Cholangiocarcinoma

Section editor transclusions

29 regimens on this page 35 variants on this page

Note: there is some overlap, especially in the earlier literature, between treatment regimens for cholangiocarcinoma and those for pancreatic adenocarcinoma, periampullary adenocarcinoma, and gallbladder cancer; please see those pages for additional regimens.

Guidelines

ASCO

• 2019: Shroff et al. Adjuvant therapy for resected biliary tract cancer: ASCO Clinical Practice Guideline

ESMO

• 2016: Valle et al. Biliary cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

NCCN

• NCCN Guidelines - Hepatobiliary Cancers

Adjuvant therapy

Capecitabine monotherapy

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Regimen

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Primrose et al. 2019 (BILCAP)	2006-2014	Phase III (E-esc)	Observation	Might have superior OS Median OS: 51 vs 36 mo (HR 0.81, 95% CI 0.63-1.04)

Note: Chemotherapy start date 8 to 16 weeks after surgery

Preceding treatment

• Surgical resection with macroscopically curative resection

Chemotherapy

• Capecitabine (Xeloda) 1250 mg/m² PO twice per day on days 1 to 14

21-day cycle for 8 cycles

References

1. BILCAP: Primrose JN, Fox RP, Palmer DH, Malik HZ, Prasad R, Mirza D, Anthony A, Corrie P, Falk S, Finch-Jones M, Wasan H, Ross P, Wall L, Wadsley J, Evans JTR, Stocken D, Praseedom R, Ma YT, Davidson B, Neoptolemos JP, Iveson T, Raftery J, Zhu S, Cunningham D, Garden OJ, Stubbs C, Valle JW, Bridgewater J; BILCAP study group. Capecitabine compared with observation in resected biliary tract cancer (BILCAP): a randomised, controlled, multicentre, phase 3 study. Lancet Oncol. 2019 May;20(5):663-673. Epub 2019 Mar 25. Erratum in: Lancet Oncol. 2019 Apr 2. link to original article PubMed NCT00363584

Capecitabine & Gemcitabine

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GemCap: Gemcitabine & Capecitabine

Regimen

Study	Years of enrollment	Evidence
Ben-Josef et al. 2015 (SWOG S0809)	2008-2012	Phase II

Preceding treatment

• Surgical resection

Chemotherapy

• Capecitabine (Xeloda) 750 mg/m²/day PO twice per day on days 1 to 14
• Gemcitabine (Gemzar) 1000 mg/m² IV once per day on days 1 & 8

21-day cycle for 4 cycles

Subsequent treatment

• Capecitabine & RT

References

1. SWOG S0809: Ben-Josef E, Guthrie KA, El-Khoueiry AB, Corless CL, Zalupski MM, Lowy AM, Thomas CR Jr, Alberts SR, Dawson LA, Micetich KC, Thomas MB, Siegel AB, Blanke CD. SWOG S0809: A phase II intergroup trial of adjuvant capecitabine and gemcitabine followed by radiotherapy and concurrent capecitabine in extrahepatic cholangiocarcinoma and gallbladder carcinoma. J Clin Oncol. 2015 Aug 20;33(24):2617-22. Epub 2015 May 11. link to original article link to PMC article contains verified protocol PubMed NCT00789958

Gemcitabine monotherapy

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Regimen

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Ebata et al. 2018 (BCAT)	2007-2011	Phase III (E-esc)	Observation	Did not meet primary endpoint of OS

Preceding treatment

• Surgical resection with macroscopically curative resection

Chemotherapy

• Gemcitabine (Gemzar) 1000 mg/m² IV once per day on days 1, 8, 15

28-day cycle for 6 cycles

References

1. BCAT: Ebata T, Hirano S, Konishi M, Uesaka K, Tsuchiya Y, Ohtsuka M, Kaneoka Y, Yamamoto M, Ambo Y, Shimizu Y, Ozawa F, Fukutomi A, Ando M, Nimura Y, Nagino M; Bile Duct Cancer Adjuvant Trial (BCAT) Study Group. Randomized clinical trial of adjuvant gemcitabine chemotherapy versus observation in resected bile duct cancer. Br J Surg. 2018 Feb;105(3):192-202. link to original article PubMed UMIN000000820

Gemcitabine/Fluorouracil & RT

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Gemcitabine/Fluorouracil & RT: Gemcitabine alternating with Fluorouracil & Radiation Therapy

Protocol

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Regine et al. 2008 (RTOG 9704)	1998-2002	Phase III (E-esc)	Fluorouracil & RT	Did not meet primary endpoint of OS1

¹Reported efficacy is based on the 2011 update.
Note: this study was in pancreatic cancer but in practice it is extrapolated to cholangiocarcinoma.

Preceding treatment

• Surgical resection

Chemotherapy, part 1

• Gemcitabine (Gemzar) 1000 mg/m² IV over 30 minutes once per day on days 1, 8, 15

21-day course, followed in 1 to 2 weeks by:

Chemotherapy, part 2

• Fluorouracil (5-FU) 250 mg/m²/day IV continuous infusion throughout radiation therapy

Radiotherapy

• Concurrent radiation therapy, 1.8 Gy fractions x 28 fractions given 5 days per week, for a total dose of 50.4 Gy. The last 5.4 Gy of the 50.4 Gy is limited to the tumor bed.

