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Kumar-Sinha C, Vats P, Tran N, Robinson DR, Gunchick V, Wu YM, Cao X, Ning Y, Wang R, Rabban E, Bell J, Shankar S, Mannan R, Zhang Y, Zalupski MM, Chinnaiyan AM, Sahai V. Genomics driven precision oncology in advanced biliary tract cancer improves survival. Neoplasia 2023; 42:100910. [PMID: 37267699 PMCID: PMC10245336 DOI: 10.1016/j.neo.2023.100910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Biliary tract cancers (BTCs) including intrahepatic, perihilar, and distal cholangiocarcinoma as well as gallbladder cancer, are rare but aggressive malignancies with few effective standard of care therapies. METHODS We implemented integrative clinical sequencing of advanced BTC tumors from 124 consecutive patients who progressed on standard therapies (N=92 with MI-ONCOSEQ and N=32 with commercial gene panels) enrolled between 2011-2020. RESULTS Genomic profiling of paired tumor and normal DNA and tumor transcriptome (RNA) sequencing identified actionable somatic and germline genomic alterations in 54 patients (43.5%), and potentially actionable alterations in 79 (63.7%) of the cohort. Of these, patients who received matched targeted therapy (22; 40.7%) had a median overall survival of 28.1 months compared to 13.3 months in those who did not receive matched targeted therapy (32; P < 0.01), or 13.9 months in those without actionable mutations (70; P < 0.01). Additionally, we discovered recurrent activating mutations in FGFR2, and a novel association between KRAS and BRAF mutant tumors with high expression of immune modulatory protein NT5E (CD73) that may represent novel therapeutic avenues. CONCLUSIONS Overall, the identification of actionable/ potentially actionable aberrations in a large proportion of cases, and improvement in survival with precision oncology supports molecular analysis and clinical sequencing for all patients with advanced BTC.
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Affiliation(s)
- Chandan Kumar-Sinha
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI 48109, USA; Department of Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Pankaj Vats
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI 48109, USA; Department of Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Nguyen Tran
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Dan R Robinson
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI 48109, USA; Department of Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Valerie Gunchick
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Yi-Mi Wu
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI 48109, USA; Department of Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Xuhong Cao
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI 48109, USA; Department of Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Yu Ning
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Rui Wang
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Erica Rabban
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Janice Bell
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Sunita Shankar
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Rahul Mannan
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Yuping Zhang
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Mark M Zalupski
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI 48109, USA
| | - Arul M Chinnaiyan
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI 48109, USA; Department of Pathology, University of Michigan, Ann Arbor, MI 48109, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI 48109, USA; Howard Hughes Medical Institute, Chevy Chase, MD 20815, USA.
| | - Vaibhav Sahai
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI 48109, USA.
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Huang Q, Wang F, Zhang X, Liu J, Dou X, Feng R, Zhu K, Jiang S, Zhang Y, Yue J. Percutaneous transhepatic cholangial drainage or antibiotic therapy worsens response to immunotherapy in advanced cholangiocarcinoma. BMC Cancer 2023; 23:657. [PMID: 37442960 DOI: 10.1186/s12885-023-11128-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Bile duct obstruction is a common issue for patients with advanced cholangiocarcinoma (CCA). Percutaneous transhepatic cholangial drainage (PTCD) is often required to relieve the obstruction. However, PTCD may alter the intestinal microbiota, which can affect the efficacy of immunotherapy. Antibiotics (ATB) can also have significant immunomodulatory effects by perturbing the gut microbiota. Therefore, this study aimed to investigate whether PTCD or ATB therapy is associated with overall survival (OS) or progression-free survival (PFS) in patients with advanced CCA receiving first-line chemotherapy plus immune checkpoint blockade (ICB) in clinical practice. We also explored whether the gut microbiota changes after receiving PTCD. METHODS We conducted a single-center retrospective analysis of PTCD and ATB therapy in patients with advanced CCA. PTCD was performed before ICB initiation, and ATB was administered within 1 month before and 6 weeks after ICB initiation. Our primary outcomes were PFS and OS. Moreover, we used 16s rRNA sequencing to analyze fecal and bile samples obtained from patients who underwent PTCD. RESULTS In total, 107 patients with CCA were included. Among patients who did not undergo PTCD, ICB plus chemotherapy significantly improved OS vs. chemotherapy alone (hazard ratio [HR] 0.21, 95% confidence interval [CI] 0.09-0.45, p < 0.0001). PFS was also significantly improved in patients who received ICB plus chemotherapy compared with chemotherapy alone (HR 0.36, 95% CI 0.16-0.80, p = 0.0024). However, ICB plus chemotherapy did not improve survival compared with chemotherapy alone among patients who received PTCD. Overall changes in the fecal microbiota of patients after PTCD involved significant reductions in which Escherichia - Shigella. CONCLUSIONS The use of ATB or PTCD in patients with CCA receiving ICB was associated with worse OS compared with chemotherapy alone, and PTCD affects the gut microbiota. Escherichia - Shigella was significantly reduced in feces of patients after PTCD.
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Affiliation(s)
- Qingyu Huang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Fuhao Wang
- School of Clinical Medicine, Weifang Medical University, Weifang, 261053, China
| | - Xiang Zhang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Jing Liu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Xue Dou
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Rui Feng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Kunli Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Shumei Jiang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Yun Zhang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Jinbo Yue
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, 250117, China.
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3
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Lo JH, Agarwal R, Goff LW, Heumann TR. Immunotherapy in Biliary Tract Cancers: Current Standard-of-Care and Emerging Strategies. Cancers (Basel) 2023; 15:3312. [PMID: 37444422 PMCID: PMC10340362 DOI: 10.3390/cancers15133312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/15/2023] Open
Abstract
Biliary tract cancers (BTCs), comprising intrahepatic, perihilar, and distal cholangiocarcinoma as well as gallbladder adenocarcinoma, continue to be challenging to manage. Conventional chemotherapy regimens for advanced disease are limited in both options and benefits, and more effective perioperative regimens are also needed. Over the last decade, immunotherapy has had a profound impact on the management of many solid tumor types, particularly in using immune checkpoint inhibition to enable a tumor-directed T cell response. Immunotherapy administered on its own has had limited utility in BTCs, in part due to a hostile immune microenvironment and the relative infrequency of biomarker-based tumor-agnostic indications for immunotherapy. However, immunotherapy in conjunction with chemotherapy, molecularly targeted therapies, and/or anti-angiogenic therapies has gained traction, supported by evidence that these agents can impart favorable immunomodulatory effects on the tumor microenvironment. The TOPAZ-1 trial led to the first BTC-specific immunotherapy approval, establishing the combination of durvalumab with gemcitabine and cisplatin as the preferred first-line treatment for advanced or metastatic disease. Recently, the KEYNOTE-966 trial showed positive results for the combination of pembrolizumab with gemcitabine and cisplatin in the same setting, adding further evidence for the addition of immune checkpoint inhibition to the standard chemotherapy backbone. Meanwhile, advances in the molecular profiling of BTCs has contributed to the recent proliferation of molecularly targeted therapeutics for the subset of BTCs harboring alterations in IDH1, FGFR2, MAP kinase signaling, HER2, and beyond, and there has been great interest in investigating combinations of these agents with immunotherapy. Emerging immunotherapy strategies beyond immune checkpoint inhibition are also being studied in BTCs, and these include immunostimulatory receptor agonists, Wnt signaling modulators, adoptive cell therapy, and cancer vaccines. A large number of trials are underway to explore promising new combinations and immune-targeted strategies, offering opportunities to expand the role of immunotherapy in BTC management in the near future.
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Affiliation(s)
| | | | | | - Thatcher R. Heumann
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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4
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Kelly RJ, Bever K, Chao J, Ciombor KK, Eng C, Fakih M, Goyal L, Hubbard J, Iyer R, Kemberling HT, Krishnamurthi S, Ku G, Mordecai MM, Morris VK, Paulson AS, Peterson V, Shah MA, Le DT. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of gastrointestinal cancer. J Immunother Cancer 2023; 11:jitc-2022-006658. [PMID: 37286304 DOI: 10.1136/jitc-2022-006658] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2023] [Indexed: 06/09/2023] Open
Abstract
Gastrointestinal (GI) cancers, including esophageal, gastroesophageal junction, gastric, duodenal and distal small bowel, biliary tract, pancreatic, colon, rectal, and anal cancer, comprise a heterogeneous group of malignancies that impose a significant global burden. Immunotherapy has transformed the treatment landscape for several GI cancers, offering some patients durable responses and prolonged survival. Specifically, immune checkpoint inhibitors (ICIs) directed against programmed cell death protein 1 (PD-1), either as monotherapies or in combination regimens, have gained tissue site-specific regulatory approvals for the treatment of metastatic disease and in the resectable setting. Indications for ICIs in GI cancer, however, have differing biomarker and histology requirements depending on the anatomic site of origin. Furthermore, ICIs are associated with unique toxicity profiles compared with other systemic treatments that have long been the mainstay for GI cancer, such as chemotherapy. With the goal of improving patient care by providing guidance to the oncology community, the Society for Immunotherapy of Cancer (SITC) convened a panel of experts to develop this clinical practice guideline on immunotherapy for the treatment of GI cancer. Drawing from published data and clinical experience, the expert panel developed evidence- and consensus-based recommendations for healthcare professionals using ICIs to treat GI cancers, with topics including biomarker testing, therapy selection, and patient education and quality of life considerations, among others.
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Affiliation(s)
- Ronan J Kelly
- Charles A. Sammons Cancer Center, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Katherine Bever
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph Chao
- City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Kristen K Ciombor
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Cathy Eng
- Department of Hematology and Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Marwan Fakih
- Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center Duarte, Duarte, California, USA
| | - Lipika Goyal
- Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Joleen Hubbard
- Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Renuka Iyer
- Department of GI Medical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Holly T Kemberling
- Department of GI Immunology Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
| | | | - Geoffrey Ku
- Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Van K Morris
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center Division of Cancer Medicine, Houston, Texas, USA
| | - Andrew Scott Paulson
- Department of Medical Oncology, Texas Oncology-Baylor Charles A Sammons Cancer Center, Dallas, Texas, USA
| | - Valerie Peterson
- Department of Thoracic Medical Oncology, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore, Maryland, USA
| | - Manish A Shah
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Dung T Le
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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5
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Serrano Uson Junior PL, Bekaii-Saab T. Moving beyond single-agent checkpoint inhibition in biliary tract cancers: what is the next frontier? Immunotherapy 2023; 15:531-540. [PMID: 37096922 DOI: 10.2217/imt-2022-0201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
Background: Immunotherapy has been shown to improve outcomes for patients with cancer. Biliary tract cancers are a group of lethal diseases, and immunotherapy is an exciting new strategy to treat patients in advanced stages. Role of immunotherapy in biliary cancers: Durvalumab, an anti-PD-L1 antibody, is a new immunotherapy option for patients with advanced biliary cancers. In a randomized phase III trial, the combination of durvalumab and chemotherapy improved disease outcomes, including overall survival, in patients with advanced biliary cancers regardless of PD-L1 expression. Future perspective: Promising new combinations with new and potent antibodies or antiangiogenics are under development. Combinations with new immunotherapy agents targeting CTLA-4 or OX40 can enhance T-cell activation and improve outcomes compared with single anti-PD-1/PD-L1 agents. Furthermore, ctDNA is being used as an alternative to tissue genomic analysis and can be used to identify actionable targets. In this review, we will discuss the most important studies involving immunotherapy in biliary cancers as well as future perspectives in the field.
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6
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Toyoda J, Sahara K, Takahashi T, Miyake K, Yabushita Y, Sawada Y, Homma Y, Matsuyama R, Endo I, Pawlik TM. Neoadjuvant Therapy for Extrahepatic Biliary Tract Cancer: A Propensity Score-Matched Survival Analysis. J Clin Med 2023; 12:jcm12072654. [PMID: 37048737 PMCID: PMC10095506 DOI: 10.3390/jcm12072654] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/19/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
Background: Although surgery is the mainstay of curative-intent treatment for extrahepatic biliary tract cancer (EBTC), recurrence following surgery can be high and prognosis poor. The impact of neoadjuvant therapy (NAT) relative to upfront surgery (US) among patients with EBTC remains unclear. Methods: The Surveillance, Epidemiology, and End Results (SEER) databases was utilized to identify patients who underwent surgery from 2006 to 2017 for EBTC, including gallbladder cancer (GBC) and extrahepatic cholangiocarcinoma (ECC). Trends in NAT utilization were investigated, and the impact of NAT on prognosis was compared with US using a propensity score-matched (PSM) analysis. Results: Among 6582 EBTC patients (GBC, n = 4467, ECC, n = 2215), 1.6% received NAT; the utilization of NAT for EBTC increased over time (Ptrend = 0.03). Among patients with lymph node metastasis, the lymph node ratio was lower among patients with NAT (0.18 vs. 0.40, p < 0.01). After PSM, there was no difference in overall survival (OS) and cancer-specific survival (CSS) among patients treated with NAT versus US (5-year OS: 24.0% vs. 24.6%, p = 0.14, 5-year CSS: 38.0% vs. 36.1%, p = 0.21). A subgroup analysis revealed that NAT was associated with improved OS and CSS among patients with stages III–IVA of the disease (OS: HR 0.65, 95%CI 0.46–0.92, p = 0.02, CSS: HR 0.62, 95%CI 0.41–0.92, p = 0.01). Conclusions: While NAT did not provide an overall benefit to patients undergoing surgery for EBTC, individuals with advanced-stage disease had improved OS and CSS with NAT. An individualized approach to NAT use among patients with EBTC may provide a survival benefit.
