with lenvatinib and PD-1 blockade yields better tumor control and survival outcomes over SC for unresectable iCCA, with manageable adverse events as well.

Durvalumab plus chemotherapy in advanced biliary tract cancer: 3-year overall survival update from the phase III TOPAZ-1 study

BACKGROUND

At the TOPAZ-1 (NCT03875235) primary analysis, durvalumab plus gemcitabine and cisplatin (GemCis) significantly improved overall survival (OS) in advanced biliary tract cancer (aBTC). We report updated exploratory analyses of OS and safety, characterisation of extended long-term survivors (eLTS), and subsequent anticancer therapy (SAT) use.

METHODS

Participants with aBTC received durvalumab+GemCis or placebo+GemCis every 3 weeks (≤8 cycles), then durvalumab or placebo monotherapy every 4 weeks until progressive disease or other discontinuation criteria were met. OS and serious adverse events (SAEs) were assessed in the full analysis and safety analysis sets (FAS/SAS), respectively. eLTS outcomes were assessed (FAS participants alive ≥30 months after randomisation).

RESULTS

685 participants were randomised: durvalumab+GemCis (n = 341); placebo+GemCis (n = 344). After a median 41.3 (95% confidence interval [CI] 39.3-44.1) months' follow-up in all participants, median OS (95% CI) for durvalumab+GemCis versus placebo+GemCis was 12.9 (11.6-14.1) versus 11.3 (10.1-12.5) months (hazard ratio, 0.74 [95% CI 0.63-0.87]); 36-month OS rate was 14.6% versus 6.9%, respectively. In participants who achieved disease control (566/685; 82.6%), the 36-month OS rate was higher for durvalumab+GemCis (17.0%) versus placebo+GemCis (7.6%). Overall, 12.8% were eLTS, with more eLTS in the durvalumab+GemCis (17.0%) versus placebo+GemCis (8.7%) arms; eLTS included all clinically relevant subgroups. Durvalumab+GemCis improved OS regardless of SAT use. In eLTS, SAEs were comparable between arms and less frequent than in the full SAS.

CONCLUSIONS

Survival benefit and manageable safety continued with durvalumab+GemCis versus placebo+GemCis approximately 3 years after the last participant was randomised. All clinically relevant subgroups were represented in eLTS, supporting standard-of-care status for durvalumab+GemCis in aBTC.

LAY SUMMARY

The TOPAZ-1 study found that treatment with durvalumab plus gemcitabine and cisplatin (chemotherapy, also known as GemCis), helped people with advanced biliary tract cancer (BTC) to live longer on average than those treated with a placebo plus GemCis. The latest results from TOPAZ-1 showed that these benefits continued for over 3 years in participants treated with durvalumab plus GemCis and side effects continued to be manageable. At an updated analysis, carried out 3 years after the last participant started the study, twice as many participants treated with durvalumab plus GemCis were alive compared to those treated with placebo plus GemCis. Results also showed that the positive effect of durvalumab plus GemCis compared with placebo plus GemCis was not affected by the use of other therapies some participants received after they finished the study treatment. These results continue to support durvalumab plus GemCis as a standard first-line treatment for people with advanced BTC.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03875235; https://clinicaltrials.gov/study/NCT03875235.

Haematological toxicities with immune checkpoint inhibitors in digestive system tumors: a systematic review and network meta-analysis of randomized controlled trials

