nature reviews clinical oncology https://doi.org/10.

1038/s41571-023-00770-1

Review article Check for updates

Cholangiocarcinoma — novel
biological insights and therapeutic
strategies
Sumera I. Ilyas1,2, Silvia Affo3, Lipika Goyal4, Angela Lamarca5,6,7, Gonzalo Sapisochin8, Ju Dong Yang 9

& Gregory J. Gores 1

Abstract Sections

In the past 5 years, important advances have been made in the scientific Introduction

understanding and clinical management of cholangiocarcinoma The TIME of CCA

(CCA). The cellular immune landscape of CCA has been characterized Desmoplasia and CAFs in CCA
and tumour subsets with distinct immune microenvironments have
Molecular diagnosis using
been defined using molecular approaches. Among these subsets, the blood and bile
identification of ‘immune-desert’ tumours that are relatively devoid
Emerging molecular
of immune cells emphasizes the need to consider the tumour immune classifications of CCA
microenvironment in the development of immunotherapy approaches. Advances in the treatment
Progress has also made in identifying the complex heterogeneity and of CCA

diverse functions of cancer-associated fibroblasts in this desmoplastic Conclusions

cancer. Assays measuring circulating cell-free DNA and cell-free tumour
DNA are emerging as clinical tools for detection and monitoring of
the disease. Molecularly targeted therapy for CCA has now become a
reality, with three drugs targeting oncogenic fibroblast growth factor
receptor 2 (FGFR2) fusions and one targeting neomorphic, gain-of-
function variants of isocitrate dehydrogenase 1 (IDH1) obtaining
regulatory approval. By contrast, immunotherapy using immune-
checkpoint inhibitors has produced disappointing results in patients
with CCA, underscoring the requirement for novel immune-based
treatment strategies. Finally, liver transplantation for early stage
intrahepatic CCA under research protocols is emerging as a viable
therapeutic option in selected patients. This Review highlights and
provides in-depth information on these advances.

A full list of affiliations appears at the end of the paper. e-mail: gores.gregory@mayo.edu

