Cholangiocarcinoma

Six year disease free survival after liver transplantation in a patient with T3 gallbladder carcinoma: case presentation and review of the literature

BACKGROUND

The incidence of gallbladder carcinoma in cirrhotics is unknown. Known risk factors are primary sclerosing cholangitis and polypoid masses.

CASE PRESENTATION

A sixty year old with primary sclerosing cholangitis, cirrhosis, and gallbladder polyps underwent liver transplantation. A polypoid lesion measuring 1.5 x 0.5 cm was found on the fundus of the gallbladder. Histological examination revealed moderately differentiated adenocarcinoma with full thickness penetration of the gallbladder encroaching liver parenchyma. Angiolymphatic invasion was noted. The lymph nodes, the cystic duct and the common duct were free of tumor (T3N0M0). Extensive evaluation did not demonstrate metastasis. No chemotherapy was given. He is currently six years post procedure and free of disease.

CONCLUSION

"Incidentally" discovered stage IIA gallbladder carcinoma may not negatively affect long term survival after liver transplantation.

Homozygous deletions of methylthioadenosine phosphorylase in human biliary tract cancers

The p16(INK4A)/CDKN2A gene on chromosome 9p21 is a site of frequent allelic loss in human cancers, and in a subset of cases, homozygous deletions at this locus encompass the telomeric methylthioadenosine phosphorylase (MTAP) gene. The MTAP gene product is the principal enzyme involved in purine synthesis via the salvage pathway, such that MTAP-negative cancers are solely dependent on de novo purine synthesis mechanisms. Inhibitors of the de novo pathway can then be used to selectively blockade purine synthesis in cancer cells while causing minimal collateral damage to normal cells. In this study, we determine that 10 of 28 (35%) biliary tract cancers show complete lack of Mtap protein expression. In vitro analysis using a selective inhibitor of the de novo purine synthesis pathway, L-alanosine, shows robust growth inhibition in MTAP-negative biliary cancer cell lines CAK-1 and GBD-1 accompanied by striking depletion of intracellular ATP and failure to rescue this depletion via addition of exogenous methylthioadenosine, the principal substrate of the MTAP gene product; in contrast, no significant effects were observed in MTAP-expressing HuCCT1 and SNU308 cell lines. Colony formation studies confirmed that L-alanosine reduced both number and size of CAK-1 colonies in soft agar assays. Knockdown of Mtap protein by RNA interference in L-alanosine-resistant HuCCT1 cells conferred sensitivity to this agent, confirming that intracellular Mtap protein levels determine response to L-alanosine. Inhibitors of de novo purine synthesis can be a potential mechanism-based strategy for treatment of biliary tract cancers, one third of which show complete loss of MTAP function.

Cholangiocarcinoma

Cholangiocarcinoma is an uncommon malignant tumor arising from biliary epithelium. The incidence increases with age and usually affects individuals in their sixth or seventh decade of life. Most patients clinically present with features of biliary obstruction. Although surgical resection offers the only hope for cure, the majority of patients are found to have unresectable disease on initial presentation and carry extremely grim prognosis. This has lead to an emphasis on the role of palliative care, with the relief of biliary obstruction being the primary goal in the management of these patients. Surgical bypass was once considered as the primary means of palliating biliary obstruction, but nonsurgical placement of biliary stents is associated with lower morbidity and mortality. Newer modalities such as photodynamic therapy, brachytherapy, and high-intensity ultrasound therapy may result in improved survival and play a future role as an adjunctive therapy to surgical resection.

Stage does not predict survival after resection of hilar cholangiocarcinomas promoting an aggressive operative approach

INTRODUCTION

Staging systems have been developed to predict survival after resection of hilar cholangiocarcinoma. Notably, they have not been validated nor compared for relative predictive ability.

METHODS

Forty-two patients underwent resection of hilar cholangiocarcinoma and have been followed through a prospectively collected database. The tumors were staged using the Bismuth-Corlette, Blumgart, and American Joint Committee on Cancer (AJCC) systems, and a significant relationship with survival was sought.