This study aims to comprehensively evaluate the hematologic toxicity profiles, toxicity spectrum, and safety rankings of immune checkpoint inhibitors (ICIs) used for digestive system tumors. The PubMed, Cochrane Library, Web of Science, and Embase databases were systematically searched from inception to August 2024 to identify randomized controlled trials (RCTs). The primary outcome was anemia, while secondary outcomes included neutropenia, neutrophil count decreased, thrombocytopenia, platelet count decreased, leukopenia, white blood cell (WBC) count decreased, lymphocyte count decreased, and febrile neutropenia (FN). Subgroup analyses were performed based on tumor type, country category, study phase, ICI regimen, control group, chemotherapy regimen, ICI plus different chemotherapy regimens. Two reviewers independently selected the studies, extracted data according to pre-specified criteria, and assessed the risk of bias using the Cochrane Collaboration risk of bias tool. RevMan 5.4 software was utilized to visualize the risk of bias assessments. Stata 16.0 was used to conduct network meta-analysis, sensitivity analysis and meta-regression. 25 phase II and III RCTs (n = 15216) were included. The general safety of ICIs ranked from high to low for grade 1-5 anemia were as follows: avelumab, nivolumab, pembrolizumab, sintilimab, camrelizumab, and tislelizumab. For grade 3-5 anemia, the general safety profile of the ICIs were as follows, from highest to lowest: avelumab, nivolumab, pembrolizumab, sintilimab, and camrelizumab. Compared to chemotherapy, treatment-related hematologic toxicities with ICIs occurred primarily in grade 1-5 anemia, neutropenia, thrombocytopenia, leukopenia, and WBC count decreased. Taking ICI monotherapy, nivolumab plus ipilimumab were generally safer than taking chemotherapy, one ICI drug with chemotherapy, or two ICI drugs with chemotherapy. In terms of grade 1-5 hematologic toxicities, tislelizumab had the highest risk of neutropenia and leukopenia; the primary treatment-adverse events (AEs) for sintilimab was neutrophil count decreased and WBC count decreased; the primary treatment-related AE associated with nivolumab was platelet count decreased; camrelizumab posed the highest risk for lymphocyte count decreased. In terms of grade 3-5 hematologic toxicities, pembrolizumab was predominantly linked to neutropenia; sintilimab showed the greatest risk for neutrophil count decreased, platelet count decreased, and lymphocyte count decreased; avelumab was most associated with WBC count decreased. FN primarily manifested as grade 3-5, with camrelizumab having the highest risk. Among agents used in gastric or gastroesophageal junction cancer, avelumab demonstrated the most favorable safety profile for anemia. Each treatment regimen has its unique safety profile. Early identification and management of ICI-related hematologic toxicities are essential in clinical practice.Systematic Review Registration: PROSPERO CRD42024571508.

Investigation of neoadjuvant gemcitabine plus cisplatin-based triplet regimens on biliary tract cancer with possible lymph node metastasis

INTRODUCTION

Biliary tract cancer (BTC) is rare. The treatment outcomes in patients with lymph node (LN) metastasis diagnosed by FDG-PET or a biopsy-who are considered to be 'biologically borderline resectable'-are poor. However, perioperative treatment is still under development. Recently, gemcitabine plus cisplatin (GC)-based triplet regimens for unresectable BTC have been developed. We applied GC-based triplet therapy in BTC with LN metastasis.

METHODS

We administered GC plus S-1 therapy (GCS) or nab-paclitaxel therapy (GCnP) to 30 patients with LN metastasis diagnosed by FDG-PET or a biopsy (GC-based triplet group). A dataset of BTC with FDG-positive LNs, previously used for an analysis of the diagnosis and treatment outcomes according to FDG uptake, was used as a control (upfront surgery group, n = 19).

RESULTS

GCS and GCnP were used by 22 and 8 patients, respectively. The median treatment period was 79 days, the objective response rate was 47 %, the tumor control rate was 87 %, and 22 patients underwent R0 resection (73 %). The groups showed no significant differences with the exception of the FDG uptake by the main tumor. The three-year overall survival (OS) rates in the GC-based triplet and upfront surgery groups were 45.4 % and 15.8 %, respectively (P = 0.0052); there were no significant differences in progression-free or recurrence-free survival. A sub-analysis showed that normalized CA19-9 levels provided better survival than non-normalized CA19-9 levels.

CONCLUSION

Neoadjuvant GC-based triplet regimens could provide survival benefits in BTC with LN metastasis diagnosed by FGD-PET or a biopsy. CA19-9 normalization may be useful for indicating surgery.

Genomic profiling unlocks new treatment opportunities for ampullary carcinoma

BACKGROUND

Ampullary carcinoma (AC) is a rare disease with an abysmal prognosis and few treatment options. The molecular landscape and its therapeutic implications remain inadequately understood. This study aims to provide a clinical and genomic characterization of AC and explore opportunities for precision oncology.