Nature Reviews Clinical Oncology | Volume 20 | July 2023 | 470–486 470

Review article
Key points
•• Cholangiocarcinomas (CCAs) are highly desmoplastic cancers
characterized by a tumour microenvironment that is poorly
immunogenic, with an abundance of immunosuppressive cell types
such as myeloid-derived suppressor cells and tumour-associated
macrophages.
•• The desmoplasia of CCAs is associated with an abundance of
heterogeneous cancer-associated fibroblasts (CAFs), with several
transcriptomically diverse CAF subtypes identified.
•• Assessments of circulating tumour cells and cell-free tumour DNA
are becoming important in the diagnosis and monitoring of CCA.
•• Potent oncogenic drivers of intrahepatic CCAs (iCCAs) include
fibroblast growth factor receptor 2 (FGFR2) gene fusions and
neomorphic, gain-of-function variants of isocitrate dehydrogenase 1
(IDH1). FGFR2 fusions and IDH1 mutations are targetable, and approved
molecularly targeted therapies are now available for the treatment
of CCAs harbouring these genetic aberrations.
•• The results of immune-checkpoint inhibitor monotherapy in patients
with CCA have been disappointing, although the combination of
gemcitabine, cisplatin and durvalumab has been approved in the
first-line setting for the treatment of advanced-stage CCA.
•• Liver transplantation is an emerging option for the subset of patients
with early stage iCCA occurring in the setting of cirrhosis.
Introduction
Cholangiocarcinoma (CCA) is an epithelial cell malignancy of the liver
and biliary tract. Histopathologically, this cancer is characterized by
features of cholangiocyte differentiation (cholangiocytes are the epi-
thelial cells that line the intrahepatic and extrahepatic bile ducts). The
incidence of CCA is increasing in several countries globally, and given
its high lethality with 5-year overall survival (OS) ranging from 7% to
20%, this disease has attracted considerable scientific and clinical inter-
est1,2. Indeed, several outstanding reviews focusing on CCA have been
published in the past few years2,3. These reviews richly describe the
three anatomical subsets of the disease — namely, perihilar cholangio-
carcinoma (pCCA), intrahepatic cholangiocarcinoma (iCCA) and distal
cholangiocarcinoma (dCCA) — and their epidemiology, histopathology,
genetics and molecular drivers. These recent reviews also summarize
the clinical diagnosis, staging and treatment of CCA. Yet given a virtual
explosion of published manuscripts (>6,000 publications) since the
last Review of CCA in this journal in 2018 (ref. 4), an update is warranted.
This update is focused on what we believe are the most perti-
nent scientific and clinical advances made in the past 5 years. CCA is
a highly desmoplastic cancer characterized by a rich tumour immune
microenvironment (TIME)2. We highlight the deepening understand-
ing of the TIME based on single-cell RNA sequencing (scRNA-seq)
and immunophenotyping. The desmoplasia of CCA is the result of
an abundance of cancer-associated fibroblasts (CAFs)5, which have
not been fully described in prior reviews, and the nature and role of
CAFs in CCA pathogenesis will be emphasized herein. Assessments
of circulating tumour cells and cell-free DNA (cfDNA) are becoming
Nature Reviews Clinical Oncology | Volume 20 | July 2023 | 470–486
important in the diagnosis and monitoring of this malignancy6,7, and are
therefore also covered in this Review. Potent oncogenic drivers of iCCA
include fibroblast growth factor receptor 2 (FGFR2) gene fusions and
neomorphic, gain-of-function variants of the genes encoding isocitrate
dehydrogenase (IDH), specifically IDH1 (refs. 8,9). Importantly, both
FGFR2 fusions and IDH1 mutations are targetable, and approved thera-
pies are now available for the targeted treatment of CCAs harbouring
these genetic aberrations10–17. We discuss the clinical efficacy of these
molecularly targeted therapies in detail, considering that informa-
tion continues to evolve regarding their efficacy and sequential use
within the treatment armamentarium for advanced-stage CCA. Finally,
emerging information regarding the efficacy of liver transplantation
for early stage iCCAs, especially those occurring in the context of
chronic liver disease, are reviewed18. We hope that our focused update
on these particularly germane topics will be of high value to scientists
and clinicians studying CCA and caring for patients afflicted with this
complex and nefarious cancer.
The TIME of CCA
Immunosuppressive barriers
CCAs are dense, desmoplastic tumours with a prominent stroma com-
prising CAFs and innate and adaptive immune cells, among other cell
types, that can have tumour-promoting or tumour-suppressive roles
depending upon the context19. The TIME of CCA is complex with intri-
cate and extensive crosstalk between the various stromal and immune
components19. Emerging literature suggests that the CCA microenvi-
ronment is ‘immune cold’, with a paucity of cytotoxic immune cells and
an abundance of immunosuppressive elements, particularly myeloid
cells20–24. Indeed, CCAs have a decreased abundance of cytotoxic
T lymphocytes (CTLs) and natural killer (NK) cells relative to adjacent
tumour-free liver tissues, whereas the density of regulatory T (Treg)
cells is increased24. Moreover, the expression of immune-checkpoint
molecules such as PD-1 and its ligand PD-L1 as well as CTLA4 is increased
on the tumour-infiltrating immune cells, indicating an immunosup-
pressive milieu20,23–25. CCAs also have a high level of intratumoural
transcriptomic heterogeneity, probably owing to the presence of
multiple different cell types that promote immunosuppression26.
These immunosuppressive elements within the TIME (Fig. 1) facili-
tate tumour growth and progression, immune evasion and resistance
to chemotherapy, and probably contribute to the limited efficacy of
immune-checkpoint inhibitor (ICI) monotherapy in clinical trials20,27,28.
Tumour-associated macrophages (TAMs) are the predominant
immunosuppressive myeloid cell type in the TIME of CCA20,21. More­
over, an abundance of TAMs is associated with poor patient outcomes21.
A high ratio of monocytes to lymphocytes in the blood is an independent
predictor of unfavourable outcomes in patients with CCA21,29–31. Further-
more, patients with iCCAs harbouring a high percentage of macro­
phages expressing CD206, a scavenger receptor expressed on TAMs,
and a low percentage expressing CD86, a co-stimulatory signal for
T cells, have a higher risk of disease recurrence and worse OS following
surgical resection than those with CD206-low, CD86-high tumours32.
TAMs mediate tumour initiation and progression via diverse path-
ways, and multiple mechanisms are involved in TAM accumulation
within the TIME. Kupffer cells, which are resident macrophages in
the liver, can facilitate cholangiocyte proliferation and oncogenic
transformation by secreting TNF that triggers JNK signalling in the
cholangiocellular compartment33. Accordingly, JNK inhibition attenu-
ates iCCA development in preclinical models33. In addition, inflamma-
tory macrophages in the TIME promote a WNT-high state that favours
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Immunosuppressive TIME
MDSC
Therapeutic strategies
• LXR agonism + anti-CSF1R antibody + ICI
TAM • CD40 agonism + ICI
• Trametinib + ICI
Treg cell • GMCSF neutralization
CD8+ T cell
CCA cell
Tumour growth and progression
Fig. 1 | Therapeutically re-engineering the TIME of CCA to reduce tumour
burden. The cholangiocarcinoma (CCA) tumour immune microenvironment
(TIME) is poorly immunogenic with an abundance of immunosuppressive
cell types such as myeloid-derived suppressor cells (MDSCs), tumour-
associated macrophages (TAMs) and regulatory T (Treg) cells that foster tumour
growth and progression. Immunotherapeutic strategies that have been
investigated in preclinical studies using mouse models include neutralization
tumour growth and progression across several preclinical models of
CCA34. Consequently, either WNT inhibition or macrophage depletion
markedly reduces the tumour burden in these models34. TNF-like weak
inducer of apoptosis (TWEAK) predominantly produced by immune
cells, including macrophages, can induce secretion of monocyte
chemoattractant protein 1 (MCP1, also known as CCL2) by CCA cells
and thereby promotes macrophage recruitment to the CCA TIME and
induces their polarization to a pro-tumour CD206+ TAM phenotype,
in association with an increase in tumour growth35. Indeed, although
resident macrophages have an essential role in CCA development,
the majority of TAMs in established murine tumours are recruited
from peripheral monocytes20. Expression of PD-L1 is an important
mechanism of tumour immune evasion, and PD-L1 expression within
the tumour front is associated with unfavourable OS following sur-
gical resection of iCCA23. Monocyte-derived TAMs in the CCA TIME
abundantly express PD-L1 and are in fact the main source of PD-L1 in
human CCAs, and these recruited PD-L1+ TAMs are essential for CCA
progression in mouse models20. However, genetic disruption of TAM
recruitment or pharmacological inhibition of TAM function did not
reduce CCA tumour burden owing to a compensatory emergence of
another immunosuppressive myeloid cell population, myeloid-derived
suppressor cells (MDSCs).
MDSCs are a heterogeneous population of immature myeloid
cells categorized as either monocytic (M-MDSCs) or granulocytic
(G-MDSCs), with the latter also referred to as polymorphonuclear
MDSCs (PMN-MDSCs)36. MDSCs foster tumour growth and have potent
immunosuppressive properties that contribute to CTL and NK cell
dysfunction in cancer20,36. Notably, patients with CCA have higher circu-
lating levels of CD14+CD11b+HLA-DR− MDSCs than individuals without
known cancer37. Moreover, high levels of MDSCs in the peripheral blood
are associated with resistance to ICIs in patients with melanoma 38.
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Re-engineered immunogenic TIME
CCA cell
TAM
MDSC
Treg cell
NK cell
CD8+ T cell CD4+ T cell
Tumour regression
of granulocyte–macrophage colony-stimulating factor (GMCSF), liver
X-receptor (LXR) agonism to inhibit MDSCs combined with macrophage
inhibition using anti-colony-stimulating factor 1 receptor (CSF1R) antibodies
and immune-checkpoint inhibitors (ICIs), as well as the combination of ICIs with
CD40 agonism or MEK inhibition with trametinib. These immunotherapeutic
strategies have the potential to re-engineer the CCA TIME to an immunogenic
one that is less favourable to the tumour. NK, natural killer.
In preclinical models of colitis or primary sclerosing cholangitis, which
is an important risk factor for CCA, intestinal barrier dysfunction and
gut dysbiosis enable bacterial cells and endotoxins to accumulate in
the liver22. Consequently, hepatocytes secrete the chemokine CXCL1,
which recruits CXCR2+ PMN-MDSCs that accelerate the development
of CCA22. This effect can be abrogated through antibiotic treatment
or neutralization of CXCL1 (ref. 22). These findings highlight the inter-
play between the gut microbiota, intestinal barrier function and the
CCA TIME.
Insights from multiomics analyses
Emerging single-cell and bulk multiomics studies have begun to illumi-
nate the complex heterogeneity of the CCA TIME, and its relationship
with distinct molecular subtypes of the disease and correlation with
patient prognosis, as well as its modulation through immunother-
apy. scRNA-seq of 144,878 cells from 14 iCCA specimens revealed two
tumour subtypes based on differential expression of the markers S100P
and SPP1 (also known as osteopontin)39. Each subtype had a distinct
TIME and correlated with a different patient prognosis. For example,
S100P+SPP1− iCCAs (termed perihilar large-duct-type tumours) had
decreased infiltration of CD4+ T cells and CD56+ NK cells while having
an increased abundance of CCL18+ macrophages and PD-1+CD8+ T cells
relative to the other tumour subtype39. By contrast, S100P−SPP1+ iCCAs
(peripheral small-duct-type) had enhanced infiltration of SPP1+ macro­
phages39. Moreover, S100P−SPP1+ iCCAs were associated with a less
aggressive tumour phenotype (including lower levels of serum CA19-9
and CEA and tumour Ki67 expression, as well as a lower prevalence of
lymph node metastasis and advanced-stage disease) and better OS
(based on immunohistochemistry microarray data from 186 patients
and RNA-seq data from 66 patients)39. In another multiomics analysis
of 151 iCCAs using proteomics analysis, whole-exome sequencing and
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scRNA-seq, the tumours were classified into three molecular subtypes:
chromatin remodelling, metabolism and chronic inflammation40. The
chronic inflammation subtype was characterized by the presence of
APOE+C1QB+ TAMs and associated with poor patient outcomes40. By
comparison, the metabolism subtype had frequent mutations in KMT2D