6-week course, followed in 3 to 5 weeks by:

Chemotherapy, part 3

• Gemcitabine (Gemzar) 1000 mg/m² IV over 30 minutes once per day on days 1, 8, 15

28-day cycle for 3 cycles

References

1. RTOG 9704: Regine WF, Winter KA, Abrams RA, Safran H, Hoffman JP, Konski A, Benson AB, Macdonald JS, Kudrimoti MR, Fromm ML, Haddock MG, Schaefer P, Willett CG, Rich TA. Fluorouracil vs gemcitabine chemotherapy before and after fluorouracil-based chemoradiation following resection of pancreatic adenocarcinoma: a randomized controlled trial. JAMA. 2008 Mar 5;299(9):1019-26. link to original article contains verified protocol PubMed NCT00003216
   1. Update: Regine WF, Winter KA, Abrams R, Safran H, Hoffman JP, Konski A, Benson AB, Macdonald JS, Rich TA, Willett CG. Fluorouracil-based chemoradiation with either gemcitabine or fluorouracil chemotherapy after resection of pancreatic adenocarcinoma: 5-year analysis of the US Intergroup/RTOG 9704 phase III trial. Ann Surg Oncol. 2011 May;18(5):1319-26. Epub 2011 Mar 10. link to original article link to PMC article PubMed

GemOx

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GemOx: Gemcitabine & Oxaliplatin

Regimen

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Edeline et al. 2019 (PRODIGE 12-ACCORD 18-UNICANCER GI)	2009-2014	Phase III (E-esc)	Observation	Did not meet primary endpoint of RFS

Preceding treatment

• Surgical resection with macroscopically curative resection

Chemotherapy

• Gemcitabine (Gemzar) 1000 mg/m² IV once on day 1
• Oxaliplatin (Eloxatin) 85 mg/m² IV once on day 2

14-day cycle for 12 cycles

References

1. PRODIGE 12-ACCORD 18-UNICANCER GI: Edeline J, Benabdelghani M, Bertaut A, Watelet J, Hammel P, Joly JP, Boudjema K, Fartoux L, Bouhier-Leporrier K, Jouve JL, Faroux R, Guerin-Meyer V, Kurtz JE, Assénat E, Seitz JF, Baumgaertner I, Tougeron D, de la Fouchardière C, Lombard-Bohas C, Boucher E, Stanbury T, Louvet C, Malka D, Phelip JM. Gemcitabine and Oxaliplatin Chemotherapy or Surveillance in Resected Biliary Tract Cancer (PRODIGE 12-ACCORD 18-UNICANCER GI): A Randomized Phase III Study. J Clin Oncol. 2019 Mar 10;37(8):658-667. Epub 2019 Feb 1. link to original article PubMed EudraCT 2008-004560-39

Metastatic disease, all lines of therapy

Capecitabine monotherapy

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Regimen

Study	Evidence
Patt et al. 2004	Retrospective

Chemotherapy

• Capecitabine (Xeloda) 1000 mg/m² PO twice per day on days 1 to 14

21-day cycles

References

1. Retrospective: Patt YZ, Hassan MM, Aguayo A, Nooka AK, Lozano RD, Curley SA, Vauthey JN, Ellis LM, Schnirer II, Wolff RA, Charnsangavej C, Brown TD. Oral capecitabine for the treatment of hepatocellular carcinoma, cholangiocarcinoma, and gallbladder carcinoma. Cancer. 2004 Aug 1;101(3):578-86. link to original article PubMed

Capecitabine & Mitomycin

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Regimen

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Kornek et al. 2004	2000-2001	Randomized Phase II (E-switch-ic)	Gemcitabine & Mitomycin	Might have superior ORR

Chemotherapy

• Capecitabine (Xeloda) 1000 mg/m² PO twice per day on days 1 to 14
• Mitomycin (Mutamycin) 8 mg/m² IV bolus once on day 1

Supportive medications

• Dexamethasone (Decadron) and 5-HT3 antagonists on the day of IV chemotherapy

28-day cycles

References

1. Kornek GV, Schuell B, Laengle F, Gruenberger T, Penz M, Karall K, Depisch D, Lang F, Scheithauer W. Mitomycin C in combination with capecitabine or biweekly high-dose gemcitabine in patients with advanced biliary tract cancer: a randomised phase II trial. Ann Oncol. 2004 Mar;15(3):478-83. link to original article contains verified protocol PubMed

CapeOx

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CapeOx: Capecitabine & Oxaliplatin
XELOX: XELoda (Capecitabine) & OXaliplatin

Regimen

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Kim et al. 2019 (SMC 2011-05-070)	2011-2016	Phase III (E-switch-ic)	GEMOX	Non-inferior PFS

Chemotherapy

• Capecitabine (Xeloda) 1000 mg/m² PO twice per day on days 1 to 14
• Oxaliplatin (Eloxatin) 130 mg/m² IV once on day 1

