Phase II trial of hepatic arterial infusion chemotherapy plus bevacizumab and toripalimab for advanced biliary tract cancers: efficacy, safety, and exploratory analysis

Introduction

Biliary tract cancers (BTCs), which arise from the biliary epithelial cells, are classified into gallbladder cancer (GBC), intrahepatic cholangiocarcinoma (iCCA), perihilar cholangiocarcinoma (pCCA), and distal cholangiocarcinoma (1,2). Most patients with BTCs are diagnosed at advanced stages and are, therefore, not candidates for surgery (2,3).

Gemcitabine plus cisplatin (GemCis) remains the mainstay first-line systemic treatment for advanced BTCs, with a median overall survival (OS) of 11.7 months, as reported in the ABC-02 trial (4). Recently, the combination of durvalumab or pembrolizumab and GemCis regimen was demonstrated to prolong the survival of patients with advanced BTCs in the TOPAZ-1 and KEYNOTE-966 studies; however, the improvements in survival were limited, with median OS of 12.9 and 12.7 months, respectively (5,6).

Hepatic arterial infusion chemotherapy (HAIC), which delivers chemotherapeutic agents directly to liver tumors to achieve high local drug concentrations, may be safer and more effective for patients with hepatobiliary malignancies (7). High tumor control and significant survival benefits of HAIC have been reported in recently published phase II trials for BTCs (8-11). Toripalimab is a humanized programmed cell death protein-1 (PD-1) monoclonal antibody that could prevent the binding of PD-1 with programmed cell death ligand-1 (PD-L1) and 2 (PD-L2) (12). In recent years, toripalimab plus chemotherapy showed synergistic effect and encouraging efficacy for various cancers, such as esophageal carcinoma, lung cancer, and nasopharyngeal carcinoma (13-15).

Vascular endothelial growth factor (VEGF) is a crucial regulator of angiogenesis in BTCs and a critical molecule that regulates immunosuppression by inhibiting dendritic cell differentiation and activity (16,17). VEGF inhibitors facilitate vascular modification and T-cell infiltration of tumors, achieving a synergic effect when combined with PD-1/PD-L1 inhibitors and enhancing the efficacy of chemotherapy (18-20). Recently, the results of the IMbrave 151 trial, which compared the efficacies of atezolizumab, bevacizumab plus cisplatin and gemcitabine to atezolizumab plus cisplatin and gemcitabine as first-line treatment for patients with advanced BTCs, with a median progression-free survival (PFS) of 8.4 vs. 7.9 months [hazard ratio (HR): 0.76], indicated a synergistic therapeutic effect of this triple combination treatment (21).

Therefore, we conducted the present open-label, single-arm, single-center, phase II trial to evaluate the efficacy and safety of a triple combination therapy comprising HAIC, bevacizumab (a VEGF inhibitor), and toripalimab (a PD-1 inhibitor) as first-line treatment for advanced BTCs. We present this article in accordance with the CONSORT reporting checklist (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-463/rc).

Methods

Study design, ethics statement, and participants

This open-label, single-arm, single-center, phase II trial was approved by the Ethics Committee of the Peking University Cancer Hospital (No. 2020YJZ38) and registered at Clinicaltrials.gov (NCT04217954). The trial was conducted in accordance with the Declaration of Helsinki (and its subsequent amendments) and Good Clinical Practice. Written informed consent was obtained from all patients.

Key eligibility criteria were as follows: (I) histopathological/cytological diagnosed advanced unresectable BTCs including iCCA, pCCA, and GBC, and confirmed by multidisciplinary team; (II) no previous loco-regional or systemic therapies; (III) ages of 18–80 years; (IV) at least one measurable lesion; (V) Eastern Cooperative Oncology Group (ECOG) performance status <2; (VI) Child-Pugh A or B (≤7); and (VII) adequate organ function, including hemoglobin level ≥90 g/L, absolute neutrophil counts ≥1.5×10⁹/L, platelet counts ≥100×10⁹/L, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels ≤2.5-fold the upper limit of normal (ULN), serum total bilirubin (TBiL) levels ≤5-fold ULN, serum creatinine levels ≤1.5-fold ULN, and serum albumin level ≥30 g/L. Participants who did not meet the inclusion criteria or refused to participate in the trial were excluded. The detailed inclusion and exclusion criteria are listed at Clinicaltrials.gov (NCT04217954).