MATERIALS AND METHODS

We carried out a retrospective analysis of clinical and genomic features in patients with AC treated in our institution. Gene mutations were categorized into molecular pathways, and potentially targetable alterations were classified according to the European Society for Medical Oncology (ESMO) Scale for Clinical Actionability of Molecular Targets (ESCAT). Key molecular findings were validated in an external cohort.

RESULTS

We included 78 patients with a median age of 66 years; 51.6% were women, and most were treated with surgery (81.2%). Histologically, they were classified as pancreaticobiliary (58.3%), intestinal (INT, 33.3%), and mixed (8.3%). The percentages of patients diagnosed at stages I, II, III, and IV disease were 18.8%, 23.4%, 32.8%, and 25.0%, respectively. Of note, the INT subtype was enriched in transforming growth factor-β pathway alterations (25.9% versus 6.1%, P = 0.03). Potentially actionable molecular alterations were found in 52% of the patients. Importantly, KRASWT tumors were enriched in potentially targetable alterations ESCAT I-IIIA both in our cohort (37.2% versus 9.4%, P = 0.006) and external validation cohort (23.0% versus 9.3%, P = 0.01), including 25.6% ERBB2 amplification/mutation, 14.0% homologous recombination deficiency status, and 7.4% microsatellite instability status. Six patients received matched targeted therapies after progression to chemotherapy, with a response rate of 50% and two patients surviving for >1 year.

CONCLUSIONS

AC patients are enriched in targetable alterations, especially KRASWT tumors, and could particularly benefit from precision oncology-based approaches.

Global burden and cross-country inequalities in gallbladder and biliary tract cancer (1990-2021) with projections to 2050: insights from the global burden of disease study 2021

Background

Gallbladder and biliary tract cancer (GBTC) presents a worldwide health challenge with a poor prognosis. Previous studies indicated an escalating burden and potential health inequalities, necessitating an updated investigation.

Methods

This study utilized data from the Global Burden of Disease (GBD) study, covering 204 countries from 1990 to 2021. Joinpoint regression evaluated temporal trends in age-standardized incidence rates (ASIR) and age-standardized disability-adjusted life years rates (ASDR) for GBTC. The Bayesian age-period-cohort (BAPC) model projected disease burden up to 2050. Inequality analysis assessed disparities by genders across countries, and decomposition analysis determined the contributions of demographic and epidemiological factors.

Results

From 1990 to 2021, the incident cases of GBTC increased from 107,797 to 216,768, while Disability-Adjusted Life Years (DALYs) rose from 2,326,089 years to 3,732,121. Joinpoint regression analysis revealed a global decrease in ASIR (AAPC = -0.39, 95% CI: -0.49 to -0.28) and ASDR (AAPC = -0.97, 95% CI: -1.07 to -0.88). Gender disparities were notable, with a polar reversal observed: females exhibited consistently higher ASDR levels across three decades, although both ASDR and ASIR showed continuous decreases. In contrast, males experienced a decreased ASDR but increased ASIR, with both metrics eventually surpassing those of females. The projection model also suggested diverging ASIR trends between genders. Cross-country inequality analysis revealed persistent disparities, where higher SDI countries continue to bear a greater burden, and global improvement in health equity for males remains insufficient. Decomposition analysis indicated that population growth and ageing were primary drivers of disease burden increase, whereas epidemiological changes contributed to a reduction, particularly in higher SDI quintiles.

Conclusion

Despite improvements, GBTC burden is still greater in high SDI regions compared to lower SDI areas, contrary to expectations. Unexpected polar reversal of gender differences warrants further attention.

MDM2 as a therapeutic target in advanced biliary tract cancers

Biliary tract cancers (BTCs) are a heterogeneous group of tumors arising from cells in the bile ducts and gallbladder. The 5-year overall survival rate for all BTC stages combined is ~20%, and treatment options for patients with unresectable disease are limited, leaving an unmet clinical need. In recent years, significant efforts have been made to refine and implement targeted therapeutic approaches for patients with BTC. The adoption of early and comprehensive molecular profiling is crucial to identifying patients who may be candidates for effective targeted therapies. Characterization of the molecular landscape of BTCs led to the identification of murine double minute 2 homolog gene (MDM2) amplification across all BTC subtypes. The MDM2 protein is a critical negative regulator of p53 stabilization and activity that is an emerging actionable biomarker in BTCs. There are multiple therapeutic approaches that aim to target MDM2 activity, thereby restoring the intrinsic tumor suppressor function of p53 and halting oncogenesis. However, these have been limited by our evolving understanding of the role of MDM2 in BTC pathogenesis. Here, we offer a review of the current understanding of the role of MDM2 in BTC biology and its therapeutic implications.

