HER2 Status in the Biliary Tract Cancers: Comparison
Please note this is a comparison between Version 2 by Jason Zhu and Version 1 by Ruveyda Ayasun.

Biliary tract cancer (BTC) is traditionally known as being hard to treat with a poor prognosis. State-of-the-art genomic technologies such as next-generation sequencing (NGS) revolutionized cancer management and shed light on the genomic landscape of BTCs. There are ongoing clinical trials to assess the efficacy of HER2-blocking antibodies or drug conjugates in BTCs with HER2 amplifications. 

  • biliary tract cancer
  • HER2 status
  • precision medicine

1. Introduction

Biliary tract cancers (BTCs) represent 3% of all gastrointestinal cancers and have a dismal prognosis with a 5 year survival rate of 2% [1]. BTCs consist of intrahepatic cholangiocarcinoma, extrahepatic cholangiocarcinoma, gallbladder cancer, and ampulla of Vater cancer [2]. Geographical location is one of the determinants of the incidence of BTCs. Due to endemic liver flukes, cholangiocarcinoma is more common in southeast Asian countries [3]. Although a growing body of literature demonstrated the efficacy of targeted therapies in patients with BTC, systemic chemotherapy remained the backbone treatment for this devastating disease. Gemcitabine with cisplatin (GEMCIS) is still recommended as first-line treatment (ABC-02 trial) [4] and mFOLFOX with active symptom control as second-line therapy (ABC-06 trial) [5]. In an era of immune-based therapies, the TOPAZ-1 trial evaluated the efficacy of durvalumab (anti-PDL1) plus GEMCIS in patients with BTC (NCT03875235). The addition of durvalumab to standard of care treatment significantly improved overall survival rate in patients with BTC. The estimated 24 month overall survival rate (OS) was 24.9% and 10.4% in the durvalumab plus GEMCIS and placebo plus GEMCIS arm, respectively [5]. Median OS was 12.8 months in the durvalumab plus GEMICS group and 11.5 months in the GEMCIS group. Considering the observed survival advantage associated with the addition of durvalumab, the NCCN updated their guidelines and reclassified GEMCIS plus durvalumab as the preferred category 1 recommendation for BTC. Despite the increased survival advantage, the disease prognosis remained dismal and the objective response rate with the addition of durvalumab to GEMCIS improved objective response rates from 18.7% to 26.7%. As a second-line treatment, options are limited, and the prognosis is very poor for patients without access to targeted therapy. The median OS for mFOLFOX as a second-line treatment showed only a minimal survival benefit of 6.2 months compared to 5.3 months in active symptom control, with an objective response rate (ORR) of 5%. These findings highlighted an unmet need for the development of novel treatments, not only as first-line therapy but also for the management of treatment-refractory BTC [5].
BTCs are heterogenous in terms of anatomy, thus their pathogenesis and genomic drivers may vary. Despite precision medicine having revolutionized cancer care over the last decades, there is an unmet need for more precise approaches in patients with BTC. The number of somatic alterations significantly differs in patients with BTC based on primary site of tumor. For instance, there is a significant difference between intrahepatic cholangiocarcinoma and gallbladder cancer or extrahepatic CCA in terms of somatic alterations [1]. To date, fibroblast growth factor receptor (FGFR) and isocitrate dehydrogenase (IDH) have been extensively studied in intrahepatic biliary tract cancers [2]. According to the results of a phase 2 study, the median overall survival (OS) data for the cohort of patients with FGFR2 fusion/rearrangement who received pemigatinib as a second-line treatment had not yet been reached at the time of the data cutoff, which was 21.1 months. This suggests that the survival benefit of pemigatinib for this patient population may be substantial, although longer follow-up is needed to confirm these results [6]. However, for the cohorts with other FGFR alterations and no FGFR alterations, the median OS was 6.7 months and 4.0 months, respectively. The 12 month OS rate for the cohort with FGFR2 fusion/rearrangement was 68%. Consequently, pemigatinib, an FGFR1-3 inhibitor, received FDA approval for the treatment of patients with BTC with FGFR2 fusions in April 2020 [6]. After the approval of a FGFR1-3 inhibitor by the FDA for the treatment of BTC, several other FGFR inhibitors were tested for their effectiveness. As a result, clinical trials were conducted to evaluate the efficacy of infigratinib and futibatinib. In a phase 2 trial evaluating infigratinib, another competitive and reversible inhibitor of FGFR1-3, as a second-line treatment option, objective response rate was determined to be 23.1%, while the median progression free survival (PFS) was 7.3 months [7]. Thus, infigratinib was granted accelerated approval by FDA in 2021 for previously treated, unresectable locally advanced, or metastatic cholangiocarcinoma with FGFR2 rearrangements. Futibatinib, a selective and irreversible FGFR1–4 inhibitor, obtained accelerated FDA approval in September 2022 after the completion of the FOENIX-101 phase 1 trial that enrolled 86 patients [8]. The results demonstrated partial responses in five patients, including three with FGFR2 fusion-positive intrahepatic cholangiocarcinoma and two with FGFR1-mutant primary brain tumors. Additionally, 41 patients (48%) achieved stable disease. Following the completion of the FOENIX-101 study, the efficacy of futibatinib was evaluated in the FOENIX-CCA2 phase 2 trial. A total of 42% of patients (95% CI, 32 to 52) had a response, and the median duration of response was 9.7 months. After a median follow-up period of 17.1 months, the trial showed a median PFS of 9.0 months and an OS of 21.7 months [9].