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Affiliation(s)
- Junya Toyoda
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Kota Sahara
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Tomoaki Takahashi
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Kentaro Miyake
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Yasuhiro Yabushita
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Yu Sawada
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Yuki Homma
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Ryusei Matsuyama
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Timothy M. Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH 43210, USA
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7
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Karasic TB, Eads JR, Goyal L. Precision Medicine and Immunotherapy Have Arrived for Cholangiocarcinoma: An Overview of Recent Approvals and Ongoing Clinical Trials. JCO Precis Oncol 2023; 7:e2200573. [PMID: 37053534 PMCID: PMC10309532 DOI: 10.1200/po.22.00573] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/31/2023] [Indexed: 04/15/2023] Open
Affiliation(s)
- Thomas B. Karasic
- Division of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA
| | - Jennifer R. Eads
- Division of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA
| | - Lipika Goyal
- Department of Medicine, Division of Hematology and Oncology, Stanford Cancer Center, Palo Alto, CA
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Testa U, Pelosi E, Castelli G. The clinical value of identifying genetic abnormalities that can be targeted in cholangiocarcinomas. Expert Rev Anticancer Ther 2023; 23:147-162. [PMID: 36654529 DOI: 10.1080/14737140.2023.2170878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Cholangiocarcinomas (CCAs) are a heterogenous group of epithelial malignancies originating at any level of the biliary tree and are subdivided according to their location into intrahepatic (iCCA) and extrahepatic (eCCA). AREAS COVERED This review provides an updated analysis of studies of genetic characterization of CCA at the level of gene mutation profiling, copy number alterations and gene expression, with definition of molecular subgroups and identification of some molecular biomarkers and therapeutic targets. EXPERT OPINION With the development of genetic sequencing, several driver mutations have been identified and targeted as novel therapeutic approaches, including FGFR2, IDH1, BRAF, NTRK, HER2, ROS, and RET. Furthermore, identification of the cellular and molecular structure of the tumor microenvironment has contributed to the development of novel therapies, such as tumor immunotherapy. Combination therapies of chemotherapy plus targeted molecules or immunotherapy are under evaluation and offer the unique opportunity to improve the outcomes of CCA patients with advanced disease.
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Affiliation(s)
- Ugo Testa
- Department of Oncology, Istituto Superiore Di Sanità, Rome, Italy
| | - Elvira Pelosi
- Department of Oncology, Istituto Superiore Di Sanità, Rome, Italy
| | - Germana Castelli
- Department of Oncology, Istituto Superiore Di Sanità, Rome, Italy
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9
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Breder VV, Ledin EV, Chubenko VA, Orlova RV, Petkau VV, Pokataev IA. Place of durvalumab in the treatment of biliary tract cancer: A review. JOURNAL OF MODERN ONCOLOGY 2023. [DOI: 10.26442/18151434.2022.4.202006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Biliary tract cancer (BTC) is a group of rare and aggressive types of malignancies that arise from the epithelium of the intra- and extrahepatic bile ducts (cholangiocarcinoma) and gallbladder. The prognosis of unresectable BTC is poor, and less than 5% of patients are alive at 5 years after diagnosis. Radical surgical resection remains the only potentially curative treatment for early stage BTC, and antitumor chemotherapy extends survival rates in patients with unresectable or metastatic BTC. With the emerging of monoclonal antibodies targeting immune checkpoints, the possibility of such therapy in first- and subsequent-line treatment of advanced BTC has been actively studied. The positive high-level results from the TOPAZ-1 Phase III trial showed durvalumab, in combination with standard-of-care chemotherapy (gemcitabine plus cisplatin), statistically improved overall survival versus chemotherapy alone and showed improvements versus chemotherapy alone in prespecified secondary endpoints including progression-free survival and objective response rate. Durvalumab plus chemotherapy was well tolerated, had a similar safety profile versus the comparator arm and did not increase the discontinuation rate due to adverse events compared to chemotherapy alone. The U.S. Food and Drug Administration approved the combination of durvalumab and chemotherapy (gemcitabine plus cisplatin) as the first immunotherapy regimen for patients with locally advanced or metastatic BTC. In July 2022, durvalumab plus chemotherapy (gemcitabine plus cisplatin) was added to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) as a preferred regimen category 1 in first-line therapy for Unresectable or metastatic BTC based on the data from TOPAZ-1. In addition, the durvalumab plus gemcitabine and cisplatin was recently added to the practical recommendations of the Russian Society of Clinical Oncology (RUSSCO) for the treatment of hepatobiliary cancers as an alternative to standard first-line treatment of BTC.
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10
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Harding JJ, Khalil DN, Fabris L, Abou-Alfa GK. Rational development of combination therapies for biliary tract cancers. J Hepatol 2023; 78:217-228. [PMID: 36150578 PMCID: PMC11111174 DOI: 10.1016/j.jhep.2022.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/06/2022] [Accepted: 09/08/2022] [Indexed: 02/01/2023]
Abstract
Biliary tract cancers are an uncommon set of gastrointestinal malignancies that are associated with high morbidity and mortality rates. Most patients present with incurable locally advanced or metastatic disease. The pathophysiology of biliary tract cancer can be exploited for direct therapeutic benefit, and indeed, chemotherapy, precision medicine, immunotherapy and combination treatments are now applied as both standard-of-care and investigational therapies. In the first-line setting, the immune-based chemotherapy combination of durvalumab plus gemcitabine and cisplatin has recently been shown to improve survival compared to chemotherapy alone. In the second-line, precision medicine can be employed in those with select genetic alterations in IDH1/2 (isocitrate dehydrogenase 1/2), FGFR2 (fibroblast growth factor receptor 2), KRAS, BRAF, ERBB2, NTRK (neurotrophic receptor tyrosine kinase), ROS, RET, and/or deficiencies in mismatch repair enzymes. In those patients without targetable genetic alterations, fluoropyridine doublets lead to modest improvements in outcomes. Next-generation sequencing is critical for direct patient care and to help elucidate genomic mechanisms of resistance in a research context. Currently, multiple clinical trials are ongoing - hence, this review seeks to provide an update on evolving standards of care and ongoing investigational agents, limitations to current treatments, and a framework for effective combination drug development for the future.
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Affiliation(s)
- James J Harding
- Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Medical College at Cornell University, New York, NY, USA
| | - Danny N Khalil
- Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Medical College at Cornell University, New York, NY, USA
| | - Luca Fabris
- Department of Molecular Medicine, University of Padua, and Division of General Medicine, Padua University-Hospital, Padua, Italy; Digestive Disease Section, Yale University School of Medicine, New Haven, CT, USA
| | - Ghassan K Abou-Alfa
- Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Medical College at Cornell University, New York, NY, USA.
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11
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Yan X, Zou H, Lai Y, Ung COL, Hu H. Efficacy and Safety of First-Line Targeted Treatment and Immunotherapy for Patients with Biliary Tract Cancer: A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 15:cancers15010039. [PMID: 36612035 PMCID: PMC9817514 DOI: 10.3390/cancers15010039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/06/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Biliary tract cancer is one of the most aggressive and fatal tumours. Gemcitabine with cisplatin chemotherapy has long been the first-line treatment, but the prognosis is poor. In recent years, targeted treatment and immunotherapy have produced encouraging outcomes requiring a thorough review and meta-analysis. METHOD For this systematic review and meta-analysis, we searched four databases, starting from the inception dates of databases to 11 January 2022. This study comprised randomised clinical trials and cohort studies that used immunotherapy or targeted treatment as the first line of treatment for patients with biliary tract cancer. RESULTS From the 888 studies extracted, 33 trials were examined and found to meet the criteria. These included 3087 patients, 16 single-arm trials, 13 RCTs, one nRCT, a prospective single-arm pilot study, and a clinical setting in the real world. From 2010 to 2020, 33 studies were conducted using targeted treatment or immunologic therapies as first-line treatments for BTC patients, and 18 of those studies had positive outcomes. CONCLUSION This study demonstrates that immunotherapy combined with chemotherapy as first-line treatment can provide survival benefits by improving the objective response rate for patients with unresectable biliary tract cancer. The potential for combination therapy to become a new trend in clinical treatment is promising but needs further clinical evaluation.
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Affiliation(s)
- Xin Yan
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao SAR, China
| | - Huimin Zou
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao SAR, China
| | - Yunfeng Lai
- School of Public Health and Management, Guangzhou University of Chinese Medicine, Guangzhou 510006, China
| | - Carolina Oi Lam Ung
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao SAR, China
- Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Macao SAR, China
| | - Hao Hu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao SAR, China
- Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Macao SAR, China
- Correspondence:
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12
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Immunotherapy in Biliary Tract Cancers: Where Are We? Curr Oncol Rep 2022; 24:1821-1828. [PMID: 36192517 DOI: 10.1007/s11912-022-01328-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Biliary tract cancers (BTCs) are a heterogenous group of cancers arising from the biliary tract. The hallmark of these cancers is the advanced stage of presentation and a paucity of durable treatment options. Despite the advances in targeted therapy and immunotherapy in solid tumors, systemic cytotoxic chemotherapy has remained the mainstay for cholangiocarcinomas. RECENT FINDINGS With advances in the understanding of the tumor microenvironment, genetic features, and inflammatory milieu, have led to the identification of tumor-infiltrating immune cells as indicators of prognosis and response to treatment in BTC. Through an improved comprehension of immunology, immuno-oncology is becoming another pillar of treatment along with traditional radiation, surgery, cytotoxic chemotherapy, and targeted therapies. This article reviews the evidence for immunotherapy use in cholangiocarcinoma, which still being in infancy, and offers promising new novel options for the management of biliary tract cancers.
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13
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Newest Therapies for Cholangiocarcinoma: An Updated Overview of Approved Treatments with Transplant Oncology Vision. Cancers (Basel) 2022; 14:cancers14205074. [PMID: 36291857 PMCID: PMC9600404 DOI: 10.3390/cancers14205074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/09/2022] [Accepted: 10/12/2022] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Cholangiocarcinoma is a relatively rare but deadly disease with traditionally limited treatment options. The disease can be categorized by anatomic location within the biliary tree, with different associated risk factors and molecular profiles. Recent years have seen a burgeoning of targeted therapies that have enhanced survival in subsets of patients with certain mutations. We herein discuss these more recent advances as well as providing an overview of more well-known treatment modalities, with the goal of providing an accessible source for practicing clinicians. Abstract A minority of cholangiocarcinoma (CCA) can be cured by surgical intervention (i.e., liver resection (LR) and liver transplantation (LT)). When modern criteria for LT are met, this intervention along with neoadjuvant treatments may achieve unprecedented survival in selected patients. Liver resection is associated with a median overall survival (OS) of 40 months, this number drastically decreases for unresectable advanced cholangiocarcinoma (CCA), which is treated with systemic therapy. The first-line chemotherapy regimen of gemcitabine and cisplatin is associated with a median overall survival of only 11.7 months. Since the Food and Drug Administration (FDA)’s approval of the isocitrate dehydrogenase (IDH) 1 inhibitor ivosidenib in August 2021, there has been increasing interest in targeted therapy for CCA patients harboring mutations in fibroblast growth factor receptor (FGFR) 2, neurotrophic receptor tyrosine kinase (NTRK), B-raf kinase (BRAF), and HER2. At the same time, immunotherapy with immune checkpoint inhibitors isalso being used in relapsed CCA. This review looks into the most recently completed and ongoing studies of targeted therapy as monotherapy or in combination with chemo- and/or immunotherapy. Whether it is resection, liver transplant, radiotherapy, chemotherapy, immunotherapy, targeted therapy, or any combination of these treatment modalities, great strides are being made to improve outcomes for this challenging disease.
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Tam VC, Ramjeesingh R, Burkes R, Yoshida EM, Doucette S, Lim HJ. Emerging Systemic Therapies in Advanced Unresectable Biliary Tract Cancer: Review and Canadian Perspective. Curr Oncol 2022; 29:7072-7085. [PMID: 36290832 PMCID: PMC9600578 DOI: 10.3390/curroncol29100555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/18/2022] [Accepted: 09/20/2022] [Indexed: 01/13/2023] Open
Abstract
Biliary tract cancer (BTC) is a group of rare and aggressive malignancies with a dismal prognosis. There is currently a significant lack in effective treatment options for BTC, with gemcitabine-cisplatin remaining the first-line standard of care treatment for over a decade. A wave of investigational therapies, including new chemotherapy combinations, immunotherapy, and biomarker-driven targeted therapy have demonstrated promising results in BTC, and there is hope for many of these therapies to be incorporated into the Canadian treatment landscape in the near future. This review discusses the emerging therapies under investigation for BTC and provides a perspective on how they may fit into Canadian practice, with a focus on the barriers to treatment access.