Procedures and treatment

HAIC was administered through a percutaneously implanted port-catheter system using the fix-catheter-tip method as previously described (22-25). The combination therapy, which was repeated every 4 weeks, consisted of HAIC and intravenous toripalimab (240 mg, day 1 prior to HAIC), with the HAIC regimen of bevacizumab (300 mg, day 1), oxaliplatin (40 mg/m², 2 h, days 1–3), and 5-fluorouracil (800 mg/m², 22 h, days 1–3). A maximum of 6 consecutive HAIC cycles were administered, followed by intravenous infusion of toripalimab (240 mg) and bevacizumab (300 mg) every 4 weeks as maintenance treatment until tumor progression, participant death, or participant withdrawal, whichever occurred first. The doses of bevacizumab, toripalimab, and intra-arterial chemotherapeutic agents were adjusted or discontinued according to treatment-related adverse events (AEs), and the subsequent treatment after the tumor progression was chosen based on the clinicians’ and participants’ decision.

Follow-up and assessments

Physical examinations, ECOG performance status assessment, routine blood tests, liver and kidney function assessments, serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels, abdominal contrast-enhanced CT/MRI, and chest radiography/CT were performed after every two cycles of treatment for evaluation until disease progression. The survival follow-up procedure was continued every 3 months after discontinuation or completion of the trial.

Two radiologists (who were blinded to the treatment protocol) with more than 10 years of experience in abdominal imaging diagnosis, assessed the follow-up CT/MRI images to reach a consensus. Tumor response was evaluated according to the Immune-Modified Response Evaluation Criteria in Solid Tumors (imRECIST) criteria (26), and post hoc evaluation was performed according to RECIST 1.1 criteria (27).

Endpoints

The primary endpoint was objective response rate (ORR) per imRECIST criteria, and the secondary endpoints were PFS, OS, and safety. PFS was defined as the date from the initiation of HAIC to disease progression or participant death, whichever occurred first. OS was calculated from the initiation of HAIC to death or last follow-up. The duration of response (DoR) was defined as the interval between the date of the first documented complete response (CR) or partial response (PR), to the date of first documented confirmed progressed disease (PD) or death. Treatment-related AEs were graded according to the Common Terminology Criteria for Adverse Events, version 4.0. Exploratory endpoint was peripheral blood protein levels before the initiation of the study treatment.

Exploratory analysis

Olink proximity extension assay with a Target 96 Immuno-Oncology panel was employed to determine the plasma levels of 92 proteins as biomarkers. The assay protocol was available online (http://olink.com/content/uploads/2022/05/olink-target-96-short-instructions.pdf). The obtained results were presented as normalized protein expression (NPX) values, which were on log2 scale and obtained by normalizing Ct-values against extension control, interpolate control and a correction factor. The high NPX value corresponds to a high protein concentration and can be linearized by using the formula 2^NPX. Values below the lowest level of detection for each marker, based on the negative controls analyzed in each run, were set to limit of detection (LOD) value.

Statistical analysis

A Simon’s two-stage design was adopted in this study, with ORR as the primary endpoint. The ORR was 26.1% in the ABC-02 trial; therefore, we assumed an ORR of 50% in this trial. The planned sample size was 29 based on α=0.05, power =0.8, and CR or PR achievement in 11 participants. If no more than 3 of the initial 11 participants were evaluated as achieving CR or PR, the trial was to be terminated. Considering an estimated dropout rate of 10%, an enrollment of 32 participants was required.

Continuous and categorical variables were presented as mean ± standard deviation and frequencies, respectively. The chi-square test was used to compare categorical variables, and the Kruskal-Wallis H test was used for the comparison of continuous variables. OS and PFS were assessed using Kaplan-Meier method, and compared using log-rank test. Student’s t-test was employed for the Olink standard differential analysis to calculate the expression differences of proteins in standardized NPX data under different experimental conditions. The Cox proportional hazards model was used in univariate and multivariable survival analysis, and variates with P<0.05 in univariate analysis were analyzed in multivariable analysis. A P value <0.05 was considered statistically significant. All statistical analyses were performed using SPSS v.23.0 software (IBM Corp, Armonk, NY, USA) or R software (R version 4.2.0, http://www.r-project.org).

Results

Participants characteristics

From July 2020 to January 2022, 32 treatment-naïve participants (20 men and 12 women) with advanced BTCs were enrolled in this trial, including 11 with iCCA, 17 with pCCA, and 4 with GBC (Figure 1). The age was 62.06±8.82 years (range, 41.0–76.0 years). Extrahepatic metastasis disease, which included lymph node and distant organ metastasis, was detected in 18 (56.25%) participants, including 12 (37.50%) with only lymph node metastasis and 6 (18.75%) with distant organ metastasis. Twenty participants underwent biliary drainage before the study treatment for obstructive jaundice, and the study treatment was initiated until the total bilirubin level decreased to less than five times the ULN after biliary drainage.