(encoding histone-lysine N-methyltransferase 2D) and was associated
with lower inflammatory activity40.
Evolving data also suggest that the CCA TIME can influence
response to immunotherapy. Multiplexed single-cell transcriptomic
and epitope sequencing of 200,000 peripheral blood mononuclear
cells from nine patients with CCA and eight matched donors without
known cancer demonstrated high levels of a unique population of
CD14+ monocytes, termed CD14CTX cells, in patients with tumours resist-
ant to anti-PD-1 antibodies41. The CD14CTX cells had increased expression
of immunosuppressive cytokines and chemotactic molecules, and
induced expression of SOCS3 in CD4+ T cells, thereby inhibiting their
functional activity. The presence of CD14CTX cell is also of prognostic
relevance, given that tumours expressing a CD14CTX gene signature
were associated with unfavourable OS in patients with CCA as well as
in those with other ICI-refractory cancers41.
Overcoming the immunosuppressive TIME
Preclinical studies have provided insights into potential strategies to
circumvent immunosuppressive barriers in the TIME of CCAs. TAMs
and MDSCs seem to have an integral role in the CCA TIME; therefore,
combined targeting of both of these cell populations is a rational thera-
peutic approach (Fig. 1). Activation of the transcription factor liver-X
receptor (LXR) restricts the survival and abundance of MDSCs42. In a
syngeneic orthotopic mouse model of CCA, pharmacological target-
ing of MDSCs using either an anti-Ly6G antibody or the LXR agonist
GW3965 combined with targeting of TAMs using an anti-CSF1R anti-
body augmented the efficacy of anti-PD-1 antibodies, with consequent
prolongation of survival20. Neutralization of granulocyte–macrophage
colony-stimulating factor (GMCSF) is another approach that has dem-
onstrated promise in preclinical models of iCCA21. GMCSF has an inte-
gral role in myeloid cell programming, and higher expression of this
cytokine is associated with unfavourable OS in patients with iCCA fol-
lowing surgical resection21. Accordingly, antibody-mediated GMCSF
blockade curtailed tumour growth in an orthotopic model of CCA by
decreasing TAM abundance and repolarizing immunosuppressive
TAMs and MDSCs in a manner that facilitated the T cell response21.
CD40 is a receptor that is expressed on antigen-presenting cells,
including dendritic cells (DCs) as well as macrophages, and promotes
DC activation and macrophage re-education to an antitumour, inflam-
matory phenotype43. In several different preclinical models of iCCA,
combination of an agonistic anti-CD40 antibody with an anti-PD-1 anti-
body markedly reduced tumour burden, in association with increases
in the abundance and activation of macrophages and DCs as well as
cytotoxic cell types including CD8+ T cells, NK cells and CD4+ T cells;
most of these cell types were functionally implicated in the antitumour
response through depletion experiments44. Furthermore, CD40 ago-
nism combined with PD-1 antagonism enhanced the efficacy of gem-
citabine–cisplatin chemotherapy, with consequent increased mouse
survival compared to gemcitabine–cisplatin alone44.
Other systemic therapies can also prime the TIME and potentiate
the response to ICIs. For example, MEK inhibition with trametinib
upregulates tumour cell expression of MHC class I (MHC I) molecules
and PD-L1. Hence, the combination of trametinib and an anti-PD-1 anti-
body had enhanced antitumour efficacy compared with that of either
Nature Reviews Clinical Oncology | Volume 20 | July 2023 | 470–486
agent alone in a mouse model of iCCA45. In aggregate, the results of
these preclinical studies support the concept that therapeutic strate-
gies that modulate the CCA TIME by shifting the balance from immuno­
suppressive factors in favour of cytotoxic elements can augment the
antitumour response and the efficacy of ICIs (Fig. 1).
Desmoplasia and CAFs in CCA
One of the main features of CCA is its highly desmoplastic nature with
an accumulation of CAFs and excessive deposition of extracellular
matrix (ECM) in the TIME, which contributes to the poor prognosis of
patients with this disease27,46–49. CAFs intercommunicate with a wide
variety of cell types including cancer cells, immune cells and endothelial
cells, all interacting in a multidirectional network influencing chol-
angiocarcinogenesis27,50. Indeed, CAFs are one of the most abundant
cell types in the TIME of CCA and contribute to tumour neoangiogen-
esis, immunomodulation and stiffness by secreting growth factors,
cytokines, exosomes and ECM proteins; therefore, CAFs have long
been considered a putative target for therapy in CCA5,48,49,51. However,
therapeutic targeting of CAFs in other tumour types has thus far failed
to improve patient outcomes, highlighting the need for a more metic-
ulous characterization of these cells52. Indeed, despite their overall
tumour-promoting role in CCA5,51,53, specific CAF mediators have now
been shown to exert tumour-promoting or tumour-restricting effects5,
adding more complexity to an already intricate picture.
CAF heterogeneity
CAFs are heterogeneous in their origins, transcriptomes and functions
(Fig. 2), as observed in several tumour types46,48,54,55. Mainly originating
from resident fibroblasts in the liver, CAFs in the CCA TIME demonstrate
considerable plasticity; for example, becoming activated in response
to the dynamic microenvironment during cholangiocarcinogenesis5,51.
Classically identified based on expression of α-smooth muscle actin
(α-SMA), CAFs are also characterized by expression of collagen type I
α1 chain (COL1A1), fibroblast activation protein, platelet-derived
growth factor receptor-α (PDGFRα) and PDGFRβ, among other pro-
teins5,26,52,54,56–59. Heterogeneity in CAF biomarkers has been confirmed
by data from both bulk RNA-seq and scRNA-seq transcriptomic stud-
ies, which also outline the coexistence of transcriptomically diverse
CAF subtypes in the TIME of CCA5,57,58. Despite the lack of a common
nomenclature, the presence of specific CAF subtypes enriched in genes
and pathways related to either a myofibroblastic or an inflammatory
phenotype (myCAFs and iCAFs, respectively) has been confirmed in
all such studies5,57,58. Moreover, the identification of intermediate CAF
populations arising from the same progenitor cell points towards the
existence of transient rather than static CAF subtypes, thus linking
CAF heterogeneity to CAF plasticity5. Despite the abundant evidence
of the overall tumour-promoting role of CAFs in CCA5,51,53, specific CAF
mediators such as COL1A1 have been shown to restrain rather than
support tumorigenesis5,56,60, thus challenging the historical paradigm
and highlighting the need to further investigate the functionality of
specific CAF subtypes.
Therapeutic opportunities
New therapeutic strategies are urgently needed to improve outcomes
in patients with CCA, and CAFs are considered an attractive target
for therapy because they actively participate in cholangiocarcino-
genesis3,27,46,49,59. With the emerging evidence of CAF heterogeneity,
however, targeting these cells becomes more challenging and makes
strategies aimed at their global targeting infeasible51. As evidenced
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Other
HSC
PF
Cell of origin
vCAF
CAF heterogeneity
iCAF
Subtype
myCAF
apCAF
Fig. 2 | Different shades of CAF heterogeneity in CCA. Cholangiocarcinoma
(CCA) is a highly desmoplastic tumour type characterized by a rich stroma
with an abundance of fibroblasts and their molecular products. These cancer-
associated fibroblasts (CAFs) are heterogeneous in several aspects including
their cell of origin, mainly arising from hepatic stellate cells (HSCs) and
portal fibroblasts (PFs). Moreover, transcriptomically diverse CAF subtypes
have been described to coexist in the same tumour and include vascular
by data from studies reported in the past 2 years, interfering with the
cancer cell–CAF crosstalk and the development of dual therapies
aimed at targeting both CAFs and cancer cells seem to be the most
promising therapeutic strategy5,56,57,60. Mediators of this direct cross-
talk that promote tumour growth include hyaluronan produced by
myCAFs and hepatocyte growth factor (HGF) secreted by iCAFs, which
can stimulate cancer cells via various hyaluronan receptors and MET,
respectively5,56. Nevertheless, myCAFs also secrete type I collagen that
can counteract these tumour-promoting effects5, as shown through
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TME
Crosstalk
Tumour
restriction
Function
Tumour
promotion
CAFs (vCAF), inflammatory CAFs (iCAF), myofibroblastic CAFs (myCAF)
and antigen-presenting CAFs (apCAF). CAF heterogeneity is also reflected
in their functionality, with evidence for subtypes with tumour-promoting
and/or tumour-restricting activities. Furthermore, diverse CAF subtypes are
likely to interact differentially with tumour cells and other cells in the tumour
microenvironment (TME) during tumorigenesis.
conditional deletion of Col1a1 in this cell type in mouse models of other
desmoplastic cancers such as pancreatic ductal adenocarcinoma60,
probably by forming a physical barrier that mechanically restrains
tumour invasion56. These opposing effects highlight the complex role
of CAFs in the TIME; a comprehensive understanding of these dual
effects would guide the development of more effective therapeutic
strategies. For example, therapeutic strategies that target tumour-
promoting CAF mediators (such as HGF) while maintaining the effect
of tumour-suppressive mediators (such as type I collagen) have the
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potential to transform CAFs from a pro-tumour to an antitumour cell
population. Furthermore, stratification of CCAs based on patient-
specific mutational profiles and TIME characteristics57 might provide
new insights to advance towards precision medicine. Therefore, a bet-
ter understanding of CAF heterogeneity and plasticity is needed to
develop new therapeutic approaches aimed at targeting CCA taking
into consideration the complexity of its TIME.
Molecular diagnosis using blood and bile
Clinical gaps exists in the early diagnosis of CCA as well as the moni-
toring of disease progression and treatment responses. Utilization
of blood-based liquid biopsy assays has shown promise in detecting
multiple types of early stage cancers61,62. Among various classes of
liquid biopsy, circulating tumour DNA (ctDNA), a fraction of cfDNA
originating from tumour cells, has been studied most extensively
for early cancer detection. Indeed, ctDNA in the blood might serve
as a diagnostic marker for CCA6,63. A proof-of-concept retrospective
study published in 2021 investigated a panel of ctDNA methyla­
tion markers for the detection of CCA specifically6. The methylated
DNA markers were identified as differentially methylated regions in
frozen CCA specimens versus matched adjacent benign biliary epithelia
and liver parenchyma tissues, and a total of nine markers were selected
from this tissue comparison6. Subsequently, this panel of methyl-
ated DNA markers was blindly tested in plasma cfDNA samples from
54 patients with pCCA and five with dCCA as well as from control groups
comprising patients with primary sclerosing cholangitis or individuals
without known liver disease (n = 22 and 95, respectively)6. The cfDNA
methylation panel had a sensitivity of 76% for the detection of CCA at
a specificity of 94%6. The panel correctly identified 64% of patients
with CCAs amenable to transplantation or surgical resection and 63%
of CCAs among patients with low serum CA19‐9 levels (≤100 U/ml)6,
highlighting the potential utility of ctDNA methylation assays for the
detection of early stage CCA. In addition, methylation of OPCML and
HOXD9 in cfDNA was assessed in a cohort of 40 patients and compared
with a disease control group comprising patients with non-malignant
biliary diseases such as cholelithiasis63. The combination of OPCML and
HOXD9 markers had a sensitivity and specificity of 62.5% and 100%,
respectively, for the diagnosis of CCA63. These findings require prospec-
tive validation in larger cohorts before methylated ctDNA markers can
be used for routine clinical care.
Genetic and epigenetic alterations detected in cfDNA are strongly
correlated with those present in tumour tissue7,64; therefore, tumour-
specific somatic mutations and epigenetic changes in plasma ctDNA
could potentially be utilized for minimally invasive longitudinal moni-
toring of dynamic changes in tumour biology and surveillance for
disease progression. In a multicentre retrospective analysis of 138
blood-derived cfDNA samples from 124 patients with CCA (70% of
whom had iCCA) using a 73-gene panel, 105 samples (76%) had one
or more detectable genetic alterations after excluding variants of
unknown significance, and 76 samples (55%) had therapeutically
