[Granulomatous inflammation in differential diagnosis of hepatobiliary malignancy]

The authors present two case reports to demonstrate wide differential diagnosis of granulomatous disorders of the hepatobiliary tract. Isolated granulomatous disorders are very rare in this area. Differantial diagnosis includes infectious and systemic diseases or chemical irritation. Granulomas often immitate malignant tumors and the surgeon could be first to diagnose this disease during liver resection or cholecystectomy.

KEY WORDS

granulomatous inflammation hepatic granuloma non-specific inflammation liver resection cholecystectomy.

Identification of Poor-outcome Biliopancreatic Carcinoma Patients With Two-marker Signature Based on ATF6α and p-p38 "STARD Compliant"

Biliopancreatic cancer is one of the most aggressive solid neoplasms, and incidence is rising worldwide. It is known that ATF6α is one of the transmembrane proteins that acts crucially in endoplasmic reticulum stress response, and knockdown induces apoptosis of pancreatic cells. Apart from this, p-p38 has been previously correlated with better outcome in pancreatic cancer. Interestingly, ATF6α knockdown pancreatic cells showed increased p-p38. The aim of this study was to evaluate the expression of these 2 proteins, p-p38 and ATF6α, and their correlation with the outcome of biliopancreatic adenocarcinoma patients. Samples from patients with biliopancreatic adenocarcinoma that underwent pancreaticoduodenectomy from 2007 to 2013 were used to construct a tissue microarray to evaluate p-p38 and ATF6α proteins by immunohistochemistry. We observed that both markers showed a tendency to impact in the time to recurrence; then a combination of these 2 proteins was analyzed. Combination of ATF6α(high) and p-p38(low) was strongly associated with a higher risk of recurrence (hazard ratio 2.918, P = 0.013). This 2-protein model remained significant after multivariate adjustment.We proposed a 2-protein signature based on ATF6α(high) and p-p38(low) as a potential biomarker of risk of recurrence in resected biliopancreatic adenocarcinoma patients.

Primary Sclerosing Cholangitis as a Premalignant Biliary Tract Disease: Surveillance and Management

Primary sclerosing cholangitis (PSC) is a premalignant biliary tract disease that confers a significant risk for the development of cholangiocarcinoma (CCA). The chronic biliary tract inflammation of PSC promotes pro-oncogenic processes such as cellular proliferation, induction of DNA damage, alterations of the extracellular matrix, and cholestasis. The diagnosis of malignancy in PSC can be challenging because inflammation-related changes in PSC may produce dominant biliary tract strictures mimicking CCA. Biomarkers such as detection of methylated genes in biliary specimens represent noninvasive techniques that may discriminate malignant biliary ductal changes from PSC strictures. However, conventional cytology and advanced cytologic techniques such as fluorescence in situ hybridization for polysomy remain the practice standard for diagnosing CCA in PSC. Curative treatment options of malignancy arising in PSC are limited. For a subset of patients selected by using stringent criteria, liver transplantation after neoadjuvant chemoradiation is a potential curative therapy. However, most patients have advanced malignancy at the time of diagnosis. Advances directed at identifying high-risk patients, early cancer detection, and development of chemopreventive strategies will be essential to better manage the cancer risk in this premalignant disease. A better understanding of dysplasia definition and especially its natural history is also needed in this disease. Herein, we review recent developments in our understanding of the risk factors, pathogenic mechanisms of PSC associated with CCA, as well as advances in early detection and therapies.

Prognostic Factors for the Selection of Patients Eligible for Second-Line Chemotherapy in Advanced Biliary Tract Cancer

BACKGROUND

The efficacy of second-line chemotherapy (CT2) after the failure of first-line chemotherapy (CT1) for advanced biliary tract cancer (BTC) has not been established. We investigated the favorable prognostic factors for CT2 to determine which patients could be expected to benefit from CT2.

METHODS

From a total of 168 patients who were treated with chemotherapy at our institution between January 2003 and December 2012, we retrospectively reviewed 50 patients who received CT2. Patients were treated with various chemotherapeutic combinations as CT1 and CT2. RESULts: The median overall survival (OS) of patients who received and CT2 was 10.2 and 5.5 months, respectively. Good performance status (PS), a serum albumin level >3.5 g/dl and metastasis to only 1 organ were independent prognostic factors that affected the OS of the patients who received CT2. Patients who had only 1 metastastic organ, a good PS and a serum albumin level >3.5 g/dl at the beginning of CT2 demonstrated prolonged survival compared to patients who did not exhibit these 3 factors (9.5 vs. 4.3 months, p < 0.005).

CONCLUSIONS

CT2 should be considered for patients with advanced BTC, especially for those who have only 1 metastatic organ and remain in generally good medical condition after the failure of CT1.

Diagnosing Biliary Malignancy

The most common malignant causes of biliary strictures are pancreatic cancer and cholangiocarcinoma. Differentiating between malignant and benign causes of biliary strictures has remained a clinical challenge. Endoscopic retrograde cholangiopancreatography (ERCP) remains the mainstay and first-line method of tissue diagnosis but has a poor diagnostic yield. This article reviews the causes of biliary strictures, the initial clinical evaluation of biliary obstruction, the diagnostic yield of ERCP-based sampling methods, the role of newer tools in the armamentarium for evaluating strictures, and ways to address the ongoing challenge of stricture evaluation in patients with primary sclerosing cholangitis.