Figure 1 Participant flowchart.

A total of 168 cycles of study treatment were performed in this trial (5.25±1.22 cycles; range, 2–6 cycles), and 21 (65.63%) participants received maintenance treatment (5.95±5.41 cycles; range, 1–20 cycles). Seventeen (53.13%) participants received subsequent treatments such as HAIC with another regimen, surgery, and systemic chemotherapy after the tumor progression. Two participants underwent surgical resection after the study treatment, and one achieved pathological CR (Figure 2). Participants characteristics are listed in Table 1.

Figure 2 MRI images of a representative participant. A participant in 40s was diagnosed with intrahepatic cholangiocarcinoma after liver puncture biopsy. (A-C) A giant tumor in the right lobe of the liver was detected on the contrast-enhanced MRI of the arterial and venous phases before treatment. The CEA level was 1.53 ng/mL, and that of CA19-9 was 2,050 U/mL. (D-F) After six cycles of treatment, the tumor had shrunk further in size and enhanced portion, and the CA19-9 (38.04 U/mL) decreased. Tumor response was designated as partial response according to the imRECIST criteria. The participant received intravenous bevacizumab and toripalimab as maintenance treatment, and the CA19-9 level decreased further to normal. Subsequently, surgical resection was performed, and pathological examination did not detect residual tumor cells in the lesion or surrounding liver tissue (pCR). The participant was alive without tumor recurrence on July 18, 2024 (OS, 33.40 months). MRI, magnetic resonance imaging; CEA, carcinoembryonic antigen; CA19-9, carbohydrate antigen 19-9; imRECIST, Immune-Modified Response Evaluation Criteria in Solid Tumors; pCR, pathological complete response; OS, overall survival.

The survival follow-up procedures were continued until July 18, 2024, with the median follow-up time of 37.20 months. Until the last follow-up, tumor progression was confirmed in 20 (62.50%) participants, and 22 (68.75%) participants died. As second-line treatment, one participant received HAIC using other regimens; four received HAIC using other regimens plus immunotherapy; two received HAIC using other regimens plus oral tyrosine kinase inhibitors (TKIs), such as regorafenib and lenvatinib, and immunotherapy; three received oral TKIs plus immunotherapy; three received systemic chemotherapy; one received systemic chemotherapy plus immunotherapy; and two received oral TKI.

Tumor response

Confirmed CR or PR was achieved in six of the first 11 enrolled participant, and the trial was therefore continued for full enrollment. With the proceeding of study treatment, two of the five participants who previously achieved stable disease (SD) achieved CR or PR among the first 11 enrolled participants. Finally, CR, PR, SD, and PD per imRECIST criteria were achieved in 3 (9.38%), 24 (75.0%), 4 (12.50%), and 1 (3.13%) participant, respectively, in all enrolled participants (Figure 3). The confirmed ORR was 84.38%, with the confirmed ORRs amongst participants with iCCA, pCCA, and GBC of 72.7%, 88.2%, and 100%, respectively. The disease control rate (DCR) per imRECIST criteria was 96.88%. The post hoc evaluation according to RECIST 1.1 criteria showed that the confirmed ORR was 75% (24/32), with 1 CR (3.13%), 23 PR (71.88%), 7 SD (21.88%), and 1 PD (3.13%) (Figure 2, Table 2).

Figure 3 Waterfall plot of tumor responses. (A) Tumor response per imRECIST criteria. (B) Tumor response per RECIST 1.1 criteria. iCCA, intrahepatic cholangiocarcinoma; pCCA, perihilar cholangiocarcinoma; GBC, gallbladder cancer; LCD, liver confined disease; EMD, extrahepatic metastatic disease; CR, complete response; PR, partial response; SD, stable disease; PD, progressed disease; imRECIST, Immune-Modified Response Evaluation Criteria in Solid Tumors.

Survival

The median OS and PFS were 19.0 months [95% confidence interval (CI): 12.22–25.78] and 13.20 months (95% CI: 8.93–17.47) (Figure 4), respectively, with the median DoR of 11.40 months (95% CI: 8.04–14.76). The post hoc evaluation showed that the median local PFS, which was identified as the period between the initiation of the study treatment and disease progression of the primary tumor site, or death from any cause, was 13.90 months (95% CI: 9.70–18.10).