relevant alterations, including BRAF mutations, ERBB2 (also known
as HER2) amplifications, FGFR2 fusions or mutations and IDH1 muta-
tions65. Thus, ctDNA could be a valuable resource for tumour molecular
profiling, especially when obtaining tumour tissue samples is techni-
cally challenging or unsafe, which is a major challenge in managing
CCA. In addition, ctDNA can be used to monitor response to chemo-
therapy and targeted therapy. A proof-of-concept study of serial plasma
cfDNA testing in eight patients with pancreaticobiliary cancers demon-
strated that changes in cfDNA mutant allele fraction correlate well with
Nature Reviews Clinical Oncology | Volume 20 | July 2023 | 470–486
changes in CA19-9 levels (Pearson’s r = 0.69 for interval slopes, r = 0.93
for interval differences), suggesting that ctDNA levels reflect changes in
disease burden over time during treatment7. Furthermore, longitudinal
profiling of ctDNA can be performed to track the emergence of resist-
ance to chemotherapy and, therefore, potentially facilitate the timely
use of second-line or third-line treatments for CCA7,64. Thus, deter-
mination of cancer-derived cfDNAs present in blood is a promising
and emerging technology for the management of patients with CCAs.
Confirmation of malignant biliary stricture is another major clini-
cal challenge in patients with indeterminate biliary strictures detected
using non-invasive imaging. The diagnostic work-up in these patients
involves endoscopic retrograde cholangiopancreatography (ERCP),
but the sensitivity of traditional methods such as ERCP-guided brush
cytology or biopsy sampling for the detection of malignant biliary
stricture is <40%66,67. To address this diagnostic dilemma, molecu-
lar characterization of biliary brush specimens and/or bile has been
evaluated as a tool for the diagnosis of malignancy. Fluorescence in situ
hybridization (FISH) analysis of biliary brush specimens for chromo-
some 1q21, 7p12, 8q24 and 9p21 aberrations was found to improve the
accuracy in diagnosing malignant biliary stricture, achieving 65%
sensitivity and a specificity of 93%67. Moreover, somatic KRAS mutations
and/or loss-of-heterozygosity alterations across ten tumour-suppressor
genes detected in DNA isolated from biliary brush specimens have been
shown to be excellent diagnostic biomarkers for malignant biliary
strictures68. In this prospective study involving 100 patients with bil-
iary strictures (41% with malignancy), routine FISH identified nine of
28 malignancies not detected on cytology analysis; mutation profil-
ing of cell-free supernatant fluid of the brush specimen identified an
additional eight malignancies not detected by FISH, increasing the
overall sensitivity to 51% versus 32% with cytology alone, whilst main-
taining 100% specificity68. These data highlight the complementary
role of these diagnostic assays. Considering the rapid evolution of next-
generation sequencing (NGS) capacity, a single-centre prospective
study in 252 patients with biliary stricture utilized BiliSeq, a targeted
NGS panel encompassing 28 genes, to screen for mutations in biliary
brush cytology samples with or without biliary biopsy specimens;
the assay had good performance for the detection of CCA with 73%
sensitivity and 100% specificity69. Notably, BiliSeq had a sensitivity of
83% in patients with primary sclerosing cholangitis69. For comparison,
the sensitivity and specificity of elevated serum CA19-9 alone were 76%
and 69%, respectively, and for pathological evaluation alone were
48% and 99%69. In another prospective study, NGS-based mutational
analysis of cfDNA from ERCP-derived bile samples using a 52-gene panel
had a sensitivity of 96.4% and a specificity of 69.2% for the detection of
CCA in 68 patients with suspicious biliary strictures70.
Altered DNA methylation markers in biliary brush specimens and/or
bile samples from patients with indeterminate biliary strictures might
also improve the diagnosis of CCA. The first proof-of-concept case–
control study in patients with CCA (n = 15 and 34 in the training and
validation cohorts, respectively) and control patients with primary
sclerosing cholangitis (n = 20 and 34) reported that a panel of four
methylation markers (in CDO1, CNRIP1, SEPT9 and VIM) measured
in DNA from biliary brush specimens had a sensitivity of 85% and a
specificity of 98% for the detection of CCA (area under the receiver
operating characteristic curve (AUC) 0.944)71. Several smaller
case–control studies have shown the outstanding performance of
DNA methylation biomarkers (for example, at loci associated with
EMX1 or HOXD8) in biliary brush and/or bile samples, with AUC val-
ues of 0.98–1 for the detection of malignant biliary strictures6,72.
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Similarly, profiling of microRNAs in bile samples has been investigated,
with promising results for the detection of CCA (AUC 0.652, 0.730,
0.765, 0.975 and 0.975 for miR-92a-3p, miR-30d-5p, miR-944, miR-9
and miR-145*, respectively)73,74.
The data from these initial biomarker studies have revealed the
great promise of ctDNA as a novel biomarker for CCA detection. We
anticipate that such liquid biopsy assays will further improve the diag-
nosis of CCA in routine clinical practice once larger-scale external
validation studies are completed in the near future. Given that compre-
hensive molecular profiling is recommended in the routine clinical care
of patients with advanced-stage CCA, ctDNA analysis might also serve
as a minimally invasive test for the selection of molecularly targeted
treatments. Plasma ctDNA will be particularly helpful in identifying
patients with CCAs harbouring IDH1 mutations or FGFR2 fusions, given
the availability of approved therapies predicated on these alterations65.
In an NGS-based analysis involving 1,671 patients with advanced-stage
CCA, genetic alterations in cfDNA were detected in samples from 84%,
with targetable alterations in cfDNA detected in samples from 44%75.
The concordance between cfDNA and tumour tissue analysis for the
detection of IDH1 and BRAFV600E mutations was 87% and 100%, respec-
tively, but was only 18% for FGFR2 fusions75. Although molecular analy-
ses of blood, biliary brush and/or bile specimens can facilitate the
implementation of precision medicine in patients with CCA, important
challenges continue to limit widespread clinical use of such assays.
First, numerous methods can be used to detect methylation markers
or mutations in cfDNA, with substantial variation in sample type (for
example, biliary brush cytology versus cell-free supernatant fluid
versus bile), handling and processing, and analysis. Standardized
ctDNA assay protocols that can capture the full spectrum of muta-
tion and methylation with high sensitivity and specificity need to be
developed and validated in order to ensure robust and generalizable
results. Second, most current supporting evidence comes from small-
cohort, single-centre, case–control studies. Given the low incidence of
CCA, these issues necessitate large-scale, collaborative, multicentre
prospective studies using standardized protocols.
Emerging molecular classifications of CCA
The prevalence of molecular profiling has enabled the definition of
transcriptome-based classes of iCCA and pCCA76–78. Importantly, the
molecular subclasses might predict patient outcomes or response to
certain therapeutic approaches. For example, a genomic and tran-
scriptomic characterization of 104 surgically resected iCCA speci-
mens revealed two distinct tumour classes associated with different
clinical outcomes and with the absence or presence of mutations in
KRAS or BRAF76. Specifically, the 5-year OS in 51 patients with ‘cluster 1’
class tumours according to a transcriptomic classifier based on 238
significantly differentially expressed genes was 72% compared with
30% in 53 patients with cluster 2 tumours (P < 0.0007)76. Patients
with cluster 2 tumours also had a shorter median time to recurrence
(13.7 ± 6.3 months versus 22.7 ± 18.1 months; P = 0.001)76. Integration
of KRAS/BRAF mutational status with the 238-gene classifier grouped
all 18 evaluable patients with such mutations into the poor prognosis
cluster 2 (ref. 76). Integrative molecular analyses have also been applied
for the detection of biological classes of CCA with differential activa-
tion of certain signalling pathways. One such analysis of 149 iCCAs
defined two principal tumour classes: an inflammation class (38%)
and a proliferation class (62%)78. Features of the inflammation class
included activation of inflammatory signalling pathways, overexpres-
sion of cytokines and activation of STAT3, whereas the proliferation
Nature Reviews Clinical Oncology | Volume 20 | July 2023 | 470–486
class was characterized by activation of oncogenic signalling pathways,
KRAS/BRAF mutations, and gene expression signatures previously asso-
ciated with poor outcomes in patients with hepatocellular carcinoma78.
Patients with proliferation class iCCAs had significantly worse OS than
patients with inflammation class tumours (median 24.3 months versus
47.2 months; P = 0.048)78. Similarly, an integrated genomic analysis of
pCCA and dCCA tumour specimens (n = 189) enabled the definition
of four distinct classes: metabolic, proliferation, mesenchymal and
immune77. Tumours of the metabolic class (comprising 19% of cases)
had a hepatocyte-like phenotype with enrichment of genes related to
bile acid metabolism77. dCCAs were more likely to be categorized into
the proliferation class (accounting for 23% of tumours overall), which
was defined by mTOR signalling, HER2 alterations and enrichment for
MYC targets77. Patients classified in the mesenchymal class (47%) had
unfavourable OS and enrichment of gene signatures associated with
epithelial-to-mesenchymal transition77. The immune class (11%) was
characterized by high levels of lymphocyte infiltration and PD-1/PD-L1
expression, as well as other transcriptomic features associated with
increased responsiveness to ICI in other tumour types77.
The increasing emphasis in oncology on immunotherapeutic
approaches has highlighted the integral role of the TIME and the
potential clinical significance of immune-based classifications of CCA.
A TIME-based classification developed using transcriptomics from a
training set comprising 198 iCCA specimens identified four immune
subclasses associated with distinct immune escape mechanisms and
patient outcomes: immune-desert, immunogenomic, myeloid and mes-
enchymal79. This classification was validated using an independent set
of 368 iCCAs and through immunohistochemical analysis of a further
64 iCCA samples79. In alignment with the concept that the CCA TIME is
‘immune cold’, the dominant subclass (present in approximately 45% of
patients overall) was the immune-desert subset characterized by low
expression of TIME gene signatures79 (Table 1). By contrast, the immuno­
genomic subclass was enriched for infiltration of adaptive and innate
immune cells and activation of inflammatory and immune-checkpoint
pathways, and was associated with the most favourable patient out-
comes79. The myeloid subset featured enrichment of monocyte-derived
and myeloid gene signatures, whereas the mesenchymal subclass
was enrichment for fibroblast gene signatures79. Similarly, a Stroma,
Tumour and Immune Microenvironment (STIM) classification of iCCA,
which as its name implies integrates stromal, tumour and immune
microenvironmental elements, categorized the preponderance of
patients into non-inflamed tumour classes (65%)57. Of the five STIM
classes of iCCA identified (Table 1), two inflamed classes were defined as
‘immune classical’ (accounting for 10% of patients) and ‘inflammatory
stroma’ (~25%), with the latter characterized by a rich stroma (extensive
desmoplasia), T cell exhaustion and KRAS mutations57. The three non-
inflamed classes are: (1) the ‘desert-like’ class (20%) with a paucity of
immune cells but enrichment of Treg cells; (2) the ‘hepatic stem-like’
class (35%) with abundant M2-like macrophages and enrichment for
IDH and BAP1 mutations and FGFR2 fusions; and (3) the ‘tumour clas-
sical’ class (10%) characterized by cell cycle pathway activation and
associated with unfavourable patient outcomes57. Although these
classifications assist in the broad categorization of CCA subtypes and
support the notion that CCAs typically have an immunosuppressive
TIME, their clinical utility is currently unclear. Prospective validation
of these classifications is needed before they can be used in routine
patient care. For example, clinical trials stratifying patients based on
these classifications with correlation to particular treatments would
help to clarify their potential utility in the management of CCA.
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Table 1 | Immune classifications of iCCA based on RNA-sequencing data