Outcome of stenting in biliary and pancreatic benign and malignant diseases: A comprehensive review

Endoscopic stenting has become a widely method for the management of various malignant and benign pancreatico-biliary disorders. Biliary and pancreatic stents are devices made of plastic or metal used primarily to establish patency of an obstructed bile or pancreatic duct and may also be used to treat biliary or pancreatic leaks, pancreatic fluid collections and to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis. In this review, relevant literature search and expert opinions have been used to evaluate the outcome of stenting in biliary and pancreatic benign and malignant diseases.

Significance of serum and bile tumor markers in the diagnostic approach of patients with malignant pancreatobiliary disease

PURPOSE

Serum and bile tumor markers are under intense scrutiny for the diagnosis of malignant disease. The purpose of our study was to report the usefulness of serum and bile tumor markers for the discrimination between benign and malignant pancreatobiliary diseases.

METHODS

Between March 2010 and May 2013, 95 patients with obstructive jaundice or history of biliary obstruction, were included in the study. During ERCP, bile samples were obtained for measurement of tumor markers CEA, CA19- 9, CA125, CA72-4 and CA242. Serum samples were taken before ERCP for the same measurements. The patients were divided into two groups: patients with malignant disease and patients with benign disease.

RESULTS

Serum tumor marker levels were significantly higher in patients with malignant disease. Serum CA242 and CA19-9 exhibited the highest diagnostic accuracy (76.8% and 73.7%, respectively). CA125 and CA72-4 levels in bile samples were significantly higher in patients with malignant disease. Bile CA125, CEA and CA72-4 achieved the best diagnostic accuracy (69, 65 and 65), respectively). The combined detection of CA19-9, CA242 in serum and CA125, CA72-4 in bile along with total bilirubin levels, showed the best diagnostic accuracy (81%).

CONCLUSIONS

Serum and bile tumor markers, when studied alone, lack the diagnostic yield to discriminate benign from malignant pancreatobiliary diseases. In cases of diagnostic dilemmas the combination of serum and bile markers might be helpful.

Cisplatin and gemcitabine in patients with advanced biliary tract cancer (ABC) and persistent jaundice despite optimal stenting: Effective intervention in patients with luminal disease

INTRODUCTION

The advanced biliary tract cancer (ABC)-02 study established cisplatin and gemcitabine (CisGem) as a reference 1(st)-line regimen for patients with advanced/metastatic biliary tract cancer; patients with bilirubin ⩾ 1.5 × upper limit of normal (ULN) were excluded and there are few extant data for systemic treatment in the context of elevated bilirubin.

METHODS

Patients with ABC, receiving CisGem with a baseline bilirubin of ⩾ 1.5 × ULN were eligible for this retrospective analysis; response, toxicity and survival data were collected.

RESULTS

Thirty-three patients of 545 screened; median age 59 years, range 23-79; 58% male, 58% with metastases (79% in the liver) of performance status (PS) 0 (33%), 1 (64%) or 2 (3%) were eligible. The median baseline bilirubin was 55 μmol/L (range 32-286); due to biliary tract obstruction (BTO, 76%) or liver metastases (LM, 24%). Toxicity was comparable to the ABC-02 study; bilirubin normalised in 64% during chemotherapy/follow-up. The median progression-free survival (PFS) was 6.9 months (95% confidence interval (CI): 4.4-9.0) and median overall survival (OS) 9.5 months (95% CI: 5.7-12.8). Patients with BTO had a longer PFS and OS than those with LM (7.0 versus 2.6 months; p = 0.1633 and 9.8 versus 4.4 months, hazard ratio (HR) 0.74; p = 0.465, respectively); not statistically significant (due to small sample size). Normalisation of bilirubin and completion of eight CisGem cycles were associated with longer OS (11.4 versus 2.9 months, HR 0.49; p = 0.08 and 15.2 versus 5.4 months, HR 0.12 p < 0.001, respectively). No difference in OS was shown between the bilirubin percentiles (for either PFS or OS).

CONCLUSION

For PS 0-1 patients with ABC and high bilirubin due to luminal disease despite optimal stenting CisGem can be used safely with results similar to those in patients with normal bilirubin.

Venous thrombosis in pancreaticobiliary tract cancer: outcome and prognostic factors

BACKGROUND

The differences in outcome among cancer patients with incidental vs. symptomatic venous thromboembolism (VTE) are unknown. In this study, patients with extrahepatic pancreaticobiliary tract cancer (PBC) were selected for a prospective cohort study between February 2008 and February 2011.

METHODS

At the time of cancer diagnosis, all patients were examined for deep vein thrombosis with bilateral compression ultrasonography (biCUS). Computed tomography pulmonary angiography was also performed to diagnose pulmonary embolisms. After inclusion, the patients were followed up with clinical examinations, blood collections, and biCUS.

RESULTS

A total of 121 PBC patients were enrolled. At the time of cancer diagnosis, 15 patients had experienced a VTE (12.4%, 95% confidence interval [CI] 7.1-19.6), including six symptomatic and nine incidental cases. A total of 25 first-time VTE events were identified (20.7%; 95% CI 13.8-29.0). Patients with a VTE had reduced survival, with a median overall survival (OS) of 4.4 months (95% CI 2.2-11.5). The median OS of the patients with incidental VTE was 3.0 months (95% CI 0.1-15.0), which was not different from the median OS of the patients with symptomatic VTE (5.0 months; 95% CI 2.1-14.5). The median OS was 11.9 months (95% CI 8.1-14.7) in the PBC patients with no VTEs.