Figure 4 Survival curves. (A) OS; (B) PFS. OS, overall survival; PFS, progression-free survival.

The median OS and PFS were similar among participants with iCCA, pCCA, and GBC, with the median OS of 19.0 vs. 21.60 vs. 12.60 months (P=0.26) and the median PFS of 14.40 vs. 14.40 vs. 8.80 months (P=0.36), respectively. Both median OS and PFS in participants with liver confined disease were numerically longer than those in participants with extrahepatic metastatic disease (25.70 vs. 14.60 months and 16.40 vs. 9.60 months, respectively), while neither the differences were statistically significant (P=0.53 and P=0.51, respectively).

Safety

All treatment-related AEs were manageable in this trial, and most participants recovered to normal before the next cycle of treatment (Table 3). Catheter dislocation was detected in one participant three months after the implantation of a port-catheter system; therefore, delivery of HAIC with a temporary indwelling catheter in the proper hepatic artery was adopted.

Thirty-one participants (96.88%) experienced treatment-related AEs of any grade, whereas grade 3 or higher treatment-related AEs were observed in only 10 participants (31.25%). The most frequent grade 3 or higher treatment-related AEs were elevated ALT/AST (4/32, 12.50%), elevated total bilirubin (3/32, 9.38%), and neutropenia (3/32, 9.38%). The study did not report any cases of symptomatic cholangitis during or after HAIC. One participant died because of a gallbladder-colon fistula and liver abscess after treatment.

Immunotherapy-related AEs were observed in three participants, including 1 hypothyroidism (3.13%), 1 diabetes (3.13%), and 1 grade 3 elevated creatine kinase (3.13%). The participant with the elevated creatine kinase recovered to normal without any medical intervention, while the participant who experienced hypothyroidism was administered levothyroxine, and the other participant was injected with insulin to treat diabetes.

Treatment delay or dose reduction of HAIC due to the grade 3 or higher AEs was observed in 6 participants (18.75%). Toripalimab interruption was required for 1 participant (3.13%), which was caused by elevated creatine kinase, and was resumed after the creatine kinase level reverted to normal. HAIC and toripalimab therapy were not discontinued in any participant.

Exploratory analysis

Blood samples were obtained from 29 participants before the initiation of the study treatment. All of the samples passed the quality control, and were used for plasma biomarkers analysis of 92 proteins.

The participants were divided into responder group (CR or PR in tumor response) and non-responder group (SD or PD in tumor response), with 24 in responder group and 5 in non-responder group. The NPX value of 13 proteins in the non-responder group were significantly higher than those in the responder group, including mucin-16 (MUC-16), tumor necrosis factor ligand superfamily member 6 (FASLG), hepatocyte growth factor (HGF), cytotoxic and regulatory T-cell molecule (CRTAM), monocyte chemotactic protein-2 (MCP-2), T-cell surface glycoprotein CD8 alpha chain (CD8A), decorin (DCN), macrophage colony-stimulating factor 1 (CSF-1), tumor necrosis factor ligand superfamily member 12 (TWEAK), C-C motif chemokine 3 (CCL3), natural cytotoxicity triggering receptor (NCR1), tumor necrosis factor receptor superfamily member 12A (TNFRSF12A), and C-C motif chemokine 4 (CCL4) (Figure 5).

Figure 5 Proteins with significant difference between responder group and non-responder group. (A) Volcano plot. (B) Box plot. NPX, normalized protein expression.

The median NPX value was adopted as the cut-off value for each protein to differentiate high and low protein levels. Low protein levels of CSF-1, T-cell surface glycoprotein CD5 (CD5), angiopoietin-2 (ANGPT2), interferon gamma (IFN-gamma), and macrophage metalloproteinase-12 (MMP12) before the study treatment were associated with better PFS (Figure 6). After the univariate and multivariable COX analysis, Child-Pugh B (HR: 22.65, 95% CI: 3.66–140.08, P=0.001) and high level of MMP12 (HR: 5.99, 95% CI: 1.60–22.37, P=0.008) were indicated as the independent risk factors related to worse PFS (Table 4).