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Affiliation(s)
- Vincent C. Tam
- Division of Medical Oncology, Department of Oncology, University of Calgary, Calgary, AB T2N 4N2, Canada
| | - Ravi Ramjeesingh
- Division of Medical Oncology, Department of Medicine, Nova Scotia Health, Dalhousie University, Halifax, NS B3H 2Y9, Canada
| | - Ronald Burkes
- Division of Medical Oncology, Princess Margaret Cancer Centre, Mount Sinai Hospital, Toronto, ON M5G 1X5, Canada
| | - Eric M. Yoshida
- Division of Gastroenterology, Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
- Medical Advisory Committee Chair, Canadian Liver Foundation, Markham, ON L3R 8T3, Canada
| | | | - Howard J. Lim
- Division of Medical Oncology, BC Cancer, Vancouver, BC V5Z 4E6, Canada
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15
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Zeng TM, Pan YF, Yuan ZG, Chen DS, Song YJ, Gao Y. Immune-related RNA signature predicts outcome of PD-1 inhibitor-combined GEMCIS therapy in advanced intrahepatic cholangiocarcinoma. Front Immunol 2022; 13:943066. [PMID: 36159865 PMCID: PMC9501891 DOI: 10.3389/fimmu.2022.943066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundImmune checkpoint inhibitor (ICI)-combined chemotherapy in advanced intrahepatic cholangiocarcinoma has been proved to have more efficacy in a series of clinical trials. However, whether the tumor microenvironment (TME) plays a vital role in immune-combined therapy has not been rigorously evaluated.MethodsFirstly, we assayed the immunogenic properties of GEM-based chemotherapy. Then, 12 ICC patients treated with PD-1 inhibitor (sintilimab) combined with gemcitabine and cisplatin (GemCis) from a phase 2 clinical trial (ChiCTR2000036652) were included and their immune-related gene expression profiles were analyzed using RNA from baseline tumor samples. Immune-related signature correlating with clinical outcome was identified according to the 12 ICC patients, and its predictive value was validated in an ICC cohort with 26 patients. Multiplexed immunofluorescence (mIF) and flow cytometry (FCM) analysis were performed to evaluate the immune-related molecules with therapeutic outcomes.ResultsGEM-based chemotherapy induced immunogenic cell death of cholangiocarcinoma cells, together with increased CD274 expression. In an ICC cohort, we found that upregulation of immune-checkpoint molecules and immune response-related pathways were significantly related to better clinical outcome. On the contrary, baseline immune-cell proportions in tumor tissues did not show any correlation with clinical benefit between responders and non-responders. Immune-related signature (including six genes) correlating with clinical outcome was identified according to the 12 ICC patients, and its predictive value was validated in a small ICC cohort with 26 patients.ConclusionImmune-related RNA signature predicts the outcome of PD-1 inhibitor-combined GEMCIS therapy in advanced intrahepatic cholangiocarcinoma, which could be tested as a biomarker for immune-chemotherapy in the future.
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Affiliation(s)
- Tian-mei Zeng
- School of Medicine, Tongji University, Shanghai, China
- Department of Oncology, Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - Yu-fei Pan
- International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - Zhen-gang Yuan
- Department of Oncology, Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - Dong-sheng Chen
- Jiangsu Simcere Diagnostics Co., Ltd, The State Key Laboratory of Translational Medicine and Innovative Drug Development, Nanjing, China
| | - Yun-jie Song
- Jiangsu Simcere Diagnostics Co., Ltd, The State Key Laboratory of Translational Medicine and Innovative Drug Development, Nanjing, China
| | - Yong Gao
- School of Medicine, Tongji University, Shanghai, China
- Department of Oncology, Shanghai East Hospital, Shanghai, China
- *Correspondence: Yong Gao,
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16
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Outcomes following FGFR Inhibitor Therapy in Patients with Cholangiocarcinoma. Target Oncol 2022; 17:529-538. [PMID: 36056231 DOI: 10.1007/s11523-022-00914-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Sequencing efforts in patients with cholangiocarcinoma (CCA) have provided insights into molecular mechanisms including fibroblast growth factor receptor (FGFR) alterations. There is a lack of data on outcomes of patients following cessation of FGFR inhibitor (FGFRi) therapy. OBJECTIVE We describe the clinical outcomes following initial FGFRi treatment in CCA harboring FGFR alterations. PATIENTS AND METHODS We conducted a multicentric, retrospective analysis of patients with FGFR-altered CCA diagnosed between 2010 and 2021. Median overall survival (OS) and progression-free survival (PFS) analyses were performed using the Kaplan-Meier method. RESULTS We identified 88 advanced or metastatic CCA patients, 28 males (31.8%) and 60 females (68.2%), harboring FGFR alterations who received FGFRi. Median PFS on initial FGFRi was 6.6 months (95% confidence interval (CI): 5.5-8.3). Following cessation of first FGFRi therapy, 55% patients received systemic therapy as next line: 67% received chemotherapy or targeted treatment and 33% received another FGFRi. Median PFS for patients who received chemotherapy or targeted agent was 2.1 months (95% CI 1.6-5.7) and for patients who received a second FGFRi was 3.7 months (95% CI 1.5-not evaluable). OS was 2.0 months for patients who did not receive any therapy compared to 8.7 months with chemotherapy and 8.6 months with another FGFRi. In addition, one patient treated with pemigatinib developed FGFR2 M540_I541insMM alteration at time of resistance, which has not been functionally characterized and its effect on protein function remains unknown. CONCLUSIONS Understanding the mechanisms of resistance with FGFRi is essential to understand sequencing of treatments. In this study, patients received standard chemotherapy in the first line and were fit enough to be considered for subsequent therapy with an FGFRi. Almost half of the patients become ineligible to receive further systemic therapy following progression on FGFRi. As more agents are being introduced, detailed understanding of outcomes following treatment with an FGFRi, including subsequent FGFRi, is essential.
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17
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Uson Junior PLS, Araujo RLC. Immunotherapy in biliary tract cancers: Current evidence and future perspectives. World J Gastrointest Oncol 2022; 14:1446-1455. [PMID: 36160750 PMCID: PMC9412936 DOI: 10.4251/wjgo.v14.i8.1446] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/30/2022] [Accepted: 07/06/2022] [Indexed: 02/05/2023] Open
Abstract
Bile duct tumors are comprised of tumors that originate from both intrahepatic and extrahepatic bile ducts and gallbladder tumors. These are aggressive tumors and chemotherapy is still the main treatment for advanced-stage disease and most of these cases have a poor overall survival. Strategies are aimed at treatments with better outcomes and less toxicity which makes immunotherapy an area of significant importance. Recent Food and Drug Administration approvals of immune checkpoint inhibitors (ICI) for agnostic tumors based on biomarkers such as microsatellite instability-high and tumor mutation burden-high are important steps in the treatment of patients with advanced bile duct tumors. Despite limited responses with isolated checkpoint inhibitors in later lines of systemic treatment in advanced disease, drug combination strategies have been demonstrating encouraging results to enhance ICI efficacy.
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Affiliation(s)
| | - Raphael LC Araujo
- Department of Surgery, Universidade Federal de São Paulo, São Paulo 04039-002, Brazil
- Department of Oncology, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
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18
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Zimpel C, Mitzlaff K, Jasper NA, Marquardt JU. Aktuelle Studien und Evidenz zum Cholangiokarzinom. Zentralbl Chir 2022; 147:389-397. [DOI: 10.1055/a-1844-0267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
ZusammenfassungCholangiokarzinome (CCA) stellen die zweithäufigsten primären Leberkarzinome dar
und umfassen eine heterogene Gruppe aus intra- und extrahepatischen
Gallenwegstumoren. Die Prognose der Patienten ist sowohl aufgrund einer hohen
Rezidivrate als auch häufig später Diagnosestellung in fortgeschrittenen Stadien
eingeschränkt. Den Goldstandard der kurativen Therapie bildet die komplette
Resektion; sie erfordert komplex-onkologische Eingriffe mit ggf. vorgeschalteten
Hypertrophieinduktionen der Restleber zur Sicherung einer postoperativ
ausreichenden Leberfunktion. Als adjuvante Therapie ist eine 6-monatige Therapie
mit Capecitabin etabliert. Die Therapielandschaft im fortgeschrittenen Stadium
der Erkrankung befindet sich aufgrund neuer Daten aus klinischen
Phase-II/III-Studien stetig im Wandel. Einerseits ebneten molekulare Analysen
den Weg hin zu effektiven zielgerichteten Behandlungen von selektionierten
CCA-Patienten mit u. a. Alterationen in FGFR2- oder IDH1-Signalwegen;
andererseits erwiesen sich in aktuellen klinischen Studien immunonkologische
Kombinationsansätze als effektive und sichere All-Comer-Therapien für die
Behandlung eines unselektionierten Patientenkollektivs. Weitere Studien
evaluieren sowohl Kombinationsbehandlungen als auch molekulare Stratifikation
als neue Therapiekonzepte auch in früheren Erkrankungsstadien und werden die
Therapielandschaft und Prognose der Patienten in Zukunft verbessern.
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Affiliation(s)
- Carolin Zimpel
- Medizinische Klinik I, UKSH Campus Lübeck, Lübeck,
Deutschland
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19
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Sahai V, Griffith KA, Beg MS, Shaib WL, Mahalingam D, Zhen DB, Deming DA, Zalupski MM. A randomized phase 2 trial of nivolumab, gemcitabine, and cisplatin or nivolumab and ipilimumab in previously untreated advanced biliary cancer: BilT-01. Cancer 2022; 128:3523-3530. [PMID: 35895381 PMCID: PMC9540241 DOI: 10.1002/cncr.34394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/02/2022] [Accepted: 06/06/2022] [Indexed: 11/08/2022]
Abstract
Background Gemcitabine and cisplatin has limited benefit as treatment for advanced biliary tract cancer (BTC). The addition of an anti‐programmed death receptor (PD‐1)/PD‐ligand (L1) antibody to either systemic chemotherapy or anti‐cytotoxic T‐lymphocyte‐associated protein 4 (CTLA4) antibody has shown benefit in multiple solid tumors. Methods In this phase 2 trial, patients 18 years or older with advanced BTC without prior systemic therapy and Eastern Cooperative Oncology Group Performance Status 0–1 were randomized across six academic centers. Patients in Arm A received nivolumab (360 mg) on day 1 along with gemcitabine and cisplatin on days 1 and 8 every 3 weeks for 6 months followed by nivolumab (240 mg) every 2 weeks. Patients in Arm B received nivolumab (240 mg) every 2 weeks and ipilimumab (1 mg/kg) every 6 weeks. Results Of 75 randomized patients, 68 received therapy (Arm A = 35, Arm B = 33); 51.5% women with a median age of 62.5 years. The observed primary outcome of 6‐month progression‐free survival (PFS) rates in the evaluable population was 59.4% in Arm A and 21.2% in Arm B. The median PFS and overall survival (OS) in Arm A were 6.6 and 10.6 months, and in Arm B 3.9 and 8.2 months, respectively, in patients who received any treatment. The most common treatment‐related grade 3 or higher hematologic adverse event was neutropenia in 34.3% (Arm A) and nonhematologic adverse events were fatigue (8.6% Arm A) and elevated transaminases (9.1% Arm B). Conclusions The addition of nivolumab to chemotherapy or ipilimumab did not improve 6‐month PFS. Although median OS was less than 12 months in both arms, the high OS rate at 2 years in Arm A suggests benefit in a small cohort of patients. Immune checkpoint inhibition alone or in combination with chemotherapy as first‐line therapy does not appear to improve efficacy when compared to chemotherapy alone for patients with advanced biliary cancer in the United States. However, at least one third of the patients were alive at 2 years in the chemoimmunotherapy arm, and additional studies are ongoing to investigate this result, and importantly, evaluate biomarkers predictive for benefit from this treatment regimen.
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Affiliation(s)
- Vaibhav Sahai
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kent A Griffith
- Center for Cancer Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Muhammad S Beg
- Division of Hematology and Oncology, Department of Internal Medicine, University of Texas, Southwestern, Dallas, Texas, USA
| | - Walid L Shaib
- Department of Hematology and Oncology, Emory University, Atlanta, Georgia, USA
| | - Devalingam Mahalingam
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - David B Zhen
- Division of Medical Oncology, Department of Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Dustin A Deming
- Division of Hematology, Medical Oncology and Palliative Care, Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Mark M Zalupski
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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20
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Scott AJ, Sharman R, Shroff RT. Precision Medicine in Biliary Tract Cancer. J Clin Oncol 2022; 40:2716-2734. [PMID: 35839428 DOI: 10.1200/jco.21.02576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Precision medicine has become a dominant theme in the treatment of biliary tract cancers (BTCs). Although prognosis remains poor, technologies for improved molecular characterization along with the US Food and Drug Administration approval of several targeted therapies have changed the therapeutic landscape of advanced BTC. The hallmark of BTC oncogenesis is chronic inflammation of the liver and biliary tract regardless of the anatomical subtype. Subtypes of BTC correspond to distinct molecular characteristics, making BTC a molecularly heterogenous collection of tumors. Collectively, up to 40% of BTCs harbor a potentially targetable molecular abnormality, and the National Comprehensive Cancer Network guidelines recommend molecular profiling for all patients with advanced BTC. Use of circulating tumor DNA, immunohistochemistry, and next-generation sequencing continues to expand the utility for biomarker-driven management and molecular monitoring of BTC. Improving outcomes using biomarker-agnostic treatment for nontargetable tumors also remains a priority, and combinational treatment strategies such as immune checkpoint inhibition plus chemotherapy hold promise for this subgroup of patients.