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.

Development and optimization of Eva1 (MPZL2) targeting chimeric antigen receptor T cells

BACKGROUND

Whereas chimeric antigen receptor gene modified T (CAR-T) cell therapy has been clinically applied to malignant lymphomas and multiple myeloma, CAR-T cell therapy for solid tumors has so far not reached clinical application. Epithelial V-like antigen 1 (Eva1), transcribed from myelin protein zero-like 2 (MPZL2), is a small surface protein highly expressed on various tumor cells. We selected Eva1 as a novel solid tumor-target antigen because of its broad expression across various tumor types. The purpose of the present study is to develop and optimize CAR-T cells targeting Eva1.

METHOD

We prepared various humanized single chain variable fragment sequences based on a mouse anti-human Eva1 monoclonal antibody. We constructed six humanized Eva1CAR-Ts and selected one that maintained specificity and good cellular proliferation after antigen stimulation. We further optimized the length of the extracellular spacer domain and the choice of the intracellular domain in vitro and in two different xenograft mouse models.

RESULTS

We confirmed Eva1 expression on various tumor cell lines by flow cytometry and analysis of public database, but we also observed that normal monocytes weakly expressed Eva1. A combination of short spacer domain and 4-1BB or CD79A/CD40 intracellular domain provided higher treatment efficacy both in vitro and in vivo. The cytokine release on autologous monocyte stimulation to Eva1CAR-T cells was comparable to that on autologous B cell stimulation to CD19CAR-T cells. Humanized Eva1CAR-T cells demonstrated excellent therapeutic efficacy by infusing a single dose of Eva1CAR-T cells (1×106) in both NCI-H1975 lung cancer and CFPAC-1 pancreatic cancer cell line grafted model.

CONCLUSIONS

In summary, these data suggest that humanized Eva1CAR-T has promising therapeutic potential for the treatment of various Eva1-positive solid tumors. Regarding on-target/off-tumor recognition, further detailed analyses of the Eva1CAR-T cell responses to normal tissues are needed.

New platinum derivatives selectively cause double-strand DNA breaks and death in naïve and cisplatin-resistant cholangiocarcinomas

BACKGROUND & AIMS

Patients with cholangiocarcinoma (CCA) have poor prognosis. Current cisplatin-based first-line chemotherapy offers limited survival benefits. Cisplatin induces single-strand DNA breaks, activating DNA repair mechanisms that diminish its effectiveness. Here, we present the design, chemical synthesis, and therapeutic evaluation of a new generation of chemotherapeutic agents (Aurkines) with unique polyelectrophilic properties. These agents cause a high frequency of double-strand DNA breaks, bypassing DNA repair, and promoting cancer cell death.

METHODS

Two novel compounds, Aurkine 16 and Aurkine 18, were designed and evaluated for their antitumor effects in both naïve and cisplatin-resistant CCA cells, cancer-associated fibroblasts (CAFs), healthy cholangiocytes, and in vivo models.

RESULTS

Aurkines effectively induced double-strand DNA breaks, leading to increased DNA damage and elevated levels of reactive oxygen species, resulting in greater cytotoxicity than cisplatin in CCA cells. Phosphoproteomic and molecular analysis revealed that cisplatin activates DNA repair pathways, while Aurkines primarily induce apoptosis. Importantly, Aurkines also triggered apoptosis in cisplatin-resistant CCA cells and CAFs without harming healthy cholangiocytes. Additionally, Aurkines demonstrated cytotoxicity in other cisplatin-resistant cancers, such as breast and ovarian cancer. This tumor selectivity results from reduced uptake, increased efflux, and compact chromatin structure in normal cells, limiting Aurkine-DNA interactions. In vivo, Aurkines inhibited the growth of subcutaneous naïve and cisplatin-resistant CCA tumors, as well as orthotopic tumors in immunocompetent mice promoting antitumor immune cell recruitment, without any adverse events. Transport studies revealed that Aurkines were selectively taken up by OCT1, OCT3, CTR1, and OATP1A2, whereas only CTR1 transported cisplatin.

