Apatinib for treating advanced intrahepatic cholangiocarcinoma after failed chemotherapy: A case report and literature review

Immunotherapy and targeted therapy for cholangiocarcinoma: Artificial intelligence research in imaging

Cholangiocarcinoma (CCA) is a highly aggressive hepatobiliary malignancy, second only to hepatocellular carcinoma in prevalence. Despite surgical treatment being the recommended method to achieve a cure, it is not viable for patients with advanced CCA. Gene sequencing and artificial intelligence (AI) have recently opened up new possibilities in CCA diagnosis, treatment, and prognosis assessment. Basic research has furthered our understanding of the tumor-immunity microenvironment and revealed targeted molecular mechanisms, resulting in immunotherapy and targeted therapy being increasingly employed in the clinic. Yet, the application of these remedies in CCA is a challenging endeavor due to the varying pathological mechanisms of different CCA types and the lack of expressed immune proteins and molecular targets in some patients. AI in medical imaging has emerged as a powerful tool in this situation, as machine learning and deep learning are able to extract intricate data from CCA lesion images while assisting clinical decision making, and ultimately improving patient prognosis. This review summarized and discussed the current immunotherapy and targeted therapy related to CCA, and the research progress of AI in this field.

Successful apatinib treatment for advanced clear cell renal carcinoma as a first-line palliative treatment: A case report

BACKGROUND

Apatinib is an orally bioavailable small-molecule receptor tyrosine kinase inhibitor. In December 2014, the China Food and Drug Administration made it the first anti-angiogenic therapy to be approved for treating metastatic gastric cancer. It was specifically designated as a third-line or later treatment for metastatic gastric cancer.

CASE SUMMARY

Here, we present a case of advanced renal cell carcinoma (RCC) with multiple metastases (Stage IV) in a 48-year-old male with an extremely poor general status (Karnofsky 30%). He was initially given pazopanib as a targeted therapeutic. However, he experienced severe adverse reactions within two weeks, including grade IV oral mucositis. We, thus, tried switching his targeted treatment to an apatinib dose of 250 mg once daily since April 2018. The patient demonstrated striking benefits from this switch to the apatinib palliative treatment. Nearly one month later, his pain and other associated symptoms were alleviated. The patient was able to move freely and had an excellent general status (Karnofsky 90%). His progress has been followed up with regularly, allowing for a documented progression-free survival interval of approximately 32 mo.

CONCLUSION

This case suggests that, like other multi-target drugs, apatinib may be a useful first-line therapeutic drug for advanced RCC. It may be a particularly helpful curative option when patients are found to be intolerant of other targeted drugs.

Efficacy and Safety of Apatinib Treatment for Advanced Cholangiocarcinoma After Failed Gemcitabine-Based Chemotherapy: An Open-Label Phase II Prospective Study

Purpose

As a novel small-molecule vascular endothelial growth factor receptor-2 tyrosine kinase inhibitor (VEGFR2-TKI), Methylsulfonic apatinib (apatinib) exhibits a specific antitumor effect in various solid tumors via inhibition of angiogenesis. The present study was performed to evaluate the clinical efficacy and safety of apatinib in the treatment of advanced cholangiocarcinoma after failed gemcitabine-based chemotherapy.

Patients and Methods

This was a prospective open-label phase II trial (NCT03521219). A total of 32 patients, in whom gemcitabine-based first-line chemotherapy for advanced intrahepatic cholangiocarcinoma had failed, were consecutively enrolled in a prospective, open, exploratory, and single-center clinical trial from November 2017 to November 2018. They were treated with apatinib mesylate second-line monotherapy (orally, 500 mg per day for a cycle of 28 days) until progressive disease or unacceptable toxicity. Using Response Evaluation Criteria in Solid Tumor version 1.1 (RECIST 1.1) and the Common Terminology Criteria for Adverse Events version 4.0 (NCI-CTCAE 4.0), the efficacy and adverse were evaluated, respectively. Kaplan-Meier method was used for survival analysis.