RESULTS

Eleven patients were treated by extrahepatic biliary resection alone, while 31 required extrahepatic biliary resections with in-continuity hepatic resections. All patients underwent adjuvant therapy. To date, 30 patients have died with a mean survival time of 30 months +/- 35.0 (SD). Twelve patients are alive with a mean survival of 90 months +/- 61.8. By regression analysis, none of the staging systems had a significant relationship with survival (Bismuth: P = .64; Blumgart: P = .66; AJCC: P = .31).

CONCLUSIONS

Most patients with hilar cholangiocarcinoma require in-continuity hepatic resections. Survival after resection promotes an aggressive approach, with cure in as many as 30%. Staging systems should not impact the decision to operate or postoperative management, as all tumors should be aggressively resected and all patients should receive adjuvant treatment.

Detection of response-predicting mutations in the kinase domain of the epidermal growth factor receptor gene in cholangiocarcinomas

PURPOSE

Epidermal growth factor receptor (EGFR) signalings have recently been implicated in the genesis and progression of cholangiocarcinomas. Thus, the EGFR kinase inhibitor appears to be promising in the treatment of this cancer. The response-predicting mutations in the tyrosine kinase domain of EGFR gene have recently been detected in non-small cell lung cancers. This study was, therefore, to investigate if these mutations are also found in cholangiocarcinomas.

METHODS

Twenty-two consecutive cholangiocarcinoma patients who underwent surgical resection were enrolled. Their resected paraffin-embedded cholangiocarcinoma specimens were used for mutation analysis, which was performed by DNA sequencing of exons 18, 19 and 21 in the EGFR gene. Clinical characteristics were compared between each group according to the presence or absence of mutations.

RESULTS

Three patients (13.6%) harbored EGFR mutations. All the mutations found were deletions in exon 19. Mutations were more common in intra-hepatic or poorly differentiated tumors. Differences in age, sex, stage at diagnosis and survival were not observed between mutation-positive and -negative patients.

CONCLUSIONS

This study, for the first time, demonstrates that a subset of cholangiocarcinoma patients has response-predicting EGFR mutations. Therefore, a highly selected application of the EGFR kinase inhibitor would be therapeutically effective in these patients.

Intrahepatic cholangiocarcinoma associated with central calcification and arterio-portal shunt

Although several diagnostic imaging modalities have been significantly improved in the recent years, the definitive diagnosis of intrahepatic cholangiocarcinoma (IHC) is still sometimes difficult because of the versatile features of IHC with each imaging. A 68-year-old Japanese man with alcoholic liver cirrhosis developed an intrahepatic tumor. Several imaging modalities demonstrated various features, such as central calcification and arterio-portal (A-P) shunt. Since we could not reach a final diagnosis and the tumor size gradually increased, partial hepatectomy was done after obtaining written informed consent from the patient. The postoperative histopathological examination revealed a cholangiocarcinoma. Herein, we report this case of IHC that was very difficult to diagnose due to the simultaneous association with central calcification and A-P shunt.

Pilot study to assess patient outcomes following endoscopic application of photodynamic therapy for advanced cholangiocarcinoma

BACKGROUND

Photodynamic therapy (PDT) has demonstrated promise in the palliative treatment of advanced cholangiocarcinoma. The aim of this pilot study was to assess the outcome in patients with non-resectable cholangiocarcinoma following endoscopic application of PDT directly into the biliary tract.

METHODS

In patients with advanced cholangiocarcinoma, endoscopic retrograde cholangiopancreatography (ERCP) was performed to define the proximal and distal extent of intraductal tumor. Sodium porfimer was administered intravenously to all patients. Forty-eight hours later, a commercially available cylindrical diffusing laser fiber (1-2.5 cm in length, OptiGuide) designed for esophageal use was advanced across the biliary strictures. Laser light was applied at a power of 400 mW/cm fiber for a total energy of 180 J/cm(2) using an argon-pumped tunable dye laser. Patients received endoscopic PDT every 3 months provided they maintained a favorable performance status. Plastic biliary stents were replaced immediately following light application and were maintained in all patients.

RESULTS

Using a preloaded catheter, adequate positioning of the laser fiber was achieved in all patients. Eight patients with advanced cholangiocarcinoma received a total of 19 PDT treatments, range 1-5 treatments/patient. All eight patients were followed until death; mean follow-up was 9.8 months. Median survival from the date of the first PDT treatment was 276 days, which compares favorably with published series that have reported median survival times between 45 and 127 days for patients with bismuth type III and IV tumors treated with stenting alone.