2. Prognostic Role of HER2 Status in BTC

There are controversial studies pertaining to the prognostic role of HER2 alterations in patients with BTC. A retrospective study of the 100 resected BTC cases from Italy found that 11% of cases exhibited HER2 overexpression, which was defined as a score of 3+ by IHC or a score of 2+ that was confirmed by FISH amplification. In the study, disease-free survival (DFS) was significantly shorter in patients with HER2-positive BTC compared to HER2-negative patients with 10.6 and 20.9 months, respectively. Although there was a noticeable disparity in the median overall survival between HER2-positive and -negative patients, which was 23.4 months and 55.2 months, respectively, the difference did not achieve statistical significance (p = 0.068) [16][10]. The median overall survival (OS) in various types of biliary tract cancers (BTCs) differed significantly. In particular, ampullary tumors had not yet reached the median OS, intrahepatic tumors had a median OS of 55.3 months, extrahepatic tumors had a median OS of 34.7 months, and gallbladder tumors had a median OS of 18.1 months. It is worth noting that these differences suggest that the primary site of BTC may be an important factor in determining patient prognosis. In another study from South Korea, HER2 alterations have been detected in 14.9% of patients with advanced BTC [17][11]. The patients with and without HER2 aberrations did not have a significant difference in tumor response to GEMCIS in the study (33.3% vs. 26.2%, p = 0.571). The median progression-free survival (PFS) to GP was 4.7 months (95% CI, 4.0 to 5.5 months) for patients with HER2 aberrations and 7.0 months (95% CI, 5.2 to 8.8 months) for those without HER2 aberrations (p = 0.776). Moreover, the median OS was not reached in either group (p = 0.739). The role of HER2 aberrations as an independent biomarker was evaluated through univariate analyses for PFS to GEMCIS and OS. The analysis for PFS to GEMCIS revealed that the grade of differentiation (poorly differentiated vs. well/moderately differentiated), disease stage (metastasis vs. locally advanced), and number of metastatic sites (≤2 vs. >2) were significant independent factors. However, HER2 aberrations did not demonstrate statistical significance as an independent factor [17][11]. The results of these studies indicated that there might be differences in the prevalence and characteristics of biliary tract cancers between various anatomical regions and between countries in Asia and non-Asia. Moreover, there are retrospective studies that investigated the differences in HER2 overexpression in Asian and Caucasian patients with biliary tract cancer. A meta-analysis revealed that HER2 expression was more prevalent in Asian patients (28.4%) than western patients (19.7%) [18][12]. In a study from Japan, 454 cases of biliary tract cancer have been assessed for HER2 positivity. It has been demonstrated that HER2 positivity differed among different subtypes of BTCs (3.7% in iCCA, 3% in perihilar eCCA, 18.5% in distal eCCA, 31.3% in GBC, and 16.4% in ampullary cancer) [19][13]. The percentage of HER2 overexpression observed in different studies may differ because of varying factors such as the use of different cutoff values to determine overexpression, the diverse detection methods employed, and the specific site of the primary tumor. Nevertheless, additional prospective cohorts are needed to validate these findings and to conclude whether HER2 alterations are prognostic for patients with advanced BTC. Given that there are accumulating clinical trials that evaluate HER2-targeting agents in patients with BTC, next-generation sequencing, along with IHC or FISH, may be required to stratify patients for anti-HER2 therapies. Intriguingly, not only membranous staining but also cytoplasmic staining might have an implication in the survival of patients with BTC. Ata et al. demonstrated that, though statistical significance was limited, lower cytoplasmic HER2 scores have been correlated with longer survival in patients with pancreatic, gallbladder, cholangiocarcinoma, and periampullary cancers (p = 0.052) [20][14].

