ESMO GI 2025 | Advanced biliary cancer: expert care & molecular-guided treatment

In biliary tract cancer we discuss the patients with advanced disease so what is important here is there are some points that are important for biliary tract cancer. Patients should be managed at expert centers, should be treated at expert center, should be evaluated by a a multidisciplinary team that is expert in biliary tract cancer should receive molecular testing as soon as possible to have all the information that we need for the selection of treatment. The treatment now for patients with advanced biliary tract cancer is represented in first line by the combination of chemotherapy and immunotherapy, cisplatin, gemcitabine, plus durvalumab or pembrolizumab. We have two positive phase 3 trials. But the second line treatment should be defined according to the molecular alterations and if they are actionable and if there are drugs available. So the molecular profiling is really important. And according to the ESMO guideline, should be done before or during first line. So when patients progress, because almost all the patients progress on first line, we already have the molecular profile and then we can select the second line treatment. And we discussed the second line treatment. We now have different drugs approved according to the different molecular alterations. For IDH1 mutation, we have ivosidenib. For FGFR2 gene fusions, we have pemigatinib and futibatinib. For HER2, we have zanidatamab, that is a bispecific antibody. And there are other alterations with drugs that are available based on agnostic approval, or they are not approved, but they can be available in clinical trials. So the molecular profiling is key. So overall, what we discuss is that the best approach to the treatment for patients with advanced disease, including chemoimmunotherapy in first line, targeted agents in second line, and the importance of the multidisciplinary team discussion and the importance of the molecular profiling.