21-day cycle for 8 cycles

References

1. SMC 2011-05-070: Kim ST, Kang JH, Lee J, Lee HW, Oh SY, Jang JS, Lee MA, Sohn BS, Yoon SY, Choi HJ, Hong JH, Kim MJ, Kim S, Park YS, Park JO, Lim HY. Capecitabine plus oxaliplatin versus gemcitabine plus oxaliplatin as first-line therapy for advanced biliary tract cancers: a multicenter, open-label, randomized, phase III, noninferiority trial. Ann Oncol. 2019 May 1;30(5):788-795. link to original article contains protocol PubMed NCT01470443

Cisplatin & Gemcitabine (GC)

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GC: Gemcitabine & Cisplatin

Regimen

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Valle et al. 2010 (ABC-02)	2002-2008	Phase III (E-esc)	Gemcitabine	Superior OS Median OS: 11.7 vs 8.1 mo (HR 0.64, 95% CI 0.52-0.80)
Morizane et al. 2019 (FUGA-BT)	2013-2016	Phase III (C)	Gemcitabine & S-1	Seems to have non-inferior OS

Chemotherapy

• Cisplatin (Platinol) 25 mg/m² IV over 60 minutes once per day on days 1 & 8, given first
• Gemcitabine (Gemzar) 1000 mg/m² IV over 30 minutes once per day on days 1 & 8, given second

Supportive medications

• Cisplatin is mixed in a solution of 1 liter of normal saline with 20 mmol potassium chloride, 8 mmol magnesium sulfate
• After cisplatin, 500 mL normal saline given over 30 minutes

21-day cycle for 4 to 8 cycles depending on response

References

1. ABC-02: Valle J, Wasan H, Palmer DH, Cunningham D, Anthoney A, Maraveyas A, Madhusudan S, Iveson T, Hughes S, Pereira SP, Roughton M, Bridgewater J; ABC-02 Trial Investigators. Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Engl J Med. 2010 Apr 8;362(14):1273-81. link to original article contains verified protocol PubMed NCT00262769
2. FUGA-BT: Morizane C, Okusaka T, Mizusawa J, Katayama H, Ueno M, Ikeda M, Ozaka M, Okano N, Sugimori K, Fukutomi A, Hara H, Mizuno N, Yanagimoto H, Wada K, Tobimatsu K, Yane K, Nakamori S, Yamaguchi H, Asagi A, Yukisawa S, Kojima Y, Kawabe K, Kawamoto Y, Sugimoto R, Iwai T, Nakamura K, Miyakawa H, Yamashita T, Hosokawa A, Ioka T, Kato N, Shioji K, Shimizu K, Nakagohri T, Kamata K, Ishii H, Furuse J; JCOG. Combination gemcitabine plus S-1 versus gemcitabine plus cisplatin for advanced/recurrent biliary tract cancer: the FUGA-BT (JCOG1113) randomized phase III clinical trial. Ann Oncol. 2019 Dec 1;30(12):1950-1958. link to original article PubMed UMIN000010667
3. NuTide:121: NCT04163900
4. FIGHT-302: NCT03656536
5. SWOG S1815: NCT03768414

Cisplatin & Gemcitabine (GC) & nab-Paclitaxel

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Regimen

Study	Years of enrollment	Evidence
Shroff et al. 2019 (MDACC 2014-0524)	2015-2017	Phase II

Prolonged median PFS and OS vs reported for historical controls treated with gemcitabine-cisplatin alone. This is the dose after a mid-protocol amendment for hematologic toxicity.

Chemotherapy

• Cisplatin (Platinol) 25 mg/m² IV over 60 minutes once per day on days 1 & 8
• Gemcitabine (Gemzar) 800 mg/m² IV once per day on days 1 & 8
• Paclitaxel, nanoparticle albumin-bound (Abraxane) 100 mg/m² IV once per day on days 1 & 8

21-day cycles

References

1. MDACC 2014-0524: Shroff RT, Javle MM, Xiao L, Kaseb AO, Varadhachary GR, Wolff RA, Raghav KPS, Iwasaki M, Masci P, Ramanathan RK, Ahn DH, Bekaii-Saab TS, Borad MJ. Gemcitabine, cisplatin, and nab-paclitaxel for the treatment of advanced biliary tract cancers: a phase 2 clinical trial. JAMA Oncol. 2019 Jun 1;5(6):824-830. Epub 2019 Apr 18. link to original article contains protocol link to PMC article PubMed NCT02392637

ECF

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ECF: Epirubicin, Cisplatin, Fluorouracil

Regimen

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Rao et al. 2005	1997-2003	Phase III (E-switch-ic)	FELV	Did not meet primary endpoint of OS

Chemotherapy

• Epirubicin (Ellence) 50 mg/m² IV once on day 1
• Cisplatin (Platinol) 60 mg/m² IV once on day 1
• Fluorouracil (5-FU) 200 mg/m²/day IV continuous infusion over 21 days, started on day 1 (total dose per cycle: 4200 mg/m²)