CONCLUSIONS

Endoscopic application of PDT demonstrates promise in prolonging survival in patients with advanced cholangiocarcinoma. Additional randomized clinical trials using commercially available fibers are needed to fully evaluate both the optimum frequency and treatment interval of endoscopic PDT in the management of advanced cholangiocarcinoma.

Risk factors of intrahepatic cholangiocarcinoma in the United States: a case-control study

BACKGROUND & AIMS

The incidence of intrahepatic cholangiocarcinoma has been recently increasing in the United States. In this case-control study, we used the Surveillance, Epidemiology, and End Results-Medicare database to evaluate the prevalence of known risk factors for intrahepatic cholangiocarcinoma and explore other potential risk factors.

METHODS

We identified all patients with intrahepatic cholangiocarcinoma aged 65 years and older diagnosed between 1993 and 1999 in the population-based Surveillance, Epidemiology, and End Results registries (14% of the US population). Controls were randomly chosen from individuals without any cancer diagnosis in the underlying population of the Surveillance, Epidemiology, and End Results regions. We obtained information on risk factors from Medicare claims (parts A and B) for all cases and controls with at least 2 years of continuous Medicare enrollment. Unadjusted and adjusted odds ratios were calculated in logistic regression analysis.

RESULTS

A total of 625 cases and 90,834 controls satisfied the inclusion and exclusion criteria. Cases were older than controls (78.7 vs. 76.5 years; P=.02) and were more likely to be male (48.3% vs. 36.8%; P <.0001). The racial composition was similar between cases and controls. Several risk factors were significantly more prevalent among cases. These included nonspecific cirrhosis (adjusted odds ratio, 27.2; P <.0001), alcoholic liver disease (adjusted odds ratio, 7.4; P <.0001), hepatitis C virus infection (adjusted odds ratio, 6.1; P <.0001), human immunodeficiency virus infection (adjusted odds ratio, 5.9; P=.003), diabetes (adjusted odds ratio, 2.0; P <.0001), and inflammatory bowel diseases (adjusted odds ratio, 2.3; P=.002).

CONCLUSIONS

This population-based study shows that in addition to previously well described risk factors, several others could be associated with intrahepatic cholangiocarcinoma. These include hepatitis C virus, human immunodeficiency virus, liver cirrhosis, and diabetes.

In-continuity hepatic resection for advanced hilar cholangiocarcinoma

BACKGROUND

The purpose of this study was to examine outcomes of patients undergoing concomitant hepatectomy and bile duct excision for advanced Klatskin tumors.

METHODS

Thirty-one patients, 16 men and 15 women, with an average age of 64 years, underwent concomitant biliary and hepatic resections for Klatskin tumors. Outcomes, including complications and survival, are reported.

RESULTS

Fifteen patients had postoperative courses free of complications. Sixteen patients experienced a total of 50 complications; 13 patients experienced 1 or more major complications (including hemorrhage [n = 1], pneumonia [n = 5], intra-abdominal abscess [n = 8], hepatic failure [n = 3], and myocardial infarction [n = 2]). Five patients died perioperatively, 1 from adult respiratory distress syndrome and 4 from multisystem organ failure precipitated by hepatic failure. One-, 3-, and 5-year survival after resection was 69%, 33%, and 26%, respectively. American Joint Committee on Cancer stage and margin status did not impact long-term survival after resection.

CONCLUSIONS

Concomitant hepatic and biliary resections for Klatskin tumors carry relatively high risk but offer hope for long-term survival. This study supports in-continuity hepatectomy and extrahepatic biliary resection for advanced Klatskin tumors even when microscopically negative margins cannot be obtained.

Imatinib mesylate induces apoptosis in human cholangiocarcinoma cells

BACKGROUND

Cholangiocarcinoma is a highly malignant, usually fatal cancer with limited therapeutic options. Receptor tyrosine kinases contribute to the development and progression of this cancer. The relatively selective tyrosine kinase inhibitor imatinib mesylate (STI-571 or Gleevec(R)) has recently been licensed. However, the ability of this drug to inhibit signal transduction and induce apoptosis in human cholangiocarcinoma cells is incompletely studied. Thus, our goal was to examine the ability of STI-571 to induce apoptosis in KMCH-1 cells, a human cholangiocarcinoma cell line.