CONCLUSIONS

Aurkines represent promising therapeutic drugs for both naïve and cisplatin-resistant cancers due to their unique polyelectrophilic properties and selective targeting of malignant cells.

IMPACT AND IMPLICATIONS

This study introduces a novel therapeutic strategy designed to induce frequent double-strand DNA breaks selectively in both naïve and cisplatin-resistant cancer cells, without evident toxic side effects at therapeutic doses. This approach may settle the basis for new strategies to overcome the critical challenge of drug resistance in cancer treatment, and has the potential to be a breakthrough not only for the treatment of biliary tumors but also for other cancers.

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

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

SENP3 induced HADHA deSUMOylation enhances intrahepatic cholangiocarcinoma chemotherapy sensitivity via fatty acid oxidation

Chemoresistance contributes to poor outcomes in patients with intrahepatic cholangiocarcinoma (ICC). This study aimed to explore the mechanisms underlying chemotherapy resistance and to develop strategies that can sensitize the chemotherapy. Patient derived organoids (PDOs) drug screening and Lipidomics profiling were performed to investigate the chemoresistance mechanism. Through multi-strategy analysis, we found that SENP3 enhanced chemotherapy sensitivity in a SUMO system dependent manner. Mechanistically, chemotherapy resistance increased METTL3 expression, which regulated SENP3 mRNA stability through YTHDF2-dependent m6A methylation modifications. SENP3 interacted with HADHA and catalyzed its deSUMOylation at two lysine residues. Specifically, SUMOylation and ubiquitination exhibited crosstalk at the same modification sites on HADHA, influencing its protein stability and, consequently, regulating fatty acid oxidation (FAO) levels. The physical interaction of SENP3, HADHA, and USP10 provides a novel molecular mechanism for the abnormal activation of FAO pathway. The lipid metabolism-targeting drug could be a promising therapeutic strategy for sensitizing ICC to chemotherapy.

Molecular Testing and Targeted Therapies in Hepatobiliary Cancers: A Review

Importance

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

Observations

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

Conclusions and Relevance

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

New frontiers in the pharmacological management of biliary tract carcinomas: the emerging role of drug conjugates

INTRODUCTION

Biliary tract cancer (BTC) is a human malignancy with a poor prognosis. However, significant progress has been made in understanding the molecular mechanisms of carcinogenesis, leading to the development of targeted therapy strategies in recent years. The challenge now is to develop new therapeutic concepts to further increase the efficacy of BTC treatments in the coming years.

AREAS COVERED

This review covers the emerging and advanced approaches of highly sophisticated antibody-drug conjugates (ADCs) and non-ADCs, particularly in relation to BTC. Additionally, the potential advantages and disadvantages of ADCs and non-ADCs regarding toxicities, bioavailability, and efficacy are presented and discussed.

EXPERT OPINION

Given the poor prognosis of BTCs, new targeted and precision therapy strategies using drug conjugates - with and without antibodies as drug carriers - have the potential to overcome the limitations of conventional chemotherapy by improving treatment specificity and efficacy while reducing systemic toxicity. However, several open questions remain regarding ADCs and non-ADCs, including chemical design, drug delivery, related diagnostic and therapeutic biomarkers, and combinatory application strategies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION ID (PROSPERO)

CRD42024627459.

Real-world outcomes of fluorouracil-based second-line therapy in patients with advanced biliary tract cancer refractory to gemcitabine and cisplatin-based treatment

Background

The prognosis for patients with advanced biliary tract cancer (BTC) who have not responded to gemcitabine and cisplatin (GP)-based therapy is dismal. Fluorouracil (5-FU)-based chemotherapy could be considered for those patients who are refractory to GP-based treatments. Our study aimed to evaluate the real-world efficacy and safety of 5-FU-based chemotherapy for BTC patients who had progressed after gemcitabine-based treatment.

