In advanced Biliary Tract Cancers (aBTCs), RAF alterations define a rare subset of patients (pts) and may predict response to inhibition of the BRAF/MEK/ERK signaling pathway. BRAF mutations are grouped in activating RAS-independent mutations (muts) signaling as monomers (class I) or as dimers (class II) and in RAS-dependent mutations with impaired kinase activity or kinase-dead (class III). Moreover, BRAF+MEK inhibitors have been FDA-approved for pts affected by BRAFV600E (class I) mutated aBTC, but real-word data on their efficacy are still lacking. The B-REAL study aims at evaluating 1) the molecular landscape of BRAF-altered aBTC, 2) the clinical characteristics of aBTC pts with BRAF alterations, and 3) the prognostic and predictive impact of BRAF alterations in pts treated with first-line chemotherapy and targeted therapy. To date, data of advanced BTCs pts treated at five Italian referral centers with available BRAF status were collected. Clinical characteristics and outcomes from standard therapy and BRAF+MEK inhibitors of patients with BRAF class I vs BRAF class II-III vs BRAF wild-type (WT) were compared. Out of 764 pts screened, 628 pts with available clinical data and BRAF status were here included, with 413 (66%) affected by intrahepatic (iCCA), 124 (20%) by extrahepatic cholangiocarcinoma and 84 (13%) by gallbladder carcinoma. BRAF alterations were found in 29 (4.6%) pts, with 15 (2.4%) BRAFV600E class I muts and 14 (2.2%) BRAFnot-V600E muts (2 class II, 9 class III and 3 of unknown significance); BRAF alterations were mostly found in iCCA (87% of BRAFV600E and 57% of BRAFnot-V600E). Patients with BRAF class I muts were younger (p=0.007) and more frequently females (p= 0.044), compared to class II-III muts and WT cases. No significant difference between BRAF WT, BRAF class I and class II-III muts pts was highlighted in terms of overall survival (OS, 17.4 vs 16.1 vs 13.2 months, p=0.831) and progression-free survival (PFS) to first-line chemotherapy (3.9 vs 5.0 vs 6.0 months, p=0.632). Nine patients with aBTC BRAFV600E mutated were treated with BRAF+/-MEK inhibitors, with a median PFS of 7.3 months (95%CI 4.5-NA) and OS of 9.4 months (95%CI 8.2-NA). Our study confirms that BRAF is a relevant biomarker for aBTC. Clinically meaningful activity of BRAF+/-MEK inhibition for BRAFV600E mutated aBTC is confirmed, while more studies are needed for a comprehensive understanding of the molecular and clinical characteristics of class II-III BRAF mutated BTC, which may support future development of RAF-directed strategies.

FGFR2 gene F/R is present in 10-15% of iCCA and FGFR2 inhibitors have demonstrated significant antitumor activity in this population. However, specific clinicopathological features of iCCA patients (pts) harboring FGFR 2 gene F/R have not yet been well clarified. So far, limited literature data seem suggest a correlation between FGFR2 gene F/R and young age and female gender. The aim of this study is to construct a nomogram predicting FGFR2 gene status. iCCA pts from four Italian Institutions were retrospectively collected. The following clinicopathological variables were selected: gender; age (< 55 vs ≥ 55 years); synchronous vs metachronous metastases (mts); number of metastatic sites (1 vs >1), lung/distant lymph-node/peritoneal/bone mts (present vs absent). A multivariate logistic regression model was used to screen out independent predictive factors with a cut-off of 0.10 and a nomogram was established. Among 464 iCCA pts retrospectively evaluated, 63 (14%) had FGFR2 gene F/R. Univariate and multivariate analysis suggested that age < 55 years [odds ratio (OR): 2.06, 95% confidence interval (CI) 1.15-3.9], bone mts (OR: 2.58, 95% CI 1.28-5.20) and female gender (OR: 1.53, 95% CI 0.88–2.67) were independent predictive factors of FGFR2 gene F/R. A predictive nomogram was established: pts with the highest score (age < 55 years, bone mts, female gender) had a 60% chance to bear FGFR2 gene F/R iCCA [AUC 0.64 (95% CI: 0.57 -0.72)] in comparison to pts with low score (age ≥ 55 years, no bone mts, male gender) which had a 7% chance to have FGFR2 positive iCCA. In the era of molecular characterization, we have developed a simple nomogram for predicting FGFR2 gene status in iCCA. This nomogram might help clinicians to identify pts more likely to harbour FGFR2 gene F/R and increase their therapeutic opportunities. An external validation-set will be analyzed to improve predictive performance.

Introduction: Cholangiocarcinoma (CCA) represents one the most common primary malignancy of the liver. Cirrhosis, HCV infection, Cholestatic diseases represent well known predisposing factors. Late diagnosis of CAA is associated with a poor prognosis. History of colorectal cancer (CRC) is supposed to be a risk factor. Method: Data were retrospectively collected from two different HPB surgical centers in Italy (Ancona, Roma-Gemelli) to identify all patients with CCA and CRC between January 2000 to December 2018. All the data from patient history, surgical and oncological treatments were examinated. Histopatological examination of both CCA and CRC characteristics were analised. Genetics characteristics of both tumours were collected. Results: A total of 26 patients developed biopsy-proven CCA after CRC. The median time between CRC and CCA diagnosis was 111,7 months. All the CRC were successfully treated with surgery and 5 patients underwent adjuvant chemotherapy. Median age at the CCA diagnosis was 66,8 years. 23 (88,4%) patients underwent R0 surgical treament. 3 patients underwent palliative treatments. After a median followup of 73,4 months, 5 years survival was 61,5%. Conclusions: To our knowledge, this is the largest series of patients with CCA and CRC. Treatment can allow a significant 5 year survival. It is also mandatory a follow up for CAA in CRC patients.