CONCLUSION

The occurrence of a VTE event in a PBC patient within the first months of the disease is associated with significantly increased mortality.

Association between Helicobacter spp. infections and hepatobiliary malignancies: a review

Hepatobiliary cancers are highly lethal cancers that comprise a spectrum of invasive carcinomas originating in the liver hepatocellular carcinoma, the bile ducts intrahepatic cholangiocarcinoma and extrahepatic cholangiocarcinoma, the gallbladder and the ampulla of Vater (collectively known as biliary tract cancers). These tumors account for approximately 13% of all annual cancer-related deaths worldwide and for 10%-20% of deaths from hepatobiliary malignancies. Cholangiocarcinoma (CCA) is a devastating disease that displays a poor survival rate for which few therapeutic options are available. Population genetics, geographical and environmental factors, cholelithiasis, obesity, parity, and endemic infection with liver flukes have been identified as risk factors that influence the development of biliary tract tumors. Other important factors affecting the carcinogenesis of these tumors include chronic inflammation, obstruction of the bile ducts, and impaired bile flow. It has been suggested that CCA is caused by infection with Helicobacter species, such as Helicobacter bilis and Helicobacter hepaticus, in a manner that is similar to the reported role of Helicobacter pylori in distal gastric cancer. Due to the difficulty in culturing these Helicobacter species, molecular methods, such as polymerase chain reaction and sequencing, or immunologic assays have become the methods of choice for diagnosis. However, clinical studies of benign or malignant biliary tract diseases revealed remarkable variability in the methods and the findings, and the use of uniform and validated techniques is needed.

MicroRNA markers for the diagnosis of pancreatic and biliary-tract cancers

It is difficult to detect pancreatic cancer or biliary-tract cancer at an early stage using current diagnostic technology. Utilizing microRNA (miRNA) markers that are stably present in peripheral blood, we aimed to identify pancreatic and biliary-tract cancers in patients. With "3D-Gene", a highly sensitive microarray, we examined comprehensive miRNA expression profiles in 571 serum samples obtained from healthy patients, patients with pancreatic, biliary-tract, or other digestive cancers, and patients with non-malignant abnormalities in the pancreas or biliary tract. The samples were randomly divided into training and test cohorts, and candidate miRNA markers were independently evaluated. We found 81 miRNAs for pancreatic cancer and 66 miRNAs for biliary-tract cancer that showed statistically different expression compared with healthy controls. Among those markers, 55 miRNAs were common in both the pancreatic and biliary-tract cancer samples. The previously reported miR-125a-3p was one of the common markers; however, it was also expressed in other types of digestive-tract cancers, suggesting that it is not specific to cancer types. In order to discriminate the pancreato-biliary cancers from all other clinical conditions including the healthy controls, non-malignant abnormalities, and other types of cancers, we developed a diagnostic index using expression profiles of the 10 most significant miRNAs. A combination of eight miRNAs (miR-6075, miR-4294, miR-6880-5p, miR-6799-5p, miR-125a-3p, miR-4530, miR-6836-3p, and miR-4476) achieved a sensitivity, specificity, accuracy and AUC of 80.3%, 97.6%, 91.6% and 0.953, respectively. In contrast, CA19-9 and CEA gave sensitivities of 65.6% and 40.0%, specificities of 92.9% and 88.6%, and accuracies of 82.1% and 71.8%, respectively, in the same test cohort. This diagnostic index identified 18/21 operable pancreatic cancers and 38/48 operable biliary-tract cancers in the entire cohort. Our results suggest that the assessment of these miRNA markers is clinically valuable to identify patients with pancreato-biliary cancers who could benefit from surgical intervention.

Paraneoplastic plaque-like cutaneous mucinosis: a case report

Plaque-like cutaneous mucinosis (PCM) is a rare disorder of dermal mucin deposition. Some patients with PCM will be found to have an associated malignancy. We report the case of a 72-year-old man presenting with new onset pruritic, waxy-appearing erythematous and skin-colored papules and nodules coalescing into plaques on his shoulder, scalp, and forehead. Skin biopsy revealed cutaneous mucinosis. Despite conservative treatment, his skin lesions progressed, and he was found to have an occult malignancy of pancreatobiliary origin. After several months of chemotherapy, his skin lesions showed progressive improvement. To our knowledge, this is the third reported case of paraneoplastic PCM and the first reported to occur in association with underlying adenocarcinoma of pancreatobiliary origin. PCM may occasionally represent a paraneoplastic dermatosis. This case highlights the importance of a search for occult malignancy in such patients.

[Surgical treatment and different preoperative preparation of patients with malignant tumors of hepatopancreatoduodenal zone]

Different tactical approaches present to optimize surgical treatment of patients with malignant tumors hepatopancreatoduodenal zone. This research based on diagnosis and results of treatment of tumors of this localization, which included 357 analyzed case histories of patients treated in the Chelyabinsk Regional Hospital from 2010 to 2014. During this study was considered the preoperative preparation of patients with malignant obstructive jaundice genesis, and was assessed its impact on the level of postoperative complications and mortality. Farther was found effectiveness of a two-stage surgical treatment of patients with obstructive jaundice malignant etiology for the reduction of postoperative mortality. The complication rate is significantly reduced radically operated patients with bilirubin level below 40 mmol/l, palliative - 80 mmol/l. Also were presented results of treatment of chronic pain.

