Fibroblast Growth Factor Receptor (FGFR) Inhibitors for the Treatment of Cholangiocarcinoma: Key Therapeutic Developments and Knowledge Gaps

Enes Erul,1,2 Sergio Cifuentes-Canaval,3 Akhil Santhosh,4 Emir Sokolović,5 Mario Della Mura,6 Gerardo Cazzato,6 Pınar Kubilay Tolunay,1,2,* Alessandro Rizzo7,* 1Department of Medical Oncology, Ankara University Faculty of Medicine, Ankara University, Ankara, 06590, Türkiye; 2Ankara University Cancer Institute, Ankara University, Ankara, 06590, Türkiye; 3Cancer Institute – The Americas Clinic – AUNA, Medellín, Colombia; 4MVR Cancer Centre and Research Institute, Kozhikode, Kerala, India; 5Clinic of Oncology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina; 6Section of Molecular Pathology, Department of Precision and Regenerative Medicine and Ionian Area (Dimepre-J), University of Bari “aldo Moro”, Bari, 70124, Italy; 7S.S.D. C.O.r.O. Bed Management Presa in Carico, TDM, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, 70124, Italy*These authors contributed equally to this workCorrespondence: Alessandro Rizzo, S.S.D. C.O.r.O. Bed Management Presa in Carico, TDM, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, 70124, Italy, Email [email protected]: Fibroblast growth factor receptor 2 (FGFR2) alterations have emerged as an important targetable oncogenic driver in a biologically distinct subset of biliary tract cancers (BTCs), particularly intrahepatic cholangiocarcinoma (iCCA), alongside other actionable genomic events such as IDH1 mutations, BRAF V600E, HER2 amplification and MSI-H. FGFR2 fusions and mutations define a distinct molecular subgroup whose prevalence varies across geographic regions and etiologic backgrounds such as liver fluke–associated disease. Clinical studies of both reversible and irreversible FGFR inhibitors have demonstrated meaningful activity in FGFR2-rearranged iCCA, while also highlighting a characteristic toxicity profile dominated by on-target hyperphosphataemia. Parallel translational work using cfDNA-based liquid biopsy has mapped a spectrum of secondary kinase-domain mutations that underlie acquired resistance, informing the development of next-generation FGFR2-selective inhibitors (eg, lirafugratinib) and combination strategies with EGFR/ERBB blockade. Collectively, these data underscore the need for comprehensive molecular profiling and innovative umbrella trial designs to optimise targeted therapy in this rare, biologically heterogeneous malignancy.Keywords: intrahepatic cholangiocarcinoma, FGFR2 alterations, biliary tract cancer, FGFR inhibitors, acquired resistance, liquid biopsy