HAIC + DEB-TACE + Toripalimab + Lenvatinib for Unresectable Intrahepatic Cholangiocarcinoma

Background: Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver malignancy. Most patients are diagnosed at locally advanced or metastatic stages, precluding curative surgical resection. For unresectable ICC, conventional chemotherapy offers limited efficacy, with a 5-year survival rate below 10%. Emerging evidence suggests that combining locoregional therapies with immunotherapy and targeted therapy may improve outcomes.

Study Design: This is a prospective, single-arm, single-center, phase II exploratory clinical trial. Approximately 29 evaluable patients will be enrolled at Zhongshan Hospital, Fudan University.

Intervention: Participants will receive a comprehensive treatment regimen consisting of:

HAIC (Hepatic Arterial Infusion Chemotherapy): Oxaliplatin 85 mg/m² and gemcitabine (total 1000 mg/m², with a portion used for DEB-TACE loading) administered via hepatic artery infusion over ≥2 hours on Day 1 of each 21-day cycle, for up to 6 cycles.

DEB-TACE (Drug-Eluting Beads Transarterial Chemoembolization): Small-sized (40-90 μm) drug-eluting beads loaded with gemcitabine, performed on Day 1 of each cycle as needed (required in Cycle 1, thereafter based on tumor vascularity and imaging assessment).

Toripalimab: 200 mg intravenous infusion on Day 1 of each 21-day cycle.

Lenvatinib: Oral daily dosing (8 mg/day for body weight <60 kg; 12 mg/day for body weight ≥60 kg), continued throughout the study.

After completion of up to 6 cycles, patients without disease progression will enter a maintenance phase receiving toripalimab plus lenvatinib until disease progression, intolerable toxicity, withdrawal of consent, or investigator decision to terminate.

Efficacy Assessments: Tumor response will be evaluated by investigators using RECIST 1.1 and mRECIST criteria every 6-8 weeks. Primary efficacy endpoints include objective response rate (ORR), progression-free survival (PFS), and overall survival (OS).

Safety Monitoring: Adverse events will be monitored throughout the study and graded according to NCI-CTCAE v5.0. Safety visits will be conducted before each TACE procedure.

Statistical Considerations: The primary analysis will be descriptive. Sample size (approximately 29 patients) was calculated using a single-stage exact design based on an expected ORR of 40% versus a null rate of 15%, with α=0.05 and power=90%. Survival outcomes will be analyzed using Kaplan-Meier methods.

Inclusion criteria

• Voluntary participation and signed informed consent.
• Age 18 to 85 years.
• Pathologically confirmed intrahepatic cholangiocarcinoma.
• Imaging-confirmed unresectable locally advanced intrahepatic cholangiocarcinoma with measurable lesions (longest diameter ≥10 mm) per RECIST 1.1.
• No distant organ metastases (excluding lymph node metastases).
• Child-Pugh liver function grade A or good B (≤7 points).
• ECOG performance status score 0-1 within 1 week before enrollment.
• Expected survival ≥12 weeks.
• No prior treatment with immune checkpoint inhibitors (including PD-1/PD-L1 antibodies and CTLA-4 inhibitors).
• Laboratory values within 7 days before enrollment meeting the following criteria:

ANC ≥1.0×10⁹/L; platelets ≥50×10⁹/L; hemoglobin ≥90 g/L (without transfusion or G-CSF within 14 days before screening).

Serum albumin ≥30 g/L; total bilirubin ≤1.5×ULN; ALT and AST ≤5×ULN; serum creatinine ≤1.5×ULN or CrCl >50 mL/min (Cockcroft-Gault formula).

INR ≤2.3 or PT prolonged ≤6 seconds above normal range.

Urine protein <2+ (if ≥2+, 24-hour quantification <1.0 g allowed).

Exclusion criteria

• Received other local treatments (excluding surgery) within 1 month before study entry. Prior TAE/TAI not allowed. Prior TACE >3 times not allowed.
• Prior systemic anti-tumor therapy (including targeted therapy, immunotherapy, chemotherapy).
• Concurrent or prior other malignancy within 5 years.
• Active autoimmune disease or history of autoimmune disease with potential relapse.
• Clinically symptomatic moderate-to-severe ascites requiring therapeutic paracentesis/drainage or Child-Pugh score >2; uncontrolled or moderate-to-large pleural/pericardial effusion.
• History of abdominal fistula, GI perforation, or intra-abdominal abscess within 6 months before study treatment.
• History of thrombosis or embolic events (e.g., cerebrovascular accident including TIA, cerebral hemorrhage, cerebral infarction, pulmonary embolism) within 6 months before study treatment.
• Known inherited or acquired bleeding disorder or thrombotic tendency; currently or recently (within 10 days) receiving full-dose anticoagulants or thrombolytics for therapeutic purposes (prophylactic low-dose aspirin or LMWH allowed).
• Major vascular disease within 6 months before study treatment (e.g., aortic aneurysm requiring surgical repair or recent peripheral arterial thrombosis).
• Severe, non-healing, or dehisced wounds, active ulcers, or untreated fractures.
• Major surgery within 4 weeks before study treatment (excluding diagnostic) or anticipated need for major surgery during the study.
• History of intestinal obstruction or clinical signs/symptoms of GI obstruction within 6 months before study treatment.
• History of hepatic encephalopathy.
• Palliative radiotherapy for non-target lesions allowed only if completed ≥2 weeks before study treatment and AEs recovered to ≤CTCAE grade 1.
• Severe infection within 4 weeks before study treatment, including hospitalization for infection, bacteremia, or severe pneumonia; oral or IV therapeutic antibiotics within 2 weeks (prophylactic allowed).
• Congenital or acquired immunodeficiency (e.g., HIV infection).
• Palliative radiotherapy involving >5% of bone marrow area within 4 weeks for patients with bone metastases.
• Received live attenuated vaccine within 28 days before study treatment, or expected to receive such vaccine during toripalimab treatment or within 60 days after last dose.
• Received other investigational drugs within 28 days before study treatment.
• Other factors judged by the investigator that may affect study results or cause premature termination, such as alcoholism, drug abuse, other serious diseases (including psychiatric) requiring concomitant treatment, severe laboratory abnormalities, family or social factors affecting patient safety.