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Affiliation(s)
- Aaron J Scott
- Division of Hematology and Oncology, University of Arizona Cancer Center, Tucson, AZ
| | - Reya Sharman
- Division of Hematology and Oncology, University of Arizona Cancer Center, Tucson, AZ
| | - Rachna T Shroff
- Division of Hematology and Oncology, University of Arizona Cancer Center, Tucson, AZ
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21
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Triple therapy in biliary tract cancers: GemOX plus immune checkpoint inhibitor in combination with lenvatinib or NGS-guided targeted therapy. J Cancer Res Clin Oncol 2022; 149:1917-1927. [PMID: 35802197 DOI: 10.1007/s00432-022-04166-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/19/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE The combination of gemcitabine-based chemotherapy and immune checkpoint inhibitors has a good efficacy in advanced biliary tract cancer (BTC). The multi-target TKI lenvatinib and NGS-guided targeted therapy are also promising in BTC treatment. This study aimed to explore the performance of GemOX plus sintilimab and TKI (either lenvatinib or by NGS-guided targeted therapy) for local advanced or metastatic BTCs. METHODS This prospective single-arm study included patients with local advanced or metastatic BTCs and applied intravenous infusion of standard GemOX plus sintilimab and lenvatinib (no targetable gene alterations) or targeted therapy based on NGS (olaparib for BRCA1/2 mutation, dasatinib for IDH1/2 mutation, afatinib for EGFR amplification, lenvatinib for PDGFR and KIT mutation, and lenvatinib for FGFR/KIT mutation). RESULTS From November 2020 to December 2021, 22 patients BTCs (6 GBC, 14 iCCA, 1 pCCA and 1 dCCA cases) were enrolled, with an average age of 58.4 years. Partial response (PR) was achieved in 10 cases, stable disease (SD) in 9 cases and progression disease (PD) in 3 cases (13.6%). The objective response rate (ORR) was 45.5%, and the disease control rate (DCR) was 86.4%. During the treatment, the incidence of adverse reactions was 81.8%, and the incidence of grade 3/4 adverse events was 9.09%. For 14 patients with NGS, 5 patients were treated by targeted therapy and there were 1 SD and 4 PR cases. For four patients with positive PD-L1 expression, the ORR was 100%. While among the three patients with super-progression markers such as RET, MDM2 and FGF14/STK24, there were two SD and one PD cases. CONCLUSION In patients with advanced BTCs, the combination of GemOX plus sintilimab and lenvatinib or NGS-guided targeted therapy showed promising ORR and DCR, especially for the patients with positive PD-L1 expression and targetable gene alterations.
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22
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Jiang Q, Huang J, Zhang B, Li X, Chen X, Cui B, Li S, Guo G. Efficacy and Safety of Anti-PD1/PDL1 in Advanced Biliary Tract Cancer: A Systematic Review and Meta-Analysis. Front Immunol 2022; 13:801909. [PMID: 35309350 PMCID: PMC8924050 DOI: 10.3389/fimmu.2022.801909] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background Anti-programmed cell death protein 1 and its ligand (anti-PD1/PDL1) have been proposed as a promising therapeutic option for advanced biliary tract cancer (aBTC). Given the scarce quantitative analyses of anti-PD1/PDL1 in aBTC, we thus did a meta-analysis to assess the benefits and risks of this emerging treatment strategy in patients with aBTC. Methods PubMed, Embase, the Cochrane Library, Web of Science, and meeting resources were searched for relevant studies. The main endpoints were median progression-free survival (mPFS), median overall survival (mOS), objective response rate (ORR), disease control rate (DCR), any-grade adverse events (AEs), and grade 3-4 AEs. Results Twenty-eight studies with 1,338 participants were included. The best curative effect was found in the anti-PD1/PDL1 combined with anti-CTLA4 and chemotherapy group (mPFS: 12.4 months; mOS: 16.0 months; ORR: 45.1%; DCR: 95.0%), followed by the anti-PD1/PDL1 plus chemotherapy group (mPFS: 8.2 months; mOS: 14.8 months; ORR: 36.3%; DCR: 84.6%), the anti-PD1/PDL1 plus antiangiogenesis group (mPFS: 4.9 months; mOS: 10.2 months; ORR: 17.5%; DCR: 68.7%), the anti-PD1/PDL1 plus anti-cytotoxic T lymphocyte antigen 4 (anti-CTLA4) group (mPFS: 2.9 months; mOS: 8.3 months; ORR: 9.9%; DCR: 36.8%), and the anti-PD1/PDL1 monotherapy group (mPFS: 2.5 months; mOS: 7.6 months; ORR: 6.8%; DCR: 34.7%). Compared with anti-PD1-containing regimens, anti-PDL1-containing regimens achieved preferable mPFS (11.1 vs. 3.8 months), mOS (12.2 vs. 9.8 months), and ORR (23.7% vs. 17.4%), despite a similar DCR (61.1% vs. 61.3%). The mPFS, mOS, ORR, and DCR were 10.6 months, 15.8 months, 42.3%, and 88.6% of first-line anti-PD1/PDL1 and 3.0 months, 9.1 months, 11.6%, and 51.1% of second-line therapy or beyond, respectively. There were 80.6% and 34.0% of the patients suffering any-grade AEs and grade 3-4 AEs. Anti-PD1/PDL1 monotherapy might be considered as a safer alternative than combination regimens. Meanwhile, obvious toxicities in the first-line setting could not be neglected. Conclusions Anti-PD1/PDL1 showed encouraging efficacy and acceptable safety profile in aBTC and, thus, could be an alternative treatment.
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Affiliation(s)
- Qi Jiang
- VIP Department, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jinsheng Huang
- VIP Department, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Bei Zhang
- VIP Department, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xujia Li
- VIP Department, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiuxing Chen
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bokang Cui
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China.,Department of Pancreaticobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Shengping Li
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China.,Department of Pancreaticobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Guifang Guo
- VIP Department, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
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23
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Giorgione R, Risaliti M, Bartolini I, Rossi G, Pillozzi S, Muiesan P, Taddei A, Antonuzzo L. The emerging role of immunotherapy in biliary tract cancer: a review of new evidence and predictive biomarkers. Immunotherapy 2022; 14:567-576. [PMID: 35382560 DOI: 10.2217/imt-2021-0257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Biliary tract cancers (BTCs) are frequently diagnosed in advanced stages and are highly lethal. Immunotherapy may play a role in the treatment of these patients. Promising results come from monotherapy or combination therapy studies in pretreated patients. In addition, several studies have demonstrated the safety and efficacy of immune checkpoint inhibitors (ICIs) in combination with chemotherapy in treatment-naive patients. Numerous biomarkers have been investigated to define their predictive role in response to ICIs. However, the full extent of the benefit of immunotherapies has not yet been fully established and, except for high microsatellite instability status, no other biomarkers were uniquely predictive of response to ICIs.
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Affiliation(s)
- Roberta Giorgione
- Medical Oncology Unit, Careggi University Hospital, Florence, 50134, Italy
| | - Matteo Risaliti
- Department of Experimental & Clinical Medicine, University of Florence, Florence, 50134, Italy
| | - Ilenia Bartolini
- Department of Experimental & Clinical Medicine, University of Florence, Florence, 50134, Italy
| | - Gemma Rossi
- Medical Oncology Unit, Careggi University Hospital, Florence, 50134, Italy
| | - Serena Pillozzi
- Medical Oncology Unit, Careggi University Hospital, Florence, 50134, Italy
| | - Paolo Muiesan
- Department of Experimental & Clinical Medicine, University of Florence, Florence, 50134, Italy
| | - Antonio Taddei
- Department of Experimental & Clinical Medicine, University of Florence, Florence, 50134, Italy
| | - Lorenzo Antonuzzo
- Medical Oncology Unit, Careggi University Hospital, Florence, 50134, Italy.,Department of Experimental & Clinical Medicine, University of Florence, Florence, 50134, Italy
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Cowzer D, Harding JJ. Advanced Bile Duct Cancers: A Focused Review on Current and Emerging Systemic Treatments. Cancers (Basel) 2022; 14:1800. [PMID: 35406572 PMCID: PMC8997852 DOI: 10.3390/cancers14071800] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/08/2022] [Accepted: 03/11/2022] [Indexed: 12/17/2022] Open
Abstract
Cancers arising in the biliary tract are rare, with varied incidence depending on geographical location. As clinical presentation is typically vague with non-specific symptoms, a large proportion of patients present with unresectable or metastatic disease at diagnosis. When unresectable, the mainstay of treatment is cytotoxic chemotherapy; however, despite this, 5-year overall survival remains incredibly poor. Diagnostic molecular pathology, using next-generation sequencing, has identified a high prevalence of targetable alterations in bile duct cancers, which is transforming care. Substantial genomic heterogeneity has been identified depending on both the anatomical location and etiology of disease, with certain alterations enriched for subtypes. In addition, immune checkpoint inhibitors with anti-PD-1/PD-L1 antibodies in combination with chemotherapy are now poised to become the standard first-line treatment option in this disease. Here, we describe the established role of cytotoxic chemotherapy, targeted precision treatments and immunotherapy in what is a rapidly evolving treatment paradigm for advanced biliary tract cancer.
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Affiliation(s)
| | - James J. Harding
- Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY 10065, USA;
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25
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Kang S, El-Rayes BF, Akce M. Evolving Role of Immunotherapy in Advanced Biliary Tract Cancers. Cancers (Basel) 2022; 14:cancers14071748. [PMID: 35406520 PMCID: PMC8996885 DOI: 10.3390/cancers14071748] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 12/17/2022] Open
Abstract
Simple Summary Biliary tract cancers (BTC) include gallbladder cancers, intrahepatic, perihilar and distal extrahepatic cholangiocarcinomas. BTCs represent a major health problem due to their increasing global incidence and associated poor prognosis. The majority of patients present with advanced stages of cancer, where cytotoxic chemotherapy provides modest survival benefit. More recently, novel treatment options have emerged with the development of agents targeting specific genetic mutations of tumors as well as immunotherapy, which enhances the immune system’s ability to target cancer cells efficiently. In this review, we will discuss current and emerging systemic therapy options and the rationale for immunotherapy in BTC. Abstract Biliary tract cancers (BTC) comprise a rare and diverse group of malignancies that involve the gallbladder and biliary tree. These cancers typically present in later stages because they are aggressive in nature and affected patients are often asymptomatic in earlier stages of disease. Moreover, BTCs are generally refractory to cytotoxic chemotherapy, which further contributes to their associated poor survival outcomes. Novel therapy approaches are clearly needed. Molecular targeted agents have been developed based on our expanding knowledge of the genetic mutations underlying BTCs and represent a promising treatment strategy in molecularly selected subgroups of patients. In addition, the advent of immunotherapy over recent years has dramatically changed the bleak outcomes observed in malignancies such as melanoma. Our growing understanding of the complex tumor microenvironment in BTC has identified mechanisms of tumor immune evasion that could potentially be targeted with immunotherapy. As a result, different immunotherapeutic approaches including immune checkpoint inhibitors, cancer vaccines, and adoptive cell therapy, have been investigated. The use of immunotherapeutic agents is currently only approved for a small subset of treatment-refractory BTCs based on microsatellite instability (MSI) status and tumor mutational burden (TMB), but this will likely change with the potential approval of immunotherapy plus chemotherapy as a result of the TOPAZ-1 trial.
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Affiliation(s)
- Sandra Kang
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA;
| | - Bassel F. El-Rayes
- Department of Internal Medicine, Division of Hematology and Oncology, O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL 35233, USA;
| | - Mehmet Akce
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA;
- Correspondence:
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Taghizadeh H, Prager GW. Immune Checkpoint Inhibitors for Advanced Biliary Tract Cancer. Curr Cancer Drug Targets 2022; 22:639-650. [PMID: 35168521 DOI: 10.2174/1568009622666220215144235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 11/22/2022]
Abstract
BTC is a rare and aggressive cancer disease bearing an overall dismal prognosis with only finite therapy options. Only combination chemotherapy regimens achieve disease control which is often only short-lived since the tumor tissue exhibits a high resistance to chemotherapy. The emergence of immune checkpoint inhibitors in recent years has significantly improved the survival of cancer patients and thus, has been integrated in the therapeutic management of several solid tumors, including melanoma, colorectal carcinoma (CRC), hepatocellular carcinoma (HCC), triple-negative breast cancer (TNBC), non-small-cell lung cancer (NSCLC). Investigation of the tumor biology of BTC and results of preliminary studies have shown that BTC may also be amenable to immunomodulation. In this review, we seek to give a comprehensive overview about the role, potential and clinical significance of ICPI in the management of BTC.
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Affiliation(s)
- Hossein Taghizadeh
- Department of Medicine I, Medical University of Vienna, Austria
- Comprehensive Cancer Center Vienna, Austria
| | - Gerald W Prager
- Department of Medicine I, Medical University of Vienna, Austria
- Comprehensive Cancer Center Vienna, Austria
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27
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Kumar-Sinha C, Sahai V. T-Cell Subsets as Potential Biomarkers for Hepatobiliary Cancers and Selection of Immunotherapy Regimens as a Treatment Strategy. J Natl Compr Canc Netw 2022; 20:203-214. [PMID: 35130506 DOI: 10.6004/jnccn.2021.7097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022]
Abstract
Patients with advanced hepatocellular or biliary cancers have a dismal prognosis with limited efficacy from standard systemic therapies. The benefit of precision medicine has so far been limited to a subset of biliary cancers, including FGFR rearrangements; hotspot mutations in IDH1/2, BRAF, and BRCA1/2; and other rare alterations. In contrast, hepatocellular carcinoma, an inflammation-driven cancer with an immune-infiltrated microenvironment, provides a promising opportunity for immunotherapy, compared with the highly desmoplastic immune desert or excluded stromal microenvironment in biliary cancers. The immune contexture in hepatobiliary cancers is mostly immunosuppressive, protumorigenic, and exhausted, which together with low tumor mutation burden and decreased neoantigens provides challenges for immunotherapy. A better understanding of the spatiotemporal profile of T cells within the tumor microenvironment and the dynamic interplay of immune modulators in the context of standard or experimental therapies is crucial to define additional markers of response and design evidence-based combinatorial regimens. This review considers recent literature in this area and highlights promising leads and emerging trends.