METHODS

Apoptosis was assessed morphologically and also biochemically by measuring caspase activity and the mitochondrial membrane potential. STI-571 induced apoptosis and inhibited growth of KMCH-1 cells in a time- and concentration-dependent manner. The induction of apoptosis was accompanied by mitochondrial depolarization followed by a 4.5-fold increase in caspase activation and was abrogated by the pancaspase inhibitor z-VAD(OMe)-fmk. Interestingly, cholangiocarcinoma cells do not express detectable PDGFR, c-Abl or c-Kit, which are protein kinases known to be directly inhibited by STI-571. However, a significant decrease in epidermal growth factor receptor (EGFR) and focal adhesion kinase (FAK) phosphorylation was observed following treatment with STI-571. This decrease in EGFR and FAK phosphorylation was associated with a reduction in Akt activity resulting in loss of Mcl-1, a potent anti-apoptotic Bcl-2 family protein.

CONCLUSIONS

These results indicate that STI-571 induces caspase-dependent apoptosis in a human cholangiocarcinoma cell line and suggest that STI-571 might warrant further investigation as a possible agent for treatment of human cholangiocarcinoma.

Hilar cholangiocarcinoma: surgical and endoscopic approaches

HCCa remains an uncommon malignancy, though increasing use of more radical surgery has led to prolonged survival in those patients who undergo curative resection. The extent of these resections suggest that the best results are likely to be obtained in centers with the resources and experience to conduct these operations in a safe fashion. Until major advances in the systemic therapy of HCCa are made, however, the management should focus on optimal preoperative imaging and palliation of jaundice with improvement in quality of life.

Magnetic Resonance Imaging of cholangiocarcinoma

Preoperative imaging with MRI/MRA/MRCP is an accurate non-invasive method for staging cholangiocarcinoma, and determining resectability. It provides information regarding tumor size, extent of bile duct involvement, vascular patency, extrahepatic extension, nodal or distant metastases, and the presence of lobar atrophy. MRCP is better for demonstrating bile ducts distal to the stricture, although with ERCP, therapeutic intervention such as stent placement and biopsy can be performed.

Hepatoma—resection or transplantation

The most frequent tumors of the liver originate from the hepatocytes, bile duct epithelium, and endothelial cells. Hepatocellular carcinoma accounts for 80% to 90% of primary liver cancer. Cholangiocarcinoma, a neoplasm that arises from the biliary tree, is the second most common primary hepatic malignancy. This article deals with the epidemiology and clinical presentation and the diagnostic confirmation and classification of both conditions, and with the use of liver resection and transplanation treatment for both.

Expression of Kit and platelet-derived growth factor receptors alpha and beta in cholangiocarcinoma, and case report of therapy with imatinib mesylate (STI571)

We have evaluated the expression of Kit, a receptor encoded by the c-kit protooncogene, and platelet-derived growth factor-receptors (PDGF-R) alpha and beta in cholangiocarcinoma specimens from 13 separate patients, and provide a case report of a therapeutic trial of imatinib mesylate in one patient. Archived pathologic samples from 13 patients with cholangiocarcinoma were obtained. Tissue sections were hybridized with anti-Kit, anti-PDGF-Ralpha and anti-PDGF-Rbeta monoclonal antibodies. Kit, PDGF-Ralpha and PDGF-Rbeta expression was seen in 31, 69 and 46% of samples, respectively. All patients with PDGF-Rbeta expression also expressed PDGF-Ralpha. Three out of four patients with Kit expression did not express either PDGF receptor and only one patient exhibiting expression of PDGF expressed Kit. Cohen's kappa statistic demonstrated that PDGF and Kit expression were inversely correlated with borderline significance (p=0.052; kappa=-0.4742, 95% confidence interval -0.9821 to 0.03364). In one case, strong Kit expression was noted in a tumor from a metastatic lymph node, but was absent in the primary tumor, suggesting that Kit may be related to invasive or metastatic potential. Given the high level of expression defined in this study, a prospective clinical trial incorporating imatinib mesylate, alone or in combination with cytotoxic chemotherapy, and especially in chemotherapy-naive patients, should be considered for patients with cholangiocarcinoma.

