Radiation and Immune Checkpoint Inhibitors in Cholangiocarcinoma

First-Line Treatment

The American Association for the Study of Liver Diseases recommends gemcitabine plus cisplatin combined with either durvalumab or pembrolizumab as standard of care for first-line systemic treatment of unresectable or metastatic cholangiocarcinoma, with a hazard ratio of 0.76 (95% CI 0.64-0.91) and median overall survival of 12.9 months 1, 2
The European Society for Medical Oncology recommends that patients with MSI-high or dMMR cholangiocarcinoma who have progressed on first-line chemotherapy should receive immune checkpoint blockade (pembrolizumab or dostarlimab) 3

The National Comprehensive Cancer Network recommends that patients must have WHO/ECOG performance status 0-2 with adequate organ function to be eligible for immunotherapy 1, 2
The American Society of Clinical Oncology recommends avoiding treatment of patients with ECOG >2, as they derive no benefit and experience increased toxicity 1, 2

The French Association for the Study of the Liver recommends stereotactic body radiation therapy (SBRT) for unique intrahepatic cholangiocarcinoma lesions less than 5 cm if surgical resection is not possible, with improved local control and overall survival 3, 4
The American Society for Radiation Oncology recommends SBRT dosing of 30-50 Gy in 3-5 fractions, depending on the ability to meet normal organ constraints and underlying liver function 4

The American Association for the Study of Liver Diseases recommends combining SBRT with systemic chemotherapy, particularly gemcitabine plus cisplatin with durvalumab or pembrolizumab, which remains the standard first-line systemic therapy 4
The European Society for Medical Oncology recommends starting with cisplatin-gemcitabine plus durvalumab or pembrolizumab as standard first-line therapy, and considering adding SBRT to oligometastatic sites during first-line immunotherapy-chemotherapy 4

The American Society of Clinical Oncology recommends FGFR inhibitors for patients with intrahepatic cholangiocarcinoma and FGFR2 fusions or other rearrangements after progression on standard first-line chemotherapy, with objective response rates of 23-42% 3
The National Comprehensive Cancer Network recommends ivosidenib for patients with IDH1 mutations who progress on first-line therapy 3

The American Society for Radiation Oncology recommends avoiding conventional low-dose palliative radiation (8 Gy in 1 fraction) for cholangiocarcinoma, as this achieves suboptimal local control 4
The American Association for the Study of Liver Diseases recommends not delaying chemotherapy-immunotherapy in eligible patients waiting for further disease progression, as early treatment correlates with improved outcomes 1, 2, 7

The European Society for Medical Oncology recommends that quality of life should be the primary focus with survival as a secondary endpoint, as achieving stable disease correlates with improved length and quality of life 5, 6, 7
The American Society of Clinical Oncology recommends good symptom control as paramount and requires multidisciplinary input 6, 7