Biliary papillomatosis: correlation of radiologic findings with percutaneous transhepatic cholangioscopy

AIM

To correlate the radiologic findings with percutaneous transhepatic cholangioscopy (PTCS) in patients with pathologically confirmed biliary papillomatosis.

METHODS

Thirteen patients diagnosed with pathologic papillomatosis or intraductal papillary neoplasms of the bile ducts were retrospectively reviewed. The imaging results from ultrasonography, multi-detector computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP) and percutaneous cholangiography (PTC) were correlated with the findings of PTCS.

RESULTS

Papillary neoplasms of the bile ducts usually appeared on ultrasound as a non-shadowing echogenic mass (60%) within dilated bile ducts. Localised dilatation of the bile duct with mild enhancing nodularities was the most common multi-detector CT finding (61.5%), followed by localised biliary dilatation with mild wall thickening (15.4 %). MRCP showed that the bile duct was locally dilated and filled with material of intermediate signal intensity (60%). An abnormal filling defect (71.4%) was the most common finding when PTC was used. In six patients who underwent PTCS, underlying fish egg-like intraluminal nodularities were noted with or without multifocal cauliflower-like papillary masses. In nine cases, the pathologic finding was intraductal papillary cholangiocarcinoma in the underlying biliary papillomatosis. Three patients were diagnosed as papillomatosis with high grade dysplasia and one as villous adenoma with underlying papillomatosis.

CONCLUSIONS

Imaging is useful for detecting bile duct tumours that cause obstruction, but its ability to detect fine features of intraductal papillary tumours is limited. Percutaneous transhepatic cholangioscopy is an effective approach that allows the direct visualisation and tissue confirmation of growing papillary tumours.

Caution in interpretation of the tumor marker CA 19.9 in patients with obstructive jaundice: illustrative case reports

BACKGROUND

Carbohydrate antigen (CA) 19.9 is a Lewis blood group oligosaccharide antigen which exists in fixed and soluble forms. The CA 19.9 antigen is synthesized by epithelial cells of the gastrointestinal tract, pancreatic duct, and biliary tree. The CA 19.9 antigen is commonly used as a tumor marker for malignancies of the pancreas and biliary tract. High levels (> 300 U/ml) of antigen have strongly suggested malignant processes.

METHODS

Four patients are described with markedly elevated levels of CA 19.9 due to benign calculous disease.

RESULTS

Three of four patients underwent endoscopic stone removal followed by cholecystectomy; the fourth patient spontaneously passed stones and had a subsequent cholecystectomy with benign inflammatory pathology. Removal or passage of the obstructing stones produced normalization of the CA 19.9 in each case even with long-term follow-up up to one year. All pathology specimens were interpreted as benign.

CONCLUSIONS

Marked elevations of CA 19.9 may be found in benign obstructive disease and should be interpreted with caution until biliary obstruction is relieved.

Pre-ERCP imaging of the bile duct and gallbladder

Advances in biliary imaging have improved making accurate diagnoses of the presence and causes of biliary obstruction. Abdominal ultrasound is a useful screening tool because it is highly specific for choledocholithiasis. New developments in CT and MRI have also been useful in the diagnosis of biliary disease. Although diagnosis of biliary disease can be achieved in a noninvasive manner, there are limitations to modern MRI and CT cholangiographic techniques; their use may not be necessary or cost effective. MRI and CT imaging of the biliary tract provides opportunities for less-invasive diagnostic techniques but should be used judiciously before interventional endoscopy.

Choledochoscopy/cholangioscopy

Miniature endoscopes that can be introduced into the bile duct through the duodenoscope during endoscopic retrograde cholangiopancreatography were developed to allow nonsurgical management of difficult biliary stones. The direct visualization enabled by these cholangioscopes of the biliary epithelium provides additional data in the assessment of biliary strictures. Cholangioscopy allows assessment of the biliary lumen, biliary epithelium, targeted tissue acquisition, targeted therapy, and wire guidance.

Burkholderia contaminans: unusual cause of biliary sepsis

We report a case of biliary tract infection caused by a strain of Burkholderia contaminans, a member of the Burkholderia cepacia complex. The patient developed sepsis after endoscopic retrograde cholangiopancreatography (ERCP). Gram-negative bacilli were isolated from blood and bile cultures. Automated bacterial identification systems identified the organism as Burkholderia cepacia, whereas DNA sequence analysis revealed that the recA gene isolate was identical to that of B. contaminans. The patient responded to therapy with the antibiotics trimethoprim/sulfamethoxazole and biliary tract decompression. This case suggests that B. contaminans can be a causative agent of healthcare-associated biliary tract infections such as ERCP-related cholangitis.

Resected biliary tract cancers: a novel clinical-pathological score correlates with global outcome

BACKGROUND

Biliary tract cancer presents a poor prognosis.

AIMS

The objective of this study is to find clinical-laboratory parameters like prognostic factors to select patients who can benefit from surgery and post-operative treatments.