Diagnosis and treatment of cholangiocarcinoma

Epidemiologic studies have demonstrated increasing mortality rates from intrahepatic cholangiocarcinoma during the past decades. Primary sclerosing cholangitis is the most important predisposing condition to the development of cholangiocarcinoma. Improvements in noninvasive diagnostic techniques have led to decreased use of invasive procedures. Magnetic resonance imaging (MRI) has the potential to depict parenchymal, ductal, and vascular tumor involvement. However, diagnosis can be difficult, and often ultrasonography, MRI, CT, and invasive cholangiography are complementary investigations. Genetic aberrations in brush cytology specimens should be explored further in prospective studies. Endoscopic ultrasonography, intraductal ultrasonography, and positron emission tomography are interesting techniques that are under evaluation. Radical surgery with negative histologic margins is the only curative option in cholangiocarcinoma. With more aggressive surgical approaches, including partial hepatectomy, 3-year survival rates of 35% to 50% can be achieved. Liver transplantation for unresectable cholangiocarcinoma was shown to be feasible in pilot studies of highly selected patients.

Intraductal Oncocytic Papillary Neoplasm of the Extrahepatic Biliary Tree: First Report

Tumors with oncocytic differentiation may occur in a variety of organs, but are extremely rare in the biliary system. Intraductal oncocytic papillary neoplasms (IOPNs) were first described in the pancreas to differentiate a rare subset of pancreatic neoplasm from the intraductal papillary mucinous neoplasms (IPMNs). IOPN of the extrahepatic biliary tree has not been previously described. We describe the first case of an intraductal oncocytic papillary neoplasm at the bifurcation of the common hepatic duct in a 52-year-old white male with a two-year history of intermittent biliary obstruction.

Fluorodeoxyglucose PET imaging in the evaluation of gallbladder carcinoma and cholangiocarcinoma

Our goal was to evaluate fluorodeoxyglucose (FDG) positron emission tomography (PET) in staging patients with biliary tract cancers. Fifty consecutive patients who underwent FDG-PET for suspected cholangiocarcinoma (n=36) or gallbladder carcinoma (n=14) were reviewed. Patients with cholangiocarcinoma were divided into two groups: group 1 had nodular type (mass=1 cm) (n=22) and group 2 had infiltrating type (n=14) cholangiocarcinoma. Thirty-one of 36 patients evaluated for cholangiocarcinoma had cholangiocarcinoma and five did not. Sensitivity was 85% for nodular morphology but only 18% for infiltrating morphology. Sensitivity for metastases was 65% but false negative for carcinomatosis in three of three patients. One false positive result occurred in a patient with primary sclerosing cholangitis who had acute cholangitis. Seven (58%) of 12 patients had FDG uptake along the tract of a biliary stent. FDG-PET led to a change in surgical management in 30% (11 of 36) of patients evaluated for cholangiocarcinoma because of detection of unsuspected metastases. Eleven of 14 patients with gallbladder carcinoma were newly diagnosed by cholecystectomy or another type of exploratory procedure, whereas three patients were undergoing follow-up. Nine had residual gallbladder carcinoma at the time of PET. Sensitivity for gallbladder carcinoma was 78%. Sensitivity for extrahepatic metastases was 50% in eight patients; six of them had carcinomatosis. These data suggest that PET is accurate in predicting the presence of nodular cholangiocarcinoma (mass>1cm) but was not helpful for the infiltrating type. PET was also helpful for detecting residual gallbladder carcinoma following cholecystectomy, but was not helpful in patients with carcinomatosis. Although FDG-PET led to a change in management in 30% of patients with cholangiocarcinoma, it must be interpreted with caution in patients with primary sclerosing cholangitis and with stents in place, as well as in those with known granulomatous disease.

Noninfectious liver disorders: assessment and diagnosis

Infectious hepatitis is often the initial suspect when abnormal serum liver function test results are discovered in primary care settings. However, noninfectious liver disorders may also present with altered liver function tests. Noninfectious liver disorders require careful assessment of patient history, physical findings, and serum laboratory tests to distinguish among entities that have varying clinical implications and treatments.

