Advanced Biliary Cancer Patients Research Articles

Significance of alterations in DNA damage repair (DDR) genes in advanced biliary cancers (ABCs) treated with second-line active-symptom-control (ASC) alone or ASC with oxaliplatin/5-FU chemotherapy (ASC+FOLFOX) in the randomised phase III, multicentre, open-label ABC-06 trial.

593 Background: The ABC-06 clinical trial established ASC+mFOLFOX as the standard of care treatment after Cisplatin and Gemcitabine (CisGem) for ABC. Translational research explored the role of alterations in DDR-related genes in the context of the ABC-06 clinical trial. Methods: Translational research using samples collected from the ABC-06 trial included all recruited patients with tissue sample containing >20% tumour cellularity with sufficient DNA extracted for analysis. Primary objective: assess the prevalence of somatic mutations within DDR genes in ABC. Secondary objectives: explore the impact of somatic mutations in DDR genes on: A) Patient’s response to platinum-based chemotherapy (predictive biomarker): 1) Retrospectively, using progression-free survival (PFS) data from 1st-line chemotherapy and 2) Prospectively, by assessing the impact on PFS/radiological response to 2nd-line FOLFOX (vs. control) and B) Overall survival (prognostic biomarker). Survival analysis was performed with Kaplan-Meier and Cox Regression. Results: Of 162 pts randomised, 83 had a sample available for analysis; of these, analysis failed in 24 despite >20% tumour content. Thus, a total of 59 patients (30 ASC arm, 29 ASC+FOLFOX arm) were eligible for this translational analysis: male 50.85%, metastatic 77.97%, intrahepatic cholangiocarcinoma 47.46%, adenocarcinoma 91.53%, median age 65.84 years (95% CI 63.36-68.91). Pathogenic mutations in DDR genes were identified in 22 patients (37.29%). PFS did not vary depending on the DDR-gene alterations either in the first-line setting with CisGem (n=59; 8.73 months vs 8.18 months; p-value 0.155) or with second-line FOLFOX (n=29; 3.19 months vs 3.45 months; p-value 0.098). Median OS for DDR-altered patients was 4.59 months (95% CI 2.17-5.88) (vs 7.23 months (95% CI 5.45-8.28) for DDR-wild-type); HR 2.63 (95% CI 1.48-4.67); p-value 0.001. This prognostic impact was confirmed when the prognostic model was adjusted for treatment arm and stratification factors (HR 3.75 (95% CI 1.99-7.09); p-value <0.001). Conclusions: For ABC patients, the presence of DDR-related gene pathogenic mutations are present in around one third of patients. Despite presence of DDR-mutations having a negative prognostic impact, their predictive role is not confirmed either for first-line CisGem or second-line FOLFOX. Clinical trial information: NCT01926236 .

Third-line chemotherapy in advanced biliary cancers (ABC): pattern of care, treatment outcome and prognostic factors from a multicenter study

ABSTRACT Objectives Here, we aim at describing the pattern of care, survival outcome and prognostic factors of ABC patients (pts) receiving third-line chemotherapy. Methods Institutional registries across three academic medical centers were retrospectively reviewed. Kaplan–Meier estimators were used to calculate survival, the log-rank test to make comparisons, and the Cox proportional hazard models to assess the progostic impact of variables. Results Among 101 pts included in the analysis. 68 (67.3%), 19 (18.8%) and 14 (13.8%) had intrahepatic and extrahepatic cholangiocarcinoma and gallbladder cancer, respectively. Atotal of 63 (62.3%) pts received monochemotherapy, while 38 (37.6%) were treated with adoublet. The median OS and PFS were 5 and 3 months, respectively. Disease control rate was achieved in 23 (22.7%) pts, with 2 (2%) partial responses. Grade 3–4 treatment-related adverse events were reported in 22 (21.7%) pts. At multivariate analysis, ECOG PS (p < 0.001), tumor burden (p = 0.01) and lymphocyte-to-monocyte ratio (p =0.02) were independent predictors of survival. Conclusions Third-line chemotherapy displayed limited activity in this real-world cohort, although prognostic factors have been identified that may assist in treatment decision. The results of this multicenter experience, highlight the need for more effective therapies and provide a benchmark for future trials in this setting.