21-day cycles

References

1. Rao S, Cunningham D, Hawkins RE, Hill ME, Smith D, Daniel F, Ross PJ, Oates J, Norman AR. Phase III study of 5FU, etoposide and leucovorin (FELV) compared to epirubicin, cisplatin and 5FU (ECF) in previously untreated patients with advanced biliary cancer. Br J Cancer. 2005 May 9;92(9):1650-4. link to original article contains verified protocol link to PMC article PubMed

Erlotinib & Bevacizumab

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Regimen

Study	Years of enrollment	Evidence
Lubner et al. 2010 (MC044G)	2006-2008	Phase II

Targeted therapy

• Erlotinib (Tarceva) 150 mg PO once per day
• Bevacizumab (Avastin) 5 mg/kg IV once per day on days 1 & 15

28-day cycles

References

1. MC044G: Lubner SJ, Mahoney MR, Kolesar JL, Loconte NK, Kim GP, Pitot HC, Philip PA, Picus J, Yong WP, Horvath L, Van Hazel G, Erlichman CE, Holen KD. Report of a multicenter phase II trial testing a combination of biweekly bevacizumab and daily erlotinib in patients with unresectable biliary cancer: a phase II Consortium study. J Clin Oncol. 2010 Jul 20;28(21):3491-7. Epub 2010 Jun 7. link to original article contains verified protocol link to PMC article PubMed NCT00356889

FELV

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FELV: Fluorouracil , Etoposide, LeucoVorin (Folinic acid)

Regimen variant #1, 500/120/60

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Glimelius et al. 1996	1991-1995	Phase III (E-esc)	Best supportive care	Superior OS

Chemotherapy

• Fluorouracil (5-FU) 500 mg/m² IV bolus once per day on days 1 to 3, given first
• Etoposide (Vepesid) 120 mg/m² IV over 40 minutes once per day on days 1 to 3, given second
• Folinic acid (Leucovorin) 60 mg/m² IV bolus once per day on days 1 to 3, given third

21-day cycles

Regimen variant #2, 600/120/60

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Rao et al. 2005	1997-2003	Phase III (C)	ECF	Did not meet primary endpoint of OS

Chemotherapy

• Fluorouracil (5-FU) 600 mg/m² IV bolus once per day on days 1 to 3, given first
• Etoposide (Vepesid) 120 mg/m² IV over 40 minutes once per day on days 1 to 3, given second
• Folinic acid (Leucovorin) 60 mg/m² IV bolus once per day on days 1 to 3, given third

21-day cycles

References

1. Glimelius B, Hoffman K, Sjödén PO, Jacobsson G, Sellström H, Enander LK, Linné T, Svensson C. Chemotherapy improves survival and quality of life in advanced pancreatic and biliary cancer. Ann Oncol. 1996 Aug;7(6):593-600. link to original article contains verified protocol PubMed content property of HemOnc.org
2. Rao S, Cunningham D, Hawkins RE, Hill ME, Smith D, Daniel F, Ross PJ, Oates J, Norman AR. Phase III study of 5FU, etoposide and leucovorin (FELV) compared to epirubicin, cisplatin and 5FU (ECF) in previously untreated patients with advanced biliary cancer. Br J Cancer. 2005 May 9;92(9):1650-4. link to original article contains verified protocol link to PMC article PubMed

FULV

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FULV: 5-FU & LeucoVorin (Folinic acid)
FUFA: 5-FU (Fluorouracil) & Folinic Acid

Regimen

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Glimelius et al. 1996	1991-1995	Phase III (E-esc)	Best supportive care	Superior OS

Chemotherapy

• Fluorouracil (5-FU) 500 mg/m² IV bolus once per day on days 1 & 2, given first
• Folinic acid (Leucovorin) 60 mg/m² IV bolus once per day on days 1 & 2, given second, 40 minutes after Fluorouracil (5-FU)

14-day cycles

References

1. Glimelius B, Hoffman K, Sjödén PO, Jacobsson G, Sellström H, Enander LK, Linné T, Svensson C. Chemotherapy improves survival and quality of life in advanced pancreatic and biliary cancer. Ann Oncol. 1996 Aug;7(6):593-600. link to original article contains verified protocol PubMed

FULV & Gemcitabine

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FULV & Gemcitabine: 5-FU, LeucoVorin (Folinic acid), Gemcitabine

Regimen

Study	Evidence
Gebbia et al. 2001	Phase II

Chemotherapy

• Fluorouracil (5-FU) 400 mg/m² IV bolus once on day 1, then 600 mg/m² IV continuous infusion over 22 hours (total dose per cycle: 1000 mg/m²)
• Folinic acid (Leucovorin) 100 mg/m² IV over 2 hours once on day 1
• Gemcitabine (Gemzar) 1000 mg/m² IV once per day on days 1 & 8

21-day cycles

References

1. Gebbia V, Giuliani F, Maiello E, Colucci G, Verderame F, Borsellino N, Mauceri G, Caruso M, Tirrito ML, Valdesi M. Treatment of inoperable and/or metastatic biliary tree carcinomas with single-agent gemcitabine or in combination with levofolinic acid and infusional fluorouracil: results of a multicenter phase II study. J Clin Oncol. 2001 Oct 15;19(20):4089-91. link to original article contains verified protocol PubMed

