Gemcitabine and Oxaliplatin Chemotherapy or Surveillance in Resected Biliary Tract Cancer (PRODIGE 12-ACCORD 18-UNICANCER GI): A Randomized Phase III Study

Minimally invasive vs. open radical cholecystectomy for gallbladder cancer: 30-day NSQIP outcomes analysis

BACKGROUND

Radical cholecystectomy (RC) is the standard procedure for gallbladder cancer (GBC) tumors stage TIb or higher. Advances in minimally invasive surgery (MIS) offer the potential for improved outcomes compared to the traditional open surgery. While small series have demonstrated the feasibility of an MIS approach, a detailed comparison of outcomes between the two approaches is lacking.

METHODS

The National Surgeon Quality Improvement Database (2010-2021) was queried to identify patients undergoing RC for GBC. Patients with T1b or higher disease were included. Thirty-day all-cause mortality and morbidity were evaluated. To assess associations between outcomes and covariates, we estimated risk ratios and risk differences using generalized linear models and adjusted the estimates using inverse propensity of treatment weights.

RESULTS

1303 patients were identified (239 MIS, 1064 Open) with 178 excluded due to the need for biliary reconstruction. There was no difference in the primary outcomes of mortality or major morbidity between the groups with four deaths occurring overall and major morbidity rates of MIS = 2.26% and Open = 2.45% (p = 0.7924). Patients who underwent MIS had significantly fewer days in the hospital (3.00 vs.5.00, p < 0.001). After weighting, the MIS group had significantly fewer blood transfusions (2.12% vs. 6.73%, p = 0.009) and superficial surgical site infections (0.45% vs. 3.29%, p = 0.020).

CONCLUSION

Our findings contribute to the growing body of evidence supporting MIS for RC as a potential alternative to open resections.

Reading and Interpreting Quality-of-Life Results in Cancer Trials

AbstractThere is growing attention paid to patient-reported outcomes and health-related quality of life as end points in clinical trials in oncology. Such results should contribute to the definition of treatment value, inform communication with patients in clinical practice, and impact treatment choice among various options. This review seeks to help clinicians gain familiarity with the correct reading and interpretation of quality-of-life results.

The Influence of Tumor Burden Score and Lymph Node Metastasis on the Survival Benefit of Adjuvant Chemotherapy in Intrahepatic Cholangiocarcinoma

INTRODUCTION

While postoperative adjuvant chemotherapy (AC) is generally recommended for intrahepatic cholangiocarcinoma (ICC), its benefit remains debated. This study aimed to identify patients that may benefit from AC following liver resection of ICC.

METHODS

Patients who underwent liver resection for ICC between 2000 and 2023 were identified from an international multi-institutional database. Individual multivariable Cox models were used to evaluate the interaction between each prognostic factor and the effect of AC on survival.

RESULTS

Among 1412 patients, 431 (30.5%) received AC. Both higher tumor burden score (TBS; hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.91-1.00; p = 0.033) and metastatic lymph node status (HR 0.58, 95% CI 0.38-0.89; p = 0.014) demonstrated interactions with the survival benefit from receipt of AC. Interaction plots highlighted how AC was associated with improved survival beyond a TBS of approximately 6. Notably, among 555 (39.3%) patients with TBS <6 and N0 or Nx status, 5-year overall survival (OS) was no different between patients who received AC versus individuals who did not (55.1% [95% CI 48.9-62.1] vs. 58.7% [95% CI 49.8-69.2]; p = 0.900). In contrast, among 857 (60.7%) patients with TBS ≥6 or N1 status, AC was associated with improved 5-year OS (30.7% [95% CI 26.2-36.0] vs. 33.0% [95% CI 26.9-40.5]; p = 0.018).

CONCLUSIONS

TBS and lymph node status may be useful in a multidisciplinary setting to inform decisions about AC planning for ICC patients following curative-intent resection.

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.

Adjuvant chemotherapy compared to observation in resected biliary tract cancers: Survival meta-analysis of phase-III randomized controlled trials

BACKGROUND

A limited number of randomized controlled trials (RCTs) investigated adjuvant chemotherapy in biliary tract cancers (BTCs). Recurrences and deaths are common in the first 2 years and survival remains poor despite adjuvant treatment.

METHODS

Phase-III RCTs were included comparing adjuvant chemotherapy and observation in resected BTCs. The primary endpoints were recurrence-free (RFS) and overall survival (OS). Proportional hazard results were used for trial-based analyses. Patient data was curated from published Kaplan-Meier curves to analyze short-term (2-year) hazards. The Parmar and generic inverse variance methods were used.

RESULTS

1308 patients in 4 trials (BILCAP, ASCOT, BCAT, PRODIGE-12) were included. Capecitabine (BILCAP) and S-1 (ASCOT) were grouped as 5-FU-based, gemcitabine (BCAT) and gemcitabine-oxaliplatin (PRODIGE-12) were grouped as gemcitabine-based chemotherapy. Adjuvant 5FU-based chemotherapy improved RFS [HR: 0.80 (95 % CI:0.68-0.95), p = 0.012] and OS [HR: 0.78 (95 % CI:0.65-0.94), p = 0.009]. However, gemcitabine-based chemotherapy did not provide benefit in RFS [HR: 0.90 (95 % CI:0.70-1.15), p = 0.428] and OS [HR: 1.03 (95 % CI:0.78-1.36), p = 0.794]. The benefit of 5-FU-based chemotherapy was more apparent in the short-term (2-year hazards) (RFS: [HR: 0.67 (95 %CI:57-0.79), p < 0.001] and OS: [HR: 0.61 (95 % CI:59-0.64), p < 0.001]). However, gemcitabine-based chemotherapy did not provide RFS benefit in the short term either [HR: 0.80 (95 % CI:0.64-0.1.01), p = 0.067] and seemed to be even detrimental for OS [HR: 1.22 (95 % CI:1.14-1.31), p < 0.001] in the first 2 years.

CONCLUSION

This study confirms using 5FU-based monotherapy in the adjuvant treatment of resected BTCs. The more prominent benefit in the first 2 years emphasizes that more effective adjuvant treatments with sustained long-term benefits are needed. Two-year proportional hazards OS and RFS are proposed here as an additional secondary end-point to consider in future clinical trials. in this setting. Registration ID (PROSPERO): CRD42024614444.

Mass-forming intrahepatic cholangiocarcinoma: treatment outcomes after curative-intent resection in an Australian tertiary referral hospital

BACKGROUND

Mass-forming intrahepatic cholangiocarcinoma (MF-ICC) is the second most common primary liver cancer and liver resection offers the best chance of possible cure. This study aimed to assess treatment outcomes and prognostic factors for long-term survival in patients who underwent curative-intent liver resection.

METHODS

A retrospective analysis was conducted on prospectively collected data from patients with MF-ICC managed at the Royal North Shore/North Shore Private Hospital from January 1998 to October 2023. Baseline, peri-operative and long-term outcomes have been analysed, including an overall survival (OS) and disease-free survival (DFS) analysis.

RESULTS

During the 25-year study period, 47 patients underwent curative-intent liver resection for primary MF-ICC at a median age of 70 years. The median OS was 36 months, with a 5-year OS of 33%. Multiple liver tumours (HR = 2.84; 95% CI = 1.24-6.48; P = 0.013) and a positive resection margin (HR = 2.46; 95% CI = 1.10-5.52; P = 0.029) were identified as independent predictors of poor long-term OS. Recurrence occurred in 62% of patients after a median DFS of 16 months, with poor tumour differentiation (HR = 3.93; 95% CI = 1.62-9.54; P = 0.002) and elevated tumour markers (HR = 3.47; 95% CI = 1.53-7.87; P = 0.003) as independent predictors of poor DFS.

CONCLUSION

Liver resection can offer a significant chance for prolonged survival in a highly selected population of patients with MF-ICC. However, the surgical challenges inherent in treating this rare disease are evident, emphasizing the need for a multimodal approach and continued exploration of additional therapies to enhance personalized treatment strategies.

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.

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.

Incidental Gallbladder Cancer: A Comprehensive Review

PURPOSE

Patients undergoing cholecystectomy for a presumed benign disease may present with histopathology report revealing carcinoma in the gallbladder specimen, in which case it is referred to as incidental gallbladder cancer (IGBC). This review highlights the approach to evaluation and management of these patients.

METHODS

Available literature from various sources has been reviewed and presented in a narrative format.

RESULTS

Early referral to a tertiary centre for appropriate staging and definitive management is paramount. Once distant metastasis is ruled out, re-resection is indicated in patients with pathological T-stage ≥T1b with the aim to attain R0 resection, and perform complete staging lymphadenectomy, and has been shown to confer survival benefit. Feasibility and safety of minimally invasive approaches have been demonstrated in recent years. Role of peri-operative chemo(radio)-therapy in IGBC remains uncertain and prospective trials are warranted.