Subclass Proportion of iCCAs (%) Key features Prognostic association

(median OS, months)

Classification based on immune gene expression signatures79

Immune-desert 46–48 TME signatures with weak expression of immune and myofibroblast 42
signatures
Immunogenomic 9–13 Signatures of recruited innate immune cells, adaptive immune cells and 73
activated fibroblasts
Activation of inflammatory pathways
Myeloid 13–19 Strong expression of monocyte-derived and/or other myeloid signatures 25
Low expression of lymphoid signatures
Mesenchymal 22–28 Strong expression of fibroblast signatures 19
Stroma, Tumour and Immune Microenvironment (STIM) classification 57

Immune classical ~10 High immune infiltration (63%) –a

Inflammatory stroma
Hepatic stem-like
Tumour classical
Desert-like
ECM, extracellular matrix; iCCA, intrahepatic cholangiocarcinoma; OS, overall survival; TME, tumour microenvironment. aIn a multivariate analysis, the STIM classes were not independent
predictors of outcome.
Moderate stromal infiltration (27%)
~25 Moderate immune infiltration (43%) –
High stromal infiltration (50%)
Abundant desmoplastic reaction and ECM deposition
High stiffness
Activated inflammatory stroma
T cell exhaustion
~35 Low immune infiltration (28%) –
Low stromal infiltration (17%)
Abundant tumour-promoting macrophages
~10 Low immune infiltration (22%) –
Low stromal infiltration (12%)
Activation of cell cycle pathways
~20 Low immune infiltration (22%) –
Low stromal infiltration (11%)
Regulatory T cell enrichment

Advances in the treatment of CCA
Given that the objective of this Review is to provide an overview of perti-
nent clinical updates since our last Review in the journal4, here we focus
on progress made over the past 5 years in systemic and non-systemic
therapeutic strategies for CCA. Locoregional therapies including radio-
therapy, transarterial chemoembolization and radioembolization
were highlighted in our prior Review4. Since then, no major advances
in locoregional treatments for CCA have been made, and thus such
therapies are not included in this update.
Molecularly targeted therapies
Several high-throughput genomic sequencing analyses have eluci-
dated the distinct mutational landscapes of iCCA, pCCA and dCCA, thus
revealing differences in biology between these anatomical subtypes
of the disease80–84. Actionable alterations such as FGFR2 fusions and
IDH1 mutations occur almost exclusively in iCCAs, whereas pCCAs
and dCCAs more commonly harbour HER2 amplifications and KRAS
mutations80–84. Mutation frequencies among CCAs vary geographi-
cally and by aetiology, with Asian populations having lower fre-
quencies of IDH1 mutations than non-Asian populations, and liver
fluke-associated CCAs having a lower prevalence of IDH1 mutations
and a higher prevalence of TP53 mutations than those with other
aetiologies85–87.
The identification of actionable genetic alterations in approxi-
mately 40–50% of iCCAs and 15–20% of pCCAs and dCCAs88 has trans-
formed the therapeutic landscape for patients with advanced-stage CCA.
Mutational profiling is usually performed on tumour tissue specimens,
but given failure rates of up to 27% in CCA biopsies, liquid biopsy
analysis of ctDNA might serve as an additional tool for identifying
therapeutic targets, as described above64,65,89. Genetic alterations
that define the eligibility of patients with CCA for molecularly tar-
geted therapies based on FDA approvals or recommendations in the
National Comprehensive Cancer Network (NCCN) guidelines are
discussed below90.
FGFR2 fusions and other rearrangements. FGFR signalling has key
roles in various physiological processes and drives cell proliferation,
growth and survival, thus making this pathway susceptible to hijack by
cancer cells91,92. FGFR2 fusions and other rearrangements, which were
first reported in CCAs in 2013 and subsequently found to be present
in 13–14% of iCCAs93–95, constitute one of the most highly actionable
alterations in this disease. The first two molecularly targeted therapies
to gain regulatory approval for the treatment of CCA were the ATP-
competitive, reversible FGFR inhibitors pemigatinib and infigratinib13,14.
These oral small-molecule inhibitors demonstrated overall response
rates (ORRs) of 35.5% and 23.1%, respectively, in single-arm phase II

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trials involving patients with previously treated advanced-stage CCAs
harbouring FGFR2 fusions or rearrangements10,11 (Table 2), resulting
in FDA Accelerated Approval for this indication in April 2020 and May
2021, respectively13,14. However, the development of infigratinib has
been halted according to a manufacturer’s press release96. A third selec-
tive FGFR inhibitor, futibatinib, binds covalently and irreversibly to the
P-loop cysteine residue in the FGFR kinase domain and achieved an ORR
of 41.7%, with responses lasting a median of 9.7 months, in a similar
phase II study involving patients with previously treated advanced-stage
FGFR2-rearranged iCCA12. These data led to FDA Accelerated Approval of
futibatinib for this indication in September 2022 (ref. 15). The safety and
efficacy of derazantinib, an FGFR1–3 inhibitor, has also been assessed
in a phase II trial involving 103 patients with advanced-stage CCA har-
bouring an FGFR2 fusion who had received at least one line of prior
treatment97. In this study, derazantinib was associated with an ORR of
21.4%, a disease control rate of 74.8% and a median OS of 15.5 months97.
Acquired resistance to FGFR inhibitors limits the effectiveness
of these agents, which are consistently associated with median pro-
gression-free survival (PFS) durations of 7–9 months10–12,97 (Table 2).
Polyclonal secondary mutations in the FGFR2 kinase domain are a
common resistance mechanism98–101. Futibatinib has shown potent
preclinical activity against many of these mutations and has shown
clinical activity after progression of CCA on treatment with reversible
FGFR inhibitors101–103. Additional next-generation inhibitors, such as the
FGFR2-selective inhibitor RLY-4008 (NCT04526106) and the multiki-
nase inhibitor tinengotinib (also known as TT-00420; NCT04919642),
are currently under investigation to assess their efficacy in overcoming
resistance to prior FGFR inhibitors104–106. RLY-4008 is a highly selective
FGFR2 inhibitor that has activity against primary FGFR2 alterations
and common resistance mutations106. In a first-in-human study involv-
ing 35 patients with FGFR2-altered CCA, this agent had encouraging
clinical activity, with >10% tumour shrinkage observed in nine (56%)
of 16 patients with CCA previous treated with an FGFR inhibitor106.
Other FGFR inhibitors under investigation in patients with CCA
include the pan-FGFR inhibitors erdafitinib (NCT02699606) and KIN-3248
(which has activity against FGFR2 gatekeeper, molecular brake and activa-
tion loop mutations105; NCT05242822), the multikinase inhibitor derazan-
tinib (NCT03230318), the bivalent FGFR1–3 inhibitor tasurgratinib (E7090,
which blocks FGF–FGFR interactions; NCT04238715), and the FGFR1–3
inhibitor HMPL-453 (NCT04353375). Moreover, phase III trials comparing
the approved FGFR inhibitors against frontline gemcitabine and cisplatin
chemotherapy are currently ongoing (pemigatinib (NCT03656536),
infigratinib (NCT03773302) and futibatinib (NCT04093362)), as are early
phase trials of combination therapies including FGFR inhibitors (gemcit-
abine and cisplatin plus pemigatinib or ivosidenib (NCT04088188) and
derazantinib plus atezolizumab (NCT05174650)).
IDH1 mutations. R132-mutant IDH1 acquires a neomorphic activity
that converts α-ketoglutarate to 2-hydroxyglutarate, an oncome-
tabolite that inhibits histone and DNA demethylases and results in
widespread epigenetic alterations and oncogenesis107. The frequency
of IDH1 mutations in CCAs varies widely across studies and was found to
be 13.1% in iCCAs and 0.8% in pCCAs and dCCAs in a systematic review of
45 studies85. Ivosidenib, an orally administered small-molecule inhibi-
tor of mutant IDH1, gained FDA approval for the treatment of chem-
orefractory IDH1-mutated CCA in August 2021 based on the results of

Table 2 | Efficacy of molecularly targeted therapies in patients with CCA

Agent Study Number of ORR (%) DCR (%) Median PFS (months) Median OS (months) Ref.
phase patientsa

FGFR inhibitors
Pemigatinibb II 107 35.5 82.2 6.9 NA 10
Infigratinibb
II 108 23.1 84.3 7.3 12.2 11
Futibatinibb II 103 41.7 82.5 9.0 21.7 12
Derazantinib I/II 103 21.4 74.8 8.0 15.5 97
IDH inhibitors
Ivosidenibb III 124 2.4 53.2 2.7 10.8 16
BRAF inhibitors
Dabrafenib plus trametinib (MEK inhibitor)b,c II 43 46.5 85.4 9.0 14.0 111
Vemurafenib c
II 9 33.3 NA NA NA 113
HER2-targeted agents
Trastuzumab plus pertuzumab II 39 23.1 51.3 4.0 10.9 115
(monoclonal antibodies)c,d
Trastuzumab deruxtecan (antibody–drug II 24 36.4 81.8 4.4 7.1 116
conjugate)c
Neratinib (pan-ErbB tyrosine kinase inhibitor)c II 25 (11 with 16 28 2.8 (1.4 in CCA subgroup) 5.4 (5.4 in CCA subgroup) 118
CCA)
Zanidatamab (bispecific antibody)c I 17 47 65 NA NA 119
CCA, cholangiocarcinoma; DCR, disease control rate; NA, not available; ORR, objective response rate; PFS, progression-free survival. aNumber of patients with target molecular aberrations:
FGFR2 fusions and/or rearrangements for FGFR inhibitors, IDH1 R132 mutations for IDH inhibitors; BRAFV600E mutations for BRAF inhibitors; and ERBB2 (also known as HER2) amplification and/or
overexpression for HER2-targeted therapies. bFDA approved for use in patients with previously treated advanced-stage CCAs harbouring the target oncogenic alteration. cData for these agents
come from patients with CCAs as well as other biliary tract cancers. dListed in National Comprehensive Cancer Network guidelines as subsequent-line therapy for patients with advanced-stage
CCA following disease progression on recommended initial treatements90.