Gemcitabine monotherapy

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Regimen variant #1

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Valle et al. 2010 (ABC-02)	2002-2008	Phase III (E-de-esc)	Cisplatin & Gemcitabine	Inferior OS

Chemotherapy

• Gemcitabine (Gemzar) 1000 mg/m² IV over 30 minutes once per day on days 1, 8, 15

28-day cycle for 3 to 6 cycles depending on response

Regimen variant #2

Study	Evidence
Gebbia et al. 2001	Phase II

Chemotherapy

• Gemcitabine (Gemzar) 1000 mg/m² IV over 30 minutes once per day on days 1, 8, 15

30-day cycles

References

1. Gebbia V, Giuliani F, Maiello E, Colucci G, Verderame F, Borsellino N, Mauceri G, Caruso M, Tirrito ML, Valdesi M. Treatment of inoperable and/or metastatic biliary tree carcinomas with single-agent gemcitabine or in combination with levofolinic acid and infusional fluorouracil: results of a multicenter phase II study. J Clin Oncol. 2001 Oct 15;19(20):4089-91. link to original article contains verified protocol PubMed
2. ABC-02: Valle J, Wasan H, Palmer DH, Cunningham D, Anthoney A, Maraveyas A, Madhusudan S, Iveson T, Hughes S, Pereira SP, Roughton M, Bridgewater J; ABC-02 Trial Investigators. Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N Engl J Med. 2010 Apr 8;362(14):1273-81. link to original article contains verified protocol PubMed NCT00262769

Gemcitabine, Cisplatin, S-1

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GCS: Gemcitabine, Cisplatin, S-1

Regimen

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Sakai et al. 2018 (KHBO1401-MITSUBA)	2014-NR	Phase III (E-esc)	Cisplatin & Gemcitabine	Seems to have superior OS

Chemotherapy

• Cisplatin (Platinol) 25 mg/m² IV once on day 1
• Gemcitabine (Gemzar) 1000 mg/m² IV once on day 1
• Tegafur, gimeracil, oteracil (S-1) 80 mg/m² PO once per day on days 1 to 7

14-day cycles

References

1. Abstract: Sakai D, Kanai M , Kobayashi S, Eguchi H, Baba H, Seo S, Taketomi A, Takayama T, Yamaue H, Ishioka C, Sho M, Takeyama Y, Fujimoto J, Toyoda M, Shimizu J, Goto T, Yoshimura K, Hatano E, Nagano H, Ioka T. Randomized phase III study of gemcitabine, cisplatin plus S-1 (GCS) versus gemcitabine, cisplatin (GC) for advanced biliary tract cancer (KHBO1401-MITSUBA). Annals of Oncology 29 (Supplement 8): viii205–viii270, 2018 link to abstract NCT02182778

Gemcitabine & Mitomycin

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Regimen

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Kornek et al. 2004	2000-2001	Randomized Phase II (E-switch-ic)	Capecitabine & Mitomycin	Might have inferior ORR

Chemotherapy

• Gemcitabine (Gemzar) 2000 mg/m² IV over 30 minutes once per day on days 1 & 15
• Mitomycin (Mutamycin) 8 mg/m² IV bolus once on day 1

Supportive medications

• Dexamethasone (Decadron) and 5-HT3 antagonists on the day of IV chemotherapy

28-day cycles

References

1. Kornek GV, Schuell B, Laengle F, Gruenberger T, Penz M, Karall K, Depisch D, Lang F, Scheithauer W. Mitomycin C in combination with capecitabine or biweekly high-dose gemcitabine in patients with advanced biliary tract cancer: a randomised phase II trial. Ann Oncol. 2004 Mar;15(3):478-83. link to original article contains verified protocol PubMed

Gemcitabine & nab-Paclitaxel

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NG: Nab-Paclitaxel & Gemcitabine

Regimen

Study	Years of enrollment	Evidence
Sahai et al. 2018 (PrE0204)	2014-2016	Phase II

Note: this regimen was intended for ECOG PS 0 to 2, and Child-Pugh score less than 8.

Chemotherapy

• Gemcitabine (Gemzar) 1000 mg/m² IV once per day on days 1, 8, 15
• Paclitaxel, nanoparticle albumin-bound (Abraxane) 125 mg/m² IV once per day on days 1, 8, 15

28-day cycles

References

1. PrE0204: Sahai V, Catalano PJ, Zalupski MM, Lubner SJ, Menge MR, Nimeiri HS, Munshi HG, Benson AB 3rd, O'Dwyer PJ. nab-Paclitaxel and gemcitabine as first-line treatment of advanced or metastatic cholangiocarcinoma: a phase 2 clinical trial. JAMA Oncol. 2018 Dec 1;4(12):1707-1712. link to original article contains protocol link to PMC article PubMed NCT02181634

Gemcitabine & S-1

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GS: Gemcitabine & S-1

Regimen

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Morizane et al. 2019 (FUGA-BT)	2013-2016	Phase III (E-switch-ic)	Gemcitabine & Cisplatin	Seems to have non-inferior OS