Successful photodynamic therapy for nonresectable cholangiocarcinoma: a randomized prospective study

BACKGROUND & AIMS

In nonrandomized trials, photodynamic therapy (PDT) had a promising effect on nonresectable cholangiocarcinoma (NCC). This prospective, open-label, randomized, multicenter study with a group sequential design compared PDT in addition to stenting (group A) with stenting alone (group B) in patients with NCC.

METHODS

In patients with histologically confirmed cholangiocarcinoma, endoscopic or percutaneous double stenting was performed. Patients fulfilling inclusion criteria were randomized to group A (stenting and subsequent PDT) and group B (stenting alone). For PDT, Photofrin 2 mg/kg body wt was injected intravenously 2 days before intraluminal photoactivation (wavelength, 630 nm; light dose, 180 J/cm(2)). Further treatments were performed in cases of residual tumor in the bile duct. The primary outcome parameter was survival time. Secondary outcome parameters were cholestasis and quality of life.

RESULTS

PDT resulted in prolongation of survival (group A: n = 20, median 493 days; group B: n = 19, median 98 days; P < 0.0001). It also improved biliary drainage and quality of life.

CONCLUSIONS

PDT, given in addition to best supportive care, improves survival in patients with NCC. The study was terminated prematurely because PDT proved to be so superior to simple stenting treatment that further randomization was deemed unethical.

PPARgamma ligands inhibit cholangiocarcinoma cell growth through p53-dependent GADD45 and p21 pathway

Ligands of peroxisome proliferator-activated receptor-gamma (PPARgamma) induce differentiation and growth inhibition in several human cancers. However, the role of PPARgamma ligands in the growth control of human cholangiocarcinoma cells remains unknown. This study was designed to investigate the biological functions and molecular mechanisms of PPARgamma ligands in the growth regulation of human cholangiocarcinoma cells. Western blot analysis showed that PPARgamma is expressed in all of the three human cholangiocarcinoma cell lines used in this study (SG231, CC-LP-1, and HuCCT1). Transient transfection assays using a peroxisome proliferator response element (PPRE) reporter construct showed that the PPARgamma expressed in human cholangiocarcinoma cells is functional as a transcription activator. Exposure of SG231, CC-LP-1, and HuCCT1 cells to PPARgamma ligands 15-deoxy-delta12, 14-prostaglandin J(2) (15d-PGJ(2)) and troglitazone for 24 to 96 hours resulted in a dose-dependent inhibition of cell growth. Flow cytometry analysis showed that 15d-PGJ(2) and troglitazone-induced cell cycle arrest at the G2/M checkpoint. Consistent with these findings, both 15d-PGJ(2) and troglitazone significantly inhibited the G2/M cyclin-dependent kinase (CDK) Cdc2 activity. Furthermore, cells treated with 15d-PGJ(2) and troglitazone showed elevated expression of p53 and two p53-controlled downstream genes, GADD45 and p21(WAF1/Cip1). Dominant negative inhibition of p53 in SG231 cells significantly blocked the 15d-PGJ(2) and troglitazone-induced growth inhibition, G2/M arrest, and GADD45/p21 induction. 15d-PGJ(2) and troglitazone failed to directly inhibit Cdc2 activity in a cell-free system in spite of direct association between GADD45 and PPARgamma proteins. In conclusion, these results show a novel p53-dependent mechanism in the PPARgamma ligand-mediated inhibition of cholangiocarcinoma growth and suggest a potential therapeutic role of PPARgamma ligands in the treatment of human cholangiocarcinoma.

Diagnosis, Staging, and Treatment of Cholangiocarcinoma

Attention has to be focused on earlier detection of cholangiocarcinoma, especially in high-risk patients such as those with primary sclerosing cholangitis (PSC). Enhanced techniques for diagnosing this disease include imaging studies such as positron emission tomography (PET) scanning, and cytologic analysis including digital image analysis (DIA) and fluorescent in situ hybridization (FISH). Magnetic resonance imaging and endoscopic ultrasonography have also improved and simplified preoperative staging. Despite recent advances in the endoscopic management of cholangiocarcinoma, this neoplastic disease is still fatal in the majority of patients. Surgical resection or liver transplantation offers the only possibility for curing this disease in its early stages. However, most patients present with advanced disease that is not amenable to such therapy. For those patients presenting with unresectable carcinoma above the cystic duct without intrahepatic or extrahepatic metastases, orthotopic liver transplantation combined with preoperative irradiation and chemotherapy is available and demonstrates improved survival on the basis of a recent study conducted at the Mayo Clinic. In the future, chemopreventive strategies aimed at blocking the links between inflammation (eg, nitric oxide synthase and cylcooxygenase 2 inhibitors) and carcinogenesis may help prevent this often fatal disease in high-risk patients (eg, patients with PSC).