Figure 6 High level of different proteins related to worse PFS of participants. (A) CSF-1. The median PFS was 9.6 vs. 16.4 months (P=0.02). (B) CD5. The median PFS was 9.6 vs. 16.4 months (P=0.02). (C) ANGPT2. The median PFS was 9.0 vs. 19.8 months (P=0.009). (D) IFN-gamma. The median PFS was 9.0 vs. 16.4 months (P=0.03). (E) MMP12. The median PFS was 8.8 vs. 13.2 months (P=0.03). PFS, progression-free survival; CSF-1, macrophage colony-stimulating factor 1; CD5, T-cell surface glycoprotein CD5; ANGPT2, angiopoietin-2; IFN-gamma, interferon gamma; MMP12, macrophage metalloproteinase-12.

Discussion

This phase II trial demonstrated the encouraging efficacy and safety of triple combination therapy with HAIC, bevacizumab and toripalimab as a first-line treatment for advanced BTCs, as indicated by ORR, DCR, median OS, and median PFS of 84.38%, 96.88%, 19.0 months, and 13.20 months, respectively. Notably, the median OS of the participants with liver confined disease was 25.70 months. Regarding the safety profile, grade 3 or higher treatment-related AEs were observed in only 10 participants (31.25%), and all AEs were manageable.

There is growing interest in the triple synergistic effect of combining chemotherapy, immunotherapy, and anti-VEFG therapy in cancer treatment. Bevacizumab (a VEGF inhibitors) could facilitate the infiltration of tumors by T-cells and improve the antigen-presenting capacity of circulating dendritic cells, suggesting the stimulation and activation of the immune system when combined with immune checkpoint inhibitors (18,28-31). Meanwhile, bevacizumab is beneficial for the normalization of tumor vessels, facilitating drug delivery, and enhancing the efficacy of chemotherapy (19,20). Chemotherapeutic agents, such as gemcitabine, cisplatin, oxaliplatin, and 5-fluorouracil, could modulate the immune system through direct immunostimulatory mechanisms, downregulation of the immunosuppressive microenvironment, and increased immunogenicity (32,33). The combination of chemotherapy combined with PD-1/PD-L1 inhibitors have been demonstrated to be more effective in lung, esophageal, and gastric cancers, and confirmed by the TOPAZ-1 and KEYNOTE-966 trials in patients with advanced BTCs (5,6,34,35).

The IMbrave151 trial was the first randomized study to evaluate the combination of PD-L1 inhibitor, VEGF inhibitors, and systemic chemotherapy for advanced BTCs. The trial demonstrated an extended median PFS after treatment with bevacizumab combined with atezolizumab plus gemcitabine and cisplatin (8.4 vs. 7.9 months, HR: 0.76), although the statistical significance was not met (21). Another phase II trial evaluated the triple combination of toripalimab (PD-1 inhibitor), lenvatinib, and chemotherapy with the GEMOX regimen for advanced iCCA (36). The trial yielded some promising results, with an ORR, median OS, and median PFS of 80%, 22.5 months, and 10.2 months, respectively. However, 56.7% of the participants experienced grade 3 or higher AEs.

HAIC can increase the concentration of chemotherapeutic agents in liver tumors, leading to better tumor control in the liver (7). Recently, HAIC with oxaliplatin and 5-fluorouracial had shown the survival benefits for patients with advanced BTCs (9,11,37,38). Furthermore, oxaliplatin and 5-fluorouracil may kill immunogenic cells and activate the adaptive immune system and immune checkpoint inhibitors (39,40). The phenomenon that most participants with extrahepatic metastatic disease did not show progression of the extrahepatic metastatic lesions at the first and second evaluations in this trial also suggests that HAIC may enhance the systemic anti-tumor effect of immunotherapy.

To our knowledge, this is the first phase II trial to investigate the efficacy of HAIC in combination with PD-1 inhibitor and bevacizumab for advanced BTCs. The triple combination therapy showed superior outcomes compared to the recommended first-line treatment for advanced BTCs in prior published phase III trials, with a higher ORR [84.38% vs. 26.1% (GemCis) vs. 26.7% (durvalumab plus GemCis) vs. 29% (pembrolizumab plus GemCis)], longer PFS [13.20 vs. 8.0 (GemCis) vs. 7.2 (durvalumab plus GemCis) vs. 6.5 months (pembrolizumab plus GemCis)], and longer OS [19.0 vs. 11.7 (GemCis) vs. 12.9 (durvalumab plus GemCis) vs. 12.7 months (pembrolizumab plus GemCis)] (4-6,41). The median OS of 25.70 months achieved in the participants with liver confined disease in this trial was also encouraging. Additionally, the median PFS and OS in participants with extrahepatic metastatic disease were 9.60 and 14.60 months, respectively, and most of them got progression in both intrahepatic and extrahepatic lesions, which may be attributed to the higher aggressive nature of such tumors compared to those without extrahepatic metastasis.