Abstract 5512: Identification of circulating myeloid cells induced in advanced biliary cancer patients responding to anti-PD1 through combined single cell RNA sequencing and protein expression analysis

Abstract Background: Patients with advanced biliary cancer (ABC) have low rates of response to immune checkpoint inhibition (CPI) monotherapy. We conducted a phase II clinical trial studying combination immunotherapy with GM-CSF and the anti-PD-1 antibody, pembrolizumab (NCT02703714), with preliminary objective response rate of 19%, higher than the reported response rate of 5.8% for pembrolizumab monotherapy in ABC. Mechanisms of response to CPI in ABC are unknown, and to our knowledge, there have not been studies of the immune response in this patient population at the single cell level. Methods: Cryopreserved serial peripheral blood mononuclear cells (PBMC) samples from n=27 ABC patients treated with pembrolizumab plus GM-CSF were assessed with single cell RNA sequencing combined with CITE-Seq, the staining of cells with &amp;gt;90 oligo-tagged antibodies. This allows for the simultaneous identification of protein and RNA expression on an individual cell basis. We used high-throughput multiplexing in which PBMC from different patients could be deconvolved from other mixed samples using individual specific SNPs (“demuxlet”). &amp;gt;100 PBMC samples, including pre-treatment and 1 week, 3 weeks, and 6 weeks post-treatment, were studied. Nine of 27 patients were characterized as responders, while 18 were non-responders. We also performed CITE-Seq on PBMC from age/gender-matched healthy controls (n=9). Results: Unbiased clustering revealed all major immune populations were present in PBMC from both ABC and controls, though the immune compositions differed, most strikingly within the myeloid compartment. A distinct population of CXCL5-expressing “cancer-associated myeloid cells”, distinct from classical and non-classical monocytes and dendritic cells, was found only within cancer patients. We also analyzed the effects of treatment on immune sub-populations within responders and non-responders and found that following anti-PD-1 monotherapy, there was an increased frequency and absolute number of non-classical monocytes in responders. Conversely, the addition of GM-CSF to anti-PD-1 therapy decreased the frequency of circulating non-classical monocytes, though there was a robust induction of pro-inflammatory genes following treatment with GM-CSF in responders. Regardless of responder status, GM-CSF also dramatically induced monocyte-derived dendritic cells within 1 week of administration. Conclusions: The compositions of the myeloid compartment differed between ABC patients and healthy individuals, with a circulating cancer-associated myeloid population identified in ABC patients. Circulating non-classical monocytes increased following anti-PD-1 monotherapy in all patients, but declined after combination with GM-CSF in responders, suggesting that anti-PD-1-induced myeloid populations may be associated with response to anti-PD1. Pre-existing and induced myeloid cell states may represent a mechanism of response to anti-PD-1 and GM-CSF. Citation Format: Bridget P. Keenan, Elizabeth E. McCarthy, Arielle Ilano, David S. Lee, Yang Sun, Brenna Sheldon, Alexander Cheung, Chun Jimmie Ye, Robin Kate Kelley, Lawrence Fong. Identification of circulating myeloid cells induced in advanced biliary cancer patients responding to anti-PD1 through combined single cell RNA sequencing and protein expression analysis [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5512.

739P - The prognostic nutritional index (PNI) is an independent predictor of survival in advanced biliary cancers (ABC) receiving first-line chemotherapy (1L)