METHODS

Between 2005 and 2010, 41 patients underwent radical surgery at our Institution. A novel score was retrospectively calculated assigning a grade to the clinical-laboratory findings at diagnosis. 0 and 1 point were respectively assigned to the normal or abnormal parameter. Two groups were identified: SCORE 0 and SCORE 1.

RESULTS

Patients with cholangiocarcinoma or Klatskin tumours or asymptomatic at diagnosis presented a significantly better overall survival (OS) than patients with different primary sites or who presented pain, jaundice or cholangitis. At univariate analysis, high levels of aspartate aminotransferase, alanine aminotransferase and CA19-9 before surgery, hyperbilirubinemia before and after surgery had a negative correlation with OS. A worse OS was observed in patients with a higher score (median OS in the "score 0" group=30.79 months vs. median OS in the "score 1"=17.98 months).

CONCLUSION

Our results suggest that pre and post-surgery clinical-laboratory parameters and the novel score, could be useful, especially for intrahepatic tumours, in predicting the outcome in patients undergoing surgery and in selecting patients to receive adjuvant therapy.

Development and validation of a symptom index for advanced hepatobiliary and pancreatic cancers: the National Comprehensive Cancer Network Functional Assessment of Cancer Therapy (NCCN-FACT) Hepatobiliary-Pancreatic Symptom Index (NFHSI)

BACKGROUND

The 45-item Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) questionnaire assesses health-related quality of life in patients with liver, bile duct, and pancreatic cancers. Although the FACT-Hep was initially derived from patient input, this study's researchers sought to verify adequate coverage of items by soliciting open-ended input from patients with advanced disease.

METHODS

As part of a larger study in collaboration with the National Comprehensive Cancer Network (NCCN), 50 people (60% male, 80% caucasian, average age 60.4 years) with stage 3 or 4 hepatobiliary or pancreatic cancer were recruited. Participants generated and ranked up to 10 important symptoms and concerns that physicians should monitor when assessing the value of chemotherapy. Patients were also able to provide open-ended, qualitative information that was evaluated systematically. Ten expert physicians also provided input on priority symptoms.

RESULTS

The resulting 18-item NCCN-FACT Hepatobiliary-Pancreatic Symptom Index (NFHSI-18) demonstrated high internal consistency (α = .89) and moderate to strong correlations with measures of physical well-being (ρ = .76), emotional well-being (ρ = 0.52), and functional well-being (ρ = 0.57). Scores on the NFHSI-18 were also highly correlated with the original hepatobiliary scale of the FACT-Hep (ρ = .82; all P < .001). Compared with patients with better performance status, patients with poor performance status had worse NFHSI-18 symptom scores, F(3,47) = 9.74; P = .0003.

CONCLUSIONS

The NFHSI-18 assesses symptoms of importance to patients with hepatobiliary and pancreatic cancers and demonstrates promising measurement properties. The scale is a good candidate for brief symptom assessment in clinical trials.

Diagnosis and treatment update: cholangiocarcinoma

Cholangiocarcinoma is a rare and very aggressive neoplasm that arises from the biliary epithelium, constitutes approximately 2% of all reported cancer, and accounts for about 3% of all gastrointestinal malignancies. Up to date, there are many modalities to diagnosis and treat with a range of sensitivity and specificity, and also the advantage and disadvantage of its modality. As a physician, we should be able to assess and choose promptly which modality is best for our patient, even for paliative care. Treatment modalities are surgery and non-surgery like adjuvant chemotherapy, radiation, chemoradiation, radiotherapy, TACE, 5-FU chemoinfusion, intralesion PEI, photodynamic therapy, liver transplantation, and paliative therapy. The choice of treatment varies individually. Radical surgery remains the optimal therapy and offering a potential for cure. Overall prognosis in these patients is poor and survival is limited to a few months.

Diagnostic significance of alpha fetoprotein in carcinomas of liver and biliary tract - a comparative study from the western region of Nepal

OBJECTIVE

To assess the diagnostic significance of α-fetoprotein in carcinomas of liver and biliary tract with the overall goal of reducing morbidity and mortality in Pokhara valley.

MATERIALS AND METHODS

It was a hospital based comparative study carried out in the Department of Biochemistry of Manipal Teaching Hospital, Pokhara, Nepal between 1st January 2009 and 31st December 2010. The variables collected were age, gender, serum alpha feto protein. Approval for the study was obtained from the institutional research ethical committee. Estimation of AFP was performed by ELISA reader for all cases. The standard procedure was followed as per manufacturer's instructions for ELISA. All these laboratory parameters were analyzed using Human reagent kits and with the help of ELISA and semi autoanalyser (Humalyser 3500, Germany).

RESULTS

Out of 1200 patients, there were 348(29%) cases of HCC. Out of that, 285 cases were found to be AFP positive with significant elevation. Furthermore, diagnosed cases were of cholangiocarcinomas (96, 8%) and secondary carcinomas of liver (216, 18%). In both of these clinical conditions, there was insignificant elevation of AFP. Another commonly diagnosed condition was cirrhosis (480, 40%) and in 90 cases, AFP values were moderately raised from the upper limit of normal reference range. The last diagnosed cases were of either Hepatitis A/E(60, 5%) and did not show any rise in levels of AFP.

CONCLUSION

Serological markers for hepatocellular carcinoma (HCC) are imperative for early identification, as well as scrutinizing of tumour aggressiveness, treatment responsiveness, reappearance and endurance. It is consequently justifiable to carry out the test for serum AFP to detect and differentiate at early stage of liver cell carcinomas.