Chemotherapy

• Gemcitabine (Gemzar)
• Tegafur, gimeracil, oteracil (S-1)

References

1. FUGA-BT: Morizane C, Okusaka T, Mizusawa J, Katayama H, Ueno M, Ikeda M, Ozaka M, Okano N, Sugimori K, Fukutomi A, Hara H, Mizuno N, Yanagimoto H, Wada K, Tobimatsu K, Yane K, Nakamori S, Yamaguchi H, Asagi A, Yukisawa S, Kojima Y, Kawabe K, Kawamoto Y, Sugimoto R, Iwai T, Nakamura K, Miyakawa H, Yamashita T, Hosokawa A, Ioka T, Kato N, Shioji K, Shimizu K, Nakagohri T, Kamata K, Ishii H, Furuse J. Combination gemcitabine plus S-1 versus gemcitabine plus cisplatin for advanced/recurrent biliary tract cancer: the FUGA-BT (JCOG1113) randomized phase III clinical trial. Ann Oncol. 2019 Dec 1;30(12):1950-1958. link to original article PubMed UMIN000010667

GemOx

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GemOx: Gemcitabine & Oxaliplatin
GEMOX: GEMcitabine & OXaliplatin

Regimen variant #1, 1000/85, bi-weekly

Study	Evidence	Efficacy
Halim et al. 2011	Phase II	ORR: 27.5%

Chemotherapy

• Gemcitabine (Gemzar) 1000 mg/m² IV over 30 minutes once on day 1, given first
• Oxaliplatin (Eloxatin) 85 mg/m² IV over 2 hours once on day 1, given second

14-day cycles

Regimen variant #2, 1000/100, bi-weekly

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Lee et al. 2011 (SMC 2008-12-024)	2009-2010	Phase III (C)	GEMOX & Erlotinib	Might have inferior PFS

Chemotherapy

• Gemcitabine (Gemzar) 1000 mg/m² IV once on day 1
• Oxaliplatin (Eloxatin) 100 mg/m² IV once on day 2

14-day cycles

Regimen variant #3, 1000/100, 2 weeks out of 3

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Kim et al. 2019 (SMC 2011-05-070)	2011-2016	Phase III (C)	XELOX	Non-inferior PFS

Chemotherapy

• Gemcitabine (Gemzar) 1000 mg/m² IV once per day on days 1 & 8
• Oxaliplatin (Eloxatin) 100 mg/m² IV once on day 1

21-day cycle for 8 cycles

Regimen variant #4, 1000/100 ("GEMOX-3")

Study	Evidence	Efficacy
Harder et al. 2006	Phase II	ORR: 26% (95% CI 14–44)

GEMOX-3: GEMcitabine & OXaliplatin, 3 visits per month

Chemotherapy

• Gemcitabine (Gemzar) 1000 mg/m² IV over 30 minutes once per day on days 1, 8, 15, given first
• Oxaliplatin (Eloxatin) 100 mg/m² IV over 2 hours once per day on days 1 & 15, given second

28-day cycles

References

1. Harder J, Riecken B, Kummer O, Lohrmann C, Otto F, Usadel H, Geissler M, Opitz O, Henss H. Outpatient chemotherapy with gemcitabine and oxaliplatin in patients with biliary tract cancer. Br J Cancer. 2006 Oct 9;95(7):848-52. link to original article link to PMC article contains verified protocol PubMed
2. Halim A, Ebrahim MA, Saleh Y. A phase II study of outpatient biweekly gemcitabine-oxaliplatin in advanced biliary tract carcinomas. Jpn J Clin Oncol. 2011 Feb;41(2):217-24. link to original article contains verified protocol PubMed
3. SMC 2008-12-024: Lee J, Park SH, Chang HM, Kim JS, Choi HJ, Lee MA, Jang JS, Jeung HC, Kang JH, Lee HW, Shin DB, Kang HJ, Sun JM, Park JO, Park YS, Kang WK, Lim HY. Gemcitabine and oxaliplatin with or without erlotinib in advanced biliary-tract cancer: a multicentre, open-label, randomised, phase 3 study. Lancet Oncol. 2012 Feb;13(2):181-8. Epub 2011 Dec 20. link to original article contains protocol PubMed NCT01149122
4. SMC 2011-05-070: Kim ST, Kang JH, Lee J, Lee HW, Oh SY, Jang JS, Lee MA, Sohn BS, Yoon SY, Choi HJ, Hong JH, Kim MJ, Kim S, Park YS, Park JO, Lim HY. Capecitabine plus oxaliplatin versus gemcitabine plus oxaliplatin as first-line therapy for advanced biliary tract cancers: a multicenter, open-label, randomized, phase III, noninferiority trial. Ann Oncol. 2019 May 1;30(5):788-795. link to original article contains protocol PubMed NCT01470443

GEMOX-B

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GEMOX-B: GEMcitabine, OXaliplatin, Bevacizumab

Regimen

Study	Evidence
Zhu et al. 2009 (MGH 05-349)	Phase II

Chemotherapy

• Gemcitabine (Gemzar) 1000 mg/m² IV over 100 minutes once per day on days 1 & 15, given second
• Oxaliplatin (Eloxatin) 85 mg/m² IV over 2 hours once per day on days 1 & 15, given third

