Assessment of Hepatic Arterial Infusion of Floxuridine in Combination With Systemic Gemcitabine and Oxaliplatin in Patients With Unresectable Intrahepatic Cholangiocarcinoma A Phase 2 Clinical Trial

Importance Unresectable intrahepatic cholangiocarcinoma (IHC) carries a poor prognosis, with a median overall survival (OS) of 11 months. Hepatic arterial infusion (HAI) of high-dose chemotherapy may have potential benefit in these patients. Objective To evaluate clinical outcomes when HAI chemotherapy is combined with systemic chemotherapy in patients with unresectable IHC. Design, Setting, and Participants A single-institution, phase 2 clinical trial including 38 patients was conducted with HAI floxuridine plus systemic gemcitabine and oxaliplatin in patients with unresectable IHC at Memorial Sloan Kettering Cancer Center between May 20, 2013, and June 27, 2019. A confirmatory phase 1/2 study using the same therapy was conducted during the same time period at Washington University in St Louis. Patients with histologically confirmed, unresectable IHC were eligible. Resectable metastatic disease to regional lymph nodes and prior systemic therapy were permitted. Patients with distant metastatic disease were excluded. Interventions Hepatic arterial infusion of floxuridine and systemic administration of gemcitabine and oxaliplatin. Main Outcomes and Measures The primary outcome was progression-free survival (PFS) of 80% at 6 months. Results For the phase 2 clinical trial at Memorial Sloan Kettering Cancer Center, 42 patients with unresectable IHC were included and, of these, 38 patients were treated (13 [34%] men; median [range] age at diagnosis, 64 [39-81] years). The median follow-up was 30.5 months. Twenty-two patients (58%) achieved a partial radiographic response, and 32 patients (84%) achieved disease control at 6 months. Four patients had sufficient response to undergo resection, and 1 patient had a complete pathologic response. The median PFS was 11.8 months (1-sided 90% CI, 11.1) with a 6-month PFS rate of 84.1% (90% CI, 74.8%-infinity), thereby meeting the primary end point (6-month PFS rate, 80%). The median OS was 25.0 months (95% CI, 20.6-not reached), and the 1-year OS rate was 89.5% (95% CI, 80.2%-99.8%). Patients with resectable regional lymph nodes (18 [47%]) showed no difference in OS compared with patients with node-negative disease (24-month OS: lymph node negative: 60%; 95% CI, 40%-91% vs lymph node positive: 50%; 95% CI, 30%-83%; P = .66). Four patients (11%) had grade 4 toxic effects requiring removal from the study (1 portal hypertension, 2 gastroduodenal artery aneurysms, 1 infection in the pump pocket). Subgroup analysis showed significant improvement in survival in patients with IDH1/2 mutated tumors (2-year OS, 90%; 95% CI, 73%-99%) vs wild-type (2-year OS, 33%; 95% CI, 18%-63%) (P = .01). In the Washington University in St Louis confirmatory cohort, 9 patients (90%) achieved disease control at 6 months; the most common grade 3 toxic effect was elevated results of liver function tests, and median PFS was 12.8 months (1-sided 90% CI, 6.4). Conclusions and Relevance Hepatic arterial infusion plus systemic chemotherapy appears to be highly active and tolerable in patients with unresectable IHC; further evaluation is warranted. This phase 2 clinical trial evaluates the use of hepatic arterial infusion of floxuridine plus systemic administration of gemcitabine and oxaliplatin in patients with unresectable intrahepatic cholangiocarcinoma. Question Is hepatic arterial infusion of floxuridine in combination with systemic gemcitabine and oxaliplatin associated with improved outcomes in patients with unresectable intrahepatic cholangiocarcinoma? Findings In this single-arm, phase 2 clinical trial, 38 patients with unresectable intrahepatic cholangiocarcinoma were treated with hepatic arterial infusion of floxuridine in combination with systemic gemcitabine and oxaliplatin, with 58% of the patients achieving an objective radiographic response and 84% achieving disease control. Median overall survival was 25.0 months, and 4 patients had sufficient response to undergo resection; lymph node status did not appear to be associated with clinical benefit. Meaning Combination hepatic arterial infusion floxuridine with systemic chemotherapy appears to be clinically active in patients with unresectable intrahepatic cholangiocarcinoma and should be investigated further.