CONCLUSION

IGBC is being increasingly diagnosed as the number of cholecystectomies for presumed benign diseases is steadily increasing globally. Overall prognosis depends on the stage and is especially poor in those with residual disease at re-operation.

Recurrence patterns and prediction of survival after recurrence for gallbladder cancer

BACKGROUND

Gallbladder cancer (GBC) is associated with a poor prognosis. Recurrence patterns and their effect on survival remain ill-defined. This study aimed to analyze recurrence patterns and develop a machine learning (ML) model to predict survival after recurrence (SAR) of GBC.

METHODS

Patients who underwent curative-intent resection of GBC between 1999 and 2022 were identified using an international database. An Extreme Gradient Boosting ML model to predict SAR was developed and validated.

RESULTS

Among 348 patients, 110 (31.6%) developed disease recurrence during follow-up. The most common recurrence site was local (29.1%), followed by multiple site (26.4%), liver (21.8%), peritoneal (18.2%), and lung (0.05%). The median SAR was the longest in patients with lung recurrence (36.0 months), followed by those with local recurrence (15.7 months). In contrast, patients with peritoneal (8.9 months), liver (8.5 months), or multiple-site (6.4 months) recurrence had a considerably shorter SAR. Patients with multiple-site recurrence had a worse SAR than individuals with single-site recurrence (6.4 vs 11.10 months, respectively; P =.014). The model demonstrated good performance in the evaluation and bootstrapping cohorts (area under the receiver operating characteristic curve: 71.4 and 71.0, respectively). The most influential variables were American Society of Anesthesiologists classification, local recurrence, receipt of adjuvant chemotherapy, American Joint Committee on Cancer T and N categories, and developing early disease recurrence (<12 months). To enable clinical applicability, an easy-to-use calculator was made available (https://catalano-giovanni.shinyapps.io/SARGB).

CONCLUSION

Except for lung recurrence, SAR for GBC was poor. A subset of patients with less aggressive disease biology may have favorable SAR. ML-based SAR prediction may help individuate candidates for curative re-resection when feasible.

Current status and prospects of targeted therapy for cholangiocarcinoma based on molecular characteristics

Cholangiocarcinoma (CCA) is a serious public health issue due to its insidious onset and dismal prognosis. The past few years have witnessed and highlighted the development of understanding and management of CCA. The combination of gemcitabine and cisplatin (GP) chemotherapy regimen with immunotherapy using immune checkpoint inhibitors has been considered the new standard first-line treatment alternative for advanced CCA. Notably, the proportion of patients with advanced CCA with targetable genetic mutations is approximately 40 %, and these patients may be considered for molecularly targeted therapy in the second-line treatment. In this review, we highlight the advances and progress in targeted therapies for advanced CCA, with special attention to data from Asian populations, including Chinese. In addition, we present in detail the phosphatase tension homolog (PTEN), a novel biomarker for both of first-line chemotherapy and second-line targeted therapy in advanced CCA, and its ability to forecast prognosis in patients with CCA. The mechanisms of rapid resistance to targeted agents warrant further investigation and address in light of the development of new targeted therapies. Precision medicine is gradually playing an increasing role in achieving optimal therapeutic outcomes.

Adjuvant Cytotoxic Chemotherapy may not be Associated with a Survival Advantage for Resected Intrahepatic Cholangiocarcinoma

BACKGROUND

Randomized data suggest improved survival with adjuvant chemotherapy for biliary tract cancers; however, subset analyses of intrahepatic cholangiocarcinoma (IHC) show limited survival benefit. This study evaluated the impact of adjuvant chemotherapy on recurrence patterns and overall survival (OS) in patients with resected IHC.

METHODS

Patients who underwent curative-intent resection for IHC were identified within a bi-institutional dataset and the National Cancer Database (NCDB). Patients were stratified by receipt of adjuvant chemotherapy. Site of first recurrence was categorized as liver only, regional, distant, or multifocal. Survival outcomes within each dataset were compared using Kaplan-Meier methods.

RESULTS

In the bi-institutional dataset, 347 patients underwent resection for IHC, and 149 (43%) patients received adjuvant cytotoxic chemotherapy. Recurrence was observed in 222 (64.0%) patients. OS was similar between groups (adjuvant vs. observation: 42 vs. 49 months; p = 0.13), and did not differ in patients who received capecitabine specifically (p = 0.09) or in a risk-adjusted multivariable analysis. Recurrence-free survival was worse in those who received adjuvant chemotherapy (p = 0.04), although the liver was the most common site of recurrence in both groups (0.63). A similar analysis of 1159 resected IHCs from the NCDB also demonstrated no association between adjuvant chemotherapy and OS (49 vs. 57 months; p = 0.1).

CONCLUSION

Adjuvant chemotherapy may not be associated with improved OS in IHC and did not have an impact on hepatic recurrence in this retrospective analysis. Future investigation to identify more effective adjuvant systemic regimens and/or explore the potential role of adjuvant liver-directed therapies to reduce hepatic recurrence that may improve OS for IHC is warranted.

Intrahepatic cholangiocarcinoma: role of imaging as a critical component for multi-disciplinary treatment approach

Cholangiocarcinoma (CCA) is a unifying title granted to epithelial adenocarcinomas specific to the bile ducts making up 10-25% of all hepatobiliary malignancies. CCA is more appropriately classified based on anatomic site of origin within the biliary tract into intrahepatic cholangiocarcinoma (iCCA), peri-hilar (pCCA) cholangiocarcinoma, and distal cholangiocarcinoma (dCCA). Intrahepatic cholangiocarcinoma makes up 10-20% of CCA and originates within and/or proximal to the second order bile ducts. The incidence of iCCA has been rising overtime with up to 1.26 per 100,000 persons, per year in the United States and up to 3.3 per 100, 000 persons, per year affected globally. Risk factors include chronic hepatic inflammation secondary to viral hepatitis, alcohol/NASH cirrhosis, biliary cystic lesions, and endemic causes, among other less common genetic drivers. Given its rarity, the recognition and diagnosis of cholangiocarcinoma, iCCA specifically, remains challenging resulting in delays in treatment initiation or any treatment at all. Median overall survival (mOS) for iCCA remains low. Early diagnosis, and stage-based treatment approaches have evolved and are associated with improved survival. To this goal, a multi-disciplinary treatment approach has been demonstrated to improve patient outcomes by providing expert evaluation as it pertains to an accurate imaging and histologic diagnosis, staging, radiologic and surgical review for resectability, operative expertise, post operative care, as well as comprehensive knowledge and implementation of systemic/targeted or liver directed therapies. Here, we discuss the central role of imaging in the diagnosis of intrahepatic cholangiocarcinoma to implement a comprehensive treatment plan that frequently involves multiple disciplines to achieve the best outcome for each patient.

A Multicenter Retrospective Study on Adjuvant S-1 Chemotherapy Versus Observation Following Major Hepatectomy for Perihilar Cholangiocarcinoma

BACKGROUND

The prognosis of perihilar cholangiocarcinoma (PHC) is poor even after curative resection, highlighting the need for effective adjuvant chemotherapy. The efficacy of adjuvant S-1 chemotherapy following major hepatectomy for PHC is unclear, and thus the aim of this study was to elucidate this.

METHODS

Consecutive patients with PHC who underwent major hepatectomy (hemihepatectomy or trisectionectomy extending to segment 1 with extrahepatic bile duct resection) at three high-volume centers in Japan from 2007 to 2020 were retrospectively evaluated. Patients with Clavien-Dindo grade V complications, pStage 0, I, or IVB disease, and those who underwent adjuvant radiation therapy were excluded from analysis. Propensity score matching analysis was performed to compare the disease-specific survival (DSS) of patients who underwent adjuvant S-1 chemotherapy with those who underwent observation.

RESULTS

Overall, 373/480 patients were eligible, of whom 81 underwent adjuvant S-1 chemotherapy and 146 underwent observation. In the global cohort, DSS was similar in the S-1 and observation groups (p = 0.18), while in the matched cohort (S-1, n = 44; observation, n = 44), DSS was similar between the S-1 and observation groups (p = 0.09). On multivariate analysis, percutaneous biliary drainage (PTBD), CA19-9 levels of ≥ 300 U/mL at operation, and lymph node (LN) metastasis were independent predictors of poor survival following major hepatectomy for PHC. In subgroup analysis of patients with LN metastasis, DSS was better in the S-1 group than in the observation group (p = 0.001).

CONCLUSIONS

Adjuvant S-1 chemotherapy following major hepatectomy might be effective in PHC patients with LN metastasis.

