Genomic Features Associated With Cholangiocarcinoma Metastasis And Its Targeting, Clinical Practice And Biomarker Research For Immunotherapy

Background:Cholangiocarcinoma is a kind of aggressively malignant tumors with high heterogeneity.Most patients are already at advanced stages when diagnosed and lymphatic metastasis is an independent risk factor for their prognosis.Currently,great progresses have been made in targeted and immunotherapy for cholangiocarcinoma,however,there still exist many problems,such as limited population benefit from targeted therapy,low efficiency of immune monotherapy,etc.In this study,we analyzed the genomic alterations in intrahepatic cholangiocarcinoma with or without lymphatic metastasis,try to find the target genes and related signaling pathways that potentially affect lymphatic metastasis.Then we investigate the immune infiltration within cholangiocarcinoma immune microenvironment,expecting to explore abnormally expressed genes as well as their relationship with the infiltrating immune cells.Methods:Carcinoma tissues and blood samples were selected from 54 patients with intrahepatic cholangiocarcinoma(ICC),of which 23 patients accompanied with lymphatic metastasis and 31 without metastasis.All the samples were subject to whole exome sequencing.Then the differences in mutations distribution,copy number variation,high frequency driver genes,single nucleotide polymorphisms and mutational signature between the two groups were analyzed.Finally,loci and pathways enrichment analysis of mutated genes were completed in cholangiocarcinoma with and without lymphatic metastasis.Meanwhile,the gene expression profile data and clinical data of 36 cholangiocarcinoma cases(TCGA-CHOL)were also retrieved from the TCGA database,by which the infiltration conditions of immune cells in the tumor were investigated using single sample gene set enrichment analysis(ssGSEA),and the relationship between tumor immune infiltration and survival of cholangiocarcinoma patients was analyzed by ESTIMATE analysis.Results:From the perspective of overall mutation level,ICC with lymphatic metastasis showed increasing but significant differences in somatic mutations,indel and copy number variants compared to ICC without lymphatic metastasis,potentially suggesting the possibility of lymphatic metastasis at the genomic level despite the absence in early ICC.After comparing the mutational signature profiles of all the samples,we found that the study-defined Signature D was highly similar to the known Signature 3 in the COSMIC database(cosine similarity=0.827),meanwhile its relative contribution was significantly more prominent in the samples with lymphatic metastasis(p=0.025),indicating that ICC with lymphatic metastasis was more sensitive to platinum-based drugs.A total of 26 statistically significant mutated genes was identified in two groups where the most significant mutation occurred in ARHGEF7 and ARID 1A(p=0.035,p=0.037).Using TCGA-CHOL data,we identified a number of differently enriched immune cells in cholangiocarcinoma and a significant survival benefit in patients with high immune scores,while early-stage cholangiocarcinoma was more enriched in immune cells compared to advanced stages.Finally,in combination with survival analysis and immune cell infiltration,we found that the genes,GPR65,KCNA3,XCL2,CHST2 and FAM105A were enhanced expressed in patients with high immune score and improved their overall survival.Conclusions:There is not significant difference in overall mutations for intrahepatic cholangiocarcinoma with lymphatic metastasis compared to that without lymphatic metastasis,but there suggests an increasing trend.Intrahepatic cholangiocarcinoma with lymphatic metastasis may be more sensitive to platinum-based chemotherapy,and the genes ARHGEF7 and ARID1A potentially affect lymphatic metastasis.The overall immune microenvironment in cholangiocarcinoma remains a disordered state and cholangiocarcinoma with abundant immune cell infiltration indicates a significantly survival benefit.Background:PD-1/L1 inhibitor-based immunotherapy is currently under investigation in biliary tract cancer(BTC).Apatinib combined with camrelizumab has achieved promising results in various tumor types.The aim of this study was to assess the safety and efficacy of apatinib plus camrelizumab for advanced biliary tract cancer patients who have received previously treatments.Methods:This prospective,non-randomized,open-label trial was conducted at Peking Union Medical College Hospital(PUMCH).All included patients received apatinib orally at 250 mg pera day and camrelizumab intravenously at 200 mg every three weeks until disease progression or intolerable toxicity occurred.Efficacy was evaluated based on the Response Evaluation Criteria in Solid Tumors RECIST Version 1.1(RECIST 1.1).Adverse events(AEs)were assessed by the National Cancer Institute Common Terminology Criteria for Adverse Events(CTCAE version 4.0).Results:A total of 22 patients were consecutively enrolled from 1st December,2018 until 1st August,2020.Among 21 patients for whom we could conduct