Immune checkpoint inhibitors in advanced cholangiocarcinoma: a systematic review of efficacy, safety, and emerging biomarkers.

Authors

Faiz Un Nisa, Moeez Ali, Talha Khan, Muskan Lohana, Aniba Asif, Nandni Kumari, Maaz Ali

Published in

Journal of the Egyptian National Cancer Institute. Volume 38. Issue 1. Jul 06, 2026. Epub Jul 06, 2026.

Abstract

Cholangiocarcinoma (CCA) is an aggressive biliary tract malignancy often diagnosed at an advanced stage. For over a decade, gemcitabine-cisplatin (GemCis) remained the standard of care with limited survival benefit. The advent of immune checkpoint inhibitors (ICIs) has transformed the therapeutic landscape, but variability in outcomes and a rapidly expanding evidence base require systematic synthesis.
A systematic review was conducted following PRISMA 2020 guidelines. The review was not registered in PROSPERO or another prospective registry. PubMed/MEDLINE and Embase were searched from inception through 31 December 2024. Studies evaluating PD-1/PD-L1/CTLA-4 inhibitors alone or in combination for advanced CCA were included. Risk of bias was assessed using ROBINS-I for non-randomized studies and Cochrane RoB 2 for randomized controlled trials. A narrative synthesis was performed due to clinical and methodological heterogeneity.
Fifty-one studies (≈ 4,800 patients) met inclusion criteria, including 8 randomized controlled trials and 43 non-randomized studies. First-line chemo-immunotherapy with durvalumab or pembrolizumab plus GemCis established new standards of care in TOPAZ-1 (mOS 12.9 vs. 11.3 months; HR 0.76) and KEYNOTE-966 (mOS 12.7 vs. 10.9 months; HR 0.83). Triplet regimens (chemotherapy + ICI + tyrosine kinase inhibitor [TKI]) demonstrated high activity (e.g., toripalimab + lenvatinib + GEMOX: ORR 80%, mOS 22.5 months). Second-line ICI monotherapy yielded modest ORRs (3-22%), while ICI + TKI combinations showed ORRs of 9-28%. Grade ≥ 3 treatment-related adverse events ranged from 10 to 17% (ICI monotherapy) to 70-75% (chemo-ICI). PD-L1 expression was not predictive in chemo-ICI; homologous recombination deficiency (HRD)/DNA damage response (DDR) mutations and circulating tumor DNA (ctDNA) clearance emerged as promising biomarkers.
ICIs combined with chemotherapy have redefined first-line treatment for advanced CCA. Triplet and locoregional combinations show encouraging efficacy, warranting further validation. Biomarker-driven selection, particularly HRD/DDR status and ctDNA monitoring, will be critical to optimizing outcomes.

PMID:
42406230
Bibliographic data and abstract were imported from PubMed on 06 Jul 2026.

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