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Affiliation(s)
| | - Vaibhav Sahai
- Division of Hematology and Oncology, Department of Internal Medicine, and.,Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
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28
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Qiu Z, Ji J, Xu Y, Zhu Y, Gao C, Wang G, Li C, Zhang Y, Zhao J, Wang C, Wen X, Zhang Z, Li B, Zhang Z, Cai S, Li B, Jiang X. Common DNA methylation changes in biliary tract cancers identify subtypes with different immune characteristics and clinical outcomes. BMC Med 2022; 20:64. [PMID: 35130881 PMCID: PMC8822710 DOI: 10.1186/s12916-021-02197-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/23/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND DNA methylation-associated studies on biliary tract cancer (BTC), including cholangiocarcinoma (CCA) and gallbladder cancer (GBC), may improve the BTC classification scheme. We proposed to identify the shared methylation changes of BTCs and investigate their associations with genomic aberrations, immune characteristics, and survival outcomes. METHODS Multi-dimensional data concerning mutation, DNA methylation, immune-related features, and clinical data of 57 CCAs and 48 GBCs from Eastern Hepatobiliary Surgery Hospital (EHSH) and 36 CCAs in the TCGA-CHOL cohort were analyzed. RESULTS In our cohort including 24 intrahepatic CCAs (iCCAs), 20 perihilar CCAs (pCCAs), 13 distal CCAs (dCCAs), and 48 GBCs, 3369 common differentially methylated regions (DMRs) were identified by comparing tumor and non-tumor samples. A lower level of methylation changes of these common DMRs was associated with fewer copy number variations, fewer mutational burden, and remarkably longer overall survival (OS, hazard ratio [HR] = 0.07, 95% confidence interval [CI] 0.01-0.65, P = 0.017). Additionally, a 12-marker model was developed and validated for prognostication after curative surgery (HR = 0.21, 95% CI 0.10-0.43, P < 0.001), which exhibited undifferentiated prognostic effects in subgroups defined by anatomic location (iCCAs, d/pCCAs, GBCs), TNM stage, and tumor purity. Its prognostic utility remained significant in multivariable analysis (HR = 0.26, 95% CI 0.11-0.59, P = 0.001). Moreover, the BTCs with minimal methylation changes exhibited higher immune-related signatures, infiltration of CD8+ lymphocytes, and programmed death-ligand 1 (PD-L1) expression, indicating an inflamed tumor immune microenvironment (TIME) with PD-L1 expression elicited by immune attack, potentially suggesting better immunotherapy efficacy. CONCLUSIONS In BTCs, DNA methylation is a powerful tool for molecular classification, serving as a robust indicator of genomic aberrations, survival outcomes, and tumor immune microenvironment. Our integrative analysis provides insights into the prognostication after curative surgery and patient selection for immunotherapy.
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Affiliation(s)
- Zhiquan Qiu
- Department of Biliary Tract Surgery I, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medicine University, No. 225 Changhai Road, Shanghai, 200438, China
| | - Jun Ji
- Department of Laboratory Medicine, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medicine University, Shanghai, China
| | - Yu Xu
- Department of Medicine, Burning Rock Biotech, Guangzhou, China
| | - Yan Zhu
- Department of Pathology, Changhai Hospital, Shanghai, China
| | - Chunfang Gao
- Department of Laboratory Medicine, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medicine University, Shanghai, China
| | - Guoqiang Wang
- Department of Medicine, Burning Rock Biotech, Guangzhou, China
| | - Chengcheng Li
- Department of Medicine, Burning Rock Biotech, Guangzhou, China
| | - Yuzi Zhang
- Department of Medicine, Burning Rock Biotech, Guangzhou, China
| | - Jing Zhao
- Department of Medicine, Burning Rock Biotech, Guangzhou, China
| | - Chenyang Wang
- Department of Research and Development, Burning Rock Biotech, Guangzhou, China
| | - Xiaofang Wen
- Department of Medicine, Burning Rock Biotech, Guangzhou, China
| | - Zhou Zhang
- Department of Bioinformatics, Burning Rock Biotech, Guangzhou, China
| | - Bingsi Li
- Department of Research and Development, Burning Rock Biotech, Guangzhou, China
| | - Zhihong Zhang
- Department of Research and Development, Burning Rock Biotech, Guangzhou, China
| | - Shangli Cai
- Department of Medicine, Burning Rock Biotech, Guangzhou, China
| | - Bin Li
- Department of Biliary Tract Surgery I, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medicine University, No. 225 Changhai Road, Shanghai, 200438, China.
| | - Xiaoqing Jiang
- Department of Biliary Tract Surgery I, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medicine University, No. 225 Changhai Road, Shanghai, 200438, China.
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Kankeu Fonkoua LA, Serrano Uson Junior PL, Mody K, Mahipal A, Borad MJ, Roberts LR. Novel and emerging targets for cholangiocarcinoma progression: therapeutic implications. Expert Opin Ther Targets 2022; 26:79-92. [PMID: 35034558 DOI: 10.1080/14728222.2022.2029412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Cholangiocarcinoma (CCA) is a heterogeneous group of aggressive biliary malignancies. While surgery and liver transplantation are the only potentially curative modalities for early-stage disease, limited options are available for most patients with incurable-stage disease. Survival outcomes remain dismal. Recent molecular profiling efforts have led to improved understanding of the genomic landscape of CCA and to the identification of subgroups with distinct diagnostic, prognostic, and therapeutic implications. AREAS COVERED : We provide an updated review and future perspectives on features of cholangiocarcinogenesis that can be translated into therapeutic biomarkers and targets. We highlight the critical studies that have established current systemic chemotherapy and targeted therapeutics, while elaborating on novel targeted and immunotherapeutic approaches in development. Relevant literature and clinical studies were identified by searching PubMed and www.ClinicalTrials.gov. EXPERT OPINION : While therapies targeting the various molecular subgroups of CCA are rapidly emerging and changing treatment paradigms, their success has been limited by the genetic heterogeneity of CCA and the plasticity of the targets. Novel strategies aiming to combine immunotherapy, chemotherapy, and molecularly-targeted therapeutics will be required to offer durable clinical benefit and maximize survival.
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Affiliation(s)
| | | | - Kabir Mody
- Rochester, MN, and Oncology in Jacksonville, FL, Mayo Clinic, USA
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Ciardiello D, Maiorano BA, Parente P, Rodriquenz MG, Latiano TP, Chiarazzo C, Pazienza V, Guerrera LP, Amoruso B, Normanno N, Martini G, Ciardiello F, Martinelli E, Maiello E. Immunotherapy for Biliary Tract Cancer in the Era of Precision Medicine: Current Knowledge and Future Perspectives. Int J Mol Sci 2022; 23:820. [PMID: 35055006 PMCID: PMC8775359 DOI: 10.3390/ijms23020820] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/09/2022] [Accepted: 01/11/2022] [Indexed: 12/20/2022] Open
Abstract
Biliary tract cancers (BTC) represent a heterogeneous and aggressive group of tumors with dismal prognosis. For a long time, BTC has been considered an orphan disease with very limited therapeutic options. In recent years a better understanding of the complex molecular landscape of biology is rapidly changing the therapeutic armamentarium. However, while 40-50% of patients there are molecular drivers susceptible to target therapy, for the remaining population new therapeutic options represent an unsatisfied clinical need. The role of immunotherapy in the continuum of treatment of patients with BTC is still debated. Despite initial signs of antitumor-activity, single-agent immune checkpoint inhibitors (ICIs) demonstrated limited efficacy in an unselected population. Therefore, identifying the best partner to combine ICIs and predictive biomarkers represents a key challenge to optimize the efficacy of immunotherapy. This review provides a critical analysis of completed trials, with an eye on future perspectives and possible biomarkers of response.
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Affiliation(s)
- Davide Ciardiello
- Oncology Unit, Casa Sollievo della Sofferenza Hospital, 71013 San Giovanni Rotondo, Italy; (B.A.M.); (M.G.R.); (T.P.L.); (C.C.); (L.P.G.); (B.A.); (E.M.)
- Oncology Unit, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (G.M.); (F.C.); (E.M.)
| | - Brigida Anna Maiorano
- Oncology Unit, Casa Sollievo della Sofferenza Hospital, 71013 San Giovanni Rotondo, Italy; (B.A.M.); (M.G.R.); (T.P.L.); (C.C.); (L.P.G.); (B.A.); (E.M.)
- Department of Translational Medicine and Surgery, Catholic University of the Sacred Heart, 000168 Rome, Italy
| | - Paola Parente
- Pathology Unit, Fondazione IRCCS Ospedale Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy;
| | - Maria Grazia Rodriquenz
- Oncology Unit, Casa Sollievo della Sofferenza Hospital, 71013 San Giovanni Rotondo, Italy; (B.A.M.); (M.G.R.); (T.P.L.); (C.C.); (L.P.G.); (B.A.); (E.M.)
| | - Tiziana Pia Latiano
- Oncology Unit, Casa Sollievo della Sofferenza Hospital, 71013 San Giovanni Rotondo, Italy; (B.A.M.); (M.G.R.); (T.P.L.); (C.C.); (L.P.G.); (B.A.); (E.M.)
| | - Cinzia Chiarazzo
- Oncology Unit, Casa Sollievo della Sofferenza Hospital, 71013 San Giovanni Rotondo, Italy; (B.A.M.); (M.G.R.); (T.P.L.); (C.C.); (L.P.G.); (B.A.); (E.M.)
| | - Valerio Pazienza
- Division of Gastroenterology, Casa Sollievo della Sofferenza Hospital, 71013 San Giovanni Rotondo, Italy;
| | - Luigi Pio Guerrera
- Oncology Unit, Casa Sollievo della Sofferenza Hospital, 71013 San Giovanni Rotondo, Italy; (B.A.M.); (M.G.R.); (T.P.L.); (C.C.); (L.P.G.); (B.A.); (E.M.)
- Oncology Unit, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (G.M.); (F.C.); (E.M.)
| | - Brunella Amoruso
- Oncology Unit, Casa Sollievo della Sofferenza Hospital, 71013 San Giovanni Rotondo, Italy; (B.A.M.); (M.G.R.); (T.P.L.); (C.C.); (L.P.G.); (B.A.); (E.M.)
- Division of Medical Oncology, Università di Bari, 70124 Bari, Italy
| | - Nicola Normanno
- Cellular Biology and Biotherapy, Istituto Nazionale Tumori, “Fondazione G. Pascale”-IRCCS, 80131 Naples, Italy;
| | - Giulia Martini
- Oncology Unit, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (G.M.); (F.C.); (E.M.)
| | - Fortunato Ciardiello
- Oncology Unit, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (G.M.); (F.C.); (E.M.)
| | - Erika Martinelli
- Oncology Unit, Department of Precision Medicine, Università degli Studi della Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (G.M.); (F.C.); (E.M.)
| | - Evaristo Maiello
- Oncology Unit, Casa Sollievo della Sofferenza Hospital, 71013 San Giovanni Rotondo, Italy; (B.A.M.); (M.G.R.); (T.P.L.); (C.C.); (L.P.G.); (B.A.); (E.M.)
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Immune suppressive checkpoint interactions in the tumour microenvironment of primary liver cancers. Br J Cancer 2022; 126:10-23. [PMID: 34400801 PMCID: PMC8727557 DOI: 10.1038/s41416-021-01453-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 05/05/2021] [Accepted: 05/27/2021] [Indexed: 12/24/2022] Open
Abstract
Liver cancer is one of the most prevalent cancers, and the third most common cause of cancer-related mortality worldwide. The therapeutic options for the main types of primary liver cancer-hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA)-are very limited. HCC and CCA are immunogenic cancers, but effective immune-mediated tumour control is prevented by their immunosuppressive tumour microenvironment. Despite the critical involvement of key co-inhibitory immune checkpoint interactions in immunosuppression in liver cancer, only a minority of patients with HCC respond to monotherapy using approved checkpoint inhibitor antibodies. To develop effective (combinatorial) therapeutic immune checkpoint strategies for liver cancer, in-depth knowledge of the different mechanisms that contribute to intratumoral immunosuppression is needed. Here, we review the co-inhibitory pathways that are known to suppress intratumoral T cells in HCC and CCA. We provide a detailed description of insights from preclinical studies in cellular crosstalk within the tumour microenvironment that results in interactions between co-inhibitory receptors on different T-cell subsets and their ligands on other cell types, including tumour cells. We suggest alternative immune checkpoints as promising targets, and draw attention to the possibility of combined targeting of co-inhibitory and co-stimulatory pathways to abrogate immunosuppression.
