Case-Based Peer Perspectives: A 61-Year-Old Woman with Metastatic Cholangiocarcinoma - Episode 6

Key Takeaways for the Treatment of Cholangiocarcinoma

Concluding his reflection on novel therapies in patients with cholangiocarcinoma, Milind Javle, MD, provides closing thoughts and practical advice for his community colleagues.

Transcript:

Milind Javle, MD: A key takeaway point for my colleagues in community oncology is, cholangiocarcinoma is a diagnosis of exclusion; it requires careful pathology, and it requires multidisciplinary care. It does not necessarily need a lot of aggressive investigations to narrow down the diagnosis. Molecular profiling has been transformative in this disease, and it’s important to consider molecular profiling as early as possible during the disease course. The access to targeted therapies, such as with infigratinib with FGFR2 fusions, has truly changed the course of this disease. I would encourage my colleagues in the community to consider these types of treatments that I’ve described, targeting FGFR, IDH1, and others. However, the key would be to get a good biopsy specimen for molecular profiling or perhaps with ctDNA [circulating tumor DNA] so we can help our patients beyond the standard systemic chemotherapy.

One of the reasons that I’ve advocated early molecular diagnosis was from our own experience with the infigratinib study. Patients who received infigratinib in the second line had a higher response rate than those who received infigratinib in subsequent lines of therapy. We are expecting now that when these targeted drugs are used in the first line during the investigational trial, perhaps we’ll see an even stronger signal. I hope the time will come when we don’t have to use chemotherapy anymore for these patients and spare these unnecessary toxicities. That time is not here yet, but I think we will get there with appropriate and early use of molecular profiling.

Transcript edited for clarity.

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Case: A 61-Year-Old Woman with Metastatic Cholangiocarcinoma

May 2019

Initial presentation

  • A 61-year-old woman presents with jaundice and changes in stool and urine color.

Clinical workup

  • Enlarged liver is palpable on physical examination
  • Blood work reveals serum levels of CA 19-9 (1400 U/ml), bilirubin 2 mg/dL, ALT 550 U/L, AST 120U/L
  • Patient undergoes CT imaging and is found to have multiple liver masses, consistent with metastatic disease or intrahepatic cholangiocarcinoma (iCCA)
  • Histopathological examination identifies adenocarcinoma, CK7+, CK20-, HepPAR-, TTF- consistent with cholangiocarcinoma or upper GI Primary
  • Patient is diabetic and somewhat non-compliant with her diabetes medication
  • Her ECOG PS is 1

July 2019

Treatment

  • Patient is treated with chemotherapy (gemcitabine + cisplatin) for 24 weeks.
  • Patient is monitored for disease progression every 2-3 months by CT imaging.

July 2020

  • Patient does well for 1 year after initiation of treatment but now has elevated CA 19-9 levels.
  • MRI scans show several liver and bone lesions but no signs of brain metastases.
  • Lab results are normal (absolute neutrophil count 4,000/mm3, platelets 150,000/ml, hemoglobin 12.1 g/dL
  • Patient undergoes NGS testing (Foundation Medicine, Inc.) and is found to have FGFR2-BICC1 gene fusion
  • Patient meets eligibility criteria for infigratinib phase 2 study and is enrolled in the trial and being treated with infigratinib
  • Patient does not show any signs of disease progression on MRI scans for six months, suggestive of stable disease and CA19-9 levels stay within normal limits.