Targeted therapy

• Bevacizumab (Avastin) 10 mg/kg IV once per day on days 1 & 15, given first

28-day cycles

References

1. MGH 05-349: Zhu AX, Meyerhardt JA, Blaszkowsky LS, Kambadakone AR, Muzikansky A, Zheng H, Clark JW, Abrams TA, Chan JA, Enzinger PC, Bhargava P, Kwak EL, Allen JN, Jain SR, Stuart K, Horgan K, Sheehan S, Fuchs CS, Ryan DP, Sahani DV. Efficacy and safety of gemcitabine, oxaliplatin, and bevacizumab in advanced biliary-tract cancers and correlation of changes in 18-fluorodeoxyglucose PET with clinical outcome: a phase 2 study. Lancet Oncol. 2010 Jan;11(1):48-54. Epub 2009 Nov 20. link to original article contains verified protocol PubMed NCT00361231

Pembrolizumab monotherapy

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Regimen

Study	Years of enrollment	Evidence
Le et al. 2017 (KEYNOTE-016)	2013-2016	Phase II, <20 pts of this subtype

Note: KEYNOTE-016 was an expansion to a CRC-specific trial.

Immunotherapy

• Pembrolizumab (Keytruda) 10 mg/kg IV once on day 1

14-day cycle for up to 52 cycles (2 years)

References

1. KEYNOTE-016: Le DT, Durham JN, Smith KN, Wang H, Bartlett BR, Aulakh LK, Lu S, Kemberling H, Wilt C, Luber BS, Wong F, Azad NS, Rucki AA, Laheru D, Donehower R, Zaheer A, Fisher GA, Crocenzi TS, Lee JJ, Greten TF, Duffy AG, Ciombor KK, Eyring AD, Lam BH, Joe A, Kang SP, Holdhoff M, Danilova L, Cope L, Meyer C, Zhou S, Goldberg RM, Armstrong DK, Bever KM, Fader AN, Taube J, Housseau F, Spetzler D, Xiao N, Pardoll DM, Papadopoulos N, Kinzler KW, Eshleman JR, Vogelstein B, Anders RA, Diaz LA Jr. Mismatch repair deficiency predicts response of solid tumors to PD-1 blockade. Science. 2017 Jul 28;357(6349):409-413. Epub 2017 Jun 8. link to original article link to PMC article contains verified protocol in supplement PubMed NCT01876511

Pemigatinib monotherapy

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Regimen

Study	Evidence
Abou-Alfa et al. 2020 (FIGHT-202)	Phase II (RT)

Note: Patients with previously treated unresectable or metastatic disease.

Biomarker eligibility criteria

• Fibroblast growth factor receptor 2 (FGFR2) fusion or other rearrangement

Targeted therapy

• Pemigatinib (Pemazyre) 13.5 mg PO once per day on days 1 to 14

21-day cycles

References

1. FIGHT-202: Abou-Alfa GK, Sahai V, Hollebecque A, Vaccaro G, Melisi D, Al-Rajabi R, Paulson AS, Borad MJ, Gallinson D, Murphy AG, Oh DY, Dotan E, Catenacci DV, Van Cutsem E, Ji T, Lihou CF, Zhen H, Féliz L, Vogel A. Pemigatinib for previously treated, locally advanced or metastatic cholangiocarcinoma: a multicentre, open-label, phase 2 study. Lancet Oncol. 2020 May;21(5):671-684. Epub 2020 Mar 20 link to original article contains verified protocol in supplement PubMed NCT02924376

Metastatic disease, subsequent lines of therapy

mFOLFOX6

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mFOLFOX6: modified FOLinic acid, Fluorouracil, OXaliplatin

Regimen

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Lamarca et al. 2021 (ABC-06)	2014-2018	Phase III (E-esc)	Active symptom control	Seems to have superior OS Median OS: 6.2 mo vs 5.3 mo (HR 0.69, 95% CI 0.50-0.97)

Chemotherapy

• Fluorouracil (5-FU) 400 mg/m² IV bolus once on day 1, then 2400 mg/m² IV continuous infusion over 46 hours (total dose per cycle: 2800 mg/m²)
• Folinic acid (Leucovorin) 350 mg/m² IV once on day 1
• Oxaliplatin (Eloxatin) 85 mg/m² IV over 2 hours once on day 1

14-day cycle for up to 12 cycles

References

1. ABC-06: Lamarca A, Palmer DH, Wasan HS, Ross PJ, Ma YT, Arora A, Falk S, Gillmore R, Wadsley J, Patel K, Anthoney A, Maraveyas A, Iveson T, Waters JS, Hobbs C, Barber S, Ryder WD, Ramage J, Davies LM, Bridgewater JA, Valle JW; Advanced Biliary Cancer Working Group. Second-line FOLFOX chemotherapy versus active symptom control for advanced biliary tract cancer (ABC-06): a phase 3, open-label, randomised, controlled trial. Lancet Oncol. 2021 Mar 30:S1470-2045(21)00027-9. Epub ahead of print. link to original article PubMed NCT01926236

mFOLFOX6 (L-Leucovorin)