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32
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Argemi J, Ponz-Sarvise M, Sangro B. Immunotherapies for hepatocellular carcinoma and intrahepatic cholangiocarcinoma: Current and developing strategies. Adv Cancer Res 2022; 156:367-413. [DOI: 10.1016/bs.acr.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Ledenko M, Patel T. What are the key challenges in the pharmacological management of cholangiocarcinoma? Expert Opin Pharmacother 2021; 23:531-533. [PMID: 34866539 DOI: 10.1080/14656566.2021.2010707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Matthew Ledenko
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Tushar Patel
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, Florida, USA
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Zhao S, Guo XG, Zhang D, Zhou G, Song P, Yang J, Zhang Y, Li P, Hu Y, Wang P. First-line chemotherapy or in combination with programmed cell death protein-1 antibody in patients with metastatic or recurrent biliary tract cancer. J Gastroenterol Hepatol 2021; 36:3541-3547. [PMID: 34423859 DOI: 10.1111/jgh.15668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/10/2021] [Accepted: 08/10/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although immune checkpoint blockade therapy has achieved great success in various types of cancers, studies on biliary tract cancer are limited. This study aimed to assess the efficacy and tolerability of immune checkpoint inhibitors (ICIs) combined with chemotherapy in Chinese patients with BTC. METHODS We collected medical records of 130 pathologically diagnosed metastatic or recurrent BTC patients who had not received chemotherapy in the advanced stage. Eligible patients who received first-line chemotherapy ± ICIs were enrolled in the efficacy and safety analysis. We compared progression-free survival (PFS), overall survival (OS), objective response rate (ORR), and duration of response (DoR) between the ICI plus chemotherapy group and chemotherapy alone group. RESULTS Of 90 enrolled patients, 45 received ICIs plus chemotherapy and 45 received chemotherapy. The median follow-up times were 18.7 and 19.6 months, respectively. The median PFS was 5.9 months (95% CI: 4.3-7.5) with ICIs plus chemotherapy, which was significantly longer than the 4.2 months (95% CI: 2.1-6.5) with chemotherapy (hazard ratio [HR] 0.62, 95% CI: 0.39-0.94; P = 0.0306). The median OS was 14.7 months (95% CI: 11.4-18.0) compared with 14.2 months (95% CI: 12.5-15.9) (HR 0.93; 95% CI: 0.57-1.50; P = 0.765). Grade 3 or 4 treatment-related adverse events were similar between these two groups (71.1% and 64.4%, respectively). CONCLUSION Although first-line ICI therapy plus chemotherapy showed a significant improvement in the median PFS compared with chemotherapy in metastatic or recurrent BTC, the benefit did not translate into a statistically significant OS prolongation. The safety profile for ICIs plus chemotherapy was similar to chemotherapy alone.
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Affiliation(s)
- Shu Zhao
- Department of Medical Oncology, The Second Medical Centre and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Xue-Guang Guo
- Department of Medical Oncology, The Second Medical Centre and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Dong Zhang
- Department of Medical Oncology, The Second Medical Centre and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Gang Zhou
- Department of Medical Oncology, The Second Medical Centre and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Peng Song
- Department of Medical Oncology, The Second Medical Centre and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Jing Yang
- Department of Medical Oncology, The Second Medical Centre and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yong Zhang
- Department of Medical Oncology, The Second Medical Centre and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Peng Li
- Department of Medical Oncology, The Second Medical Centre and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yi Hu
- Department of Medical Oncology, The Fifth Medical Centre, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Peng Wang
- Department of Medical Oncology, The Second Medical Centre and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
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Manne A, Woods E, Tsung A, Mittra A. Biliary Tract Cancers: Treatment Updates and Future Directions in the Era of Precision Medicine and Immuno-Oncology. Front Oncol 2021; 11:768009. [PMID: 34868996 PMCID: PMC8634105 DOI: 10.3389/fonc.2021.768009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/13/2021] [Indexed: 12/12/2022] Open
Abstract
The effective management of biliary tract cancers (BTCs) has been hampered by limited options for systemic therapy. In recent years, the focus on precision medicine has made technologies such as next-generation sequencing (NGS) accessible to clinicians to identify targetable mutations in BTCs in tumor tissue (primarily) as well as blood, and to treat them with targeted therapies when possible. It has also expanded our understanding of functional pathways associated with genetic alterations and opened doors for identifying novel targets for treatment. Recent advances in the precision medicine approach allowed us to identify new molecular markers in BTCs, such as epigenetic changes (methylation and histone modification) and non-DNA markers such as messenger RNA, microRNA, and long non-coding RNA. It also made detecting these markers from non-traditional sources such as blood, urine, bile, and cytology (from fine-needle aspiration and biliary brushings) possible. As these tests become more accessible, we can see the integration of different molecular markers from all available sources to aid physicians in diagnosing, assessing prognosis, predicting tumor response, and screening BTCs. Currently, there are a handful of approved targeted therapies and only one class of immunotherapy agents (immune checkpoint inhibitors or ICIs) to treat BTCs. Early success with new targets, vascular endothelial growth factor receptor (VEGFR), HER2, protein kinase receptor, and Dickkopf-1 (DKK1); new drugs for known targets, fibroblast growth factor receptors (FGFRs) such as futabatinib, derazantinib, and erdafitinib; and ICIs such as durvalumab and tremelimumab is encouraging. Novel immunotherapy agents such as bispecific antibodies (bintrafusp alfa), arginase inhibitors, vaccines, and cellular therapy (chimeric antigen receptor-T cell or CAR-T, natural killer cells, tumor-infiltrating lymphocytes) have the potential to improve outcomes of BTCs in the coming years.
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Affiliation(s)
- Ashish Manne
- Department of Internal Medicine, Division of Medical Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
| | - Edward Woods
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, United States
| | - Arjun Mittra
- Department of Internal Medicine, Division of Medical Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
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Prete MG, Cammarota A, D'Alessio A, Zanuso V, Rimassa L. Current options and future directions of systemic therapy for advanced biliary tract cancer. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2021; 2:416-433. [PMID: 36045701 PMCID: PMC9400707 DOI: 10.37349/etat.2021.00054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/09/2021] [Indexed: 11/19/2022] Open
Abstract
Biliary tract cancers (BTCs) are aggressive tumors arising from different portions of the biliary tree and classified according to the anatomical location in intrahepatic (i) cholangiocarcinoma (CCA, iCCA), perihilar CCA (pCCA), and distal CCA (dCCA), gallbladder cancer (GBC), and ampulla of Vater cancer (AVC). Due to their silent behavior, BTCs are frequently diagnosed at advanced stages when the prognosis is poor. The available chemotherapeutic options are palliative and unfortunately, most patients will die from their disease between 6 and 18 months from diagnosis. However, over the last decade, amounting interest has been posed on the genomic landscape of BTCs and deep-sequencing studies have identified different potentially actionable driver mutations. Hence, the promising results of the early phase clinical studies with targeted agents against isocitrate dehydrogenase (IDH) 1 mutation or fibroblast growth factor (FGF) receptor(FGFR) 2 aberrations inintrahepatic tumors, and other agents against humanepidermal growth factor receptor (HER) 2 overexpression/mutations, neurotrophic tyrosine receptor kinase (NTRK) fusions or B-type Raf kinase (BRAF) mutations across different subtypes of BTCs, have paved the way for a “precision medicine” strategy for BTCs. Moreover, despite the modest results when used as monotherapy, beyond microsatellite instability-high (MSI-H) tumors, immune checkpoint inhibitors are being evaluated in combination with platinum-based chemotherapy, possibly further expanding the therapeutic landscape of advanced BTCs. This review aims to provide an overview of the approved systemic therapies, the promising results, and the ongoing studies to explore the current and future directions of advanced BTC systemic treatment.
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Affiliation(s)
- Maria Giuseppina Prete
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy; Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Antonella Cammarota
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy; Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Antonio D'Alessio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy; Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Valentina Zanuso
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy; Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy; Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
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Yoon JG, Kim MH, Jang M, Kim H, Hwang HK, Kang CM, Lee WJ, Kang B, Lee CK, Lee MG, Chung HC, Choi HJ, Park YN. Molecular Characterization of Biliary Tract Cancer Predicts Chemotherapy and Programmed Death 1/Programmed Death-Ligand 1 Blockade Responses. Hepatology 2021; 74:1914-1931. [PMID: 33884649 DOI: 10.1002/hep.31862] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 03/30/2021] [Accepted: 04/09/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Biliary tract cancer (BTC) exhibits diverse molecular characteristics. However, reliable biomarkers that predict therapeutic responses are yet to be discovered. We aimed to identify the molecular features of treatment responses to chemotherapy and immunotherapy in BTCs. APPROACH AND RESULTS We enrolled 121 advanced BTC patients (68 cholangiocarcinomas [33 intrahepatic, 35 extrahepatic], 41 gallbladder cancers, and 12 Ampulla of Vater cancers) whose specimens were analyzed by clinical sequencing platforms. All patients received first-line palliative chemotherapy; 48 patients underwent programmed death 1 (PD-1)/programmed death-ligand 1 (PD-L1) blockade therapy after failed chemotherapy. Molecular and histopathological characterization was performed using targeted sequencing and immunohistochemical staining to investigate treatment response-associated biomarkers. Genomic analysis revealed a broad spectrum of mutational profiles according to anatomical location. Favorable responses to chemotherapy were observed in the small-duct type compared with the large-duct type intrahepatic cholangiocarcinoma, with frequent mutations in BRCA1-associated protein-1/isocitrate dehydrogenase 1/2 and KRAS proto-oncogene, GTPase/SMAD family member 4 genes, respectively. The molecular features were further analyzed in BTCs, and transforming growth factor beta and DNA damage response pathway-altered tumors exhibited poor and favorable chemotherapy responses, respectively. In PD-1/PD-L1 blockade-treated patients, KRAS alteration and chromosomal instability tumors were associated with resistance to immunotherapy. The majority of patients (95.0%) with these resistance factors show no clinical benefit to PD-1/PD-L1 blockade and low tumor mutational burdens. Low tumor-infiltrating lymphocyte (TIL) density in tumors with these resistance factors indicated immune-suppressive tumor microenvironments, whereas high intratumoral TIL density was associated with a favorable immunotherapy response. CONCLUSIONS This study proposes predictive molecular features of chemotherapy and immunotherapy responses in advanced BTCs using clinical sequencing platforms. Our result provides an intuitive framework to guide the treatment of advanced BTCs benefiting from therapeutic agents based on the tumors' molecular features.
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Affiliation(s)
- Jihoon G Yoon
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Hwan Kim
- Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Republic of Korea
| | - Mi Jang
- Department of Pathology, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Pathology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Hoguen Kim
- Department of Pathology, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ho Kyoung Hwang
- Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Republic of Korea.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chang Moo Kang
- Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Republic of Korea.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woo Jung Lee
- Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Republic of Korea.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Beodeul Kang
- Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Republic of Korea
| | - Choong-Kun Lee
- Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Republic of Korea
| | - Min Goo Lee
- Department of Pharmacology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyun Cheol Chung
- Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Jin Choi
- Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Republic of Korea
| | - Young Nyun Park
- Department of Pathology, Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Republic of Korea
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Zhang R, Puzzoni M, Mariani S, Zheng Y, Liscia N, Guo Y, Donisi C, Liu Y, Impera V, Fang W, Scartozzi M. Emerging treatment evolutions and integrated molecular characteristics of biliary tract cancers. Cancer Sci 2021; 112:4819-4833. [PMID: 34534382 PMCID: PMC8645726 DOI: 10.1111/cas.15139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/05/2021] [Accepted: 09/07/2021] [Indexed: 12/13/2022] Open
Abstract
Biliary tract cancers (BTCs) consist of a group of highly heterogeneous malignancies that are characterized by genomic differences among tumors from different anatomic sites. The current treatment for BTC includes surgery, chemotherapy, target therapy, and immunotherapy. Although surgery remains the primary option for localized disease, representing the only potential curative treatment, a high risk of recurrence cannot be neglected. Chemotherapy has been considered the standard of care for both advanced and metastatic disease and in adjuvant settings. However, drug resistance is a major obstacle associated with chemotherapy. The development of genetic testing technologies, including next‐generation sequencing, has opened the door for the identification of drug targets and candidate molecules. A series of preclinical studies has demonstrated the role of gene mutations, abnormal signaling pathways, and immunosuppression in the pathogenesis of BTC, laying the foundation for the application of targeted therapy and immunotherapy. A variety of molecularly targeted agents, including pemigatinib, have shown promising survival benefits in patients with advanced disease. The rapidly evolving role of multimodal therapy represents the subject of this review.
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Affiliation(s)
- Ruyi Zhang
- Department of Medical Oncology, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Marco Puzzoni
- Department of Medical Oncology, Medical Oncology, University Hospital of Cagliari, University of Cagliari, Cagliari, Italy
| | - Stefano Mariani
- Department of Medical Oncology, Medical Oncology, University Hospital of Cagliari, University of Cagliari, Cagliari, Italy
| | - Yi Zheng
- Department of Medical Oncology, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Nicole Liscia
- Medical Oncology Unit, Sapienza University of Rome, Rome, Italy
| | - Yixuan Guo
- Department of Medical Oncology, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Clelia Donisi
- Department of Medical Oncology, Medical Oncology, University Hospital of Cagliari, University of Cagliari, Cagliari, Italy
| | - Yu Liu
- Department of Medical Oncology, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | | | - Weijia Fang
- Department of Medical Oncology, School of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Mario Scartozzi
- Department of Medical Oncology, Medical Oncology, University Hospital of Cagliari, University of Cagliari, Cagliari, Italy
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Hack SP, Zhu AX. Atezolizumab: an investigational agent for the treatment of biliary tract cancer. Expert Opin Investig Drugs 2021; 30:1007-1015. [PMID: 34459336 DOI: 10.1080/13543784.2021.1974838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Biliary tract cancers (BTCs) have a dismal prognosis and limited treatment options. The role of immunotherapy in BTC is unclear. BTCs respond poorly to PD-(L)1 blockade, highlighting the need for combination regimens to augment antitumor immunity. Atezolizumab (anti-PD-L1) combined with other therapies is under investigation in advanced BTC. AREAS COVERED This paper provides an overview of the recent progress and future applications of immunotherapy for BTCs and sheds light on the status and therapeutic potential of atezolizumab. We discuss published data for atezolizumab and an examine the rationale and design of ongoing clinical studies. We offer insights and opinions on the future applications and challenges of immunotherapy in BTC. EXPERT OPINION Atezolizumab monotherapy has demonstrated limited antitumor activity in BTC, indicating the need for combination regimens to unlock effective anticancer immunity, and the development of predictive biomarkers to enrich the population. Data for atezolizumab combined with chemotherapy, anti-VEGF agents and other targeted drugs in solid tumors justifies their evaluation in BTC. Several novel atezolizumab-based combinations have been or are currently under investigation in Phase II studies. It is hoped that data from these studies, along with other immunotherapy trials, will provide more effective treatments for patients with BTC.