BackgroundABC portend a dismal prognosis despite standard chemotherapy treatment. A proper risk-stratification is key to optimize the benefit-to-risk ratio of palliative treatment. The PNI is an immune-inflammatory and nutritional indicator showing to be prognostic across a number of malignancies. We aimed at investigating the impact on survival of the PNI in ABC patients (pts) treated with 1L. MethodsElectronic medical records of pts diagnosed with ABC and treated with 1L between 2002 and 2018 at the Modena Cancer Centre were retrospectively reviewed. Clinical, pathological and biochemical variables of potential interest were collected. The PNI was calculated as follows: 10 × serum albumin concentration (g/dL) + 0.005 × peripheral lymphocyte count (number/mm2) and dichotomized using the ROC analysis with 36.7 as the cut-off value. Univariate and multivariate analysis were performed to assess the impact of covariates on overall survival (OS). Kaplan-Meier survival curves were generated and log-rank testing was used to make comparisons. ResultsOverall, 114 pts fulfilled the inclusion criteria and were included in the analysis. 51% (n=58) were female and 49% (n=56) had an ECOG PS of 0. 35% (n=40) of pts received a platinum/gemcitabine doublet, while 65% (n=74) were treated with other regimens. The median OS in the cohort was 8.1 months. At the univariate analysis the following covariates were associated with OS: PNI (P<0.0001), CA19.9 (P=0.0063), CEA (P=0.0004), LDH (P=0.0360), alkaline phosphatase (P=0.0308), monocyte count (P=0.0124), neutrophil count (P=0.0013), ECOG PS (P<0.0001), neutrophil/lymphocyte ratio (NLR) (P<0.0001). Interestingly, the PNI retained a statistical significance (P=0.0011) also at the multivariate analysis, together with NLR (P=0.0046) and ECOG PS (<0.0001). The median OS in pts with a PNI > 36.7 and < 36.7 was 12.1 months and 5.4 months, respectively. ConclusionsWe demonstrated an independent prognostic role for the PNI in a cohort of ABC treated with 1L. Since it is based on easy-to-collect and inexpensive parameters it should be implemented in the clinical practice to improve the accuracy of current available tools. Legal entity responsible for the studyFrancesco Caputo. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

The A.L.A.N. score identifies prognostic classes in advanced biliary cancer patients receiving first-line chemotherapy

BackgroundChemotherapy is the mainstay treatment for advanced biliary cancer (ABC). Best supportive care and clinical trials are currently alternative options. The identification of a prognostic score that can be widely applied to daily practice has the potential to better inform clinical management of ABC patients. MethodsA cohort of 123 ABC patients undergoing first-line chemotherapy was used as an exploratory cohort to define the prognostic value of laboratory tests routinely performed in clinical practice. Kaplan–Meier analysis was used to investigate the association between the variables and overall survival (OS). Those variables that were statistically significant at the multivariate analysis were combined in a multiplex score. Performance of the novel prognostic score was confirmed in a validation cohort of 60 ABC patients. ResultsBaseline actual neutrophil count, lymphocytes-monocytes ratio, neutrophil-lymphocytes ratio and albumin (A.L.A.N.) correlated with OS at the multivariate analysis in the exploratory cohort. When combined in the multiplex, A.L.A.N. score was able to identify three classes of ABC patients with significantly different OS (high-risk: median OS, 5 months; intermediate-risk: median OS, 12 months and low-risk: median OS, 22 months; p:<0.001). The score performed well in the different subtypes of ABC and was independent of stage, performance status and chemotherapy regimen. The performance of the A.L.A.N. score was confirmed in a validation cohort of cholangiocarcinoma patients (high-risk: median OS, 4.3 months; intermediate-risk: median OS 9.3 months, low-risk: median OS 13 months; p:0.005). ConclusionsThe A.L.A.N score can be derived by variables routinely recorded in clinical practice and can provide prognostic assessment of ABC patients considered for first-line treatment.

Abstract 4063: Single cell immune profiling of patients with advanced biliary cancers treated with combination checkpoint inhibition and GM-CSF reveals diverse T cell and myeloid cell mechanisms of action