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a phase III trial showing an improvement in PFS over placebo (median
2.7 versus 1.4 months; HR 0.37, 95% CI 0.25–0.54; P < 0.0001)16,17
(Table 2). OS was not significantly improved (HR 0.79, 95% CI 0.56–1.12;
P = 0.093); however, the fact that 70% of patients in the placebo
group crossed over to receive ivosidenib following disease progres-
sion is likely to have confounded this result16. Additional IDH1 inhib­
itors under investigation in patients with CCA include olutasidenib
(FT-2102; NCT03684811), LY3410738 (NCT04521686) and HMPL-306
(NCT04762602). Given that IDH1 mutations can lead to deficiencies in
the repair of double-stranded DNA damage108,109, several ongoing trials
of poly(ADP-ribose) polymerase (PARP) inhibitors are also including
patients with IDH1-mutant CCA (olaparib (NCT03212274). olaparib
plus the ATR inhibitor ceralasertib (NCT03878095) and olaparib plus
durvalumab (NCT03991832)).
BRAFV600E mutations. BRAFV600E mutations occur in up to 5% of bili­
ary tract cancers (BTCs), primarily in iCCAs110. Treatment with the
BRAF inhibitor dabrafenib in combination with the MEK inhibitor
trametinib led to an ORR of 47% and a median PFS of 9.0 months in
the BTC cohort of the phase II ROAR basket trial111 (Table 2). In June
2022, this combination gained FDA approval for use in patients with
previously treated non-colorectal solid tumours, thus including CCAs,
harbouring a BRAFV600E mutation and no satisfactory alternative treat-
ment options, based on data from ROAR and several other trials112. Data
on BRAF inhibitors as monotherapy for BTCs are limited, although
vemurafenib induced partial responses in three of nine patients with
BRAFV600E-mutant BTCs in another basket trial113.
HER2 alterations. HER2 belongs to the ErbB family of receptor
tyrosine kinases and is overexpressed more frequently in pCCAs and
dCCAs (17.4%) and gallbladder cancers (19.1%) than in iCCAs (4.8%)114.
The combination of two anti-HER2 antibodies, trastuzumab and
pertuzumab, achieved an ORR of 23% and a median PFS of 4.0 months
in 39 patients with HER2-amplified and/or overexpressing BTCs in the
phase IIa MyPathway basket study115 (Table 2), gaining a listing in
the NCCN guidelines as a recommended therapy for previously treated
HER2-positive BTCs90. The antibody–drug conjugate trastuzumab
deruxtecan demonstrated an ORR of 36.4% (including two complete
responses (CRs)), a median PFS of 4.4 months and a median OS of
7.1 months in a similar phase II trial population (n = 22)116, and a partial
response was also seen in one of eight patients with HER2-low disease.
Trastuzumab deruxtecan is being further explored in patients with
BTCs in an ongoing phase II trial (NCT04482309). Another phase II
trial evaluated the efficacy of combination folinic acid, 5-fluorouracil
and oxaliplatin (FOLFOX) chemotherapy plus trastuzumab in
the second-line setting in 34 patients with HER2-positive BTCs; the
ORR was 29.4%, median PFS was 5.1 months and median OS was
10.7 months117.
Additionally, the oral, irreversible, pan-ErbB tyrosine kinase
inhibitor (TKI) neratinib has been evaluated in patients with previ-
ously treated HER2-mutant CCA (as opposed to merely HER2-posi-
tive disease) as part of the SUMMIT basket trial118. Results from the
phase II BTC cohort of this trial, which included 11 patients with CCAs,
demonstrated an ORR of 16% in all 25 patients evaluated, with a median
PFS of 2.8 months and median OS of 5.4 months (1.4 months and
5.4 months, respectively, in the CCA subgroup)118 (Table 2).
The novel bispecific anti-HER2 antibody zanidatamab, which
targets the same epitopes as trastuzumab and pertuzumab, achieved
an interim ORR of 47% and a median response duration of 6.6 months
Nature Reviews Clinical Oncology | Volume 20 | July 2023 | 470–486
in 17 patients with advanced-stage HER2-positive BTCs119 (Table 2),
and this agent is being further evaluated in studies including patients
with CCAs and other BTCs (NCT04466891 and NCT03929666). Other
therapeutic strategies currently being evaluated in trials involving
patients with HER2-overexpressing CCAs include the combination of
trastuzumab and the HER2 TKI tucatinib (NCT04579380) and novel
antibody–drug conjugates (A166 (NCT03602079) and zanidatamab
zovodotin (NCT03821233)).
NTRK fusions. NTRK fusions occur in approximately 0.2% of CCAs
and are highly actionable alterations in solid tumours120. These NTRK
fusions are therapeutically actionable using the TRK inhibitors laro-
trectinib and entrectinib, which received FDA approval agnostic of
tumour histology based on efficacy across cancer types (summary ORR
of 75% with larotrectinib and 57% with entrectinib); partial responses
were observed in two of three patients with CCA included in the pivotal
trials of these agents121–124.
RET fusions. RET fusions are also very rare in CCAs, with a prevalence
of 0.15% in iCCA and 0.11% in pCCA/dCCA125. The phase I/II ARROW
trial evaluated the potent, selective of RET inhibitor pralsetinib in
29 patients with advanced-stage RET-altered solid tumours126. Of the
three patients with CCA included in this basket study cohort, two had a
partial response and one had stable disease126, gaining pralsetinib a list-
ing on the NCCN guidelines90. The safety and efficacy of selpercatinib,
another highly selective RET inhibitor, are being evaluated in patients
with RET fusion-positive cancers, including two patients with CCA,
in the ongoing phase I/II LIBRETTO-001 basket trial127.
Immunotherapies
The role of ICI-based immunotherapy for the treatment of CCA has
changed drastically over the past few years128. It is important to differ-
entiate the role of immunotherapy for CCA according to two separate
scenarios129.
The first scenario is related to exploration of immunotherapies
in a tumour-agnostic manner, whereby selection of patients relies on
specific molecular alterations, regardless of the primary tumour site
or histology. In this regard, the ICI pembrolizumab is indicated for use
in patients harbouring CCAs with deficient mismatch repair (dMMR)
and/or high microsatellite instability (MSI-H)130–132. Pembrolizumab,
an anti-PD-1 antibody, had an ORR of 53% (21% CR rate) in a cohort of
86 patients with advanced-stage dMMR solid tumours; four patients
with CCA were included in this cohort and one had a CR, with the
other three having stable disease130. An updated analysis of the multi­
cohort phase II KEYNOTE-158 study of pembrolizumab in patients with
advanced-stage MSI-H/dMMR non-colorectal cancers included data
from 22 patients with CCA131. In the CCA cohort, pembrolizumab was
associated with an ORR of 40.8% (CR rate 13.5%), a median response
duration of 30.6 months, a median PFS of 4.2 months and median OS of
19.4 months, with a 3-year OS of 30.3%131. In addition, ICIs have notable
activity against cancers with a high tumour mutational burden (TMB).
Indeed, pembrolizumab has also been granted histology-agnostic
approval by the FDA for patients with a high TMB (≥10 mutations
per megabase)133, based on a reported ORR of 29% (CR rate 4%) in a
cohort of 102 patients with previously treated advanced-stage solid
tumours (not specified how many had CCA); responses were dura-
ble, lasting ≥12 months in 57% of patients and ≥24 months in 50%134.
Unfortunately, these tumour-agnostic approaches are applicable to
only a very limited proportion of patients with CCA, given that <5% of
479
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this patient population have dMMR/MSI-H or TMB-high tumours129.
Therefore, developing and applying immunotherapies in a way that
would enable a wider spectrum of patients to benefit is of substantial
importance.
Indeed, the second scenario is the development of immuno-
therapy in unselected populations of patients with advanced-stage
CCA. This approach is mainly based on translational research work
suggesting a potential role for immune-directed therapies in the
treatment of CCA and other BTCs, considering that markers of a pre-
existing antitumour T cell response are generally associated with a
favourable prognosis in patients with these cancers135–138. Hence, first
efforts in this regard were mainly focused on the use of monotherapy
approaches with ICIs. Unfortunately, this strategy had limited efficacy
in patients with BTCs, with an ORR of 5.8%, a median PFS of 2.0 months
and median OS of 7.4 months with single-agent pembrolizumab in the
phase II KEYNOTE-158 study28. Moreover, the efficacy was not clearly
better in patients with PD-L1-positive tumours (ORR 6.6% and 13.0%
in KEYNOTE-158 and KEYNOTE-028, respectively)28. Given these find-
ings, alternative approaches have been pursued, mainly in the form of
combining ICIs with cytotoxic chemotherapy.
Preliminary results from a retrospective study by Sun and col-
leagues139 suggested better outcomes with the addition of anti-PD-1
antibodies to chemotherapy (38 patients) than with anti-PD-1 anti-
bodies alone (20 patients) or chemotherapy alone (19 patients); the
median PFS durations were 5.1 months, 2.2 months and 2.4 months,
respectively, and the median OS was 14.9 months versus 4.1 months
versus 6.0 months. Additional phase II studies in patients with previ-
ously untreated advanced-stage BTCs supported this rationale140–142. In
the largest of these phase II studies, Oh and colleagues142 recruited 124
patients to three different treatment arms: (1) chemotherapy (gemcit-
abine plus cisplatin) followed by concurrent chemotherapy and dual ICI
therapy with the anti-PD-L1 antibody durvalumab and the anti-CTLA4
antibody tremelimumab from cycle 2 (30 patients); (2) concurrent
chemotherapy plus durvalumab from cycle 1 (47 patients); or (3) con-
current chemotherapy plus durvalumab and tremelimumab from
cycle 1 (47 patients). Whenever tremelimumab was administered, a
maximum of four cycles were given. The primary end point of the study
was ORR, which was highest in the arms in which ICIs were administered
from cycle 1 onwards (ORRs of 50%, 72% and 70% in arms 1, 2 and 3,
respectively); however, the median PFS was similar between arms
(12.8 months, 11.8 months and 12.3 months, respectively)142. In view
of a more favourable toxicity profile without compromised efficacy
in the arm without tremelimumab, the combination of gemcitabine,
cisplatin and durvalumab was selected for further assessment in the
phase III TOPAZ-1 trial.
In TOPAZ-1, 685 patients with treatment-naive advanced-stage
CCAs or gallbladder cancer were randomly assigned to receive gem-
citabine and cisplatin plus either durvalumab or placebo143. The
primary end point was OS, which was significantly improved with
durvalumab (median 12.8 months versus 11.5 months in the placebo
group; 24-month OS 24.9% versus 10.4%; HR 0.80, 95% CI 0.66–0.97;
P = 0.021)143. The durvalumab group also had improvements in PFS
(median 7.2 months versus 5.7 months; HR 0.75, 95% CI 0.63–0.89;
P = 0.001) and ORR (26.7% versus 18.7%; OR 1.60, 95% CI 1.11–2.31)143.
This improved activity was reported without additional toxicity (for
example, grade 3−4 adverse events in 75.7% versus 77.8% of patients)143,
and with a trend towards a longer time to deterioration in patient-
reported global health status according to EORTC QLQ C30 scores
favouring the durvalumab arm (HR 0.87, 95% CI 0.69–1.12; P = 0.279)144.
Nature Reviews Clinical Oncology | Volume 20 | July 2023 | 470–486
Interestingly, subgroup analyses did not reveal significant differences
in outcomes depending on PD-L1 expression143, primary tumour site145,
disease status (that is, initially unresectable versus recurrent)146 or
geographical area (Asian versus rest of the world)147. On the basis of
these results, the FDA approved the combination of gemcitabine, cispl-
atin and durvalumab in 2022 (ref. 148), and the latest NCCN guidelines
for hepatobiliary cancer (version 1.2022)90 recommend this regimen
as the preferred first-line treatment option for advanced-stage CCA.
Similarly, the KEYNOTE-966 trial, the largest phase III trial in patients
with CCA to date, evaluated the combination of chemotherapy and
ICI therapy in the first-line treatment of patients with unresectable,
locally advanced or metastatic CCA or gallbladder cancer149. In this
randomized, double-blind trial, 533 patients were allocated to receive
pembrolizumab plus gemcitabine and cisplatin and 536 patients to
receive placebo plus gemcitabine and cisplatin149. The primary end
point was median OS, which was 12.7 months in the pembrolizumab
plus gemcitabine and cisplatin group compared with 10.9 months in the
placebo group (HR 0.83, 95% CI 0.72–0.95; one-sided P = 0.0034)149. In
contrast to the TOPAZ-1 trial, maintenance gemcitabine was allowed
in both arms without a maximum duration while cisplatin was admin-
istered for a maximum of eight cycles149. This may have accounted for
the ORR being the same in both arms (29%)149. On the basis of these two
trials, the role of ICIs in the first-line treatment of advanced-stage CCA
has been firmly established.
Several other clinical trials of ICIs are ongoing in patients with
BTCs128. Beyond their addition to chemotherapy, combinations of
ICIs with TKIs have also been tested, albeit early results have been
mediocre. For example, a small-cohort phase II study found an ORR
of only 10% with the combination of lenvatinib plus pembrolizumab in
patients with previously treated advanced-stage BTCs150. Nevertheless,
other ongoing clinical trials are exploring this potential alternative,
chemotherapy-free ICI-based therapeutic strategy (NCT04211168).
Thus, the future of immunotherapy for CCA looks bright for the
first time. Efforts to identify predictive biomarkers for patient selection
and to understand the mechanisms of resistance will be paramount in
order to realize the full potential of ICIs and other immunotherapies.
Liver transplantation for iCCA
Transplant oncology is a developing field that merges the discip­lines
of organ transplantation and oncology151. iCCA is one of the para-
digms of transplant oncology, but remains a formal contraindication
for liver transplantation outside clinical trials in most jurisdictions.
Two distinct populations of patients with iCCA might benefit from
liver transplantation: (1) patients with decompensated cirrhosis who
have a liver mass with imaging characteristics that are not diagnostic
of hepatocellular carcinoma and are found to have iCCA following
biopsy sampling; and (2) those with multifocal and large iCCAs usually
occurring in otherwise healthy livers.
In the past 10 years, enthusiasm to incorporate iCCA as an indi-
cation for liver transplantation has increased after data from sev-
eral retrospective studies demonstrated excellent outcomes in
patients with cirrhosis and with ‘very early’ and ‘early’ iCCAs (defined
as single tumours ≤2 cm and ≤5 cm, respectively) who received a liver
transplant (Table 3). Most of these studies involved patients either
initially misdiagnosed with hepatocellular carcinoma or with an inci-
dental iCCA mass found on explant pathology. A prospective phase II
trial of liver transplantation in patients with cirrhosis and very early
iCCA (NCT02878473) is now underway (Table 3); however, accruing
patients has been challenging owing to the difficulty of listing such
480
Review article