Results

Twenty-six patients were enrolled in full analysis set. At the end of follow-up, two patients were lost to follow-up, 24 of 26 patients in FAS were included in efficacy analyses. For the efficacy analysis set, the objective response rate (ORR) was 20.8% [95% confidence interval (CI): 9.24-40.47%] and the disease control rate (DCR) was 62.5% (95% CI: 112.86-387.14 days). One patient (4%) showed complete response (CR), 4 patients (17%) showed partial response (PR), 10 patients (41.7%) stable disease (SD), and 9 patients (37.5%) had progressive disease (PD). Meanwhile, apatinib therapy achieved the median progression-free survival PFS was 95 days (95% CI: 79.70-154.34 days), and the median OS was 250 days (95% CI: 112.86-387.14 days). Furthermore, univariate analysis revealed that age and tumor's anatomic location significantly affected PFS (P < 0.05). The most common clinically adverse events (AEs) included myelosuppression (69.2%), hypertension (57.7%), proteinuria (46.2%). The AEs were mild, mainly in grade 1 or 2, and no toxicity-induced death occurred.

Conclusion

Apatinib monotherapy is an effective and promising regimen for treating patients with advanced cholangiocarcinoma who experienced failure of gemcitabine-based chemotherapy.

The efficacy and safety of apatinib treatment for patients with advanced or recurrent biliary tract cancer: a retrospective study

INTRODUCTION

The present study aims to evaluate the efficacy and safety of apatinib monotherapy or combination therapy for patients with advanced or recurrent biliary tract cancer (BTC).

METHODS

Twenty-eight patients with advanced or recurrent BTC who progressed after prior systemic therapies and treated with apatinib from January 2017 to June 2019 were enrolled in this retrospective and observational study. The primary end point was progression free survival (PFS). Secondary end points included overall survival (OS), objective response rate (ORR), disease control rate (DCR), and toxicity.

RESULTS

A total of 28 patients with advanced or recurrent BTC who progressed after prior systemic therapies received apatinib monotherapy or combination therapy (with capecitabine, S-1, oxaliplatin, irinotecan or PD-1 inhibitor), including 9 cases of gallbladder cancer and 19 cases of cholangiocarcinoma. Six patients achieved PR, 15 patients had SD and 7 patients had PD. Median progression-free survival (PFS) and overall survival (OS) was 4.3 months (95%CI = 1.8-6.8) and 6.2 months (95% CI = 4.6-7.8) respectively. The ORR and DCR were 21.4% (6/28) and 75.0% (21/28), respectively. Most of the adverse events were grade 1-2 in severity, apatinib treatment was well tolerated.

CONCLUSIONS

Apatinib monotherapy or combination therapy can improve PFS in patients with advanced or recurrent BTC who progressed after prior systemic therapies, and adverse reactions can be well tolerated. Our study support apatinib therapy as a feasible therapeutic strategy in advanced or recurrent BTC.

Apatinib as non-first-line treatment in patients with Intrahepatic Cholangiocarcinoma

Purpose: There is limited standard treatment for patients with advanced cholangiocarcinoma after refractory of chemotherapy. Apatinib is a tyrosine kinase inhibitor targeting VEGFR-2, which exhibited broad-spectrum antitumor activities in previous studies. We aim to evaluate the efficacy and safety of apatinib as non-first-line treatment in patients with advanced cholangiocarcinoma. Methods: This was a prospective open-label phase II trial (NCT03251443). Patients with pathology-confirmed cholangiocarcinoma after prior systemic therapy were enrolled. Participants were treated with apatinib 500 mg orally once daily. The primary end point was overall response rate (ORR). Results: Between August 8, 2017 and November 13, 2018, 30 patients participated in this study, and 26 patients received apatinib treatment except 4 patients withdrew consent before the first dosage. For full analysis set, the ORR was 11.5% and the disease control rate was 50.0%. 3 patients (11.5%) achieved partial response and no patients achieved complete response. The median progression free time was 2.0 (95% CI: 0.7-3.3) months and median overall survival was 9. 0 (95% CI: 4.6-13.4) months. The most common adverse events of any grade were fatigue (80.8%), hypertension (73.1%) and decreased appetite (38.5%). Grade 3 adverse events occurred in 23.1% patients and no grade 4 adverse events occurred. The most common grade 3 adverse events were hypertension (23.1%) and elevated transaminase (11.5%). Conclusion: Apatinib as non-first-line monotherapy has potential therapeutic efficacy in patients with advanced cholangiocarcinoma.