3. HER2 Alterations in BTC

HER2-targeting agents have demonstrated remarkable responses in patients with HER2 alterations in gastric and breast cancer. Based on the ToGA study, HER2 scoring allows the appropriate selection of patients eligible for treatment with HER2-targeted therapies in gastric cancer. This also revealed that immunohistochemistry should be the initial test and 2+ samples should be retested with FISH [21][15]. Hence, the vast majority of knowledge on the role of HER2 in oncology stems from breast and gastric cancer trials. Due to the widespread acceptance of tumor-agnostic approaches in precision medicine, there is currently significant interest in investigating whether anti-HER2 therapies can be applied to other types of cancer, including biliary tract cancer (BTC). This may have important implications for the development of targeted therapies for BTC and other cancers with HER2 aberrations. It has been previously demonstrated that 54.3% of patients with BTC have a HER2 IHC score of 1+ and that 10.9% of them have a HER2 score of 3+ [2,22][2][16]. More recently, a nationwide retrospective study for clinicopathological data of 642 gallbladder cancer (GBC) patients from the Netherlands unveiled that about 50% of patients with GBC harbor actionable targets [23][17]. HER2 overexpression (IHC score of 3+) has been observed in 7% of patients with GBC. Notably, HER2 mutations typically occur in the absence of HER2 amplifications in all types of cancers [2]. G660D, V659E, R678Q, and Q709L mutations have been recognized as the most common HER2 alterations in all types of cancers. Functional analysis of these alterations has shown them to be activating [24][18]. Although HER2 amplifications (5–15%) and overexpression (20%) have been observed more frequently than HER2 mutations (2%) in BTC, activating HER2 mutations emerged as druggable by anti-HER2 therapies in patients with BTC without amplification or overexpression [2]. The frequency of HER2 alterations may vary according to the primary tumor site. Researchers from South Korea analyzed the HER2 status of 121 patients with BTC. HER2 alterations were found in 14.9% of patients with the highest frequency in GBC (36.4%) [17][11]. These findings encourage future world-wide studies investigating HER2 aberrations in patients with BTC. Since point mutations have been found in 27.8% of patients, it is critical to assess whether they are activating mutation, namely, druggable by HER2-targeting agents such as neratinib [25][19].