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Affiliation(s)
- Stephen P Hack
- Product Development (Oncology), Genentech Inc, South San Francisco, CA, USA
| | - Andrew X Zhu
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA.,Jiahui International Cancer Center, Jiahui Health, Shanghai, China
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40
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The State of Immunotherapy in Hepatobiliary Cancers. Cells 2021; 10:cells10082096. [PMID: 34440865 PMCID: PMC8393650 DOI: 10.3390/cells10082096] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 08/02/2021] [Accepted: 08/13/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatobiliary cancers, including hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), and gallbladder carcinoma (GBC), are lethal cancers with limited therapeutic options. Curative-intent treatment typically involves surgery, yet recurrence is common and many patients present with advanced disease not amenable to an operation. Immunotherapy represents a promising approach to improve outcomes, but the immunosuppressive tumor microenvironment of the liver characteristic of hepatobiliary cancers has hampered the development and implementation of this therapeutic approach. Current immunotherapies under investigation include immune checkpoint inhibitors (ICI), the adoptive transfer of immune cells, bispecific antibodies, vaccines, and oncolytic viruses. Programmed cell death protein 1 (PD-1) and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) are two ICIs that have demonstrated utility in HCC, and newer immune checkpoint targets are being tested in clinical trials. In advanced CCA and GBC, PD-1 ICIs have resulted in antitumor responses, but only in a minority of select patients. Other ICIs are being investigated for patients with CCA and GBC. Adoptive transfer may hold promise, with reports of complete durable regression in metastatic CCA, yet this therapeutic approach may not be generalizable. Alternative approaches have been developed and promising results have been observed, but clinical trials are needed to validate their utility. While the treatment of hepatobiliary cancers involves unique challenges that these cancers present, the progress seen with ICIs and adoptive transfer has solidified immunotherapy as an important approach in these challenging patients with few other effective treatment options.
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Hack SP, Verret W, Mulla S, Liu B, Wang Y, Macarulla T, Ren Z, El-Khoueiry AB, Zhu AX. IMbrave 151: a randomized phase II trial of atezolizumab combined with bevacizumab and chemotherapy in patients with advanced biliary tract cancer. Ther Adv Med Oncol 2021; 13:17588359211036544. [PMID: 34377158 PMCID: PMC8326820 DOI: 10.1177/17588359211036544] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 07/12/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Biliary tract cancers (BTCs) are heterogenous, highly aggressive tumors that harbor a dismal prognosis for which more effective treatments are needed. The role of cancer immunotherapy in BTC remains to be characterized. The tumor microenvironment (TME) of BTC is highly immunosuppressed and combination treatments are needed to promote effective anticancer immunity. Vascular endothelial growth factor (VEGF) drives immunosuppression in the TME by disrupting antigen presentation, limiting T-cell infiltration, or potentiating immune-suppressive cells. Many VEGF-regulated mechanisms are thought to be relevant to repressed antitumor immunity in BTC, making dual targeting of VEGF and programmed cell death protein 1 (PD-1)/PD-L1 pathways a rational approach. Gemcitabine and Cisplatin (Gem/Cis) can also modulate anticancer immunity through overlapping and complementary mechanisms to those regulated by VEGF. Anti-PD-L1/VEGF inhibition, coupled with chemotherapy, may potentiate antitumor immunity leading to enhanced clinical benefit. Methods: IMbrave 151 is a randomized, double-blind, placebo-controlled, multicenter, international phase II study to evaluate atezolizumab (a PD-L1 inhibitor) in combination with chemotherapy (gemcitabine and cisplatin) and bevacizumab (an anti-VEGF monoclonal antibody) as a first-line treatment for advanced BTC. Approximately 150 patients with previously untreated, advanced BTC will be randomized to either Arm A (atezolizumab + bevacizumab + Gem/Cis) or Arm B (atezolizumab + placebo + Gem/Cis). Randomization is stratified by the presence of metastatic disease, primary tumor location, and geographic region. The primary efficacy endpoint is investigator-assessed progression-free survival (PFS) per RECIST 1.1. Secondary endpoints include objective response rate (ORR), duration of response (DoR), disease control rate (DCR), overall survival (OS), and safety and patient reported outcomes (PROs). Tissue, blood, and stool samples will be collected at baseline and on-treatment in order to perform correlative biomarker analyses. Discussion: IMbrave 151 represents the first randomized study to evaluate combined PD-L1/VEGF blockade on a chemotherapy backbone in BTC. Trial registration: NCT identifier: NCT04677504; EUDRACT number: 2020-003759-14
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Affiliation(s)
- Stephen P Hack
- Genentech, Inc, 1 DNA Way, South San Francisco, CA 94080, USA
| | | | - Sohail Mulla
- Hoffmann-La Roche Limited, Mississauga, ON, Canada
| | - Bo Liu
- Genentech, South San Francisco, CA, USA
| | | | - Teresa Macarulla
- Department of Medical Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Zhenggang Ren
- Zhongshan Hospital, Fudan University, Shanghai, China
| | - Anthony B El-Khoueiry
- USC Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Andrew X Zhu
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
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42
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Chen X, Qin S, Gu S, Ren Z, Chen Z, Xiong J, Liu Y, Meng Z, Zhang X, Wang L, Zhang X, Zou J. Camrelizumab plus oxaliplatin-based chemotherapy as first-line therapy for advanced biliary tract cancer: A multicenter, phase 2 trial. Int J Cancer 2021; 149:1944-1954. [PMID: 34309846 DOI: 10.1002/ijc.33751] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/18/2021] [Accepted: 07/01/2021] [Indexed: 12/19/2022]
Abstract
Biliary tract cancer (BTC) is a highly malignant tumor with limited treatment options and poor prognosis. Our study aimed to evaluate camrelizumab plus oxaliplatin-based chemotherapy as first-line therapy for advanced BTC. In this multicenter, open-label, phase 2 trial conducted in China (ClinicalTrials.gov, NCT03092895), untreated patients with advanced BTC were given camrelizumab (3 mg/kg iv drip injection, every 2 weeks) plus typical FOLFOX4 (Cam-FOLFOX4 group; infusional 5-fluorouracil, leucovorin and oxaliplatin) or GEMOX (Cam-GEMOX group; infusional gemcitabine and oxaliplatin). The primary endpoint was objective response rate (ORR). Ninety-two patients were enrolled: 29 received Cam-FOLFOX4 and 63 received Cam-GEMOX. The confirmed ORR and disease control rate were 16.3% (95% confidence interval [CI] = 9.4-25.5) and 75.0% (95% CI = 64.9-83.4), respectively. Median duration of response was 8.7 months (95% CI = 5.1-not reached). Median progression-free survival and overall survival were 5.3 months (95% CI = 3.7-5.7) and 12.4 months (95% CI = 8.9-16.1), respectively. Grade ≥3 treatment-related adverse events (TRAEs) occurred in 82.8% of patients receiving Cam-FOLFOX4 and in 68.3% receiving Cam-GEMOX, with no unexpected effects observed. Six (6.5%) patients discontinued treatment due to TRAE. Camrelizumab plus FOLFOX4 or GEMOX as first-line treatment was effective and tolerable for Chinese patients with advanced BTC, warranting phase 3 trials.
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Affiliation(s)
- Xinni Chen
- Department of Medical Oncology Center, Bayi Affiliated Hospital, Nanjing University of Chinese Medicine, Nanjing, China
| | - Shukui Qin
- Department of Medical Oncology Center, Bayi Affiliated Hospital, Nanjing University of Chinese Medicine, Nanjing, China
| | - Shanzhi Gu
- Department of Interventional Radiology, Hunan Cancer Hospital, Changsha, China
| | - Zhenggang Ren
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhendong Chen
- Department of Medical Oncology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Jianping Xiong
- Department of Medical Oncology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ying Liu
- Department of Medical Oncology, Henan Cancer Hospital, Zhengzhou, China
| | - Zhiqiang Meng
- Minimally Invasive Therapy Center, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xiao Zhang
- Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Linna Wang
- Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Xiaojing Zhang
- Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Jianjun Zou
- Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
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43
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Charalampakis N, Papageorgiou G, Tsakatikas S, Fioretzaki R, Kole C, Kykalos S, Tolia M, Schizas D. Immunotherapy for cholangiocarcinoma: a 2021 update. Immunotherapy 2021; 13:1113-1134. [PMID: 34190581 DOI: 10.2217/imt-2021-0126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Cholangiocarcinoma (CCA) is a rare malignancy with generally dismal prognosis. Immunotherapy has revolutionized the management of cancer patients during the last decade, offering durable responses with an acceptable safety profile, but there are still no significant advances regarding CCA. Novel immunotherapeutic methods, such as cancer vaccines, oncolytic viruses, adoptive cell therapy and combinations of immune checkpoint inhibitors with other agents are currently under investigation and may improve prognosis. Efforts to find robust biomarkers for response are also ongoing. In this review, we discuss the rationale for the use of immunotherapy in CCA and available clinical data. Ongoing trials will also be presented, as well as key findings from each study.
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Affiliation(s)
- Nikolaos Charalampakis
- Department of Medical Oncology, Metaxa Cancer Hospital of Piraeus, Piraeus, 185 37, Greece
| | - Georgios Papageorgiou
- Department of Medical Oncology, Metaxa Cancer Hospital of Piraeus, Piraeus, 185 37, Greece
| | - Sergios Tsakatikas
- Department of Medical Oncology, Metaxa Cancer Hospital of Piraeus, Piraeus, 185 37, Greece
| | - Rodanthi Fioretzaki
- Department of Medical Oncology, Metaxa Cancer Hospital of Piraeus, Piraeus, 185 37, Greece
| | - Christo Kole
- First Department of Surgery, National & Kapodistrian University of Athens, Laikon General Hospital, Athens, 115 27, Greece
| | - Stylianos Kykalos
- Second Propedeutic Department of Surgery, National & Kapodistrian University of Athens, Laikon General Hospital, Athens, 115 27, Greece
| | - Maria Tolia
- Department of Radiation Oncology, University Hospital of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Dimitrios Schizas
- First Department of Surgery, National & Kapodistrian University of Athens, Laikon General Hospital, Athens, 115 27, Greece
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Czauderna C, Kirstein MM, Tews HC, Vogel A, Marquardt JU. Molecular Subtypes and Precision Oncology in Intrahepatic Cholangiocarcinoma. J Clin Med 2021; 10:2803. [PMID: 34202401 PMCID: PMC8269161 DOI: 10.3390/jcm10132803] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/08/2021] [Accepted: 06/18/2021] [Indexed: 01/06/2023] Open
Abstract
Cholangiocarcinomas (CCAs) are the second-most common primary liver cancers. CCAs represent a group of highly heterogeneous tumors classified based on anatomical localization into intra- (iCCA) and extrahepatic CCA (eCCA). In contrast to eCCA, the incidence of iCCA is increasing worldwide. Curative treatment strategies for all CCAs involve oncological resection followed by adjuvant chemotherapy in early stages, whereas chemotherapy is administered at advanced stages of disease. Due to late diagnosis, high recurrence rates, and limited treatment options, the prognosis of patients remains poor. Comprehensive molecular characterization has further revealed considerable heterogeneity and distinct prognostic and therapeutic traits for iCCA and eCCA, indicating that specific treatment modalities are required for different subclasses. Several druggable alterations and oncogenic drivers such as fibroblast growth factor receptor 2 gene fusions and hotspot mutations in isocitrate dehydrogenase 1 and 2 mutations have been identified. Specific inhibitors have demonstrated striking antitumor activity in affected subgroups of patients in phase II and III clinical trials. Thus, improved understanding of the molecular complexity has paved the way for precision oncological approaches. Here, we outline current advances in targeted treatments and immunotherapeutic approaches. In addition, we delineate future perspectives for different molecular subclasses that will improve the clinical care of iCCA patients.
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Affiliation(s)
- Carolin Czauderna
- Department of Medicine I, University Medical Center Schleswig-Holstein—Campus Lübeck, 23562 Lübeck, Germany; (C.C.); (M.M.K.); (H.C.T.)
| | - Martha M. Kirstein
- Department of Medicine I, University Medical Center Schleswig-Holstein—Campus Lübeck, 23562 Lübeck, Germany; (C.C.); (M.M.K.); (H.C.T.)
| | - Hauke C. Tews
- Department of Medicine I, University Medical Center Schleswig-Holstein—Campus Lübeck, 23562 Lübeck, Germany; (C.C.); (M.M.K.); (H.C.T.)
- Departement of Internal Medicine I, University Hospital Regensburg, 93042 Regensburg, Germany
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, 30625 Hannover, Germany;
| | - Jens U. Marquardt
- Department of Medicine I, University Medical Center Schleswig-Holstein—Campus Lübeck, 23562 Lübeck, Germany; (C.C.); (M.M.K.); (H.C.T.)