Efficacy and Safety of Apatinib Treatment for Patients with Advanced Intrahepatic Cholangiocarcinoma

Purpose

Effective treatment options for intrahepatic cholangiocarcinoma (ICC) are limited. This study was intended to explore the efficacy and safety of apatinib in advanced ICC with lymph node metastasis or distant metastasis.

Patients and Methods

The efficacy and toxicity of apatinib were evaluated in patients with ICC between November 2017 and March 2020 at the Second Affiliated Hospital of Anhui Medical University. Survival analysis was estimated using Kaplan–Meier method.

Results

Ten patients with advanced ICC were enrolled. The median progression-free survival (PFS) was 3.0 months (95% CI: 1.450–4.550). No patient achieved a complete response (CR). One patient gained partial response (PR), and 6 patients had stable disease (SD). The objective response rate (ORR) was 10%, and the disease control rate (DCR) was 70%. The common treatment-related adverse events were hypertension (20%), proteinuria (30%), hand and foot syndrome (10%) or emesis (10%). No grade 3/4 toxicities occurred. Toxicities were mild and tolerable.

Conclusion

Apatinib is potentially an effective treatment option with tolerable toxicities for patients with advanced ICC.

Comparison of the efficacy and safety among apatinib plus drug-eluting bead transarterial chemoembolization (TACE), apatinib plus conventional TACE and apatinib alone in advanced intrahepatic cholangiocarcinoma

This study aimed to compare the efficacy and safety of apatinib plus drug-eluting bead (DEB) transarterial chemoembolization (TACE), apatinib plus conventional TACE (cTACE) and apatinib alone in advanced intrahepatic cholangiocarcinoma (ICC) patients. We analyzed 35 advanced ICC patients retrospectively, including the apatinib plus DEB-TACE group (n=10), the apatinib plus cTACE group (n=12) and the apatinib group (n=13). Treatment response, survival data (including progression-free survival (PFS) and overall survival (OS)) and adverse events were assessed during the follow-up. Both the objective response rate (ORR) and the disease control rate (DCR) showed trends to be the highest in the apatinib plus DEB-TACE group (ORR: 84.6%/DCR: 100.0%), followed by the apatinib plus cTACE group (ORR: 75.0%/DCR: 91.7%) and then the apatinib group (ORR: 40.0%/DCR: 80.0%). PFS and OS were both the highest in the apatinib plus DEB-TACE group, followed by the apatinib plus cTACE group, and the shortest in the apatinib group, which was also confirmed by a multivariate Cox regression analysis. The incidences of adverse events were similar between the apatinib plus DEB-TACE group and the apatinib plus cTACE group but were higher in the apatinib plus DEB-TACE group and the apatinib plus cTACE than in the apatinib group; however, all of the adverse events were tolerable in the three groups. In conclusion, apatinib plus DEB-TACE is a promising therapeutic strategy for the treatment of advanced ICC.

A metastatic skull tumor from intrahepatic cholangiocarcinoma: A case report and literature review

RATIONALE

Intrahepatic cholangiocarcinoma (ICC) originates from the epithelial cells of the secondary branches that are distant from the intrahepatic bile duct. ICC is a rare pathological type of primary liver cancer, with a high malignancy rate and poor prognosis. However, patients with ICC metastasis to the skull are extremely rarely encountered. Herein, we present a case of a metastatic skull tumor from ICC, along with a literature review.

