Role of ctDNA in Genetic Profiling & Outcomes for Advanced BTC

Официальное название

Role of Circulating Tumor DNA (ctDNA) in Genetic Profiling and Clinical Outcomes for Advanced Biliary Tract Cancer (BTC) Patients - A Multicenter, Prospective, Observational Epidemiology Study

Обзор

Biliary tract cancer (BTC) is a rare and heterogeneous disease with high incidence and mortality in Korea. Molecular profiling has enabled the identification of actionable alterations such as Isocitrate Dehydrogenase 1 (IDH1) mutations, FGFR2 fusions, ERBB2 amplifications, and dMMR/MSI-H status. However, the utility of tumor tissue-based next-generation sequencing (NGS) is often limited by difficulties in obtaining adequate tissue samples and the lack of in-house sequencing capacity across many hospitals. Circulating tumor DNA (ctDNA) analysis offers a minimally invasive alternative that can provide rapid and reliable genomic profiling. In a previous study, ctDNA testing showed high concordance with tissue-based genomic profiling for clinically significant alterations, particularly IDH1 mutations, and identified additional mutations not detected in tumor tissue. These findings suggest that ctDNA may expand access to targeted therapies such as ivosidenib . This multicenter, prospective, observational epidemiology study, organized by the Korean Cancer Study Group (KCSG) Biliary Tract Cancer Subcommittee, will evaluate the clinical utility of ctDNA-based genomic profiling in patients with advanced BTC. The study will assess concordance between ctDNA and tumor tissue sequencing, describe the prevalence of actionable alterations, and explore the impact of ctDNA testing on treatment decisions and clinical outcomes. By leveraging a nationwide network of BTC specialists, this study seeks to validate ctDNA as a feasible and scalable tool for precision oncology, supporting timely and personalized therapy for patients with BTC.

Подробное описание

Biliary tract cancer (BTC) encompasses a rare and diverse group of tumors characterized by varying anatomical locations-including extrahepatic, intrahepatic, and gallbladder lesions. Therapeutic innovations in advanced BTC are hindered by the rarity and heterogeneity of its subtypes, with particularly high incidence and mortality rates observed in Korea.

Recent advances in molecular profiling have enabled the identification of potential therapeutic targets for BTC. These findings have led to the approval of several therapies for BTC, including those targeting IDH1 mutations, FGFR2 fusions, ERBB2 amplifications, as well as immunotherapies for DNA mismatch repair-deficient (dMMR) or microsatellite instability-high (MSI-H) subtypes. Genomic profiling is essential to detect these targetable alterations, helping to guide appropriate, targeted therapies for patients with BTC. Traditional genomic profiling is typically conducted using formalin-fixed paraffin-embedded (FFPE) tumor tissues; therefore, the challenge of obtaining adequate tumor tissue samples in BTC can impede molecular evaluations. Circulating tumor DNA (ctDNA) from blood may offer an alternative to tissue-based analysis.

In a previous study, the investigators assessed the concordance between ctDNA and tissue genomic profiling in a large cohort of Asian patients with advanced BTC and evaluated the feasibility of liquid biopsy in the treatment of BTC. As a result, ctDNA-based genotyping exhibited acceptable concordance with tissue genomic profiling for clinically significant mutations classified as tier 1 or 2, with a sensitivity of 84.8% and a positive predictive value (PPV) of 79.4%. Notably, high concordance of actionable alterations between ctDNA and tissue for IDH1 mutations was observed, with 100% sensitivity (5/5) and 71.4% PPV (5/7), and for FGFR2 fusions with 66.7% sensitivity (2/3) and 100% PPV (2/2). Additionally, using ctDNA, five IDH1 mutations were identified in tissue samples and two additional IDH1 mutations were detected only in ctDNA.

The IDH1 mutations have significant clinical implications for patients with BTC due to their considerable frequency (approximately 13% in intrahepatic cholangiocarcinoma; range, 9-20%) and the availability of targeted therapy; ivosidenib was approved by both the U.S. Food and Drug Administration (FDA) and the Ministry of Food and Drug Safety (MFDS) in Korea. Although relatively high concordance between ctDNA and tumor tissue for IDH1 mutations was found, the occurrence of these alterations was low, and a more comprehensive comparative analysis is warranted. Therefore, the validation of ctDNA genomic profiling in a larger cohort of patients with BTC is not just a suggestion, but a pressing need to establish its potential as a promising approach for guiding personalized treatment strategies.

Justification for ctDNA in BTC:

The Korean Cancer Study Group (KCSG) Biliary Tract Cancer Subcommittee includes nearly 100 specialists from hospitals across the country. However, not all hospitals in Korea have in-house capabilities for NGS (Next-Generation Sequencing), making it challenging to implement NGS as recommended in biliary tract cancer treatment guidelines. In contrast, ctDNA allows for the detection of a patient's genetic alterations through a simple, non-invasive blood sampling process. This method can identify targetable alterations, facilitating appropriate treatments. Additionally, ctDNA offers a shorter turnaround time, which can help shorten diagnostic timelines and streamline patient access to treatments like ivosidenib.

Long-Term Benefits:

As demonstrated in a recently published study by Immune \& Biotech Diagnostics (IMBDx, Seoul, South Korea), IMBDx's ctDNA test, Alpha Liquid 100, not only identified all five cases of IDH1 mutation detected by conventional tissue NGS but also identified two additional IDH1 mutations that tissue NGS failed to detect. This capability could enable more patients to access treatment with ivosidenib. Moreover, if ctDNA-based NGS testing becomes routine within the KCSG Biliary Tract Cancer Subcommittee, which includes a substantial number of specialists dedicated to treating biliary tract cancer in Korea, it is likely that the use of ctDNA for IDH1 mutation detection will continue beyond this study.

