Evolution of the Targeted Therapy Landscape for Cholangiocarcinoma: Is Cholangiocarcinoma the ‘NSCLC’ of GI Oncology?

SIMPLE SUMMARY: In the past 20 years, the development of targeted therapies that can be matched to a tumor’s molecular and immune abnormalities has resulted in the improvement of outcomes for patients suffering from advanced aggressive malignancies. Remarkably, non-small cell lung cancer (NSCLC) has become the poster child for a lethal malignancy in which numerous molecular aberrations have become druggable. Similar to NSCLC, there are limited responses in cholangiocarcinoma (CCA) to conventional chemotherapy. Next-generation sequencing has identified novel genomic alterations in CCA that vary between patients. Gene- and immune-targeted therapies are leading to a new era of precision/personalized medicine for patients with CCA. Herein, we review the current status of molecularly matched precision-targeted therapy for CCA. ABSTRACT: In the past two decades, molecular targeted therapy has revolutionized the treatment landscape of several malignancies. Lethal malignancies such as non-small cell lung cancer (NSCLC) have become a model for precision-matched immune- and gene-targeted therapies. Multiple small subgroups of NSCLC defined by their genomic aberrations are now recognized; remarkably, taken together, almost 70% of NSCLCs now have a druggable anomaly. Cholangiocarcinoma (CCA) is a rare tumor with a poor prognosis. Novel molecular alterations have been recently identified in patients with CCA, and the potential for targeted therapy is being realized. In 2019, a fibroblast growth factor receptor 2 (FGFR2) inhibitor, pemigatinib, was the first approved targeted therapy for patients with locally advanced or metastatic intrahepatic CCA who had FGFR2 gene fusions or rearrangement. More regulatory approvals for matched targeted therapies as second-line or subsequent treatments in advanced CCA followed, including additional drugs that target FGFR2 gene fusion/rearrangement. Recent tumor-agnostic approvals include (but are not limited to) drugs that target mutations/rearrangements in the following genes and are hence applicable to CCA: isocitrate dehydrogenase 1 (IDH1); neurotrophic tropomyosin-receptor kinase (NTRK); the V600E mutation of the BRAF gene (BRAF(V600E)); and high tumor mutational burden, high microsatellite instability, and gene mismatch repair-deficient (TMB-H/MSI-H/dMMR) tumors. Ongoing trials investigate HER2, RET, and non-BRAF(V600E) mutations in CCA and improvements in the efficacy and safety of new targeted treatments. This review aims to present the current status of molecularly matched targeted therapy for advanced CCA.