Abstract Background: Advanced biliary cancers (ABC) including cholangiocarcinoma and gallbladder adenocarcinoma are rising in incidence with limited standard treatment options. While checkpoint inhibition (CPI) achieves durable tumor responses in subsets of patients across many malignancies, less than 10% of ABC patients respond to single agent PD-1-targeted therapy. Combination immunotherapy aims to overcome pre-existing and adaptive resistance to immunotherapy. GM-CSF is a cytokine that activates and matures antigen-presenting cells, suggesting the potential to enhance immune responses. The exact mechanisms of action of this cytokine have not been defined in cancer patients. The combination of GM-CSF and anti-CTLA-4 CPI demonstrated safety along with inducing clinical responses in melanoma and prostate cancer. We conducted a phase II trial of the novel combination of GM-CSF and pembrolizumab (Pembro) in patients with ABC which has resulted in durable clinical responses in greater proportion than previously reported with anti-PD-1 monotherapy. Methods: We assessed peripheral blood mononuclear cells (PBMC) from patients on Pembro monotherapy and combined Pembro/GM-CSF by mass cytometry (CyTOF) and T cell receptor (TCR) sequencing. We explored for the differences between clinical responders versus non-responders. Results: We find that the addition of GM-CSF to Pembro leads to a higher frequency of myeloid cells overall; however, certain sub-populations of classical monocytes and conventional dendritic cells decreased in peripheral blood following upfront Pembro followed by GM-CSF. GM-CSF did not seem to change the phenotypes or relative frequencies of circulating T cell subsets. We also find that clinical responders possess specific circulating populations of classical monocyte and conventional dendritic cells prior to treatment. Responders also had higher percentages of CD8+ T cells expressing CD39 following Pembro treatment compared to non-responders. Combination therapy with Pembro/GM-CSF led to different effects on the T cell repertoire compared to Pembro alone. Conclusions: The addition of GM-CSF to Pembro leads to dynamic shifts in myeloid cell subsets in the peripheral blood of ABC patients treated with immunotherapy, whereas Pembro alone led to changes in the activation states of T cell subsets. The TCR repertoire shifts reflect distinct mechanisms of action for Pembro monotherapy versus Pembro/GM-CSF. Future studies will explore the mechanisms driving the increased response rate seen with combination immunotherapy in comparison to Pembro alone in ABC patients, both through the study of peripheral immune responses as well as via immune-profiling of tumors from sequential biopsies of patients on Pembro monotherapy versus combined Pembro/GM-CSF. Citation Format: Bridget P. Keenan, Whitney Tamaki, Eric Liu, Brandon Chen, Alexander Cheung, John D. Gordan, Brenna Sheldon, Li Zhang, Robin K. Kelley, Lawrence Fong. Single cell immune profiling of patients with advanced biliary cancers treated with combination checkpoint inhibition and GM-CSF reveals diverse T cell and myeloid cell mechanisms of action [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4063.

Gemcitabine and oxaliplatin (GEMOX) alone or with cetuximab in first-line treatment of advanced biliary cancers (ABC): Exploratory analyses according to tumor KRAS/BRAF mutations and EGFR expression in a randomized phase II trial (BINGO).

4127 Background: Gemcitabine-platinum regimens are the standard of care for ABC. Whether GEMOX-cetuximab may be beneficial in ABC patients (pts) was tested in BINGO, an international, open-label, randomized phase II study (ASCO 2012). With a 4-month progression-free survival (PFS) rate of 63% [CI: 52-74], the primary endpoint was met (target, ≥60%; GEMOX, 54% [43-65]). However, median PFS (6.1 vs. 5.5 months) and overall survival (OS) (11.0 vs. 12.4 months) were similar in both arms. Available data on KRAS/BRAF mutation rates in ABC pts are sparse. Methods: Planned exploratory endpoints included tumor KRAS/BRAF mutational status (high-resolution melting and DNA sequencing) and EGFR expression score (immunohistochemistry [IHC]), and their impact on patient outcome according to treatment arm. Results: Tumor samples were collected for 91 (61%) consenting pts among the 150 randomized pts, and were suitable for DNA analysis and IHC in 75 (50%) and 77(51%) pts, respectively. Tumor KRAS and BRAF mutations (MT) were found in 14 (19%) and 4 (5%) pts, respectively. High EGFR score (≥ 200) was observed in 18 (23%) pts. 4-month PFS rates did not differ according to tumor KRAS MT (wild-type [WT] vs. MT: 62% vs. 57%, p=0.72), BRAF MT (61% vs. 75%, p=1.00) or EGFR score (≥ vs. &lt;200: 56% vs. 63%, p=0.42) overall, or according to treatment arm (table). PFS and OS (log rank test) also did not significantly differ according to these biomarkers, overall or between treatment arms. Conclusions: Tumor KRAS/BRAF mutations and EGFR overexpression were found in 24% and 23% of pts respectively. With the limit of statistical power in these exploratory analyses, they had no statistically significant prognostic or predictive impact. Clinical trial information: 2007-001200-20. [Table: see text]

Detection of circulating tumor cells in cancers of biliary origin.