Hepatobiliary mucinous cystadenoma and cystadenocarcinoma: report of six cases and review of the literature

BACKGROUND/AIMS

The aim of this investigation was to describe the clinical features, diagnosis, pathologic characteristics, and optimal surgical management for patients with mucious hepatobiliary cystadenomas (HBCAs).

METHODOLOGY

From 2005 to 2008, our institutional experience for treating six patients with HBCAs was reviewed and reported. The clinical features, radiological characteristics and management were analyzed retrospectively.

RESULTS

Two of six patients were respectively misdiagnosed as hydatid cyst and simple cyst pre-operatively. The histopathologic examination showed HBCA in four patients and hepatobiliary cystadenocaiconoma (HBCAC) in two patients. Three HBCA patients and two HBCAC patients had undergone total excision treatment. In a median of 37.5 months follow-up visit, four have no evidence of recurrence and one HBCAC patient experienced a recurrence 31 months after surgery. Another HBCA patient who underwent fenestration initially with subsequent recurrence, died 15 months after the therapy.

CONCLUSIONS

Owing to its potential for malignant transformation into HBCAC, along with the consideration that it tends to recur after incomplete resection, radical excision treatment with adequate surgical margins is regarded as the most suitable mode of therapy for the HBCA.

Primary biliary cystadenocarcinoma mimicking a complicated hydatid cyst

Cystadenocarcinoma of the liver is a rare neoplasm that originates from hepatobiliary epithelium. Primary location of this tumor is generally intrahepatic and most cases are in the right hepatic lobe. Herein we present a case of intrahepatic cystadenocarcinoma in a 53-year-old man who had been followed up for 8 years as hydatic cyst disease of the liver. He was admitted to our hospital with jaundice and loss of appetite. Ultrasound and computed tomography showed a cystic lesion that looked like type II cyst hidatic. Thereafter magnetic resonance imaging revealed a cystic lesion associated with biliary tree. On diagnostic laparotomy peritoneal infiltrations were observed and pathologic examination revealed a biliary cystadenocarcinoma and peritonitis carcinomatosa was diagnosed. Unfortunately correct diagnosis was extremely late and no curative management was possible.

Human apurinic/apyrimidinic endonuclease (APE1) is a prognostic factor in ovarian, gastro-oesophageal and pancreatico-biliary cancers

BACKGROUND

Altered DNA repair may be associated with aggressive tumour biology and impact upon response to chemotherapy and radiotherapy. We investigated whether expression of human AP endonuclease (APE1), a key multifunctional protein involved in DNA BER, would impact on clinicopathological outcomes in ovarian, gastro-oesophageal, and pancreatico-biliary cancer.

METHODS

Formalin-fixed human ovarian, gastro-oesophageal, and pancreatico-biliary cancers were constructed into TMAs. Expression of APE1 was analysed by IHC and correlated to clinicopathological variables.

RESULTS

In ovarian cancer, nuclear APE1 expression was seen in 71.9% (97 out of 135) of tumours and correlated with tumour type (P=0.006), optimal debulking (P=0.009), and overall survival (P=0.05). In gastro-oesophageal cancers previously exposed to neoadjuvant chemotherapy, 34.8% (16 out of 46) of tumours were positive in the nucleus and this correlated with shorter overall survival (P=0.005), whereas cytoplasmic localisation correlated with tumour dedifferentiation (P=0.034). In pancreatico-biliary cancer, nuclear staining was seen in 44% (32 out of 72) of tumours. Absence of cytoplasmic staining was associated with perineural invasion (P=0.007), vascular invasion (P=0.05), and poorly differentiated tumours (P=0.068). A trend was noticed with advanced stage (P=0.077).

CONCLUSIONS

Positive clinicopathological correlations of APE1 expression suggest that APE1 is a potential drug target in ovarian, gastro-oesophageal, and pancreatico-biliary cancers.

A new NMR-based metabolomics approach for the diagnosis of biliary tract cancer

BACKGROUND & AIMS

Biliary tract cancer is highly lethal at presentation, with increasing mortality worldwide. Current diagnostic measures employing multiple criteria such as imaging, cytology, and serum tumor markers are not satisfactory, and a new diagnostic tool is needed. Because bile is a cognate metabolite-rich bio-fluid in the biliary ductal system, we tested a new metabolomic approach to develop an effective diagnostic tool.

METHODS

Biles were collected prospectively from patients with cancer (n=17) or benign biliary tract diseases (n=21) with percutaneous or endoscopic methods. Nuclear magnetic resonance spectra (NMR) of these biles were analyzed using orthogonal partial least square discriminant analysis (OPLS-DA).

RESULTS

The metabolomic 2-D score plot showed good separation between cancer and benign groups. The contributing NMR signals were analyzed using a statistical TOCSY approach. The diagnostic performance assessed by leave-one-out analysis exhibited 88% sensitivity and 81% specificity, better than the conventional markers (CEA, CA19-9, and bile cytology).

CONCLUSION

The NMR-based metabolomics approach provides good performance in discriminating cancer and benign biliary duct diseases. The excellent predictability of the method suggests that it can, at least, augment the currently available diagnostic approaches.

Immunocytochemical assessment of p53 protein to detect malignancy in increased cell-yield brush cytology from the biliopancreatic tree

BACKGROUND

Malignancies arising from the biliopancreatic tree are often diagnostic challenges for the gastroenterologist and the pathologist, especially when strictures without masses are present.