Propensity score analysis of adjuvant therapy in radically resected gallbladder cancers: A real world experience from a regional cancer center

Backgrounds/Aims

Given the high mortality associated with gallbladder cancer (GBC), the efficacy of adjuvant therapy (AT) remains controversial. We audited our data over an 11-year period to assess the impact of AT.

Methods

This study included all patients who underwent curative resection for GBC from 2007 to 2017. Analyses were conducted of clinicopathological characteristics, surgical details, and postoperative therapeutic records. The benefits of adjuvant chemotherapy (CT) or chemoradiotherapy (CTRT) were evaluated against surgery alone using SPSS version 20 for statistical analysis.

Results

The median age of patients (n = 142) was 50 years. The median overall survival (OS) was 93, 34, and 30 months with CT, CTRT, and surgery alone respectively (p = 0.612). Multivariate analysis indicated that only disease stage and microscopically involved margins significantly impacted OS and disease-free survival (DFS). CT showed increased effectiveness across all prognostic subsets, except for stage 4 and margin-positive resections. Following propensity score matching, median DFS and OS were higher in the CT group than in the CTRT group, although the differences were not statistically significant (p > 0.05).

Conclusions

Radically resected GBC patients appear to benefit more from adjuvant CT, while CTRT should be reserved for cases with high-risk features.

The efficacy of adjuvant chemotherapy for curative resected biliary tract cancers: a systematic review and network meta-analysis of randomized clinical trials

BACKGROUND

Despite complete resection, the recurrence rate of biliary tract cancer (BTC) remains high, leading to poor prognosis. Postoperative adjuvant chemotherapy (ACT) following radical resection may substantially reduce the recurrence risk by eradicating micrometastatic lesions. However, the benefits of postoperative ACT and the optimal ACT strategy are still unclear for BTC. The objectives of this study are to evaluate the prognostic value of ACT and compare the effectiveness of different ACTs among BTC patients after curative resection.

METHODS

A comprehensive literature search was conducted across PubMed, Cochrane Library, Web of Science, and EMBASE databases to identify randomized controlled trials (RCTs) comparing the benefits of ACT versus no intervention or other ACTs in BTC patients after curative resection. A random-effects network meta-analysis was performed to compare overall survival (OS) and relapse-free survival (RFS). The quality of evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation framework.

RESULTS

Eight RCTs comprising 1803 patients were included in the meta-analysis. ACT was associated with significant improvements in 5-year all-cause mortality [four RCTs, hazard rate (HR) 0.93; 95% confidence interval (CI), 0.87-1.00, marginally significant; low-certainty evidence], RFS (five RCTs, HR 0.87; 95% CI, 0.78-0.98; moderate-certainty evidence), and OS (7 studies, HR 0.85; 95% CI, 0.75-0.96; low-certainty evidence) compared with observation. ACT had significantly better survival benefits on patients with negative margins (R0), lymph node-positive (N+), and tumor node metastasis classification (TNM) stage I/II ( P < 0.05). Further network meta-analysis demonstrated that fluorouracil-based ACT was significantly inferior to gemcitabine-based ACT (HR 1.20; 95% CI, 1.10-1.25) in improving RFS. However, both were superior to observation ( P < 0.05). No statistical difference in OS was observed between gemcitabine-based and fluorouracil-based chemotherapy (HR 1.00; 95% CI, 0.86-1.20). In subgroup analysis, fluorouracil-based ACT but not gemcitabine-based ACT achieved significantly better OS benefits on patients with N+ (HR 0.67; 95% CI, 0.52-0.86) and R0 (HR 0.69; 95% CI, 0.54-0.88).

CONCLUSION

Compared with observation, ACT should be routinely recommended to improve survival outcomes in BTC patients after curative resection, especially for those with R0, N+, and TNM stage I/II. Gemcitabine-based ACT performed better than other chemotherapies in improving RFS. This network meta-analysis provides precise information for determining the best adjuvant treatment for resected BTC. Further thorough and high-quality RCTs are needed.

Prediction of survival after pancreatoduodenectomy for distal cholangiocarcinoma: independent external validation of a prognostic model for 3-year overall survival in Sweden

OBJECTIVES

The only treatment with curative potential for distal cholangiocarcinoma (dCCA) is radical surgery which can be complemented with adjuvant chemotherapy. The aim of the present study was to perform an independent external validation of a prognostic model for 3-year overall survival based on routine clinicopathological variables for patients treated with pancreatoduodenectomy for dCCA.

MATERIALS AND METHODS

All patients with a histopathological confirmed dCCA that underwent pancreatoduodenectomy in Sweden from 2009 through 2019 were identified in the Swedish National Registry for Pancreatic and Periampullary Cancer. Model performance was estimated using the C-index and calibration plots.

RESULTS

In total 220 patients were included in the study. The median survival was 33 months (IQR 26-40) and 3-year survival rate 47% (95% CI 40-53%). The prognostic model had a C-index of 0.69 (95% CI 0.62-0.72). Calibration plots revealed overestimated risk of death across risk groups in the full cohort. Calibration was good in the subgroup of patients that did not receive adjuvant treatment.

CONCLUSIONS

The prognostic model showed reasonable discriminative ability but some miscalibration likely since the effect of adjuvant treatment is not included in the model. Given that the model was developed in cohorts treated prior to the current adjuvant standard of care the model can be used to estimate baseline risk prior to risk/benefit decision for adjuvant treatment as well as stratification for clinical trials but with a risk to underestimate 3-year overall survival for patients that receive adjuvant treatment.

Surgical management, including the role of transplantation, for intrahepatic and peri-hilar cholangiocarcinoma

Intrahepatic and peri-hilar cholangiocarcinoma are life threatening disease with poor outcomes despite optimal treatment currently available (5-year overall survival following resection 20-35%, and <10% cured at 10-years post resection). The insidious onset makes diagnosis difficult, the majority do not have a resection option and the high recurrence rate post-resection suggests that occult metastatic disease is frequently present. Advances in perioperative management, such as ipsilateral portal vein (and hepatic vein) embolisation methods to increase the future liver remnant volume, genomic profiling, and (neo)adjuvant therapies demonstrate great potential in improving outcomes. However multiple areas of controversy exist. Surgical resection rate and outcomes vary between centres with no global consensus on how 'resectable' disease is defined - molecular profiling and genomic analysis could potentially identify patients unlikely to benefit from resection or likely to benefit from targeted therapies. FDG-PET scanning has also improved the ability to detect metastatic disease preoperatively and avoid futile resection. However tumours frequently invade major vasculo-biliary structures, with resection and reconstruction associated with significant morbidity and mortality even in specialist centres. Liver transplantation has been investigated for very selected patients for the last decade and yet the selection algorithm, surgical approach and both value of both neoadjuvant and adjuvant therapies remain to be clarified. In this review, we discuss the contemporary management of intrahepatic and peri-hilar cholangiocarcinoma.

Advancements in Locoregional Therapies for Unresectable Intrahepatic Cholangiocarcinoma

Intrahepatic cholangiocarcinoma is an aggressive malignancy with rising incidence and poor outcomes. This review examines recent advancements in locoregional therapies for unresectable intrahepatic cholangiocarcinoma, focusing on external beam radiotherapy, transarterial radioembolization (TARE), hepatic artery infusion pump (HAIP) chemotherapy, and liver transplantation. Stereotactic body radiation therapy and proton beam therapy have shown promise in achieving local control and improving survival. TARE, with personalized dosimetry, has demonstrated encouraging results in select patient populations. HAIP chemotherapy, primarily studied using floxuridine, has yielded impressive survival outcomes in phase II trials. Liver transplantation, once contraindicated, is now being reconsidered for carefully selected patients with localized disease. While these locoregional approaches show potential, randomized controlled trials comparing them to standard systemic therapy are lacking. Patient selection remains crucial, with factors such as liver function, tumor burden, and molecular profile influencing treatment decisions. Ongoing research aims to optimize treatment sequencing, explore combination strategies with systemic therapies, and refine phenotype identification and patient selection criteria. As the landscape of intrahepatic cholangiocarcinoma management evolves, a multidisciplinary approach is essential to tailor treatment strategies and improve outcomes for patients with this challenging disease.

Design of studies on neoadjuvant therapy for intrahepatic cholangiocarcinoma

The high recurrence rate and dismal prognosis of localized intrahepatic cholangiocarcinoma (ICC) indicate the unmet need for effective adjuvant and neoadjuvant therapy. In recent years, progress has been made in immunotherapy and targeted therapy for the treatment of advanced biliary tract cancer (BTC), leading to clinical exploration of the provision of these therapies in the perioperative period. Based on years of experience in clinical research on hepatobiliary cancers, the authors discuss the design of studies on neoadjuvant therapy for ICC, aiming to provide references for future neoadjuvant studies.

