• Cholangiocarcinoma 2020: the next horizon in mechanisms and management

      Banales, J. M.; Marin, J. J. G.; Lamarca, Angela; Rodrigues, P. M.; Khan, S. A.; Roberts, L. R.; Cardinale, V.; Carpino, G.; Andersen, J. B.; Braconi, C.; et al. (2020)
      Cholangiocarcinoma (CCA) includes a cluster of highly heterogeneous biliary malignant tumours that can arise at any point of the biliary tree. Their incidence is increasing globally, currently accounting for ~15% of all primary liver cancers and ~3% of gastrointestinal malignancies. The silent presentation of these tumours combined with their highly aggressive nature and refractoriness to chemotherapy contribute to their alarming mortality, representing ~2% of all cancer-related deaths worldwide yearly. The current diagnosis of CCA by non-invasive approaches is not accurate enough, and histological confirmation is necessary. Furthermore, the high heterogeneity of CCAs at the genomic, epigenetic and molecular levels severely compromises the efficacy of the available therapies. In the past decade, increasing efforts have been made to understand the complexity of these tumours and to develop new diagnostic tools and therapies that might help to improve patient outcomes. In this expert Consensus Statement, which is endorsed by the European Network for the Study of Cholangiocarcinoma, we aim to summarize and critically discuss the latest advances in CCA, mostly focusing on classification, cells of origin, genetic and epigenetic abnormalities, molecular alterations, biomarker discovery and treatments. Furthermore, the horizon of CCA for the next decade from 2020 onwards is highlighted.
    • Letter to the editor: does multiple intrahepatic cholangiocarcinoma worsen prognosis as 'M1' stage? Reply

      Lamarca, Angela; Santos-Laso, A.; Utpatel, K.; La Casta, A.; Stock, S.; Forner, A.; Adeva, J.; Folseraas, T.; Fabris, L.; Macias, R. I. R.; et al. (2021)
    • Liver metastases of intrahepatic cholangiocarcinoma: implications for a potential new staging system

      Lamarca, Angela; Santos-Laso, A.; Utpatel, K.; La Casta, A.; Stock, S.; Forner, A.; Adeva, J.; Folseraas, T.; Fabris, L.; Ir Macias, R.; et al. (2020)
      Background: Intrahepatic cholangiocarcinoma (iCCA) with liver metastases (LM) are perceived to have a poor prognosis but the American Joint Committee on Cancer (AJCC) classifies them as early stage in the absence of lymph nodes or extrahepatic spread. Methods: Patients with iCCA from the European Network for the Study of Cholangiocarcinoma (ENS-CCA) and Surveillance, Epidemiology, and End Results (SEER) registries with survival/staging (AJCCv.7) data were eligible. Modified staging was used (mAJCCv.7): Group-A: stages-I-III (excluding T2bN0); Group-B: stage-IVa (excluding T2bN1M0); Group-C: LM (T2bN0/1) and Group-D: stage-IVb (extra-hepatic metastases). Survival analysis (Kaplan Meier and Cox Regression) was performed in an ENS-CCA training cohort (TC) and findings internally [ENS-CCA (iVC)] and externally [SEER] validated. The aim was to assess if LM (Group-C) had a shorter survival compared to other early stages (Group-A). A modified version of AJCCv.8 (mAJCCv.8) is proposed. Results: Total of 574 and 4,171 patients from the ENS-CCA and SEER registries were included. Following the new classification, 19.86% and 17.31% of patients from the ENS-CCA and SEER registries were reclassified into the Group-C, respectively. In the ENS-CCA TC, multivariable Cox Regression was adjusted for obesity (p-value 0.026) and performance status (p-value <0.001); patients in Group-C (HR 2.53 (95%CI 1.18-5.42); p-value 0.017) had a higher risk of death (vs Group-A). Findings were validated in the ENS-CCA iVC (HR 2.93 (95%CI 2.04-4.19); p-value <0.001) and in the SEER registry (HR of 1.88 (95%CI 1.68-2.09); p-value <0.001). Conclusions: iCCA LM have a worse outcome than other early stages. As AJCCv.8 does not take this into consideration, a modification of AJCC v.8 (mAJCCv.8) including "liver metastases: multiple liver lesions, with or without vascular invasion" as a novel "M1a stage" is suggested.
    • Reply to (20-1119.R1) Surgery for advanced intrahepatic cholangiocarcinoma warrants further investigation

      Lamarca, Angela; Santos-Laso, A.; Utpatel, K.; La Casta, A.; Stock, S.; Forner, A.; Adeva, J.; Folseraas, T.; Fabris, L.; Macias, R. I.; et al. (2021)
      We thank Jansson & Sparrelid for their Letter to the Editor(1)regarding our publication(2). We stated that "based on our results, patients with liver metastases should not be offered therapeutic strategies suitable for early stages, in view of poor survival". Jansson(1) argues that "the role of surgery in multiple intrahepatic cholangiocarcinoma (iCCA) should not be dismissed without further analysis"; similar to Zhang's views(3).
    • Targeted therapies for extrahepatic cholangiocarcinoma: preclinical and clinical development and prospects for the clinic

      Cadamuro, M.; Lasagni, A.; Lamarca, Angela; Fouassier, L.; Guido, M.; Sarcognato, S.; Gringeri, E.; Cillo, U.; Strazzabosco, M.; Marin, J. J.; et al. (2021)
      Introduction: Until recently, cholangiocarcinoma (CCA) was a largely overlooked disease, and among CCAs, extrahepatic CCA (eCCA) was even more neglected. Despite the growing impact of molecularly targeted therapies and immunotherapy, prognosis of eCCA is dismal. Therefore, unraveling the complex molecular landscape of eCCA has become an urgent need. Deep phenotyping studies have revealed that eCCA is a heterogeneous tumor, harboring specific alterations categorizable into four classes, 'Mesenchymal', 'Proliferation', 'Immune', 'Metabolic'. Molecular alterations convey the activation of several pro-oncogenic pathways, where either actionable drivers or outcome predictors can be identified.Areas covered: We offer insights on perturbed pathways, molecular profiling, and actionable targets in eCCA and present a perspective on the potential stepping-stones to future progress. A systematic literature search in PubMed/ClinicalTrials.gov websites was performed by authors from different disciplines according to their specific topic knowledge to identify the newest and most relevant advances in precision medicine of eCCA.Expert opinion: eCCA is a distinct entity with unique features in terms of molecular classes, oncogenic drivers, and tumor microenvironment. Since more prevalent mutations are currently undruggable, and immunotherapy can be offered only to a minority of patients, international collaborations are instrumental to improve the understanding of the molecular underpins of this disease.