AIM

To evaluate the diagnostic yield of p53 immunocytology for the detection of malignancies in material obtained by biliopancreatic tree brushing by means of an increased cell-yield procedure.

PATIENTS AND METHODS

Cytologic specimens obtained from biliary and pancreatic tree brushing in 24 patients with biliary strictures suspected for malignancy were assessed by conventional Papanicolau staining and p53 immunocytochemistry.

RESULTS

Papanicolau staining detected 67% and p53 87% of the malignancies in the study group. p53 immunocytology displayed excellent sensitivity, specificity, and diagnostic accuracy.

CONCLUSIONS

p53 immunocytology may represent a useful diagnostic tool in the detection of malignancies from biliary and pancreatic tree brushing, especially when using an increasing cell-yield procedure.

Biliary rhabdomyoscarcoma mimicking choledochal cyst

A 3-year old male presented with complaints of pruritus, abdominal pain for 3 weeks and jaundice. Stools were acholic. There was jaundice, liver palpable 3 cm below right costal margin, no ascites or palpable masses. Serology revealed albumin 2.9 g/dl; ammonia of 31 mmol/l; elevated conjugated bilirubin, GGT, ALT, AST and alkaline phosphatase; alpha fetoprotein 1.3 ngm/ml; BhCG 9.1 IU/; PT 12.3 secs, INR 0.9; negative hepatitis A,B,C serology. CT scan showed a non-calcified heterogeneously enhancing mass centered at the liver hilum. MRCP showed a large heterogeneously enhancing, partially solid mass in the region of the porta hepatic. Liver biopsy revealed patternless proliferation of polymorphic oval to spindled shaped neoplastic cells. There was bile ducts distortion. Immunohistochemistry revealed positivity for vimentin, desmin.These findings were diagnostic for biliary rhabdomyosarcoma.There was no evidence of metastasis. Chemotherapy was initiated. Repeat imaging 6 months after initiation of treatment showed improvement in the degree of intrahepatic ductal dilatation and decrease in tumor bulk size. Rhabdomyosarcoma is the most common malignant tumor of the biliary tree in childhood. It is difficult to diagnose and delayed diagnosis influences the prognosis.

[Endoscopic retrograde cholangiopancreatography-guided brush cytology diagnosis of pancreatobiliary tumors]

OBJECTIVE

To study the cytologic features of pancreatobiliary tumors in endoscopic retrograde cholangiopancreatography (ERCP)-guided brushing preparations and to evaluate the usefulness of cytology in the diagnosis of pancreatobiliary malignancy.

METHODS

A retrospective analysis of 212 cases of ERCP-guided brush cytology smears performed during the period from January, 2004 to December, 2006. The cytologic diagnosis was confirmed either by the histologic diagnosis or the strict clinical criteria.

RESULTS

Two of the cases studied were unsatisfactory for diagnosis, with no epithelial cells identified. One hundred and thirty-seven smears were diagnosed as "negative", 45 of which subsequently confirmed to be malignant (negative predictive value = 60.2%). Six of the 11 cases with "low-grade atypia" were proven to be malignant (positive predictive value = 54.5%), as compared to 19 of 23 cases of "high-grade atypia" (positive predictive value = 86.4%). All of the 41 cases with cytologic diagnosis of "malignancy" were confirmed to be malignant (positive predictive value = 100%). The cytologic features of malignancy in ERCP-guided brushing preparations included overlapping nuclei, anisonucleosis, coarse chromatin pattern, poor cellular cohesion, tumor diathesis, prominent nucleoli and atypical mitotic figures.

CONCLUSIONS

The accuracy of ERCP-guided brush cytology relies on good specimen preparation and application of morphologic criteria. Grading of cytologic atypia is of clinical significance. A "negative" or "low-grade atypia" cytologic diagnosis requires further diagnostic workup to rule out the possibility of underlying malignancy, while a "high-grade atypia" or "malignant" diagnosis is relatively specific in guiding subsequent management of suspected pancreatobiliary malignancy.

Post-cholecystectomy biliary strictures: not always benign

BACKGROUND

Post-cholecystectomy malignant biliary obstruction masquerading as benign biliary stricture (BBS) has not been reported in the literature; it presents a diagnostic and management challenge.

METHODS

Of the 349 post-cholecystectomy BBS managed at a tertiary care hospital in northern India between 1989 and 2004, 11 patients were found to have biliary malignancy. Records of these 11 patients were analyzed retrospectively for the purpose of this study.

RESULTS

Mean age of patients with malignant biliary strictures was significantly higher (52 vs 38 years, P = 0.000); they were more likely to have jaundice (100% vs 78%, P = 0.008) and pruritus (82% vs 48%, P = 0.03). Unlike most patients with BBS referred from elsewhere to us, they had had a smooth postoperative course uncomplicated by bile leak, had a longer cholecystectomy-presentation interval, and were more likely to have high strictures ((Bismuth type III/IV) 91% vs 49%, P = 0.008).

CONCLUSIONS

Post-cholecystectomy biliary obstruction is not always benign. High bilirubin levels and hilar strictures, especially after an uneventful cholecystectomy, in a middle-aged patient should raise a suspicion of underlying missed malignancy.