efficacy evaluations,no patients achieved a complete response(CR),4 patients(19%)achieved partial response(PR),and 11 patients had stable disease with a disease control rate of 71.4%.The median overall survival was 13.1 months(95%CI,8.1-18.2),and the median progression-free survival was 4.4 months(95%CI,2.4-6.3).All patients experienced treatment related AEs,and grade 3 or 4 AEs occurred in 14(63.6%)of 22 patients.No treatment related deaths were observed.Conclusions:This is the first report focusing on the efficacy and safety of camrelizumab plus apatinib in pretreated biliary tract cancer patients.The finding suggests this regimen has favorable therapeutic effects with relatively manageable toxicity.Further trials with a control arm are required to investigate.Clinical Trial Number(NCT04642664).Background:Cholangiocarcinoma has a high degree of malignancy and poor prognosis.The treatment choice is very scarce,and there is an urgent need for the exploration of new treatment.Several target therapies based on genetic testing have shown excellent efficacy in cholangiocarcinoma.Lenvatinib is a multi-targeted tyrosine kinase inhibitor targeting the vascular endothelial growth factor receptor VEGFR1-3,fibroblast growth factor receptor FGFR1-4 and platelet-derived growth factor receptor PDGFR-?.At present,lenvatinib has shown well anti-tumor effect in various tumors,such as hepatocellular carcinoma,thyroid cancer and so on.The aim of this study is to explore the efficacy and safety of lenvatinib monotherapy in the after-line treatment of advanced cholangiocarcinoma,with a hope to exploring treatment that may provide better benefit to patients.Methods:This is an open-label,single-arm,single-center prospective clinical study to evaluate the efficacy and safety of lenvatinib as a second-line treatment option and beyond in patients with advanced cholangiocarcinoma.All patients administrate lenvatinib 8mg or 12mg/day orally depending on body weight,until occur disease progression or intolerable toxicities occurring.Treatment efficacy was evaluated according to the RECIST 1.1,Adverse events were evaluated according to the CTCAE 4.0.The study also recorded the changes in the carbohydrate antigen 19-9(CA19-9)during treatment and the results of next generation sequence to predict efficacy.Results:Forty-six patients with advanced cholangiocarcinoma were included in this study,five patients due to lacking complete evaluation data were excluded.41 patient's treatment efficacy were evaluated.The overall objective rate(ORR)for patients was 12.2%[95%CI,1.7-22.7],the disease control rate(DCR)was 78.0%[95%CI,64.8-91.3],the median progression-free survival(mPFS)was 3.8 months[95%CI:1.3-6.3]and the median overall survival(mOS)for patients was 11.4 months[95%Cl:6.6-16.2].84.8%(39/46)of patients occurred adverse events(AEs)during treatment,and the incidence of grade 3-4 AEs was 17.4%(8/46).The sensitivity and specificity of changes of CA19-9 predicting tumor response are 77.7%and 73.9%respectively.The genomic alteration of 28 patients suggested that the most common mutations in patients with shrinking tumor were DNMT3A,TP53 and KRAS.Conclusions:Lenvatinib monotherapy shows initial efficacy in advanced cholangiocarcinoma in second-line treatment and beyond.Generally,the safety is manageable.Changes in the serum biomarker CA19-9 before and after treatment is associated with the patients' response to treatment.The results still need to be further validated by more rigorously designed randomized controlled studies.NCT04656249Background:Several studies have shown that cholangiocarcinoma(CCA)patients could benefit from immune checkpoint inhibitor(ICI)therapy.However,the prognostic factors mediating the limited response to ICI therapy remain unclear.Methods:The study recruited 84 cholangiocarcinoma patients who received ICI therapy from two trials(NCT03895970,NCT03892577).Clinical characteristics were collected on these patients.The impact of human leukocyte antigen class I(HLA-I)evolutionary divergence(HED),HLA-? heterozygosity,and HLA-I genotype on ICI therapy efficacy in hepatobiliary cancers were analyzed.HLA-? genotyping was obtained from germline white blood cell DNA panel sequencing data.Results:High HED and heterozygosity at the HLA-B genotype were associated with better OS in CCA patients who received ICI therapy(P<0.05).Even among patients fully heterozygous at HLA-B,patients with high HED had better OS than those with low HED(P<0.05).Moreover,among patients with low tumor burden score(TBS),those with high HED at HLA-B showed favorable OS and PFS,while those with low HED at HLA-B had poor OS and PFS,which was similar to patients with high TBS(P<0.05).Additionally,patients with the HLA-A24 and HLA-C01 alleles had poor PFS after ICI therapy.A prognostic nomogram integrating these significant factors was constructed to predict the survival of receiving ICI therapy.Conclusions:This study indicated that the evolutionary divergence of HLA-B combined with the HLA class I genotype and TBS can be used to predict the clinical outcome of ICI therapy in cholangiocarcinoma.