Methods

This study analyzed patients from Seoul St. Mary's Hospital and St. Vincent's Hospital with advanced BTC who had previously failed treatment with GP-based chemotherapy. From June 2020 and May 2024, these patients received 5-FU-based chemotherapy as a second-line treatment. The 5-FU-based systemic treatments encompassed 5-FU, leucovorin, and oxaliplatin (FOLFOX); 5-FU, leucovorin, and liposomal irinotecan (Nal-IRI/FL); and 5-FU, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX). Our investigation focused on evaluating the survival outcomes and safety profiles of each regimen within this cohort.

Results

In our analysis of 147 patients, the primary tumor sites were distributed with 56 (38.1%) having intrahepatic cholangiocarcinoma, 51 (34.7%) with extrahepatic cholangiocarcinoma, and 40 (27.2%) with gallbladder cancer. Regarding the 5-FU-based regimens, 57 patients (38.8%) were treated with FOLFOX, 56 (38.1%) with Nal-IRI/FL, and 34 (23.1%) with FOLFIRINOX. The median progression-free survival (PFS) and overall survival (OS) were 2.3 months (95% confidence interval (CI), 2.0-2.6) and 4.8 months (95% CI, 3.8-5.8), respectively. Poor performance status and higher histologic grade were associated with worse PFS and OS, while female gender and prior surgery were linked to improved OS. FOLFOX and Nal-IRI/FL demonstrated comparable efficacy, with a median OS of 5.4 months (95% CI, 3.5-7.3) for FOLFOX and 4.7 months (95% CI, 2.6-6.9) for Nal-IRI/FL, and no significant differences were observed across subgroups. Grade 3 or higher neutropenia and biliary events were less frequent with FOLFOX, which also showed a lower incidence of adverse events and higher relative dose intensity than Nal-IRI/FL or FOLFIRINOX.

Conclusion

In patients with advanced BTC who failed GP treatment, the FOLFOX regimen demonstrated comparable efficacy, and a more favorable safety profile compared to other 5-FU-based treatments. Given its favorable toxicity profile in a real-world setting, FOLFOX should be considered a standard second-line treatment option.

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.

Diagnostic Yield of a Novel 11-Fr Digital Cholangioscope for Indeterminate Biliary Disease Using Macroscopic-On-Site Evaluation: Prospective Comparative Study

BACKGROUND AND AIM

A novel 11-Fr digital cholangioscope (eyeMAX) has recently become available. However, a prospective comparative study of the diagnostic yield of the eyeMAX and of a conventional cholangioscope (SpyGlass DS II) has not been reported. Therefore, the aim of this study was to prospectively compare the diagnostic yield of the eyeMAX and of the SpyGlass DS II for indeterminate biliary disease.

PATIENTS AND METHOD

Forceps biopsy was repeated until visible core tissue was obtained. The primary outcome of this study was the diagnostic accuracy of the biopsy specimens obtained by the eyeMAX. The secondary outcomes were comparisons of the diagnostic yield of visual findings, tissue size, number of forceps biopsies until MOSE positivity, and adverse events.

RESULTS

Fifty patients were prospectively enrolled in the eyeMAX group. And 47 patients in the SpyGlass DS II group were enrolled as a historical control. The number of biopsies was significantly fewer in the eyeMAX group than in the SpyGlass DS II group (p = 0.001). Tissue size was larger in the eyeMAX group (2.96 ± 0.69 mm2) than in the SpyGlass DS II group (1.80 ± 1.61 mm2). The diagnostic accuracy was also higher in the eyeMAX group (96.0%, 48/50) than in the SpyGlass DS II group (80.9%, 38/47). The diagnostic accuracy for the final diagnosis was slightly higher in the eyeMAX group (93.5%, 47/50) than in the SpyGlass DS II group (89.3%, 42/47).

CONCLUSIONS

The eyeMAX has a favorable diagnostic yield in terms of visual findings and the forceps biopsy specimen.

TRIAL REGISTRATION

000049465.