Here, we showed that all AEs were manageable in this trial, and only 31.25% of the participants experienced grade 3 or higher AEs [31.25% vs. 70.7% (4) vs. 62.7% (5) vs. 70% (6) vs. 73% (21) vs. 56.7% (36)]. This may be explained as follows: the dosages of chemotherapeutic agents used for HAIC were lower than those used for systemic chemotherapy. Additionally, a 3-day circulatory infusion of HAIC reduced the toxicities of the chemotherapy. However, a gallbladder-colon fistula occurred in one participant 2 months after the initiation of the study treatment. This may be due to the quick and deep regression of the tumor in the context of tumor invasion of the colon, so that the normal tissue did not have sufficient time to heal the defect caused by the tumor disappearance. Drainage of the biliary tract, liver, and abdominal abscesses combined with antibiotic therapy and intravenous nutrition was administered when the fistula and abscessed were detected. However, the participant died 5.7 months after the initiation of treatment. Thus, this triple combination treatment should be carefully considered in patients whose tumors have severely invaded the gastrointestinal tract and other organs.

Olink proteome technology is a circulating protein biomarker test that can predict prognosis and monitor the efficacy of treatment, and can be performed using the plasma of patients without the requirement of tumor tissue (42,43). Therefore, the Olink proteome technology was employed to detect protein biomarkers in this trial owing to both its accessibility and its cost-effectiveness. In this study, participants in non-responder group presented significant higher level of MUC-16, FASLG, HGF, CRTAM, MCP-2, CD8A, DCN, CSF-1, TWEAK, CCL3, NCR1, TNFRSF12A, and CCL4 than participants in responder group. Interestingly, seven of them were identified as the biomarkers associated with tumor proliferation, invasion, and metastasis by previously published studies, including MUC-16, HGF, MCP-2, TWEAK, CCL3, TNFRSF12A, and CCL4 (44-49). Meanwhile, high level of MUC-16, FASLG, and CSF-1 have been demonstrated to be conducive to inhibit anticancer immune responses and lead immune escape (44,50,51). Therefore, we speculated the worse tumor response to the study treatment might due to the high expression of the proteins mentioned above. Additionally, high level of MMP12 was identified as one of the independent risk factors related to the worse PFS in this study. The result was consistent with the previous study which indicated MMP12 helps cancer cells grow and the elevated MMP12 expression serves as a biomarker of poor prognosis in various cancers (52). However, the results should be interpreted with caution due to the post-hoc analysis nature, limited number of participants with available and qualified blood samples for analysis, and the great quantitative differences between responder group and non-responder group. Therefore, further studies with large sample size are required to verify the results in the present study and explore the underlying mechanism related to the biomarkers mentioned above.

This trial has other limitations. First, more than 50% of participants with extrahepatic metastatic disease were enrolled, which may have reduced the maximization of survival benefits because of the progression of extrahepatic disease. Second, subsequent treatments, which depended on the decision of clinicians or participants after disease progression or treatment discontinuation may eventually affect survival results. Third, only four participants with GBC were enrolled, which may limit the generalization of the results to patients with GBC. Fourth, the status of microsatellite instability was not considered in the inclusion and exclusion criteria and was unknown to most participants, limiting subgroup comparison between participants with different extents of microsatellite instability. Fifth, the sample size was small in this phase II trial, and the results require further validation in a randomized phase III trial.

Conclusions

This phase II trial demonstrated that HAIC combined with bevacizumab and toripalimab may represent an effective first-line treatment for advanced BTCs, as supported by long survival, great tumor control, and an acceptable safety profile. Meanwhile, MMP12 may serve as a predictor of worse prognosis for this triple combination treatment. However, randomized phase III trial is required to verify these results.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CONSORT reporting checklist. Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-463/rc

Trial Protocol: Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-463/tp

Data Sharing Statement: Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-463/dss

Peer Review File: Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-463/prf

Funding: This trial was supported by National Natural Science Foundation of China (No. 82172039), Beijing Hospitals Authority Clinical Medicine Development of Special Funding Support (No. ZYLX202117), and Beijing Municipal Natural Science Foundation (No. 7212198).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-463/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (and its subsequent amendments). The study was approved by the Ethics Committee of the Peking University Cancer Hospital (No. 2020YJZ38) and informed consent was obtained from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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