4. Resistance to Anti-HER2 Therapies

There are multiple FDA-approved HER2-targeted therapies, including antibody–drug conjugates (e.g., T-DM1 and DS-8201), monoclonal antibodies (e.g., trastuzumab and pertuzumab), and small-molecule HER1/2 TKIs (e.g., tucatinib, lapatinib, and neratinib) [27][20]. However, intrinsic or acquired resistance is a major limitation of these therapies. Activating HER2 mutations have been linked to resistance to lapatinib but responsiveness to neratinib in prior breast cancer studies [28][21]. The efficacy of neratinib, which is an irreversible HER2 inhibitor, has been evaluated in patients with HER2-mutant, nonamplified breast cancer. Ma et al. demonstrated in this trial that the clinical benefit ratio was 31% [29][22]. Therefore, an IHC score of 0 or 1+ HER2 may not be the sole predictor for responsiveness to HER2 therapies [30][23]. Due to intratumor heterogeneity, some cell clones within tumor tissue may express low levels of HER2 or may not be HER2-dependent, resulting in primary resistance to anti-HER2 therapies [31][24].
The downstream pathway of HER2 induces PI3K/AKT/mTOR activation, thus anti-HER2 therapies inhibit this signaling pathway. However, the constitutive activation of PI3K has previously been described in breast cancer patients. Alterations in PI3K/AKT/mTOR signaling pathway occur in 40% and 25% of extrahepatic cholangiocarcinoma (eCCA) and intrahepatic cholangiocarcinoma (iCCA) patients, respectively [32][25]. Hence, the clinical utility of PI3K inhibitors such as taselisib may benefit patients who are irresponsive to anti-HER2 therapies and have constitutively active PI3K signaling. Moreover, FGFR1 and FGF3 amplification has been linked to lower pathologic response in patients with HER2-positive breast cancer treated with neoadjuvant trastuzumab [33][26]. Given that pemigatinib (FGFR 1-2-3 inhibitor) was among the very first targeted therapies that was approved by the FDA for the management of advanced BTC [34][27], it could be considered in patients that progressed on anti-HER2 therapies. In the phase 2 SUMMIT basket trial, 25 patients with treatment-refractory metastatic BTC were enrolled and screened for HER2 mutations. The most common HER2 mutations in these cohorts were S310F (n = 11, 48%) and V777L (n = 4, 17%). In this trial, patients who received neratinib treatment demonstrated an ORR of 16% (95% CI, 4.5–36.1%) and a clinical benefit rate (CBR) of 28% (95% CI, 12.1–49.4%) [35][28]. The diagnostic tests for HER2 gene mutations that were approved by the FDA in August 2022 are as follows: Guardant360 CDx (blood) and Oncomine Dx Target Test (tumor tisssue). Even though HER2 amplifications (2–3%) or overexpression (2.5%) occur to a lesser extent in lung cancer, trastuzumab deruxtecan, an antibody–drug conjugate, received accelerated approval by FDA for patients with HER2-mutant non-small-cell lung cancer in August 2022 due to an encouraging phase 2 study [36][29]. In the study, trastuzumab deruxtecan showed durable responses in patients who had metastatic HER2-mutant non-small-cell lung cancer that was refractory to standard treatment. The confirmed objective response rate was 55% (95% CI, 44 to 65), with a median OS of 17.8 months (95% CI, 13.8 to 22.1). Objective responses were observed in various HER2 mutation subtypes and even among patients with undetectable HER2 expression or HER2 amplification. This landmark study may also provide the clinical rationale of HER2-targeted therapy for patients with HER2-mutant BTC.