Table 3 | Summary of key contemporary studies of liver transplantation in patients with iCCA

Study (year of Tumour size iCCAs discovered Patients OS RFS Recurrence rate Chemotherapy
publication) (n) incidentally/initially with treatment
misdiagnosed as HCC cirrhosis (n)
Retrospective studies in patients with incidental or misdiagnosed small iCCAs, mainly associated with cirrhosis
Sapisochin Single ≤2 cm 23 (79%)/6 (21%) 29 (100%) Overall: 79% at 1 year; NR Overall: 11% None
et al. (2014)156 (8) 61% at 3 years; 45% at at 1 year; 29% at
Multiple or 5 years. 3 years; 29% at
single >2 cm ≤2 cm tumour group: 5 years.
(21) 100% at 1 year; 73% at ≤2 cm tumour
3 years; 73% at 5 years. group: 0% at 1 year;
>2 cm tumour group: 71% 0% at 3 years;
at 1 year; 43% at 3 years; 0% at 5 years.
34% at 5 years >2 cm tumour
group: 26% at
1 year; 42% at
3 years; 42%
at 5 years
Sapisochin Single >2 cm 8 (24%)/25 (76%) 33 (100%) 1 year: 79% NR 1 year: 30% None
et al. (2016)157 or multiple 3 years: 50% 3 years: 47%
tumours of any
5 years: 45% 5 years: 61%
size (33)
Single ≤2 cm 7 (47%)/8 (53%) 15 (100%) 1 year: 93% NR 1 year: 7% None
(15) 3 years: 84% 3 years: 18%
5 years: 65% 5 years: 18%
Jung et al. Single ≤2 cm 1 (6%)/14 (88%) 12 (13%) 1 year: 81% (63%a) NR 1 year:56% (50%a) None
(2017)158 (4) 3 years: 52% (63%a) 3 years:56% (50%a)
Multiple ≤2 cm 5 years: 52% 5 years:78%
(2)
Single >2 cm
(10)
De Martin et al. Largest nodule 5 (10%)/44 (90%) 49 (100%) 1 year: 90% (88%b, 92%c) 1 year: 87% NR None
(2020)159 ≤5 cm (49; 24 3 years: 76% (65%b, 87%c) (81%b, 78%c)
patients with 3 years: 79%
5 years: 67% (65%b,
iCCA only (74%b, 69%c)
69%c)
combined with
5 years: 75%
25 patients
(74%b, 55%c)
with mixed
HCC–iCCA
for analyses)
Retrospective studies in patients with large multifocal iCCAs diagnosed prior to liver transplantation
Lunsford et al. Among 6 NA 1 (17%) 1 year: 100% 1 year: 50% 1 year: 50% Yes, neoadjuvant
(2018)160 patients: 3 years: 83.3% 3 years: 50% 3 years: 50% and adjuvant
median
5 years: 83.3% 5 years: 50% 5 years: 50%
number of
tumours 4
(IQR 3.0–5.8);
median
cumulative
diameter
10.5 cm (IQR
7.0–13.5 cm)

Ito et al. 22 of 31 NA 14 (45%) 1 year: 80% 5 years 42% NR Yes, neoadjuvant,

(2022)161 patients (71%) 3 years: 63% sometimes com-
had tumours bined with loco­
5 years: 49%
larger ≥5 cm regional therapy
5-year OS was 100% in (10 patients received
patients who received neoadjuvant loco­
both neoadjuvant chemo­ regional therapy
therapy and locoregional with or without
therapy, compared with neoadjuvant chemo-
77%, 57% and 41% at 1, 3 therapy); 11 patients
and 5 years, respectively received adjuvant
in those who did not or chemotherapy
received neoadjuvant
locoregional therapy
alone

Nature Reviews Clinical Oncology | Volume 20 | July 2023 | 470–486 481

Review article

Table 3 (continued) | Summary of key contemporary studies of liver transplantation in patients with iCCA

Study (year of Tumour size iCCAs discovered Patients OS RFS Recurrence rate Chemotherapy
publication) (n) incidentally/initially with treatment
misdiagnosed as HCC cirrhosis (n)