A phase I study of autologous dendritic cell-based immunotherapy for patients with unresectable primary liver cancer

BACKGROUND/AIMS

To evaluate the safety and feasibility of immunotherapy based on autologous dendritic cells (DC) for patients with unresectable primary liver cancer (PLC).

METHODS

A total of ten patients were enrolled and immunized with DCs. Autologous DCs were generated ex vivo in the presence of granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin-4 (IL-4). Cells were then pulsed with tumor lysate (TL), tumor necrosis factor-alpha (TNF-alpha) and keyhole limpet hemocyanin (KLH). Non-adherent cells were collected on day 9 and cells were administered into the inguinal lymph node. Each patient received 1-10 x 10(6) cells four times at weekly intervals.

RESULTS

Immunization was well tolerated in all patients without significant toxicity. DC vaccination induced delayed-type hypersensitivity (DTH) against KLH in seven out of ten patients. In one patient, one of the two liver tumors (tumor in segment 7, 13 mm in diameter) decreased in size to 7 mm and showed necrotic change on computed tomography examination after eight immunizations. In two patients, serum levels of tumor markers decreased after vaccination.

CONCLUSION

The present clinical trial suggested that immunization by TL-pulsed DCs is feasible in patients with unresectable PLC without any toxicity. Further improvement in the clinical results of immunotherapy might be expected by modifying the therapeutic protocol.

Advanced intrahepatic cholangiocarcinoma in hepatitis C virus-related decompensated cirrhosis: case report and review of the literature

A 75-year-old man with no known previous liver disease was admitted to our institution because of right pleural effusion, backache, and pain in the upper right quadrant. Physical and laboratory work-up revealed decompensated liver cirrhosis. Spiral computed tomography (CT) showed a 6-cm tumour in the right liver lobe. Serum levels of aminotransferases, prothrombin time, total bilirubin, alphafetoprotein and carcinoembryonic antigen were within normal limits. However, the patient had elevated cholestatic enzymes, diffuse hypergammaglobulinaemia, a six-fold increase in carbohydrate antigen 19-9 (CA 19-9), cryoglobulinaemia, and reactivity against hepatitis C virus (anti-HCV). Although hepatocellular carcinoma is the most common cancer in a cirrhotic patient with chronic viral hepatitis, the investigation revealed the presence of intrahepatic cholangiocarcinoma (ICC). This is a less frequently occurring primary liver tumour, the aetiology and pathogenesis of which remain unclear in the majority of cases. The coexistence of HCV liver disease and ICC might be an incidental finding, but recently some reports have shown a relatively high incidence of this tumour in patients with HCV-related cirrhosis. The current aspects regarding ICC prevalence in HCV patients, the possible aetiopathogenetic links between this tumour and HCV, and the importance for ICC detection and characterization using the enhancement patterns with quadruple-phase spiral CT scan are also discussed.

Multivariate statistical analysis of clinicopathologic factors influencing survival of patients with bile duct carcinoma

AIM: To evaluate the influence of various clinicopathologic factors on survival of patients with bile duct carcinoma after curative resection.

METHODS: A retrospective analysis was made for 86 cases of bile duct carcinoma treated from January 1981 to September 1995. Fifteen clinicopathologic factors possibly influencing survival were selected. Independent variables were first analyzed by univariate methods. Survival for variable was estimated by the method of Kaplan and Meier. The variables that were statistically significant by univariate analysis were included in a multivariate analysis, which were confirmed using the Cox stepwise proportion hazard model with the help of SPSS 10.0 for Windows software.

