A 75-Year-Old Man with Metastatic Cholangiocarcinoma - Episode 2

Treatment of Patients With Metastatic Cholangiocarcinoma

Reactions to the management of metastatic cholangiocarcinoma and prediction of patient response to treatments used in early lines of therapy.

Afsaneh Barzi, MD, PhD: Cholangiocarcinoma is a heterogeneous disease. We have patients who do well for a long time, and those who decline very quickly. Predicting how a patient will do based on the information we have is most of the time very difficult. One thing is critical, these patients need to be followed very closely. Although radiographic assessment for definition of the progression is and should be standard of care, if we notice any significant decline in organ function or a patient’s performance status and symptoms, it is reasonable to consider subsequent lines of therapy. This is even more relevant to the current time. Up until recently, cholangiocarcinoma did not have any established subsequent lines of therapy past the gemcitabine and cisplatin that we discussed earlier, although over the past 2.5 to 3 years, we’ve had multiple trials that have shown active agents in subsequent lines of therapy.

These include chemotherapy combinations such as FOLFOX [folinic acid, fluorouracil, oxaliplatin], which was studied in the ABC-06 trial, and more recently published, 5-FU [fluorouracil] and Onivyde [liposomal irinotecan] based on the NIFTY trial. Also, there are targeted therapies for selected populations, such as ivosidenib, which is FDA-approved for patients with IDH mutations. In addition, there are agents that target FGFR alterations, such as pemigatinib and infigratinib. Given that the number of options for this patient population is expanding, it’s really important to identify the patients who are intolerant or not benefiting from their frontline therapy, and appropriately transition them in a timely manner to subsequent lines of therapy. This allows them to see the benefit of the drugs that they’re not exposed to in the frontline setting.

Transcript edited for clarity.

Case: A 75-Year-Old Man with Metastatic Cholangiocarcinoma

May 2021

Initial presentation

  • A 75-year-old man presents with abdominal pain and weight loss.

Clinical workup

  • History of hepatitis B infection more than 10 years ago and hypertension which is controlled with medication
  • Blood work reveals serum levels of CA 19-9 (1200 U/ml), bilirubin 1.5 mg/dL, ALT 250 U/L, AST 95 U/L
  • MRI imaging shows multiple liver masses
  • Histopathological examination identifies adenocarcinoma with primarily mucin-producing glands
  • Patient is identified to have intrahepatic cholangiocarcinoma (iCCA).
  • CBC is unremarkable (absolute neutrophil count 3,500/mm3, platelets 300,000/ml, hemoglobin 10.1 g/dL)
  • ECOG PS is 1 and the patient is in good health.
  • Patient is referred to oncologists for next steps and is started on treatment with gemcitabine and cisplatin in June 2021.

Sept. 2021

  • Patient is experiencing grade 2-3 neutropenia and fatigue and the oncologist has adjusted the dose to reduce toxicities with chemotherapy.