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45
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Hewitt DB, Rahnemai-Azar AA, Pawlik TM. Potential experimental immune checkpoint inhibitors for the treatment of cancer of the liver. Expert Opin Investig Drugs 2021; 30:827-835. [PMID: 34102935 DOI: 10.1080/13543784.2021.1940948] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Introduction: Traditional systemic therapies offer limited benefit for advanced cancers of the liver. Immune checkpoints are inhibitory regulators of the immune system and the success of immune checkpoint inhibitors (ICIs) in the treatment of other cancers has led to clinical trials investigating the use of ICIs alone or in combination with other therapies for liver cancers.Area covered: Clinical trials involving ICIs for the treatment of liver cancer were broadly reviewed. Hepatocellular carcinoma and intrahepatic cholangiocarcinoma were examined. Phase I/II trials were prioritized, and relevant phase III trials were discussed. MEDLINE, PubMed, ASCO meeting library, and Web of Science databases were searched with the keywords 'immune checkpoint inhibitor' or 'targeted therapy' in combination with 'hepatocellular carcinoma,' or 'intrahepatic cholangiocarcinoma'. Major outcomes were safety and efficacy defined by response rate, progression-free survival, or overall survival.Expert opinion: ICIs can improve progression-free and overall survival among patients with advanced disease with an acceptable safety profile. Given the heterogeneity of liver disease, ideal strategies will likely include a combination of ICIs with additional therapies to achieve the most robust and durable response. Additional biomarkers will be needed to guide combination therapy to personalize treatment regimen for patients with primary liver cancers.
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Affiliation(s)
- D Brock Hewitt
- Division of Surgical Oncology, Department of Surgery, The Ohio State Wexner Medical Center, the James Comprehensive Cancer Center, Columbus, OH, USA
| | - Amir A Rahnemai-Azar
- Division of Surgical Oncology, Department of Surgery, Arrowhead Regional Cancer Center, California University of Science and Medicine, Colton, CA, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State Wexner Medical Center, the James Comprehensive Cancer Center, Columbus, OH, USA
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The Emerging Role of Immunotherapy in Intrahepatic Cholangiocarcinoma. Vaccines (Basel) 2021; 9:vaccines9050422. [PMID: 33922362 PMCID: PMC8146949 DOI: 10.3390/vaccines9050422] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/18/2021] [Accepted: 04/20/2021] [Indexed: 12/17/2022] Open
Abstract
Biliary tract cancer, and intrahepatic cholangiocarcinoma (iCC) in particular, represents a rather uncommon, highly aggressive malignancy with unfavorable prognosis. Therapeutic options remain scarce, with platinum-based chemotherapy is being considered as the gold standard for the management of advanced disease. Comprehensive molecular profiling of tumor tissue biopsies, utilizing multi-omics approaches, enabled the identification of iCC’s intratumor heterogeneity and paved the way for the introduction of novel targeted therapies under the scope of precision medicine. Yet, the unmet need for optimal care of patients with chemo-refractory disease or without targetable mutations still exists. Immunotherapy has provided a paradigm shift in cancer care over the past decade. Currently, immunotherapeutic strategies for the management of iCC are under intense research. Intrinsic factors of the tumor, including programmed death-ligand 1 (PD-L1) expression and mismatch repair (MMR) status, are simply the tip of the proverbial iceberg with regard to resistance to immunotherapy. Acknowledging the significance of the tumor microenvironment (TME) in both cancer growth and drug response, we broadly discuss about its diverse immune components. We further review the emerging role of immunotherapy in this rare disease, summarizing the results of completed and ongoing phase I–III clinical trials, expounding current challenges and future directions.
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Yoo C, Shin SH, Park JO, Kim KP, Jeong JH, Ryoo BY, Lee W, Song KB, Hwang DW, Park JH, Lee JH. Current Status and Future Perspectives of Perioperative Therapy for Resectable Biliary Tract Cancer: A Multidisciplinary Review. Cancers (Basel) 2021; 13:cancers13071647. [PMID: 33916008 PMCID: PMC8037230 DOI: 10.3390/cancers13071647] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/27/2021] [Accepted: 03/27/2021] [Indexed: 12/13/2022] Open
Abstract
Simple Summary For decades, there has been no globally accepted neoadjuvant or adjuvant therapy in resectable biliary tract cancer. Based on the results of the BILCAP trial, adjuvant capecitabine has been widely regarded as standard adjuvant therapy. Focusing on the management of resectable biliary tract cancer, this article reviews each therapeutic strategy including surgery, chemotherapy and radiotherapy, and summarises published and ongoing clinical trials of neoadjuvant and adjuvant therapy. Abstract Biliary tract cancers (BTCs) are a group of aggressive malignancies that arise from the bile duct and gallbladder. BTCs include intrahepatic cholangiocarcinoma (IH-CCA), extrahepatic cholangiocarcinoma (EH-CCA), and gallbladder cancer (GBCA). BTCs are highly heterogeneous cancers in terms of anatomical, clinical, and pathological characteristics. Until recently, the treatment of resectable BTC, including surgery, adjuvant chemotherapy, and radiation therapy, has largely been based on institutional practice guidelines and evidence from small retrospective studies. Recently, several large randomized prospective trials have been published, and there are ongoing randomized trials for resectable BTC. In this article, we review prior and recently updated evidence regarding surgery, adjuvant and neoadjuvant chemotherapy, and adjuvant radiation therapy for patients with resectable BTC.
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Affiliation(s)
- Changhoon Yoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (K.-P.K.); (J.H.J.); (B.-Y.R.)
- Correspondence: (C.Y.); (J.H.L.); Tel.: +82-2-3010-1727 (C.Y.); +82-2-3010-1521 (J.H.L.)
| | - Sang Hyun Shin
- Department of Surgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Korea;
| | - Joon-Oh Park
- Division of Hematology and Oncology, Department of Internal Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Korea;
| | - Kyu-Pyo Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (K.-P.K.); (J.H.J.); (B.-Y.R.)
| | - Jae Ho Jeong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (K.-P.K.); (J.H.J.); (B.-Y.R.)
| | - Baek-Yeol Ryoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (K.-P.K.); (J.H.J.); (B.-Y.R.)
| | - Woohyung Lee
- Department of Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul 05505, Korea; (W.L.); (K.-B.S.); (D.-W.H.)
| | - Ki-Byung Song
- Department of Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul 05505, Korea; (W.L.); (K.-B.S.); (D.-W.H.)
| | - Dae-Wook Hwang
- Department of Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul 05505, Korea; (W.L.); (K.-B.S.); (D.-W.H.)
| | - Jin-hong Park
- Department of Radiation Oncology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul 05505, Korea;
| | - Jae Hoon Lee
- Department of Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul 05505, Korea; (W.L.); (K.-B.S.); (D.-W.H.)
- Correspondence: (C.Y.); (J.H.L.); Tel.: +82-2-3010-1727 (C.Y.); +82-2-3010-1521 (J.H.L.)
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Boilève A, Hilmi M, Smolenschi C, Ducreux M, Hollebecque A, Malka D. Immunotherapy in Advanced Biliary Tract Cancers. Cancers (Basel) 2021; 13:1569. [PMID: 33805461 PMCID: PMC8036747 DOI: 10.3390/cancers13071569] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/20/2021] [Accepted: 03/25/2021] [Indexed: 12/11/2022] Open
Abstract
Biliary tract cancers are rare tumors with a poor prognosis. Two-thirds of these primary liver malignancies are diagnosed at advanced stages where therapeutic options are limited. Whereas several molecular targeted therapies emerge in biliary tract cancers, immunotherapy is still investigational, the only approved immunotherapy to date being the immune checkpoint inhibitor pembrolizumab for the small fraction of patients with microsatellite-instable tumors. In microsatellite-stable, pre-treated biliary tract cancers, single-agent immune checkpoint blockade has a limited albeit often long-lasting clinical activity in a still ill-defined subgroup of patients. The identification of predictive biomarkers will allow a better selection of patients that may benefit from immunotherapy. Combinations of immunotherapies with each other, with chemotherapy or targeted molecular therapies are being investigated in early lines of therapy, including first-line.
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Affiliation(s)
- Alice Boilève
- Département de Médecine Oncologique, Gustave Roussy, F-94805 Villejuif, France; (A.B.); (C.S.); (M.D.); (A.H.)
- Université Paris-Saclay, F-91190 Saint-Aubin, France
| | - Marc Hilmi
- Département D’Innovations Thérapeutiques et D’Essais Précoces, Gustave Roussy, F-94805 Villejuif, France;
| | - Cristina Smolenschi
- Département de Médecine Oncologique, Gustave Roussy, F-94805 Villejuif, France; (A.B.); (C.S.); (M.D.); (A.H.)
- Département D’Innovations Thérapeutiques et D’Essais Précoces, Gustave Roussy, F-94805 Villejuif, France;
| | - Michel Ducreux
- Département de Médecine Oncologique, Gustave Roussy, F-94805 Villejuif, France; (A.B.); (C.S.); (M.D.); (A.H.)
- Université Paris-Saclay, F-91190 Saint-Aubin, France
| | - Antoine Hollebecque
- Département de Médecine Oncologique, Gustave Roussy, F-94805 Villejuif, France; (A.B.); (C.S.); (M.D.); (A.H.)
- Département D’Innovations Thérapeutiques et D’Essais Précoces, Gustave Roussy, F-94805 Villejuif, France;
| | - David Malka
- Département de Médecine Oncologique, Gustave Roussy, F-94805 Villejuif, France; (A.B.); (C.S.); (M.D.); (A.H.)
- Université Paris-Saclay, F-91190 Saint-Aubin, France
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Seesaha PK, Wang KX, Wang GQ, Cui TY, Zhao FJ, Pan LL, Li XC, Shu YQ, Chen XF. Current Progress and Future Perspectives of Immune Checkpoint Inhibitors in Biliary Tract Cancer. Onco Targets Ther 2021; 14:1873-1882. [PMID: 33737812 PMCID: PMC7966382 DOI: 10.2147/ott.s269671] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 11/27/2020] [Indexed: 12/30/2022] Open
Abstract
Biliary tract cancer (BTC) is an uncommon and aggressive neoplasm, with most patients presenting in an advanced stage. Systemic chemotherapy is the limited treatment available but is unsatisfactory, while targeted therapy is still awaiting validation from clinical trials. Given the potential effect of immune checkpoint inhibitors (ICIs) in the treatment of BTC, this review aims to summarize the evidence-based benefits and predictive biomarkers for using inhibitors of cytotoxic T-lymphocyte-associated protein-4 (CTLA-4) ligand, or programmed cell death protein-1 and its ligand (PD-1 and PD-L1) as monotherapy or combined with other anti-tumor therapies, while also pointing out certain pitfalls with the use of ICIs which need to be addressed.
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Affiliation(s)
- Poshita-Kumari Seesaha
- Department of Oncology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Kang-Xin Wang
- Department of Oncology, Pukou Branch Hospital of Jiangsu Province Hospital (Nanjing Pukou Central Hospital), Nanjing, 211800, People's Republic of China
| | - Guo-Qun Wang
- Department of Oncology, Pukou Branch Hospital of Jiangsu Province Hospital (Nanjing Pukou Central Hospital), Nanjing, 211800, People's Republic of China
| | - Ting-Yun Cui
- Department of Oncology, Pukou Branch Hospital of Jiangsu Province Hospital (Nanjing Pukou Central Hospital), Nanjing, 211800, People's Republic of China
| | - Feng-Jiao Zhao
- Department of Oncology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Lan-Lan Pan
- Department of Oncology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Xiang-Cheng Li
- Hepatobiliary Center of the First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Yong-Qian Shu
- Department of Oncology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Xiao-Feng Chen
- Department of Oncology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, People's Republic of China.,Department of Oncology, Pukou Branch Hospital of Jiangsu Province Hospital (Nanjing Pukou Central Hospital), Nanjing, 211800, People's Republic of China
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Rizzo A, Ricci AD, Brandi G. Durvalumab: an investigational anti-PD-L1 antibody for the treatment of biliary tract cancer. Expert Opin Investig Drugs 2021; 30:343-350. [PMID: 33645367 DOI: 10.1080/13543784.2021.1897102] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: The prognosis of patients with advanced biliary tract cancer (BTC) remains dismal, with a 5-year overall survival rate of less than 10%. Although immune checkpoint inhibitors (ICIs) have revolutionized the treatment landscape of several hematological and solid tumors, controversial results have been reported in BTC. In this setting, the anti-PD-L1 inhibitor durvalumab is currently under investigation in several clinical trials as monotherapy, or in combination with other pharmacological agents.Areas covered: We offer an overview of immunotherapies for BTC, discuss recently published or presented data on durvalumab pharmacology, safety, and efficacy in the treatment of BTC and consider future research directions for the agent in this setting.Expert opinion: The promising antitumor activity shown by durvalumab in early trials warrants further investigation because it may provide more effective, much needed treatment options. The results of clinical trials of this PD-L1 inhibitor, as a monotherapy or in combination, are eagerly awaited. Future efforts should focus on the identification and development of reliable biomarkers of response to durvalumab in BTC, clarifying the role of PD-L1 expression, microsatellite instability (MSI), mismatch repair (MMR), tumor mutational burden (TMB) and other emerging predictors.
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Affiliation(s)
- Alessandro Rizzo
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Angela Dalia Ricci
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Giovanni Brandi
- Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
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