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mFOLFOX6: modified FOLinic acid, Fluorouracil, OXaliplatin

Regimen

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Lamarca et al. 2021 (ABC-06)	2014-2018	Phase III (E-esc)	Active symptom control	Seems to have superior OS Median OS: 6.2 mo vs 5.3 mo (HR 0.69, 95% CI 0.50-0.97)

Chemotherapy

• Fluorouracil (5-FU) 400 mg/m² IV bolus once on day 1, then 2400 mg/m² IV continuous infusion over 46 hours (total dose per cycle: 2800 mg/m²)
• Levoleucovorin (Fusilev) 175 mg/m² IV once on day 1
• Oxaliplatin (Eloxatin) 85 mg/m² IV over 2 hours once on day 1

14-day cycle for up to 12 cycles

References

1. ABC-06: Lamarca A, Palmer DH, Wasan HS, Ross PJ, Ma YT, Arora A, Falk S, Gillmore R, Wadsley J, Patel K, Anthoney A, Maraveyas A, Iveson T, Waters JS, Hobbs C, Barber S, Ryder WD, Ramage J, Davies LM, Bridgewater JA, Valle JW; Advanced Biliary Cancer Working Group. Second-line FOLFOX chemotherapy versus active symptom control for advanced biliary tract cancer (ABC-06): a phase 3, open-label, randomised, controlled trial. Lancet Oncol. 2021 Mar 30:S1470-2045(21)00027-9. Epub ahead of print. link to original article PubMed NCT01926236

Infigratinib monotherapy

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Regimen

FDA-recommended dose

Study	Years of enrollment	Evidence
Javle et al. 2017 (CBGJ398X2204)	2014-NR	Phase II (RT)

Biomarker eligibility criteria

• FGFR2 gene fusions or translocations or other FGFR genetic alterations

Targeted therapy

• Infigratinib (Truseltiq) 125 mg PO once per day on days 1 to 21

28-day cycles

References

1. CBGJ398X2204: Javle M, Lowery M, Shroff RT, Weiss KH, Springfeld C, Borad MJ, Ramanathan RK, Goyal L, Sadeghi S, Macarulla T, El-Khoueiry A, Kelley RK, Borbath I, Choo SP, Oh DY, Philip PA, Chen LT, Reungwetwattana T, Van Cutsem E, Yeh KH, Ciombor K, Finn RS, Patel A, Sen S, Porter D, Isaacs R, Zhu AX, Abou-Alfa GK, Bekaii-Saab T. Phase II study of BGJ398 in patients with FGFR-altered advanced cholangiocarcinoma. J Clin Oncol. 2018 Jan 20;36(3):276-282. Epub 2017 Nov 28. link to original article link to PMC article contains verified protocol PubMed NCT02150967

Ivosidenib monotherapy

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Regimen

Study	Years of enrollment	Evidence	Comparator	Comparative Efficacy
Abou-Alfa et al. 2020 (ClarIDHy)	2017-2019	Phase III (E-esc)	Placebo	Superior PFS

Note: Patients with unresectable or metastatic disease with IDH1 mutation with progression after at least one prior systemic therapy.

Biomarker eligibility criteria

• IDH1 mutation

Targeted therapy

• Ivosidenib (Tibsovo) 500 mg PO once per day

28-day cycles

References

1. ClarIDHy: Abou-Alfa GK, Macarulla T, Javle MM, Kelley RK, Lubner SJ, Adeva J, Cleary JM, Catenacci DV, Borad MJ, Bridgewater J, Harris WP, Murphy AG, Oh DY, Whisenant J, Lowery MA, Goyal L, Shroff RT, El-Khoueiry AB, Fan B, Wu B, Chamberlain CX, Jiang L, Gliser C, Pandya SS, Valle JW, Zhu AX. Ivosidenib in IDH1-mutant, chemotherapy-refractory cholangiocarcinoma (ClarIDHy): a multicentre, randomised, double-blind, placebo-controlled, phase 3 study. Lancet Oncol. 2020 Jun;21(6):796-807. Epub 2020 May 13. Erratum in: Lancet Oncol. 2020 Oct;21(10):e462. link to original article contains protocol link to PMC article PubMed NCT02989857

Regorafenib monotherapy

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Regimen

Study	Years of enrollment	Evidence
Sun et al. 2019 (UPMC 13-100)	2014-2017	Phase II

Only studied in patients with advanced biliary cancer who failed at least 1 line of systemic therapy.

Targeted therapy

• Regorafenib (Stivarga) 120 mg PO once per day on days 1 to 21

28-day cycles

References

1. UPMC 13-100: Sun W, Patel A, Normolle A, Patel K, Ohr J, Lee JJ, Bahary N, Chu E, Streeter N, Drummond S. A phase 2 trial of regorafenib as a single agent in patients with chemotherapy-refractory, advanced, and metastatic biliary tract adenocarcinoma. Cancer. 2019 Mar 15;125(6):902-909. Epub 2018 Dec 18. link to original article link to PMC article PubMed NCT02053376