Hepatobiliary cystadenoma: a report of two cases

We report two cases of hepatobiliary cystadenoma. Case 1. A 58-year-old male presented with dull abdominal pain and recurrent jaundice. Abdominal echo revealed biliary tracts dilatation; ERCP revealed amorphous filling defect inside the dilated CBD, a cystic tumor in the left lobe communicated with bile duct was disclosed by MRI/MRCP. He received left lobectomy and microscopic findings proved hepatobiliary cystadenoma. Case 2. Abdominal ultrasound detected a huge cystic tumor over the left hepatic lobe in a 69-year-old male. Abdominal CT revealed a large cystic mass lesion over the left hepatic lobe with septations and multiple papillary projections. A liver biopsy was performed and microscopic findings proved biliary cystadenoma. An abdominal ultrasound 6 months later revealed intrahepatic spread of cystadenocarcinoma over both lobes. Hepatobiliary cystadenoma is a rare benign cystic tumor of the liver. It usually occurs in middle-aged women and can undergo malignant change and become lethal. It is frequently misdiagnosed and should be suspected when a uni- or multilocular cystic lesion with papillary infoldings is detected in the liver by CT or ultrasound. ERCP/MRCP have a role in pre-operative evaluation. Elevated serum and cystic fluid tumor markers CA19-9 are only seen in some patients; cystic fluid cytology does not provide adequate diagnostic aid. Its morphologic features maybe confused with biliary papillomatosis or IPMN of bile duct. Its prognosis is excellent after complete resection.

Biliary cystic intraductal papillary mucinous tumor and cystadenoma/cystadenocarcinoma: differentiation by CT

PURPOSE

To identify differential findings of biliary cystic intraductal papillary mucinous tumor (IPMT) and biliary cystadenoma/cystadenocarcinoma on CT images.

MATERIALS AND METHODS

Records of 7 patients with biliary cystic IPMT and 17 patients with biliary cystadenoma/cystadenocarcinoma were accessed. A pathologist reviewed gross morphologic and microscopic findings and confirmed the diagnosis. Two radiologists who were blind to the pathologic diagnosis reviewed CT images regarding size of cystic mass, mural nodule, septa, calcification, dilatation of the proximal, and distal bile ducts to the tumor, and the results were analyzed using multivariate analysis.

RESULTS

Mural nodule and dilatation of the bile ducts distal to the cystic tumor were more commonly seen in patients with cystic IPMT than in patients with biliary cystadenoma/cystadenocarcinoma and these are statistically significant, the P values being 0.029 and 0.016, respectively. Size of the cystic tumor, presence of septa, calcification, and dilatation of the bile duct proximal to the cystic tumor were not statistically different.

CONCLUSION

Biliary cystic IPMT could be differentiated from biliary cystadenoma/cystadenocarcinoma on CT images based on the presence of mural nodules and dilatation of the bile ducts distal to the cystic tumor.

Palliative antecolic isoperistaltic gastrojejunostomy: a randomized controlled trial comparing open and laparoscopic approaches

Gastric outlet obstruction is a common, often preterminal, event for patients with inoperable neoplasms of the distal stomach, duodenum, and biliopancreatic area. It can be surgically managed by open or laparoscopic gastrojejunostomy. This study aimed to compare the results of open and laparoscopic palliative gastrojejunostomy for patients with gastric outlet obstruction resulting from inoperable neoplasms. A total of 24 patients were randomized prospectively to undergo laparoscopic (12 patients) or open (12 patients) palliative laterolateral antecolic isoperistaltic gastrojejunostomy. All the procedures were completed as planned. The mean duration of surgery was not significantly different between the two groups (p = 0.75). The mean intraoperative blood loss was significantly less after laparoscopic gastrojejunostomy (LGJ) (p = 0.0001). Time to oral solid food intake was longer after open gastrojejunostomy (OGJ) (p = 0.04). Two patients in the OGJ group experienced postoperative delayed gastric empting, whereas no patients in the LGJ group experienced such a complication (p = 0.04). The mean postoperative stay was shorter in the LGJ group, but the difference did not reach statistical significance (p = 0.65). No readmissions were registered after a minimum follow-up period of 2 months. The findings show that LGJ is a safe, feasible, and effective alternative to OGJ. However, because the current data involved only a small number of patients, large studies still are required for further evaluation of the this operation's effectiveness.

Flowcharts for the management of biliary tract and ampullary carcinomas

No strategies for the diagnosis and treatment of biliary tract carcinoma have been clearly described. We developed flowcharts for the diagnosis and treatment of biliary tract carcinoma on the basis of the best clinical evidence. Risk factors for bile duct carcinoma are a dilated type of pancreaticobiliary maljunction (PBM) and primary sclerosing cholangitis. A nondilated type of PBM is a risk factor for gallbladder carcinoma. Symptoms that may indicate biliary tract carcinoma are jaundice and pain in the upper right area of the abdomen. The first step of diagnosis is to carry out blood biochemistry tests and ultrasonography (US) of the abdomen. The second step of diagnosis is to find the local extension of the carcinoma by means of computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP). Because resection is the only way to completely cure biliary tract carcinoma, the indications for resection are determined first. In patients with resectable disease, the indications for biliary drainage or portal vein embolization (PVE) are checked. In those with nonresectable disease, biliary stenting, chemotherapy, radiotherapy, and/or best supportive care is selected.