Introduction: Addressing the Challenge of Resistant Cholangiocarcinoma
The landscape of biliary tract cancer treatment has been transformed by the identification of fibroblast growth factor receptor 2 (FGFR2) fusions as a primary driver in intrahepatic cholangiocarcinoma. While first-generation FGFR inhibitors like pemigatinib and futibatinib have improved outcomes, their efficacy is frequently curtailed by the emergence of secondary mutations. The clinical community has long sought therapeutic options for patients who progress on these targeted therapies. Recent findings from a Phase 2 trial of tinengotinib, published in The Lancet Gastroenterology & Hepatology, suggest that this next-generation multi-kinase inhibitor may provide a viable path forward for this difficult-to-treat population.
Highlights
The study provides several critical insights for oncology professionals:
Superior Response in Acquired Resistance
Tinengotinib demonstrated a 30.0% objective response rate (ORR) specifically in patients with acquired resistance to prior FGFR inhibitors.
Broad Clinical Activity
Efficacy was not limited to FGFR2 fusions; patients with other FGFR alterations (Cohort B) showed a 23.1% ORR.
Manageable Toxicity
While Grade 3 adverse events occurred, they were generally manageable through dose modifications, with no treatment-related deaths reported.
Paving the Way for Phase 3
The data has successfully supported the transition to a global Phase 3 registration trial (NCT05907278).
Background: The Disease Burden and the Resistance Paradox
Cholangiocarcinoma is a rare but highly aggressive malignancy of the bile ducts. For patients with advanced disease, systemic chemotherapy with gemcitabine and cisplatin was the standard for over a decade. The discovery of FGFR2 fusions in approximately 10–15% of intrahepatic cases led to the approval of several FGFR inhibitors. However, the ‘resistance paradox’ remains: while these drugs are initially effective, the tumor eventually evolves. Acquired mutations in the FGFR2 kinase domain, such as the N549H or V564F gatekeeper mutations, render first-generation inhibitors ineffective. Tinengotinib was designed specifically to overcome these molecular hurdles by inhibiting not only FGFR1-3 but also VEGFR and Aurora kinases, providing a multi-pronged attack on the tumor’s survival mechanisms.
Study Design: A Targeted Investigation
This open-label, multicentre, Phase 2 trial (NCT04919642) was conducted across 32 medical centers in the USA. The investigators enrolled 55 adult patients with advanced or metastatic cholangiocarcinoma who had failed at least one prior systemic therapy. Patients were stratified into four distinct cohorts based on their molecular profile:
Cohort A1
FGFR2 fusions with primary resistance to prior FGFR inhibitors.
Cohort A2
FGFR2 fusions with acquired resistance to prior FGFR inhibitors.
Cohort B
Other FGFR alterations (e.g., mutations or amplifications).
Cohort C
FGFR wild-type. Patients received tinengotinib 10 mg orally once daily in 28-day cycles. The primary endpoint was the objective response rate (ORR) as assessed by the investigator using RECIST version 1.1.
Key Findings: Efficacy Across Molecular Subgroups
The results highlighted a significant disparity in response based on the nature of previous resistance. In the efficacy-evaluable population (n=51), the most impressive results were seen in Cohort A2 (acquired resistance), where the ORR reached 30.0% (95% CI 6.7–65.3). This suggests that tinengotinib is particularly effective at overcoming the secondary mutations that develop after initial FGFR inhibition. In Cohort B, which included patients with diverse FGFR alterations beyond fusions, the ORR was 23.1% (95% CI 5.0–53.8), indicating that tinengotinib’s utility may extend beyond the traditional fusion-positive population. Conversely, Cohort A1 (primary resistance) showed a lower ORR of 6.3%, and no responses were observed in the wild-type Cohort C. This underscores the necessity of biomarker-driven patient selection for tinengotinib therapy.
Safety and Tolerability Profile
The safety of tinengotinib was assessed in all 55 patients. The most common treatment-related adverse events (TRAEs) were consistent with the drug’s multi-kinase inhibition profile. Grade 3 TRAEs included hypertension (31%), palmar-plantar erythrodysesthesia syndrome (13%), and stomatitis (11%). Grade 4 events were rare, occurring in only 4% of patients (one case of increased lipase and one case of posterior reversible encephalopathy syndrome). Importantly, there were no Grade 5 TRAEs. These toxicities, while significant, are typical for VEGFR and Aurora kinase inhibitors and were generally managed through supportive care and dose adjustments.
Expert Commentary: Clinical Implications and Mechanistic Insights
The efficacy of tinengotinib in the post-FGFR inhibitor setting is clinically significant. For clinicians, the 30% ORR in patients with acquired resistance is particularly encouraging, as this population currently has no established targeted standard of care. Mechanistically, tinengotinib’s ability to inhibit Aurora A/B kinases and VEGFR2 may provide synergistic anti-tumor effects that prevent the ‘bypass signaling’ often seen in resistant tumors. However, the study’s small sample size in individual cohorts and the open-label design are limitations. The ongoing Phase 3 trial will be essential to confirm these findings against standard chemotherapy or other salvage therapies.
Conclusion: A New Horizon in Biliary Tract Cancers
The Phase 2 trial of tinengotinib marks an important milestone in the management of FGFR-driven cholangiocarcinoma. By demonstrating activity against acquired resistance mutations and other FGFR alterations, tinengotinib addresses a critical unmet need in the oncology community. As we move toward more personalized medicine, the ability to sequence targeted therapies based on specific resistance patterns will become the hallmark of biliary tract cancer management.
Funding and Trial Registration
This study was funded by TransThera Sciences. The trial is registered with ClinicalTrials.gov, number NCT04919642.
References
1. Javle M, et al. Tinengotinib for adults with advanced or metastatic cholangiocarcinoma: a multicentre, open-label, phase 2 trial. Lancet Gastroenterol Hepatol. 2026 Feb;11(2):137-149. doi: 10.1016/S2468-1253(25)00230-4.
2. Abou-Alfa GK, et al. Pemigatinib for previously treated, locally advanced or metastatic cholangiocarcinoma: a multicentre, open-label, phase 2 study (FIGHT-202). Lancet Oncol. 2020;21(5):671-684.
3. Goyal L, et al. Futibatinib for FGFR2-Rearranged Intrahepatic Cholangiocarcinoma. N Engl J Med. 2023;388(3):228-239.