Management of intrahepatic cholangiocarcinoma: a review for clinicians

Intrahepatic cholangiocarcinoma (iCCA) is an aggressive liver malignancy that arises from second-order biliary epithelial cells. Its incidence is gradually increasing worldwide. Well-known risk factors have been described, although in many cases, they are not identifiable. Treatment options are continuously expanding, but the prognosis of iCCA remains dismal. R0 liver resection remains the only curative treatment, but only a limited number of patients can benefit from it. Frequently, major hepatectomies are needed to completely remove the tumour. This could contraindicate surgery or increase postoperative morbidity in patients with chronic liver disease and small remnant liver volume. In cases of anticipated inadequate future liver remnant, regenerative techniques may be used to expand resectability. The role and extent of lymphadenectomy in iCCA are still matters of debate. Improvements in iCCA diagnosis and better understanding of genetic profiles might lead to optimized surgical approaches and drug therapies. The role of neoadjuvant and adjuvant therapies is broadening, gaining more and more acceptance in clinical practice. Combining surgery with locoregional therapies and novel drugs, such as checkpoint-inhibitors and molecular-targeted molecules, might improve treatment options and survival rates. Liver transplantation, after very poor initial results, is now receiving attention for the treatment of patients with unresectable very early iCCA (i.e. <2 cm) in cirrhotic livers, showing survival outcomes comparable to those of hepatocellular carcinoma. Ongoing prospective protocols are testing the efficacy of liver transplantation for patients with unresectable, advanced tumours confined to the liver, with sustained response to neoadjuvant treatment. In such a continuously changing landscape, the aim of our work is to review the state-of-the-art in the surgical and medical treatment of iCCA.

Efficacy analysis of drug-eluting beads transcatheter arterial chemoembolization combining systemic chemotherapy and immune checkpoint inhibitors in unresectable intrahepatic cholangiocarcinoma: a multicenter retrospective cohort study based on propensity score matching

OBJECTIVE

To investigate the efficacy and safety of drug-eluting beads transcatheter arterial chemoembolization(DEB-TACE) combined with systemic chemotherapy and immune checkpoint inhibitors in the treatment of unresectable intrahepatic cholangiocarcinoma.

METHODS

This study used retrospective cohort analysis to collect the clinical data of 209 patients with unresectable intrahepatic cholangiocarcinoma treated in Linyi Cancer Hospital, Affiliated Zhongshan Hospital of Dalian University, Affiliated Central Hospital of Dalian University of Technology from January 2020 to January 2024. The patients were divided into observation group and control group based on their treatment plans. The observation group was treated with DEB-TACE combined with systemic chemotherapy and immune checkpoint inhibitor, and the control group was treated with simple systemic chemotherapy and immune checkpoint inhibitor. Based on propensity score matching analysis, the clinical treatment efficacy, survival prognosis, and incidence of adverse reactions of two groups of patients were evaluated.

RESULTS

82 patients in the observation group received DEB-TACE combined with systemic chemotherapy and immune checkpoint inhibitors, The control group of 127 patients were treated with systemic chemotherapy and immune checkpoint inhibitors. After a propensity score matching analysis to control for the consistency of patient age, sex, tumor size, tumor number, Child grade, ECOG score, and tumor stage. Propensity score matching analysis created 71 pairs of patients in 2 groups. The objective response rate (ORR, 76.06%) and disease control rate (DCR, 97.18%) in the observed group were significantly higher than that in the control group (52.11%, 85.92%), Progression-free survival (PFS, 10 months) and overall survival (OS, 17 months) were higher than the control group (8 months, 11 months). The Cox proportional hazards model analysis revealed that, Child grade and treatment modality were independent predictors of PFS and OS in patients. The adverse effects during treatment were similar in the two groups, with no statistical difference.

CONCLUSIONS

Compared with systemic therapy alone (systemic chemotherapy + immune checkpoint inhibitor), combined DEB-TACE improves the tumor control rate of patients with unresectable intrahepatic cholangiocarcinoma, extends the survival time and without increasing treatment-related adverse effects, which is a safe and feasible treatment modality.

Digestive cancers: mechanisms, therapeutics and management

Cancers of the digestive system are major contributors to global cancer-associated morbidity and mortality, accounting for 35% of annual cases of cancer deaths. The etiologies, molecular features, and therapeutic management of these cancer entities are highly heterogeneous and complex. Over the last decade, genomic and functional studies have provided unprecedented insights into the biology of digestive cancers, identifying genetic drivers of tumor progression and key interaction points of tumor cells with the immune system. This knowledge is continuously translated into novel treatment concepts and targets, which are dynamically reshaping the therapeutic landscape of these tumors. In this review, we provide a concise overview of the etiology and molecular pathology of the six most common cancers of the digestive system, including esophageal, gastric, biliary tract, pancreatic, hepatocellular, and colorectal cancers. We comprehensively describe the current stage-dependent pharmacological management of these malignancies, including chemo-, targeted, and immunotherapy. For each cancer entity, we provide an overview of recent therapeutic advancements and research progress. Finally, we describe how novel insights into tumor heterogeneity and immune evasion deepen our understanding of therapy resistance and provide an outlook on innovative therapeutic strategies that will shape the future management of digestive cancers, including CAR-T cell therapy, novel antibody-drug conjugates and targeted therapies.

Time to deterioration of patient-reported outcome endpoints in cancer clinical trials: targeted literature review and best practice recommendations

BACKGROUND

Time to deterioration (TTD) endpoints are often utilized in the analysis of patient-reported outcome (PRO) data in oncology clinical trials but different endpoint definitions and analysis frameworks exist that can impact result interpretation. This review examined the analysis, reporting and heterogeneity of TTD endpoints in the literature, the impact of analysis methods on results, and provides recommendations for future trials.

METHODS

A targeted literature review of articles published between 2017 and 2022 was performed to collate TTD endpoints reported in oncology randomized controlled trials (RCTs). Details of endpoints and results were extracted including; deterioration definition, PRO assessment schedule, methods for handling intercurrent events, statistical analysis methods, main trial results (overall survival and/or progression-free survival) and TTD endpoint results.

RESULTS

Seventy RCTs were included covering 849 individual TTD endpoints. There were 17 primary cancer types, with lung (26%), breast (11%), and prostate (7%) cancers the most common. Most trials (71%) were for people with advanced cancer. Full definitions of TTD endpoints were often missing. There were no clear trends for a specific TTD definition within cancer types or stages. However, statistical analysis methods were consistent among trials.

CONCLUSION

The TTD definition can vary and is ultimately driven by the research question. Points to consider for successfully implementing PRO TTD endpoints in oncology include consideration of the trial setting (e.g., early vs. advanced cancer), expected treatment effect (e.g., improvement vs. worsening), likely adverse event profile (including early vs. delayed) and PRO data collection frequency in order to improve utility of these endpoints.

FGFR2 fusion/rearrangement is associated with favorable prognosis and immunoactivation in patients with intrahepatic cholangiocarcinoma

Increasing evidence highlights that fibroblast growth factor receptor 2 (FGFR2) fusion/rearrangement shows important therapeutic value for patients with intrahepatic cholangiocarcinoma (ICC). This study aims to explore the association of FGFR2 status with the prognosis and immune cell infiltration profiles of patients with ICC. A total of 226 ICC tissue samples from patients who received surgery at the Department of Liver Surgery at Zhongshan Hospital, Fudan University, were collected retrospectively and assigned to a primary cohort (n = 152) and validation cohort (n = 74) group. Fluorescence in situ hybridization was performed to determine FGFR2 status. Multiplex immunofluorescence (mIF) staining and immunohistochemistry were performed to identify immune cells. Thirty-two (14.2%) ICC tissues presented with FGFR2 fusion/rearrangement. FGFR2 fusion/rearrangement was associated with low levels of carcinoembryonic antigen (CEA, P = .026) and gamma glutamyl transferase (γ-GGT, P = .003), low TNM (P = .012), CNLC (P = .008) staging as well as low tumor cell differentiation (P = .016). Multivariate COX regression analyses revealed that FGFR2 fusion/rearrangement was an independent protective factor for both overall survival (OS) and relapse-free survival in patients with ICC. Furthermore, correlation analysis revealed that an FGFR2 fusion/rearrangement was associated with low levels of Tregs and N2 neutrophils and high levels of N1 neutrophils infiltrating into tumors but not with CD8+ T-cell or macrophage tumor infiltration. FGFR2 fusion/rearrangement may exert a profound impact on the prognosis of ICC patients and reprogram the tumor microenvironment to be an immune-activated state. FGFR2 status may be used for ICC prognostic stratification and as an immunotherapeutic target in patients with ICC.