A Randomized Study of Consolidation Chemoradiotherapy Versus Observation After First-line Chemotherapy in Advanced Gallbladder Cancers: RACE-GB study

PURPOSE

Chemotherapy (CT) is the standard of care for patients presenting with unresectable advanced gallbladder carcinoma (GBC) but their prognosis remains poor. The value of consolidation CT and radiation therapy (RT) after initial CT is uncertain. We, therefore, conducted a single-center open-label randomized trial evaluating consolidation CTRT versus observation after 4 cycles of CT in patients whose disease did not progress during CT (partial responders/stable disease).

METHODS AND MATERIALS

Responders to 4 cycles of CT were randomized (1:1) to CTRT versus observation (n = 135). CTRT was delivered using 3-dimensional-conformal RT (Field in the field when required) along with concurrent capecitabine. The dose of RT was 45 Gy in 25 fractions to GBC and lymphatics followed by a boost of 9 Gy in 5 fractions to the GBC. The primary endpoint was overall survival (OS) which was calculated from the date of randomization.

RESULTS

A total of 67 patients were randomized to observation and 68 to CTRT. Consolidation CTRT led to an improvement in median OS from 4 to 10 months (hazard ratio, 0.43; 95% CI, 0.32-0.62; P < .001). The actual median OS from accrual was 7 months (95% CI, 6.114-7.88 months) versus 13 months (95% CI, 11.13 -14.84 months). Adverse events (grade 3 or higher) because of CTRT were nausea (3%), anemia (9%), gastrointestinal bleeding (5.8%), and hepatotoxicity (13%). Functional Assessment of Cancer Therapy-General score and the Functional Assessment of Cancer Therapy-Hepatobiliary score did not deteriorate because of CTRT compared with observation (P values, .053 and .097).

CONCLUSIONS

To our knowledge, this is the first-ever randomized study in a low-middle-income country setting to demonstrate that consolidation CTRT significantly prolonged OS without deterioration in quality of life and should be the alternative standard of care in advanced unresectable GBC.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

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.

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

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

Pathological Complete Response after Pembrolizumab Treatment for Unresectable Perihilar Cholangiocarcinoma with High Microsatellite Instability: A Case Report

INTRODUCTION

Pembrolizumab has been introduced to solid cancers with microsatellite instability (MSI)-high cases; however, its clinical experience for cholangiocarcinoma remains very limited. Here, we present a case who successfully underwent conversion surgery following pembrolizumab treatment for MSI-high perihilar cholangiocarcinoma, which pathologically exhibited complete response.

CASE PRESENTATION

A 69-year-old male with Bismuth IV perihilar cholangiocarcinoma with bulky lymphadenopathy was referred, who initially required left hepatic trisectionectomy, caudate lobectomy, bile duct resection, and portal vein resection and reconstruction (H123458-B-PV). During the waiting period after preoperative portal vein embolization, the right hepatic artery was involved by rapid tumor progression, needing a modification of the initially scheduled surgical procedure to additional hepatic artery resection and reconstruction (H123458-B-PV-HA). We revised the surgical decision of resectable to locally unresectable disease. He received systemic chemotherapy with gemcitabine and cisplatin as first-line, showing the best effect of stable disease followed by slight tumor progression and re-elevation of tumor marker after 5 courses of treatment. Cancer multi-gene panel analysis using percutaneous biopsy specimen showed the nature of MSI-high. Therefore, he received pembrolizumab treatment as second-line therapy, leading to a drastic downsize >30% in tumor diameter and normalization of the tumor marker as well after only 2 cycles of administration. After confirmation of keeping tumor shrinkage during 22 courses of pembrolizumab treatment without any severe adverse events, we decided to perform conversion surgery and performed left trisectionectomy, caudate lobectomy, and bile duct resection with portal vein resection (H123458-B-PV). Although the right hepatic artery was extensively fibrotic, there was no evidence of malignancy by frozen section histologic diagnosis. The pathological findings showed pathological complete response with no residual tumor cells. The patient is under periodical checkup without adjuvant chemotherapy, and no tumor recurrence was observed at 4 months postoperatively.

CONCLUSIONS

We experienced clinical partial response but pathological complete response after second-line pembrolizumab treatment for unresectable locally advanced perihilar cholangiocarcinoma with a biologic nature of MSI-high. Conversion surgery may be considered as a promising option for such effective case, whereas there is a possibility to avoid resection in the MSI-high setting.