Circulating Tumor Cells (CTCs) have been described in malignancies of epithelial origin. In this study we examined the detection of CTCs using CellSearch assay in cholangiocarcinoma and gallbladder cancer. The clinical outcomes and detection of CTCs were examined in sixteen patients with biliary cancer using the CellSearch assay. Stages of cancer, baseline demographic data and overall survival were evaluated. Thirteen patients had cholangiocarcinoma and three had gallbladder cancer. Using a cut off of two or more CTCs per 7.5 mL of blood, 3/13 cholangiocarcinoma and 1/3 gallbladder cancer patients had detectable CTCs. At 12 months of follow up from time CTC is drawn; 1/4(25%) of patients with positive CTC were alive while 6/12 (50%) of patients with negative CTC remained alive without a significant difference in survival between the two groups. Our finding that 25% of patients with cholangiocarcinoma and gallbladder cancer have two or more detectable CTCs/7.5 mL is the first report to our knowledge in this disease. Larger patient numbers are needed to determine the prognostic significance of finding CTCs in biliary cancer. Prospective validation of the role of CTC in advanced biliary cancer patients is on going.

A phase I study of S-1 treatment with a 3 week schedule in advanced biliary cancer patients with or without hepatic dysfunction

A 3 week treatment schedule consisting of 2 weeks of S-1 therapy and 1 week of no therapy was introduced to reduce the toxicity and increase the convenience of combination chemotherapy. Hepatic dysfunction (HD) is common in patients with biliary tract cancer. A phase I study was conducted to assess the effects of a 3 week treatment schedule in Asian patients with or without HD. Forty-six patients were stratified into four groups, according to the HD criteria of the National Cancer Institute Organ Dysfunction Working Group. A three dose escalation schema was used. In the normal hepatic function group, two dose-limiting toxicity (DLT) events occurred among 12 patients at the prespecified maximal dose of 100 mg/m²/day. This dose was thereby established as the maximal tolerable dose (MTD). No DLT events were observed at the predefined maximal dose of 80 mg/m²/day in the mild HD group. In the moderate HD group, two DLT events occurred among five patients treated with 80 mg/m²/day, and the MTD was defined as 70 mg/m²/day. Two of six subjects in the severe HD group experienced DLT events at doses of 60 mg/m²/day and none developed DLT events at 50 mg/m²/day. The MTDs for a 3 week schedule of S-1 treatment were defined in patients with or without hepatic dysfunction. A 3 week treatment regimen of S-1 might be a platform for combination with newer cytotoxic agents or biologics.

The retrospective analysis of single agent gemcitabine for biliary tract cancers

14122 Background: At present, outcomes of advanced biliary tract cancers are dismal despite the prognosis of other many cancers are improving. Methods: We retrospectively analyzed survivals of 46 advanced biliary tract cancer patients, who were diagnosed between January 2001 and June 2005, and treated with gemcitabine 600–1,000 mg/m2 as an intravenous 30-min infusion on days 1, 8, and 15 for every 28 days, thereafter. Results: The median age was 63 (range 41–76) with 28 males and 18 females. Twenty-nine (63.0%) had no prior chemotherapy and 18 (30.4%) patients were inoperable cases. One (2.2%) achieved complete response; 5 (10.9%) achieved partial responses; 25 (54.3%) had stable diseases; 9 (19.6%) had progressive disease; and 6 (13.0%) were not evaluated for response. The median survival time and the 1 year-survival of all advanced biliary cancer patients were 8.6 months and 43.9%, respectively, those of the patients, who had the recurrence or residual cancer lesions after surgical resection were 13.5 months and 68.8%, and those of the inoperable patients were 5.4 months and 8.3%. Patients reported grade 3/4 neutropenia/leucopenia (4.3%) and grade 3 thrombocytopenia (2.2%). Grade 3 non-hematologic toxicities were general fatigue (4.3%) and renal failure (2.2%). Multivariate analysis demonstrated that history of surgical resection with tumor recurrence or with residual tumor was the independent predictors for survival. Moreover, except the features of the history of surgical resection, the prognosis of patients with low levels of serum albumin (&lt; 3.7 g/dl) or ≥ 70 ages was worse than that of high levels of serum albumin (≥ 3.7 g/dl) or &lt; 70 ages. Conclusions: In the treatment of biliary tract cancer, it seems that surgical resection even with possible residual tumor is beneficial for patients with good surgical candidate. The present study also suggests the possibility that the prognosis of patients with low levels of serum albumin (&lt; 3.7 g/dl) or ≥ 70 ages might be worse than that of high levels of serum albumin (≥ 3.7 g/dl) or &lt; 70 ages. No significant financial relationships to disclose.