Systemic approaches in biliary tract cancers: a review in the era of multidirectional precision medicine

INTRODUCTION

Despite a rising incidence, biliary tract cancers (BTCs) are still considered a rare tumor entity. The disease's subtle clinical presentation and lack of effective early detection strategies often lead to a diagnosis at an advanced or unresectable stage, where curative options are limited.

AREAS COVERED

This review provides an overview of current systemic therapies and emerging novel approaches for BTC. For decades, the combination of gemcitabine with cisplatin (GemCis) has been the standard of care for palliative treatment. However, since 2020, the diagnostic and therapeutic landscape for BTC has evolved considerably, not only in the first-line setting but also beyond, driven by the development of clinical trials exploring immunotherapy and molecularly targeted agents. Due to the high frequency of targetable genetic alterations in BTC patients, there is a growing emphasis on obtaining tissue or liquid biopsy samples to identify markers like microsatellite instability and other actionable oncogenic driver genes.

EXPERT OPINION

Early initiation of systemic therapies in combination with multimodal approaches is essential for maximizing survival outcomes in patients with BTC.

Cholangiocarcinoma

Management of intrahepatic cholangiocarcinoma relies on a thorough understanding of the tumor's location and proximity to critical vasculobiliary structures. Mid-common bile duct tumors may require hemihepatectomy or pancreatoduodenectomy based on the status of the intraoperative frozen section. Distal common bile tumors are treated with pancreatoduodenectomy. When appropriate, volumetric assessment of the remnant liver should be performed to identify cases requiring preoperative liver augmentation strategies. A similar strategy should be employed for perihilar tumors, which require a right trisegmentectomy with bilioenteric reconstruction to achieve a negative margin. Adjuvant systemic therapy is recommended and increasing usage of neoadjuvant treatment is being incorporated into borderline resectable or regionally advanced cases.

Individualizing care for patients with gallbladder cancer

The rarity and lack of Level I Evidence compromise our ability to care for patients with gallbladder cancer.

METHODS

NCDB cohort study of with resected Stage Groups IB-IVA gallbladder adenocarcinoma between 2004 and 2018. Patients were included.

RESULTS

8484 patients were included, median survival was 29.8 (CI 28.6-31.2); Stage IB: 67.0, Stage II: 36.6, and Stage III/IVA 18.4 months. A survival benefit was noted for surgery beyond cholecystectomy (Stage IB 105 vs. 36 months, HR 0.56, p < 0.001; Stage II 56 vs. 20 months, HR 0.72, p < 0.001; and Stage III/IVA 23.8 vs. 9.9 months, HR 0.67, p < 0.001) and chemoradiotherapy (Stage IB 102 vs. 64.8, HR 0.87, CI 0.62-1.23, p = 0.4; ' Stage II 49 vs. 33.5 months, HR 0.78, CI 0.68-0.91, p = 0.002; and Stage III/IVA 31 vs. 12.2 HR 0.60, CI 0.52-0.70, p < 0.001). Adjuvant chemotherapy improved survival in Stage III/IVA (20 vs. 12.2 months, HR 0.74, p < 0.001) but not Stage II and trend toward harm in Stage IB. A nomogram with created with these data.

CONCLUSION

Surgery beyond cholecystectomy provides a benefit to all. Adjuvant chemotherapy (Stage III and IVA) benefits and chemoradiotherapy (II, III, and IVA) only patients with higher stage disease.

Machine learning prediction of early recurrence after surgery for gallbladder cancer

BACKGROUND

Gallbladder cancer is often associated with poor prognosis, especially when patients experience early recurrence after surgery. Machine learning may improve prediction accuracy by analysing complex non-linear relationships. The aim of this study was to develop and evaluate a machine learning model to predict early recurrence risk after resection of gallbladder cancer.

METHODS

In this cross-sectional study, patients who underwent resection of gallbladder cancer with curative intent between 2001 and 2022 were identified using an international database. Patients were assigned randomly to a development and an evaluation cohort. Four machine learning models were trained to predict early recurrence (within 12 months) and compared using the area under the receiver operating curve (AUC).

RESULTS

Among 374 patients, 56 (15.0%) experienced early recurrence; most patients had T1 (51, 13.6%) or T2 (180, 48.1%) disease, and a subset had lymph node metastasis (120, 32.1%). In multivariable Cox analysis, resection margins (HR 2.34, 95% c.i. 1.55 to 3.80; P < 0.001), and greater AJCC T (HR 2.14, 1.41 to 3.25; P < 0.001) and N (HR 1.59, 1.05 to 2.42; P = 0.029) categories were independent predictors of early recurrence. The random forest model demonstrated the highest discrimination in the evaluation cohort (AUC 76.4, 95% c.i. 66.3 to 86.5), compared with XGBoost (AUC 74.4, 53.4 to 85.3), support vector machine (AUC 67.2, 54.4 to 80.0), and logistic regression (AUC 73.1, 60.6 to 85.7), as well as good accuracy after bootstrapping validation (AUC 75.3, 75.0 to 75.6). Patients classified as being at high versus low risk of early recurrence had much worse overall survival (36.1 versus 63.8% respectively; P < 0.001). An easy-to-use calculator was made available (https://catalano-giovanni.shinyapps.io/GallbladderER).

CONCLUSION

Machine learning-based prediction of early recurrence after resection of gallbladder cancer may help stratify patients, as well as help inform postoperative adjuvant therapy and surveillance strategies.

The clinical significance of the lymph node ratio as a recurrence indicator in ampullary cancer after curative pancreaticoduodenectomy

BACKGROUND

The clinical significance of the lymph node ratio (LNR), the number of metastatic lymph nodes per dissected lymph node, has not been sufficiently clarified in ampullary cancer.

METHODS

Among patients diagnosed histopathologically with ampullary cancer between 1980 and 2018, the study included 106 who underwent pathological radical resection by pancreaticoduodenectomy. The relationships between the LNR and metastatic lymph node sites and prognosis were examined.

RESULTS

Multivariate analysis revealed that sex and lymph node metastasis were independent prognostic factors. In the 46 patients (43%) with metastatic lymph nodes, the LNR in the recurrence group was significantly higher than that in the non-recurrence group (0.15 ± 0.11 vs. 0.089 ± 0.071, p = 0.025). The receiver operating characteristic curve demonstrated that the LNR cut-off value, 0.07 (area under the curve = 0.70, sensitivity 81%, specificity 56%), was a significant indicator for recurrence (22% vs. 61%, p = 0.016) and prognosis (5-year survival: 48% vs. 83%, p = 0.028). Among the metastatic lymph node sites in the 46 positive cases, lymph node metastases developed from the peripancreatic head region (80%, 37/46) to the superior mesenteric artery (33%, 15/46) and para-aortic (11%, 5/46) regions.

CONCLUSION

Lymph node metastasis is an independent prognostic factor, and the LNR is a significant indicator for recurrence and prognosis in patients with ampullary cancer.

Chinese national clinical practice guideline on diagnosis and treatment of biliary tract cancers

BACKGROUND

Biliary tract carcinoma (BTC) is relatively rare and comprises a spectrum of invasive tumors arising from the biliary tree. The prognosis is extremely poor. The incidence of BTC is relatively high in Asian countries, and a high number of cases are diagnosed annually in China owing to the large population. Therefore, it is necessary to clarify the epidemiology and high-risk factors for BTC in China. The signs associated with BTC are complex, often require collaborative treatment from surgeons, endoscopists, oncologists, and radiation therapists. Thus, it is necessary to develop a comprehensive Chinese guideline for BTC.

METHODS

This clinical practice guideline (CPG) was developed following the process recommended by the World Health Organization. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess the certainty of evidence and make recommendations. The full CPG report was reviewed by external guideline methodologists and clinicians with no direct involvement in the development of this CPG. Two guideline reporting checklists have been adhered to: Appraisal of Guidelines for Research and Evaluation (AGREE) and Reporting Items for practice Guidelines in Healthcare (RIGHT).

RESULTS

The guideline development group, which comprised 85 multidisciplinary clinical experts across China. After a controversies conference, 17 clinical questions concerning the prevention, diagnosis, and treatment of BTC were proposed. Additionally, detailed descriptions of the surgical principles, perioperative management, chemotherapy, immunotherapy, targeted therapy, radiotherapy, and endoscopic management were proposed.

CONCLUSIONS

The guideline development group created a comprehensive Chinese guideline for the diagnosis and treatment of BTC, covering various aspects of epidemiology, diagnosis, and treatment. The 17 clinical questions have important reference value for the management of BTC.

Has Management of Intrahepatic Cholangiocarcinoma Evolved with the Evidence? Trends and Practice Patterns from the National Cancer Database

BACKGROUND

Management of intrahepatic cholangiocarcinoma (IHC) has advanced in recent decades, including randomized trial evidence supporting systemic therapy in the palliative and adjuvant setting. Mounting observational evidence suggests resection of IHC with multifocal disease (IHC-MF) or lymph node metastasis (IHC-LNM) should be limited. It is unknown how real-world practice has evolved in light of research advances. This study characterizes trends in management and outcomes of IHC without distant metastasis.