Cost-effectiveness analysis of pembrolizumab plus chemotherapy as first-line treatment for advanced biliary tract cancer: perspectives from US and Chinese payers

BACKGROUND

The KEYNOTE-966 study demonstrated that pembrolizumab combined with chemotherapy is more effective than chemotherapy alone as first-line treatment for patients with advanced biliary tract cancer (BTC). However, the cost-effectiveness of pembrolizumab combined with chemotherapy in the USA and China remains uncertain.

OBJECTIVE

This study aimed to evaluate the cost-effectiveness of pembrolizumab plus chemotherapy compared with placebo plus chemotherapy from the perspective of US and Chinese payers.

DESIGN

Markov models with three health states were developed to simulate the process of advanced BTC. Cost data were obtained from available databases and published literature in the US scenario, and from local institutions from the China scenario. Utility values were derived from previous studies.

OUTCOME MEASURES

Primary outcomes included quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs).

RESULTS

In the US scenario, pembrolizumab plus chemotherapy increased costs by US$97,222.13, compared with chemotherapy alone, with a gain of 0.12 QALYs, resulting in an ICER of US$810 184.42 per QALY. In the China scenario, the ICER was $360 933.50 per QALY. Sensitivity analyses indicated the costs of pembrolizumab had the greatest impact on the model in both scenarios. Further analyses suggested that the optimal price of pembrolizumab in the USA would be nearly US$10.33 /mg, while a price reduction of over 90% would be required for the combined therapy to be cost-effective for patients in China.

CONCLUSION

Based on the willingness-to-pay threshold set at three times the gross domestic product per capita, pembrolizumab plus chemotherapy is not a cost-effective option for patients with advanced BTC in either the USA or China. Significant price reduction for pembrolizumab may be necessary to achieve an acceptable ICER.

TRIAL REGISTRATION NUMBER

NCT04003636; postresults.

Adjuvant chemotherapy compared with observation in patients with resected biliary tract cancer: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

Several randomized controlled trials compared adjuvant systemic chemotherapy with observation in patients with resected biliary tract cancer (BTC) have yielded inconsistent outcomes. In order to assess the efficacy of adjuvant therapy in these patients, we conducted this systematic review and meta-analysis.

METHODS

We conducted a thorough search in various databases, which included MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, ASCO Abstracts, ESMO Abstracts and ClinicalTrials.gov. All relevant randomized controlled trials investigating the adjuvant chemotherapy compared with observation in resected biliary tract cancer were identified. The primary outcome of interest was overall survival (OS), while secondary outcome was relapse-free survival (RFS). Statistical analyses were conducted using Review Manager 5.3. Additionally, publication bias was evaluated using Egger's test in Stata 12.0.

RESULTS

A total of 5 randomized controlled trials, involving 1406 patients, were included in this analysis. Compared with observation, adjuvant chemotherapy improved RFS [HR 0.84 (0.73-0.96), p=0.01] (I2=0%, p=0.89) but not OS [HR 0.89 (0.77-1.03), p=0.12] (I2=51%, p=0.09) in the entire population after BTC resection. Subgroup analyses revealed that adjuvant chemotherapy did improve both OS [HR 0.76 (0.62-0.93), p=0.009] (I2=7%, p=0.37) and RFS [HR 0.74 (0.58-0.95), p=0.02] (I2=0%, p=0.39) in patients with lymph node positivity. Furthermore, patients receiving oral fluoropyrimidine monotherapy showed benefit from the adjuvant therapy, with longer OS [HR 0.78 (0.65-0.94), p=0.009] (I2=2%, p=0.31) and RFS [HR 0.81 (0.68-0.95), p=0.01] (I2=0%, p=0.95).

CONCLUSIONS

To conclude, adjuvant chemotherapy have the potential to offer advantages in patients with resected BTC. Specifically, patients demonstrating positive lymph node status have a higher likelihood of benefiting from adjuvant therapy. Our analysis supports the current standard of care of adjuvant fluoropyrimidine. However, the recommendation of oral fluoropyrimidine monotherapy as the preferred option is not definitive, as it is based on limited studies. Further validation of these outcomes is necessary by conducting extensive randomized controlled trials.