Вмешательства

• Генная терапия Circulating Tumor DNA (ctDNA) Testing (ctDNA-based Next-Generation Sequencing (NGS))
  Peripheral blood will be collected from patients with advanced biliary tract cancer for circulating tumor DNA (ctDNA) testing. Next-generation sequencing (NGS) will be performed to detect clinically relevant genomic alterations, including IDH1 mutations, FGFR2 fusions, ERBB2 amplifications, and MSI-H/dMMR. The ctDNA results will be compared with tissue-based genomic profiling to evaluate concordance and clinical utility.

Первичные конечные точки

• Concordance Between ctDNA and Tissue-Based Genomic Profiling [Срок оценки: Within 4 weeks of study enrollment, prior to initiation of systemic therapy]

Вторичные конечные точки (3)

• Detection Rate of Actionable Alterations using ctDNA [Срок оценки: At baseline (prior to treatment initiation, within 4 weeks of enrollment)]
• Positive Predictive Value (PPV) and Sensitivity of ctDNA [Срок оценки: At baseline (prior to treatment initiation, within 4 weeks of enrollment)]
• Feasibility of ctDNA Testing in Clinical Practice [Срок оценки: From baseline through study completion, up to 24 months]

Критерии участия

Критерии включения

• Patients with histologically confirmed advanced or metastatic biliary tract cancer (including intrahepatic cholangiocarcinoma, extrahepatic cholangiocarcinoma, and gallbladder cancer).
• Patients who meet one of the following conditions:

• Patients prior to initiation of first-line systemic chemotherapy, or
• Patients previously treated with systemic chemotherapy who can provide a blood sample immediately before starting subsequent therapy.
• Age ≥ 19 years at the time of enrollment.
• Willingness to provide a blood sample for ctDNA analysis.

Критерии исключения

• Patients who refuse to provide blood samples for ctDNA testing.
• Patients unable to provide written informed consent.
• Patients concurrently enrolled in a similar study within the same institution. Prior screening will be performed to prevent duplicate enrollment.

Критерии приведены из реестра в оригинале (на английском). Окончательную оценку соответствия проводит исследовательский центр.

Здоровые добровольцы: Нет

Дизайн исследования

Модель наблюдения

Когортное

Центры проведения

South Korea · 1 центр

• Bundang CHA Medical Center — Seongnam-si

Публикации

• Baria K, De Toni EN, Yu B, Jiang Z, Kabadi SM, Malvezzi M. Worldwide Incidence and Mortality of Biliary Tract Cancer. Gastro Hep Adv. 2022 Apr 15;1(4):618-626. doi: 10.1016/j.gastha.2022.04.007. eCollection 2022. PMID 39132071
• Valle JW, Lamarca A, Goyal L, Barriuso J, Zhu AX. New Horizons for Precision Medicine in Biliary Tract Cancers. Cancer Discov. 2017 Sep;7(9):943-962. doi: 10.1158/2159-8290.CD-17-0245. Epub 2017 Aug 17. PMID 28818953
• 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- PMID 32416072
• Zhu AX, Macarulla T, Javle MM, Kelley RK, Lubner SJ, Adeva J, Cleary JM, Catenacci DVT, Borad MJ, Bridgewater JA, Harris WP, Murphy AG, Oh DY, Whisenant JR, Lowery MA, Goyal L, Shroff RT, El-Khoueiry AB, Chamberlain CX, Aguado-Fraile E, Choe S, Wu B, Liu H, Gliser C, Pandya SS, Valle JW, Abou-Alfa GK. Final Overall Survival Efficacy Results of Ivosidenib for Patients With Advanced Cholangiocarcino PMID 34554208
• 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, Feliz 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. doi: 10.1016/S1470-2045(20)30 PMID 32203698
• Javle M, Roychowdhury S, Kelley RK, Sadeghi S, Macarulla T, Weiss KH, Waldschmidt DT, Goyal L, Borbath I, El-Khoueiry A, Borad MJ, Yong WP, Philip PA, Bitzer M, Tanasanvimon S, Li A, Pande A, Soifer HS, Shepherd SP, Moran S, Zhu AX, Bekaii-Saab TS, Abou-Alfa GK. Infigratinib (BGJ398) in previously treated patients with advanced or metastatic cholangiocarcinoma with FGFR2 fusions or rearrangements: PMID 34358484
• Javle M, Borad MJ, Azad NS, Kurzrock R, Abou-Alfa GK, George B, Hainsworth J, Meric-Bernstam F, Swanton C, Sweeney CJ, Friedman CF, Bose R, Spigel DR, Wang Y, Levy J, Schulze K, Cuchelkar V, Patel A, Burris H. Pertuzumab and trastuzumab for HER2-positive, metastatic biliary tract cancer (MyPathway): a multicentre, open-label, phase 2a, multiple basket study. Lancet Oncol. 2021 Sep;22(9):1290-1300. PMID 34339623
• Le DT, Kim TW, Van Cutsem E, Geva R, Jager D, Hara H, Burge M, O'Neil B, Kavan P, Yoshino T, Guimbaud R, Taniguchi H, Elez E, Al-Batran SE, Boland PM, Crocenzi T, Atreya CE, Cui Y, Dai T, Marinello P, Diaz LA Jr, Andre T. Phase II Open-Label Study of Pembrolizumab in Treatment-Refractory, Microsatellite Instability-High/Mismatch Repair-Deficient Metastatic Colorectal Cancer: KEYNOTE-164. J Clin On PMID 31725351

Идентификаторы

NCT: NCT07142226 · CHAMC2025-03-043

Первоисточники (государственные реестры)

• ClinicalTrials.gov (NIH, США)

Открыть это исследование на ClinicalTrials.gov ↗