METHODS

We queried the National Cancer Database (NCDB) for patients treated for IHC without distant metastasis (M0) and identified subgroups with lymph node (cN1) or multifocal hepatic involvement (cT2b). Two-sided Cochran-Armitage tests evaluated trends in initial treating modality and perioperative chemotherapy. Logistic regression evaluated associations with choice of initial treating modality. Overall survival (OS) was evaluated by using Kaplan-Meier methods.

RESULTS

Between 2004 and 2020, 11,368 patients were treated for IHC without extrahepatic metastasis. Forty-three percent underwent resection. Initial management shifted from resection towards radiation or systemic therapy in IHC-MF and IHC-LNM. Use of perioperative chemotherapy increased from 39% pre-2010 to 70% in 2018-2020 (p < 0.001), most often delivered postoperatively. Across the entire cohort, median OS improved from 16 (95% confidence interval [CI] 15-18) to 27 months (95% CI 26-29). More modest improvements were observed in IHC-MF and IHC-LNM.

CONCLUSIONS

Use of perioperative chemotherapy has been widely adopted, predating randomized trial evidence in the adjuvant setting. Initial management of IHC-MF and IHC-LNM has shifted from resection to systemic and/or radiation therapy. While OS has improved overall, outcomes of IHC-MF and IHC-LNM remain poor, warranting further investigation.

Adjuvant Therapy Use for Patients With Inadequately Resected T1b-T3 Gallbladder Cancer

INTRODUCTION

Up to 90% of patients undergo inadequate resection for incidentally diagnosed T1b-T3 gallbladder cancer (GBC). We evaluated whether adjuvant therapies (ATs) are associated with prolonged overall survival (OS) for patients undergoing inadequate resection of T1b-T3 GBC.

METHODS

Patients who underwent inadequate resection, defined as simple cholecystectomy, for T1b-T3, Nx-N2, and M0 GBC were identified from the National Cancer Database (2004-2016). Patient characteristics, variables associated with AT use, and OS were described using the chi-square test, multivariable logistical regression, Kaplan-Meier, and Cox proportional hazard models.

RESULTS

Of 1386 patients who met inclusion criteria, most received no AT (64%), 20% received chemotherapy (CT), and 16% received chemoradiotherapy (CRT). Patients who received no AT were generally older (51% ≥ 75 y) and had no comorbidities (65% Charlson Comorbidity Index 0). Among those who received AT, CRT rather than CT, tended to be employed for patients who were older (≥75 y) or had more comorbidities (Charlson Comorbidity Index ≥1). Patients with advanced disease (T3, positive lymph nodes, or positive margins) were more likely to receive CRT. For T1b-T3 GBC, any AT was associated with prolonged median OS compared to no AT (22 months versus 15 mo, P < 0.01). Relative to no AT, CT (hazard ratio 0.76, 95% confidence interval 0.67-0.92) and CRT (0.59, 95% confidence interval 0.49-0.72) were associated with decreased risk of death.

CONCLUSIONS

AT was associated with prolonged OS for patients with inadequately resected T1b-T3 GBC. CRT may have a role in treatment for patients with high-risk disease following inadequate resection of T1b-T3 GBC.

Cholangiocarcinoma of the Middle Bile Duct: A Narrative Review

Resectable cholangiocarcinoma (CCA) arising from the middle of the extrahepatic biliary tree has historically been classified as perihilar or distal CCA, depending on the operation contemplated or performed, namely the associated hepatectomy or pancreaticoduodenectomy, respectively. Segmental bile duct resection is a less invasive alternative for select patients harboring true middle extrahepatic CCA (MCC). A small, yet growing body of literature has emerged detailing institutional experiences with bile duct resection versus pancreaticoduodenectomy or concomitant hepatectomy for MCC. Herein, we provide a brief overview of the epidemiology, preoperative evaluation, and emerging systemic therapies for MCC, and narratively review the existing work comparing segmental resection with pancreaticoduodenectomy or less commonly, hepatectomy, for MCC, with emphasis on the surgical management and oncologic implications of the approach used.

Network meta-analysis of adjuvant chemotherapy in biliary tract cancers: Setting the scene for new randomized evidence

BACKGROUND AND AIMS

The best adjuvant chemotherapy for resected biliary tract cancer (BTC) is under debate, with capecitabine supported by weak evidence. Aim of this network meta-analysis is to estimate the efficacy of different phase II/III regimens, comparing monotherapies (gemcitabine or fluoropyrimidines) head-to-head, against observation and combination regimens.

METHODS

A comprehensive literature search was conducted on PubMed and EMBASE for phase II/III randomized clinical trials (RCTs) available as of December 2023, reporting hazard ratios (HRs) of overall survival (OS) and event-free survival (EFS). A frequentist framework employing a random-effects model was applied; treatment rankings were outlined according to P-score, based on direct and indirect evidence. Exploratory subgroup analyses for OS were also performed (primary site, resected margin status and nodal involvement).

RESULTS

Six RCTs (1979 total patients) were identified. Fluoropyrimidine monotherapy showed significantly better OS (HR .84 [.72-.97]) and EFS (HR .79 [.69-.91]) than observation, as any monotherapy did (HR .84 [.74-.96]; HR .79 [.70-.89]). In the head-to-head comparison for OS, only S1 confirmed to be superior to observation alone (HR .69 [.49-.98]) while fluoropyrimidines achieved the best P score (.81), similarly to any monotherapy (0.92). Combinations failed to prove superior to monotherapies with respect both to OS and EFS. Subgroup analyses were inconclusive due to results' inconsistency and limited sample size.

CONCLUSIONS

Our work confirmed that adjuvant chemotherapy grants OS and EFS benefit for resected BTC patients. Fluoropyrimidines appeared the most effective option, confirming capecitabine as the preferred choice for the Western population.

Predictive MINT Pathologic Risk Score for Adjuvant Chemotherapy in Resected Cholangiocarcinoma: A Propensity Score-Matched Multicenter Study in Thailand

PURPOSE

This study aims to clarify the benefit of adjuvant chemotherapy (AC) in resectable cholangiocarcinoma (CCA) and develop a predictive risk score for treatment selection.

METHODS

Patients with resected CCA undergoing curative surgery, with or without AC, were identified from three centers in Thailand. Patients with R2 resection and 30 days postoperative death were excluded. Using the largest center as the discovery cohort, we generated propensity score matching (PSM). A predictive model for overall survival (OS) was identified, and a predictive risk score was developed from the PSM discovery cohort, classifying patients into high- and low-risk groups. The proposed risk score was validated in the other two centers.

RESULTS

In the discovery cohort, 493 patients were identified. After PSM, 328 patients were categorized into surgery (n = 164) and surgery + AC (n = 164) groups. The baseline characteristics in the PSM discovery cohort were well-balanced. In the validation cohort (n = 83), patients with positive lymph node 1 received AC more frequently than those under observation (47% v 18%; P = .02). A MINT pathologic risk score was developed from multivariate analysis for OS. The score includes margin, perineural invasion, pathologic nodal status, and pathologic tumor size. In the PSM discovery cohort, for the low-risk score group, the surgery group had significantly longer OS compared with the surgery + AC group (49.4 v 31.5 months; hazard ratio [HR], 1.78 [95% CI, 1.11 to 2.86]; P = .016). Conversely, for the high-risk score group, the surgery + AC group had better OS than the surgery group (18.8 v 8 months; HR, 0.60 [95% CI, 0.46 to 0.79]; P < .001). The results were comparable in the validation cohort.

CONCLUSION

Patients with resected CCA with a high-risk MINT pathologic risk score were likely to benefit from AC, whereas those with a low-risk score were not. Further validation in a larger prospective cohort is warranted.

Management of intrahepatic and perihilar cholangiocarcinomas: Guidelines of the French Association for the Study of the Liver (AFEF)

Intrahepatic cholangiocarcinoma (iCCA) is the second most common malignant primary liver cancer. iCCA may develop on an underlying chronic liver disease and its incidence is growing in relation with the epidemics of obesity and metabolic diseases. In contrast, perihilar cholangiocarcinoma (pCCA) may follow a history of chronic inflammatory diseases of the biliary tract. The initial management of CCAs is often complex and requires multidisciplinary expertise. The French Association for the Study of the Liver wished to organize guidelines in order to summarize the best evidence available about several key points in iCCA and pCCA. These guidelines have been elaborated based on the level of evidence available in the literature and each recommendation has been analysed, discussed and voted by the panel of experts. They describe the epidemiology of CCA as well as how patients with iCCA or pCCA should be managed from diagnosis to treatment. The most recent developments of personalized medicine and use of targeted therapies are also highlighted.