RESULTS: The overall cumulative survival rate was 72.6% at 1 year, 32.4% at 3 years, and 18.7% at 5 years. The results of univariate analysis showed that the major significant prognostic factors influencing survival of these patients were histological type of lesion, lymph node metastasis, pancreatic invasion, duodenal invasion, perineural invasion, macroscopic vessel involvement, resected surgical margin and depth of cancer invasion (P = 0.02, 0.02, 0.004, 0.005, 0.01, 0.43, 0.03 and 0.04). Age, sex, location of tumor, size of tumor, macroscopic type of lesions, hepatic metastasis, and hepatic invasion were not significantly associated with prognosis (P > 0.05). Pancreatic invasion, perineural invasion and lymph node metastases were the three most important prognostic factors by multivariate analysis using the Cox proportional hazards model.

CONCLUSION: Pancreatic invasion, perineural invasion and lymph node metastases are the most important prognostic factors for bile duct carcinoma after curative resection.

Tamoxifen (TMX)/Fas induced growth inhibition of human cholangiocarcinoma (HCC) by gamma interferon (IFN-gamma)

OBJECTIVES

To evaluate the response of human cholangoicarcinoma cells to TMX treatment through the Fas pathway by pretreatment with IFN-gamma.

SUMMARY BACKGROUND DATA

Cholangiocarcinoma remains one of the most difficult tumors to treat in clinical medicine. Currently, there are no effective chemotherapy treatments for this disease. Surgery offers the only opportunity for a cure, with the majority of patients failing to qualify for such treatment. This study seeks to evaluate a potential new modality for treatment of this disease.

METHODS

Human cholangiocarcinoma cells were treated with anti Fas mab and sorted to two populations (Fas-positive and Fas-negative) by FAC analysis. In vitro individual cell populations were pretreated with IFN-gamma 250 units/mL x 18hs. The treated cells assayed for caspase 3, 7, 8, Bak, and for apoptosis with Annexin V after treatment with or without TMX. In Vivo 2 x 106 5 SK-ChA-1 Fas-negative cells were injected into nude mice for development of tumor xenografts. Mice received either no treatment or intra tumor IFN-gamma and/or intra peritoneal TMX.

RESULTS

More than 90% (90% +/- 3.5%) of Fas-positive and 70% (71 +/- 2.3%) of Fas-negative cells underwent apoptosis after TMX treatment when pretreated with IFN-gamma. In contrast, TMX alone and IFN-gamma alone stimulated apoptosis by only 22% (22 +/- 3%) P <.00013, and 17% (17 +/- 2%) P <.0001 in Fas-ve cells respectively. In vivo human cholangiocarcinomas xenograft growth was significantly inhibited by a combination of TMX + IFN-gamma compared to controls P <.0007.

CONCLUSION

TMX exposure to human cholangiocarcinoma after pretreatment with IFN-gamma allows for induction of apoptosis in vitro and significant inhibition tumor xenograft growth. The combination of these two compounds may provide novel treatment regimen for cholangiocarcinoma.

COX-2 inhibits Fas-mediated apoptosis in cholangiocarcinoma cells

Fas expression has been shown to negatively regulate the progression of cholangiocarcinoma cells in xenografts. However, many human cholangiocarcinomas express Fas, suggesting these cancers have developed mechanisms to inhibit Fas-mediated apoptosis. Cyclooxygenase-2 (COX-2), which generates prostanoids, is expressed by many cholangiocarcinomas. Therefore, our aim was to determine whether COX-2 expression inhibits death receptor--mediated apoptosis in KMBC cells, a cholangiocarcinoma cell line. These cells express messenger RNA for the death receptors Fas, tumor necrosis factor receptor 1 (TNF-R1), death receptor 4 (DR4), and DR5. Agonists for these death receptors, CH-11, TNF-alpha, and TRAIL all induced apoptosis. However, COX-2, whether induced by proinflammatory cytokines or transient transfection, only significantly inhibited Fas-mediated apoptosis. The COX-2 inhibitor NS-398 restored Fas-mediated apoptosis in COX-2 transfected cells. Prostaglandin E2 reduced apoptosis and mitochondrial depolarization after treatment with the Fas agonist CH-11. Of a variety of antiapoptotic proteins examined, COX-2/prostaglandin E2 only increased expression of Mcl-1, an antiapoptotic member of the Bcl-2 family. In conclusion, these data suggest that prostanoid generation by COX-2 specifically inhibits Fas-mediated apoptosis, likely by up-regulating Mcl-1 expression. Pharmacologic inhibition of COX-2 may be useful in augmenting Fas-mediated apoptosis of cholangiocarcinoma cells.