Biliary tract tumours, including bile duct, gallbladder, and ampulla of Vater malignancies, pose a rare but formidable oncologic challenge. Typically diagnosed at advanced stages, these tumours offer limited treatment options and dismal prognoses, with a five-year survival rate below 20%. First-line chemotherapy with gemcitabine-cisplatin has demonstrated only modest efficacy, leaving a pressing need for improved therapeutic strategies. This comprehensive review provides a detailed examination of the current landscape of second-line chemotherapy for biliary tract tumours. The pivotal ABC-06 trial established FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) as the standard second-line therapy, demonstrating improved overall survival compared to active symptom control alone. Conversely, the NIFTY trial introduced nal-IRI (nanoliposomal irinotecan) plus 5-FU/LV (5-fluorouracil and leucovorin) as an alternative option, demonstrating substantial gains in progression-free and overall survival. However, the posterior NALIRICC trial presented conflicting results, raising questions about the added benefit of nal-IRI. Challenges in delivering second-line chemotherapy include rapid patient performance deterioration post-first-line treatment and limited access to second-line therapy. Only a fraction of eligible patients receive second-line therapy, emphasising the need for more effective first-line therapies to maintain patient fitness. The role of monotherapy in the second-line setting remains uncertain, particularly in unfit patients, and the absence of biomarkers for tailored treatment underscores the need for ongoing research. While challenges persist, ongoing investigations offer hope for optimising second-line therapy for biliary tract tumours, promising improved outcomes for patients facing this disease. This review provides an overview of current facts and challenges when delivering second-line chemotherapy for advanced biliary tract tumours.

Palliative sedation (PS) is a therapeutic measure used in end-of-life care to alleviate the suffering caused by refractory symptoms. The objectives of our study were to determine the frequency of PS in a specialized inpatient acute palliative care unit (APCU), describe the characteristics of patients who received PS, compare patients who required PS with those who did not, and compare patients who received a single medication for PS with those who received multiple medications. This was a retrospective study of 444 patients with cancer who died in a specialized inpatient APCU of a tertiary public hospital. A total of 167 patients received PS (38%). The most frequent indication was delirium (64%). The mean duration of PS was 49 h. Patients who received PS were significantly younger (p = 0.001), had higher anxiety (p = 0.024), had longer hospital admissions (p = 0.001), were more likely to have a spouse as their primary caregiver (p = 0.003), were more aware of their prognosis (p = 0.024), and had more advance directives (p = 0,001) than those who did not receive PS. Forty-six patients (28%) required two or three drugs for PS. They had a longer PS (p = 0.002) and received more parental hydration (p = 0.015) than did those who received one drug. Patients receiving midazolam as first-line treatment were less likely to receive a second drug (p = 0.003). A total of 38% of patients with cancer receiving specialized palliative care required PS before death. Patients who received PS were younger, had a longer hospital stay, were more likely to have their spouse be their primary caregiver, were better informed and had more advance directives. 28% of sedated patients required more than one drug, which was associated with a longer PS, the maintenance of parental hydration during PS and the initiation of PS with levomepromazine instead of midazolam.