  1. Kam, A.E.; Masood, A.; Shroff, R.T. Current and emerging therapies for advanced biliary tract cancers. Lancet Gastroenterol. Hepatol. 2021, 6, 956–969.
  2. Oh, D.Y.; Bang, Y.J. HER2-targeted therapies—A role beyond breast cancer. Nat. Rev. Clin. Oncol. 2020, 17, 33–48.
  3. Clements, O.; Eliahoo, J.; Kim, J.U.; Taylor-Robinson, S.D.; Khan, S.A. Risk factors for intrahepatic and extrahepatic cholangiocarcinoma: A systematic review and meta-analysis. J. Hepatol. 2020, 72, 95–103.
  4. Valle, J.; Wasan, H.; Palmer, D.H.; Cunningham, D.; Anthoney, A.; Maraveyas, A.; Madhusudan, S.; Iveson, T.; Hughes, S.; Pereira, S.P.; et al. Cisplatin plus gemcitabine versus gemcitabine for biliary tract cancer. N. Engl. J. Med. 2010, 362, 1273–1281.
  5. Lamarca, A.; Palmer, D.H.; Wasan, H.S.; Ross, P.J.; Ma, Y.T.; Arora, A.; Falk, S.; Gillmore, R.; Wadsley, J.; Patel, K.; et al. 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, 22, 690–701.
  6. Abou-Alfa, G.K.; Sahai, V.; Hollebecque, A.; Vaccaro, G.; Melisi, D.; Al-Rajabi, R.; Paulson, A.S.; Borad, M.J.; Gallinson, D.; Murphy, A.G.; et al. Pemigatinib for previously treated, locally advanced or metastatic cholangiocarcinoma: A multicentre, open-label, phase 2 study. Lancet Oncol. 2020, 21, 671–684.
  7. Javle, M.; Roychowdhury, S.; Kelley, R.K.; Sadeghi, S.; Macarulla, T.; Weiss, K.H.; Waldschmidt, D.-T.; Goyal, L.; Borbath, I.; El-Khoueiry, A.; et al. Infigratinib (BGJ398) in previously treated patients with advanced or metastatic cholangiocarcinoma with FGFR2 fusions or rearrangements: Mature results from a multicentre, open-label, single-arm, phase 2 study. Lancet Gastroenterol. Hepatol. 2021, 6, 803–815.
  8. Bahleda, R.; Meric-Bernstam, F.; Goyal, L.; Tran, B.; He, Y.; Yamamiya, I.; Benhadji, K.A.; Matos, I.; Arkenau, H.-T. Phase I, first-in-human study of futibatinib, a highly selective, irreversible FGFR1-4 inhibitor in patients with advanced solid tumors. Ann. Oncol. 2020, 31, 1405–1412.
  9. Goyal, L.; Meric-Bernstam, F.; Hollebecque, A.; Valle, J.W.; Morizane, C.; Karasic, T.B.; Abrams, T.A.; Furuse, J.; Kelley, R.K.; Cassier, P.A.; et al. Futibatinib for FGFR2-Rearranged Intrahepatic Cholangiocarcinoma. N. Engl. J. Med. 2023, 388, 228–239.
  10. Vivaldi, C.; Fornaro, L.; Ugolini, C.; Niccoli, C.; Musettini, G.; Pecora, I.; Insilla, A.C.; Salani, F.; Pasquini, G.; Catanese, S.; et al. HER2 Overexpression as a Poor Prognostic Determinant in Resected Biliary Tract Cancer. Oncologist 2020, 25, 886–893.
  11. Kim, H.; Kim, R.; Kim, H.R.; Jo, H.; Kim, H.; Ha, S.Y.; Park, J.O.; Park, Y.S.; Kim, S.T. HER2 Aberrations as a Novel Marker in Advanced Biliary Tract Cancer. Front. Oncol. 2022, 12, 834104.
  12. Galdy, S.; Lamarca, A.; McNamara, M.G.; Hubner, R.A.; Cella, C.A.; Fazio, N.; Valle, J.W. HER2/HER3 pathway in biliary tract malignancies; systematic review and meta-analysis: A potential therapeutic target? Cancer Metastasis Rev. 2017, 36, 141–157.
  13. Hiraoka, N.; Nitta, H.; Ohba, A.; Yoshida, H.; Morizane, C.; Okusaka, T.; Nara, S.; Esaki, M.; Kishi, Y.; Shimada, K. Details of human epidermal growth factor receptor 2 status in 454 cases of biliary tract cancer. Hum. Pathol. 2020, 105, 9–19.
  14. Ata, A.; Polat, A.; Serinsöz, E.; Sungur, M.A.; Arican, A. Prognostıc value of increased HER2 expression in cancers of pancreas and biliary tree. Pathol. Oncol. Res 2015, 21, 831–838.
  15. Rüschoff, J.; Hanna, W.; Bilous, M.; Hofmann, M.; Osamura, R.Y.; Penault-Llorca, F.; van de Vijver, M.; Viale, G. HER2 testing in gastric cancer: A practical approach. Mod. Pathol. 2012, 25, 637–650.