Transforming pancreaticobiliary cancer treatment: Exploring the frontiers of adoptive cell therapy and cancer vaccines

Pancreaticobiliary cancer, encompassing malignancies of both the pancreatic and biliary tract, presents a formidable clinical challenge marked by a uniformly bleak prognosis. The asymptomatic nature of its early stages often leads to delayed detection, contributing to an unfavorable 5-year overall survival rate. Conventional treatment modalities have shown limited efficacy, underscoring the urgent need for alternative therapeutic approaches. In recent years, immunotherapy has emerged as a promising avenue in the fight against pancreaticobiliary cancer. Strategies such as therapeutic vaccines and the use of tumor-infiltrating lymphocytes have garnered attention for their potential to elicit more robust and durable responses. This review seeks to illuminate the landscape of emerging immunotherapeutic interventions, offering insights from both clinical and research perspectives. By deepening our understanding of pancreaticobiliary cancer and exploring innovative treatment modalities, we aim to catalyze improvements in patient outcomes and quality of life.

The impact of lymph node ratio on survival in gallbladder cancer: a national cancer database analysis

BACKGROUND

The study aimed to investigate the impact of lymph node ratio (LNR) on survival in patients with resectable gallbladder adenocarcinoma.

METHODS

We retrospectively analyzed the National Cancer Database from 2004 to 2020. We included patients with gallbladder adenocarcinoma who had undergone resection of the primary site as well as adequate lymphadenectomy. Exclusions comprised patients with distant metastasis and missing key data. LNR was calculated as a proportion of positive lymph nodes (LNs) to examined LNs.

RESULTS

Patients were stratified into LNR groups: LNR0 - 343 patients (55%); 168 (26.9%) patients with LNR < 30%; and 113 (18.1%) with LNR ≥ 30%. The mean age was 67.3 ± 10.7 years, with 71.6% being female and 75.8% identifying as white. The mean overall survival (OS) was 52.8 months for the LNR0 group, 36.3 months for LNR < 30%, and 27 months for LNR ≥ 30% (p < 0.001). The difference in survival was significant when adjusted for adjuvant chemotherapy status and surgical margins using Cox regression - HR 3.2 (2.4-4.5 95% CI) for LNR < 30% and HR 4.9 (3.5-6.8 95% CI) for LNR ≥ 30%.

CONCLUSION

The study suggests that LNR is a valuable prognostic factor for resectable gallbladder cancer patients and could potentially guide treatment decisions.

Facts and Hopes in the Systemic Therapy of Biliary Tract Carcinomas

Biliary tract cancers (BTC) are a heterogeneous group of cancers that continue to present a particularly poor prognosis. BTC treatment is rapidly evolving yet facing many challenges to improve patient outcomes and maximize benefit from treatment. Only a minority of patients are diagnosed with early-stage disease and are suitable for curative resection. Current surgical strategies are limited by a high relapse rate, and despite extensive efforts focused on adjuvant strategies, the development of more effective adjuvant strategies remains a challenge. In addition, the role of locoregional strategies, liver transplant, and neoadjuvant treatment remains unclear. Systemic treatment in the advanced setting is based on three main pillars: first, cytotoxic chemotherapy options; second, the addition of immunotherapy to chemotherapy; and third, targeted therapies. The role of targeted therapies is oriented by many promising targets, including IDH1 mutations, FGFR2 fusions, BRAF-V600E mutations, and HER2 amplifications. The aim of this review is to provide an overview of current facts and future hopes in the management of BTC, including an overview of the unmet need, and particularly focus on systemic therapies.

Research progress and prospect of postoperative adjuvant therapy for resectable intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary malignancy of the liver, following hepatocellular carcinoma (HCC). Surgical resection remains the only potentially curative treatment for ICC. However, due to its high malignancy and propensity for postoperative recurrence, the prognosis for ICC is generally poor, and there is currently little standardized approach for adjuvant therapy following curative surgery. This article aims to explore adjuvant treatment strategies for ICC post-curative surgery by reviewing retrospective studies and clinical trials conducted in recent years. The analysis focuses on the effectiveness, challenges, and potential developments in the management of ICC post-surgery, considering the high recurrence rates and the need for improved therapeutic approaches to enhance patient outcomes. Additionally, we discuss the various types of adjuvant treatments that have been explored, including chemotherapy, radiation therapy, and targeted therapies. The goal is to provide a comprehensive overview of the current landscape and highlight promising directions for future research to improve survival and quality of life for ICC patients.

Subdivision of pT1N0 (American Joint Committee on Cancer 8th edition) distal cholangiocarcinoma for adjuvant chemotherapy consideration

BACKGROUND

The adjuvant S-1 trial affirmed adjuvant chemotherapy for biliary tract cancer but excluded pT1N0 distal cholangiocarcinoma (DCC) according to the seventh edition of the American Joint Committee on Cancer (AJCC) classification. The introduction of tumor depth of invasion (DOI) for T-classification in the eighth edition complicates identifying DCC patients less likely to benefit from adjuvant chemotherapy.

METHODS

Our cohort consisted of 185 patients with DCC who underwent pancreaticoduodenectomy between 2002 and 2019. We compared clinicopathological factors and survival outcomes between pT1N0 patients in the seventh edition and those in the eighth edition. New DOI cutoffs for subdividing pT1N0 (8th edition) patients were evaluated to identify patients less likely to benefit from adjuvant chemotherapy.

RESULTS

Transitioning to the eighth edition increased in pT1N0 cases from eight to 46. The 5-year cumulative recurrence rates of them were 14.3% for the seventh edition and 28.3% for the eighth edition. We proposed a DOI cutoff of <2 mm, at which the 5-year cumulative recurrence rate was 11.5%.

CONCLUSION

The eighth AJCC classification revealed that a significant proportion of pT1N0 DCC patients were at risk for recurrence. A DOI cutoff of <2 mm may be considered to potentially improve patient selection for adjuvant chemotherapy.

Adjuvant Chemoradiation in Resected Biliary Adenocarcinoma: Evaluation of SWOG S0809 with a Large National Database

BACKGROUND

There is a paucity of evidence supporting the use of adjuvant radiation therapy in resected biliary cancer. Supporting evidence for use comes mainly from the small SWOG S0809 trial, which demonstrated an overall median survival of 35 months. We aimed to use a large national database to evaluate the use of adjuvant chemoradiation in resected extrahepatic bile duct and gallbladder cancer.

METHODS

Using the National Cancer Database, we selected patients from 2004 to 2017 with pT2-4, pN0-1, M0 extrahepatic bile duct or gallbladder adenocarcinoma with either R0 or R1 resection margins, and examined factors associated with overall survival (OS). We examined OS in a cohort of patients mimicking the SWOG S0809 protocol as a large validation cohort. Lastly, we compared patients who received chemotherapy only with patients who received adjuvant chemotherapy and radiation using entropy balancing propensity score matching.

RESULTS

Overall, 4997 patients with gallbladder or extrahepatic bile duct adenocarcinoma with available survival information meeting the SWOG S0809 criteria were selected, 469 of whom received both adjuvant chemotherapy and radiotherapy. Median OS in patients undergoing chemoradiation was 36.9 months, and was not different between primary sites (p = 0.841). In a propensity score matched cohort, receipt of adjuvant chemoradiation had a survival benefit compared with adjuvant chemotherapy only (hazard ratio 0.86, 95% confidence interval 0.77-0.95; p = 0.004).

CONCLUSION

Using a large national database, we support the findings of SWOG S0809 with a similar median OS in patients receiving chemoradiation. These data further support the consideration of adjuvant multimodal therapy in resected biliary cancers.

Adjuvant Gemcitabine Plus Cisplatin and Chemoradiation in Patients With Gallbladder Cancer: A Randomized Clinical Trial

IMPORTANCE

There is limited evidence with regard to the benefit of adjuvant chemotherapy chemoradiotherapy in resected gallbladder cancers (GBCs).

OBJECTIVE

To establish a baseline survival rate for operated GBCs in patients receiving either gemcitabine plus cisplatin (GC) or capecitabine and capecitabine concurrent with chemoradiation (CCRT).

DESIGN, SETTING, AND PARTICIPANTS

The GECCOR-GB study was a multicenter, open-label, randomized phase 2 noncomparator "pick the winner" design trial of adjuvant GC and CCRT in patients with resected histologically confirmed adenocarcinoma or adenosquamous carcinoma of the gallbladder, (stage II/III) with no local residual tumor (R0) or microscopic residual tumor (R1). The study was carried out in 3 tertiary cancer institutions in India. Patients 18 years or older with adequate end-organ functions, and Eastern Cooperative Oncology Group Performance Status of 1 or lower between May 2019 and February 2022 were enrolled. The cutoff date for data analysis was February 28, 2023.