PATIENT CONCERNS

A 50-year-old right-handed man who did not smoke was diagnosed with a poorly differentiated ICC (T2aN0M0) in segment VI of the liver in February 2017. Hepatectomy was performed. The patient then presented with a painful mass in the posterior occipital region with dizziness experienced since 1 month, for which he underwent posterior occipital craniotomy. Postoperative specimens were sent for pathological examination.

DIAGNOSES

We diagnosed the patient with a metastatic skull tumor from ICC.

INTERVENTIONS

The patient underwent posterior occipital craniotomy and total resection of the tumor.

OUTCOMES

The patient received chemotherapy 1 month after surgery, and after 6 months of follow-up, the patient was alive.

LESSONS

ICC often shows metastases to the vertebrae. Therefore, physicians should consider the possibility of metastasis in patients with ICC, especially in those who show a painful skull mass of unknown origin; moreover, among patients with vertebral metastasis, physicians should be very vigilant about an occipital mass. We believe that the craniospinal venous system may be the pathway for occipital metastasis in patients with ICC.

Remarkable Response of Metastatic Gallbladder Carcinoma to Apatinib After Failed Multiline Chemotherapies: A Case Report and Literature Review

Gallbladder carcinoma (GBC) is a relatively rare and aggressive malignant tumor with a poor prognosis. A systematic review of current clinical studies illustrates an extreme paucity of second-line therapeutic options following the failure of standard-of-care cisplatin-gemcitabine chemotherapy. The efficacy of apatinib, an highly potent and selective oral inhibitor of VEGFR-2 tyrosine kinase, for refractory advanced GBC has not yet been clarified. Herein, we report a case of advanced GBC that presented a durable partial response to apatinib used as monotherapy after the failure of multiline chemotherapies including S-1 monotherapy, capecitabine monotherapy, gemcitabine plus capecitabine, and irinotecan plus oxaliplatin. The patient achieved an efficacy of partial response within 2 months. By September 23, 2019, the duration of treatment had extended for almost 1 year with a satisfactory quality of life, and the administration of apatinib was continued. Dose reduction of apatinib occurred at week four due to grade 2 hypertension and hand-foot skin reaction (HFSR). No fatigue, proteinuria, mucositis, or thrombocytopenia occurred. To the best of our knowledge, this is the first case of a successful use of apatinib monotherapy for heavily pretreated GBC. Further prospective studies are warranted to confirm the efficacy and safety of apatinib in GBC.

Outcome of postoperative radiation therapy for cholangiocarcinoma and analysis of dose-volume histogram of remnant liver

The aim of this study was to analyze dose-volume histogram (DVH) of the remnant liver for postoperative cholangiocarcinoma (CCA) patients, to find toxicity rates, and to confirm efficacy of postoperative radiation therapy (RT).Thirty-two postoperative CCA patients received partial liver resection and postoperative RT with curative intent. The "liver reduction rate" was calculated by contouring liver volume at computed tomography (CT) just before the surgery and at CT for planning the RT. To evaluate late toxicity, the radiation-induced hepatic toxicity (RIHT) was determined by the common terminology criteria for adverse events toxicity grade of bilirubin, aspartate transaminase, alanine transaminase, alkaline phosphatase, and albumin, and was defined from 3 months after RT until liver metastasis was revealed. The radiation-induced liver disease (RILD) was also evaluated.Tumor stages were distributed as follows: I: 1, II: 8, IIIA: 1, IIIB: 6, IIIC: 14, IVA: 2. Median prescribed total dose was 50 Gy. Median follow-up time was 27 months. Two-year overall survival (OS): 72.4%, disease-free survival: 47.7%, local control: 65.3%, and the median survival time was 40 months. The median "liver reduction rate" was 21%. The OS had statistically significant difference in nodal status (P = .032) and "liver reduction rate" >30% (P = .016). In the association between the ≥grade 2 RIHT and DVH, there were significantly differences in V30 and V40 (P = .041, P = .034), respectively. The grade ≥2 RIHT rates differ also significantly by sex (P = .008). Two patients (6.2%) were suspected of RILD.We suggest that RT for remnant liver should be considered the liver V30, V40 to prevent radiation-induced liver dysfunction.