Retrospective studies in patients with large multifocal iCCAs diagnosed prior to liver transplantation (continued)
McMillan et al. Among 18 NA 6 (33%) 1 year: 100% 3 years: 52% 7 (38.9%); median Yes, neoadjuvant
(2022)152 patients: 3 years: 71% time to recurrence and adjuvant
median 11 months (range
5 years: 57%
number of 4–42 months)
tumours 2
(1–11); median
tumour size
10.4 cm
(2.5–19.9 cm)
Ongoing prospective clinical trials
University Single iCCA NA 100% NR (5-year OS is primary NR NR (secondary end NR
Health Network ≤2 cm with no end point) (secondary point)
Toronto phase II extrahepatic end point)
multicentre trial disease or
NCT02878473 vascular
(NA) invasion (target
of 30 patients
who are not
candidates
for tumour
resection and
have serum
CA19.9 levels
≤ 100 ng/ml)
Oslo University NA; NA NR NR (3-year OS is primary NR NR Patients must have
phase II histologically end point) (secondary stable disease
TESLA trial proven iCCA end point) after ≥6 months
with no of systemic
NCT04556214
extrahepatic chemotherapy
(NA)
disease, or locoregional
vascular treatment
invasion or
lymph node
involvement
(target of
15 patients
who are not
candidates
for tumour
resection)
University NA; NA NR NR (5-year OS is primary NR (5-year NR Patients must have
Health Network histologically end point; 1-year OS is RFS is stable disease or
Toronto phase II proven iCCA secondary end point) secondary tumour regression
single-centre with no end point) lasting ≥6 months
trial extrahepatic after systemic
disease, chemotherapy
NCT04195503
vascular or locoregional
(NA)
invasion or treatment
lymph node
involvement
(target of
10 patients
who are not
candidates
for tumour
resection
and have a
potential live
liver donor)
HCC, hepatocellular carcinoma; iCCA, intrahepatic cholangiocarcinoma; IQR, interquartile range; NA, not applicable; NR, not reported; OS, overall survival; RFS, recurrence-free survival.
a
Data for patients with iCCA alone (n = 8), as opposed to concurrent iCCA and HCC (n = 7) or mixed HCC–iCCA (n = 1). bData for patients with iCCA and mixed HCC–iCCA tumours >2 cm but
≤5 cm (n = 24). cData for patients with iCCA ≤2 cm and mixed HCC–iCCA tumours (n = 25).

Nature Reviews Clinical Oncology | Volume 20 | July 2023 | 470–486 482

Review article
patients for transplantation and finding an allograft. Before liver trans-
plantation can be recommended for such patients outside clinical
trials, several questions remain to be answered. First, do patients with a
known diagnosis of iCCA have similar outcomes to those in whom iCCA
was diagnosed incidentally? Second, should these patients undergo
neoadjuvant treatments? Third, should this transplant indication be
limited to single iCCAs of ≤2 cm or could this be expanded to those
with single larger tumours?
With advances in the understanding of iCCA biology and improve-
ments in patient management, the concept of considering liver trans-
plantation has also been revisited for patients with unresectable iCCA,
no extrahepatic disease and a sustained response to systemic and/or
local therapies18. The largest prospective study to date involved a series
of 65 patients referred for liver transplantation evaluation; 37 patients
met the criteria and were listed, although five patients were subse-
quently excluded owing to conversion to resectable disease with the
stipulated neoadjuvant chemotherapy, and 18 eventually received
a liver transplant152. The results of that study demonstrated a 5-year
OS of 57% and a 3-year disease-free survival of 52% after transplanta-
tion152. Several questions remain, and these results need to be externally
validated, although they are encouraging and will serve as a baseline in
future studies to identify the optimal candidates for liver transplanta-
tion153. To our knowledge, several centres are now considering liver
transplantation as an option for patients with unresectable locally
advanced iCCA who have a sustained response to systemic and/or local
therapies and no evidence of extrahepatic disease at any time point.
With the development of molecularly targeted therapies for iCCA and a
better understanding of mutations associated with a favourable prog-
nosis, such as FGFR genetic aberrations154, the proportion of patients
who might be eligible for liver transplantation in the future might
increase. When considering alternative treatments for these patients,
the options are extremely limited owing to very poor outcomes with
resection or hepatic artery infusion pump chemotherapy155.
In the next few years, more data on liver transplantation for iCCA
will be published and this treatment modality is expected to become
available to patients at many centres. Until then, liver transplantation
should be performed under strict research protocols with stringent
inclusion criteria.
Conclusions
As is evident from this update, many crucial scientific and clinical ques-
tions remain despite the recent progress in CCA research and manage-
ment. Although the TIME presents potential targets for the treatment
of CCA, the limited antitumour activity of ICIs in this disease highlights
the need for a more in-depth and fundamental understanding of the
immunosuppressive cell populations. Further information will also
be needed to stratify TIME-based subgroups for a precision therapy
approach, and perhaps some subtypes such as the immune-desert
tumours will prove difficult if not impossible to target effectively. Given
the heterogeneity of CAFs in CCAs, targeting this cell popu­lation is
also likely to prove more difficult than originally conceptualized.
Better diagnostic modalities are necessary for pCCA and perhaps the
emerging technology of measuring cfDNA and ctDNA will address this
problem; the use of such assays would also greatly facilitate monitor-
ing of disease activity following surgical resection or during systemic
therapy. Indeed, we are optimistic that these liquid biopsy assays will
achieve clinical utility in the management of CCA. Although an impor-
tant advance, targeted therapies for patients with FGFR2 fusions or IDH1
mutations are often met with intrinsic resistance or a short durability
Nature Reviews Clinical Oncology | Volume 20 | July 2023 | 470–486
of response owing to acquired resistance; combinatorial approaches
will need to be examined in model systems and patients in order to
improve outcomes. The use of neoadjuvant and adjuvant therapies in
combination with surgery and/or locoregional therapies to improve
outcomes is also an unmet need that warrants further studies. Finally,
selection of patients who will benefit from liver transplantation will
require national organ allocation systems to acknowledge patients
with iCCA as candidates for this procedure. We look forward to future
updates on CCA, which will hopefully report solutions to these unmet
needs in patients with this disease.
Published online: 15 May 2023
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Acknowledgements
The work of the authors is supported by the US National Institutes of Health (NIH)/National
Cancer Institute (NCI) grants SPORE P50 CA210964 (to S.I.I. and G.J.G.) and 1K08CA236874
(to S.I.I.). The work of S.A. is supported by a fellowship from “la Caixa” Foundation
Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. 2Department of Immunology, Mayo Clinic, Rochester, MN, USA.
1
3
Liver, Digestive System and Metabolism Research, Institut d’Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. 4Department of
Medicine, Mass General Cancer Center, Harvard Medical School, Boston, MA, USA. 5Department of Oncology, OncoHealth Institute, Fundación Jiménez
Díaz University Hospital, Madrid, Spain. 6Department of Medical Oncology, The Christie NHS Foundation, Manchester, UK. 7Division of Cancer Sciences,
University of Manchester, Manchester, UK. 8Ajmera Transplant Program and HPB Surgical Oncology, Toronto General Hospital, University of Toronto,
Toronto, Canada. 9Karsh Division of Gastroenterology and Hepatology, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center,
Los Angeles, CA, USA.
Nature Reviews Clinical Oncology | Volume 20 | July 2023 | 470–486
(ID 100010434) and by the European Union’s Horizon 2020 research and innovation
programme under the Marie Skłodowska-Curie grant agreement no. 847648. The work of
L.G. is supported by American Cancer Society Clinical Scientist Development Grant 134013‐
CSDG‐19‐163‐01‐TBG and NIH/NCI Gastrointestinal Cancer SPORE P50 CA127003. A.L. has
received funding from The Christie Charity and the European Union’s Horizon 2020 research
and innovation programme (grant no. 82551, ESCALON). J.D.Y. has received an American
College of Gastroenterology Junior Faculty Development Award and a U.S. Department of
Defense Peer Reviewed Cancer Research Program Career Development Award (CA 191051).
Author contributions
S.I.I., J.D.Y. and G.J.G. contributed substantially to discussion of the content and reviewed
and/or edited the manuscript before submission. All authors contributed to researching
data for the article and writing the manuscript.
Competing interests
S.I.I. serves as an adviser and consultant to AstraZeneca. L.G. has received research
funding (via her institution) from Adaptimmune, Bayer, Bristol Myers Squibb, Eisai, Eli Lilly,
Genentech, Incyte, Leap Therapeutics, Loxo Oncology, Macrogenics, Merck, Novartis,
Nucana, QED Therapeutics, Relay Therapeutics, Servier and Taiho Oncology, and serves
as an adviser or consultant to Alentis Therapeutics, AstraZeneca, Black Diamond,
Exelixis, Genentech, H3Biomedicine, Incyte, QED Therapeutics, Servier, Sirtex Medical,
Taiho Oncology and Transthera Bio. A.L. declares travel and educational support from
Advanced Accelerator Applications, Bayer, Delcath, Ipsen, Mylan, Novartis, Pfizer and
SirtEx; speaker’s honoraria from Advanced Accelerator Applications, AstraZeneca, Eisai,
Incyte, Ipsen, Merck, Pfizer, QED Therapeutics and Servier; and advisory or consultancy
roles with Albireo Pharma, AstraZeneca, Boehringer Ingelheim, Boston Scientific, Eisai,
GENFIT, Ipsen, Nutricia, QED Therapeutics, Roche, Servier and TransThera Biosciences;
and is a member of the Knowledge Network and NETConnect Initiatives funded by
Ipsen. G.S. has received grant support from Roche, and declares consultancy roles with
AstraZeneca, Chiesi, Evidera, Integra, Novartis and Roche. S.A., J.D.Y. and G.J.G. declare
no competing interests.
Additional information
Peer review information Nature Reviews Clinical Oncology thanks C. Berasain, H. Francis,
T. Greten, and J. Harding for their contribution to the peer review of this work.
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