INTERVENTIONS

Patients were randomized 1:1 to receive either GC every 3 weeks (maximum of 6 cycles) or CCRT comprising capecitabine with concurrent chemoradiation (capecitabine concurrent with radiotherapy) sandwiched between capecitabine chemotherapy.

MAIN OUTCOMES AND MEASURES

The primary outcome was disease-free survival (DFS) at 1 year in randomized patients. This study was conducted as 2 parallel, single-stage phase 2 clinical trials. Within each treatment arm, a 1-year DFS rate of less than 59% was considered as insufficient activity, whereas a 1-year DFS rate of 77% or higher would be considered as sufficient activity.

RESULTS

With a median follow-up of 23 months, 90 patients were randomized, 45 in each arm. Overall, there were 31 women (69%) and 14 men (31%) in the GC arm with a mean (range) age of 56 (33-72) years and 34 women (76%) and 11 men (24%) in the CCRT group with a mean (range) age of 55 (26-69) years. In the GC and CCRT arms, 1-year DFS and estimated 2-year DFS was 88.9% (95% CI, 79.5-98.3) and 74.8% (95% CI, 60.4-89.2), and 77.8% (95% CI, 65.4-90.2) and 74.8% (95% CI, 59.9-86.3), respectively. Completion rates for planned treatment was 82% in the GC arm and 62% in the CCRT arm.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, GC and CCRT crossed the prespecified trial end points of 1-year DFS in patients with resected stage II/III GBCs. The results set a baseline for a larger phase 3 trial evaluating both regimens in operated GBCs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: CTRI/2019/05/019323I.

Focusing on the Immune Cells: Recent Advances in Immunotherapy for Biliary Tract Cancer

Biliary tract cancer (BTC) represents a challenging malignancy characterized by aggressive behavior, high relapse rates, and poor prognosis. In recent years, immunotherapy has revolutionized the treatment landscape for various cancers, but its efficacy in BTC remains limited. This article provides a comprehensive overview of the advances in preclinical and clinical studies of immunotherapy for BTC. We explore the potential of immune checkpoint inhibitors in reshaping the management of BTC. Despite disappointing results thus far, ongoing clinical trials are investigating the combination of immunotherapy with other treatment modalities. Furthermore, research on the tumor microenvironment has unveiled novel targets for immunotherapeutic interventions. By understanding the current state of immunotherapy in BTC and highlighting future directions, this article aims to fuel further exploration and ultimately improve patient outcomes in this challenging disease.

The conditional recurrence-free survival after R0 hepatectomy for locally advanced intrahepatic cholangiocarcinoma: A competing risk analysis based on inflammation-nutritional status

Background

Conditional survival analysis can serve as a dynamic prognostic metric, which helps to estimate the real-time survival probability over time. The present study conducted a conditional recurrence-free survival (CRFS) analysis for locally advanced intrahepatic cholangiocarcinoma (ICC) after R0 hepatectomy from an inflammatory-nutritional perspective using the competing risk method.

Methods

We extracted the medical data of 164 locally advanced ICC patients after R0 resection from Sun Yat-sen University Cancer Center. The calculation formula of the CRFS rate is CRFS(y/x) = RFS(y + x)/RFS(x). Univariable and multivariable COX regression analysis and competing risk analysis were conducted to identify RFS indicators.

Results

Considering death before recurrence as a competing risk factor, the conditional RFS rates every 6 months gradually increased over time. The 24-month RFS rate increased from 29.2 % to 49.9 %, 68.5 %, and 85.1 % given 6, 12, and 18-month already recurrence-free survival, respectively. Both in multivariate COX regression analysis and competing risk analysis, tumor diameter and number, lymph node metastasis, aggregate systemic inflammation index score (AISI), and albumin-bilirubin score (ALBI) all remained significant. For both AISI and ALBI variables, the CRFS rates in the low-value set were higher than those of the high-value set.

Conclusions

Conditional RFS rates of locally advanced ICC after R0 hepatectomy dynamically increased over time, which contributed to reducing survivors' psychological distress and facilitating personalized follow-up schedules. In addition, a person's inflammatory and nutritional status significantly impact the recurrence risk. Oncologists should consider the role of inflammation-nutritional status when making decisions for patients with locally advanced ICC.

Outcomes of Resectable Gallbladder Cancer: A Retrospective Analysis From a Tertiary Care Centre in India

Background Gallbladder carcinoma (GBC) has deleterious outcomes, but due to its reduced incidence in Western countries, there is a paucity of data on this disease. Here we report the outcomes of a retrospective analysis of resectable gallbladder cancer from a tertiary cancer centre in eastern India. The primary objective of this study is to evaluate the overall survival (OS) and relapse-free survival (RFS) rates among patients with resectable GBC. Methods A retrospective analysis was carried out on patients who underwent radical surgery between 2007 and 2022 and received various neoadjuvant and adjuvant chemotherapy methods. Patients who had adjuvant chemoradiotherapy concurrently or who did not receive adjuvant therapy were excluded. All the baseline clinicopathological characteristics were retrieved from electronic medical records. The survival data were collected from records of follow-up visits as well as telephonic calls to the patients who were lost to follow-up. Simple proportions were used for baseline characteristics, and the Kaplan-Meier method was used for survival analysis. Results A total of 161 patients were identified, and data were captured from electronic medical records. The included patients' ages ranged between 26 and 80 years, with a median age of 56 years. Among the participants, 103 were female (64%) and 58 (36%) were male. Among the 161 patients, the median number of lymph nodes harvested was nine (ranging from one to 43), and only three patients were margin-positive. The tumour, nodes, and metastasis (TNM) distributions were as follows: pT2 in 111 patients (70.25%), pT3 in 44 patients (27.85%), and pT4 in three patients (1.90%). The nodal statuses were pN0 in 91 patients (61.9%), pN1 in 51 patients (34.69%), and pN2 in five patients (3.4%). The majority (64%) received single-agent capecitabine, 27% received gemcitabine-based platinum doublet therapy, and 4.3% received neoadjuvant therapy. Of the full sample, 2.4% received concurrent adjuvant chemo plus radiation therapy, and three patients did not receive any adjuvant therapy. Additionally, among the 161 patients, 34.16% had a relapse, with 47% being local and 52% being distant relapses. The median follow-up was 49 months (interquartile range (IQR) 23-71 months). The 24-month RFS rate was 67.1% (SD+/- 4.3%), and the 24-month OS rate was 78.1% (SD+/- 4.1%). Conclusion Our data, which is from one of the largest samples from India, show that resectable gallbladder cancer has very good outcomes after radical surgery and adjuvant chemotherapy. There was a higher proportion of T2 and node-negative disease, which could have led to better survival compared to published literature.

The road to tailored adjuvant chemotherapy for all four non-pancreatic periampullary cancers: An international multimethod cohort study

BACKGROUND

Despite differences in tumour behaviour and characteristics between duodenal adenocarcinoma (DAC), the intestinal (AmpIT) and pancreatobiliary (AmpPB) subtype of ampullary adenocarcinoma and distal cholangiocarcinoma (dCCA), the effect of adjuvant chemotherapy (ACT) on these cancers, as well as the optimal ACT regimen, has not been comprehensively assessed. This study aims to assess the influence of tailored ACT on DAC, dCCA, AmpIT, and AmpPB.

PATIENTS AND METHODS

Patients after pancreatoduodenectomy for non-pancreatic periampullary adenocarcinoma were identified and collected from 36 tertiary centres between 2010 - 2021. Per non-pancreatic periampullary tumour type, the effect of adjuvant chemotherapy and the main relevant regimens of adjuvant chemotherapy were compared. The primary outcome was overall survival (OS).

RESULTS

The study included a total of 2866 patients with DAC (n = 330), AmpIT (n = 765), AmpPB (n = 819), and dCCA (n = 952). Among them, 1329 received ACT, and 1537 did not. ACT was associated with significant improvement in OS for AmpPB (P = 0.004) and dCCA (P < 0.001). Moreover, for patients with dCCA, capecitabine mono ACT provided the greatest OS benefit compared to gemcitabine (P = 0.004) and gemcitabine - cisplatin (P = 0.001). For patients with AmpPB, no superior ACT regime was found (P > 0.226). ACT was not associated with improved OS for DAC and AmpIT (P = 0.113 and P = 0.445, respectively).

DISCUSSION

Patients with resected AmpPB and dCCA appear to benefit from ACT. While the optimal ACT for AmpPB remains undetermined, it appears that dCCA shows the most favourable response to capecitabine monotherapy. Tailored adjuvant treatments are essential for enhancing prognosis across all four non-pancreatic periampullary adenocarcinomas.