  16. Nam, A.R.; Kim, J.-W.; Cha, Y.; Ha, H.; Park, J.E.; Bang, J.-H.; Jin, M.H.; Lee, K.-H.; Kim, T.-Y.; Han, S.-W.; et al. Therapeutic implication of HER2 in advanced biliary tract cancer. Oncotarget 2016, 7, 58007–58021.
  17. de Bitter, T.J.J.; de Reuver, P.R.; de Savornin Lohman, E.A.; Kroeze, L.I.; Vink-Börger, M.E.; van Vliet, S.; Simmer, F.; von Rhein, D.; Jansen, E.A.M.; Verheij, J.; et al. Comprehensive clinicopathological and genomic profiling of gallbladder cancer reveals actionable targets in half of patients. NPJ. Precis. Oncol. 2022, 6, 83.
  18. Pahuja, K.B.; Nguyen, T.T.; Jaiswal, B.S.; Prabhash, K.; Thaker, T.M.; Senger, K.; Chaudhuri, S.; Kljavin, N.M.; Antony, A.; Phalke, S.; et al. Actionable Activating Oncogenic ERBB2/HER2 Transmembrane and Juxtamembrane Domain Mutations. Cancer Cell 2018, 34, 792–806.e5.
  19. Ayasun, R.; Sahin, I. Trastuzumab plus FOLFOX for HER2-positive biliary tract cancer. Lancet Gastroenterol. Hepatol. 2023, 8, 211.
  20. Wu, X.; Yang, H.; Yu, X.; Qin, J.-J. Drug-resistant HER2-positive breast cancer: Molecular mechanisms and overcoming strategies. Front. Pharmacol. 2022, 13, 1012552.
  21. Bose, R.; Kavuri, S.M.; Searleman, A.C.; Shen, W.; Shen, D.; Koboldt, D.C.; Monsey, J.; Goel, N.; Aronson, A.B.; Li, S.; et al. Activating HER2 mutations in HER2 gene amplification negative breast cancer. Cancer Discov. 2013, 3, 224–237.
  22. Ma, C.X.; Bose, R.; Gao, F.; Freedman, R.A.; Telli, M.L.; Kimmick, G.; Winer, E.; Naughton, M.; Goetz, M.P.; Russell, C.; et al. Neratinib Efficacy and Circulating Tumor DNA Detection of HER2 Mutations in HER2 Nonamplified Metastatic Breast Cancer. Clin. Cancer Res. 2017, 23, 5687–5695.
  23. Meric-Bernstam, F.; Johnson, A.M.; Dumbrava, E.E.I.; Raghav, K.; Balaji, K.; Bhatt, M.; Murthy, R.K.; Rodon, J.; Piha-Paul, S.A. Advances in HER2-Targeted Therapy: Novel Agents and Opportunities Beyond Breast and Gastric Cancer. Clin. Cancer Res. 2019, 25, 2033–2041.
  24. Vernieri, C.; Milano, M.; Brambilla, M.; Mennitto, A.; Maggi, C.; Cona, M.S.; Prisciandaro, M.; Fabbroni, C.; Celio, L.; Mariani, G.; et al. Resistance mechanisms to anti-HER2 therapies in HER2-positive breast cancer: Current knowledge, new research directions and therapeutic perspectives. Crit. Rev. Oncol. Hematol. 2019, 139, 53–66.
  25. Bogenberger, J.M.; DeLeon, T.T.; Arora, M.; Ahn, D.H.; Borad, M.J. Emerging role of precision medicine in biliary tract cancers. NPJ. Precis. Oncol. 2018, 2, 21.
  26. Hanker, A.B.; Garrett, J.T.; Estrada, M.V.; Moore, P.D.; Ericsson, P.G.; Koch, J.P.; Langley, E.; Singh, S.; Kim, P.S.; Frampton, G.M.; et al. HER2-Overexpressing Breast Cancers Amplify FGFR Signaling upon Acquisition of Resistance to Dual Therapeutic Blockade of HER2. Clin. Cancer Res. 2017, 23, 4323–4334.
  27. Rizzo, A.; Ricci, A.D.; Brandi, G. Pemigatinib: Hot topics behind the first approval of a targeted therapy in cholangiocarcinoma. Cancer Treat Res. Commun. 2021, 27, 100337.
  28. Harding, J.J.; Piha-Paul, S.A.; Shah, R.H.; Cleary, J.M.; Quinn, D.I.; Brana, I.; Moreno, V.; Borad, M.J.; Loi, S.; Spanggaard, I.; et al. Targeting HER2 mutation–positive advanced biliary tract cancers with neratinib: Final results from the phase 2 SUMMIT basket trial. J. Clin. Oncol. 2022, 40 (Suppl. 16), 4079.
  29. Li, B.T.; Smit, E.F.; Goto, Y.; Nakagawa, K.; Udagawa, H.; Mazières, J.; Nagasaka, M.; Bazhenova, L.; Saltos, A.N.; Felip, E.; et al. Trastuzumab Deruxtecan in HER2-Mutant Non–Small-Cell Lung Cancer. N. Engl. J. Med. 2022, 386, 241–251.
Video Production Service