Hepatolithiasis associated with cholangiocarcinoma. Possible etiologic significance

von Meyenburg complexes are more frequently associated with cholangiocarcinoma

AIM

There is some evidence that von Meyenburg complexes (VMCs) can progress to cholangiocarcinoma (CC). This study aimed to evaluate the prevalence of VMCs in CC cases.

METHODS

All hepatic resections and explants with intra-hepatic CC (I-CC) and hilar-CC (H-CC) from 1985 to 2020 were studied. Hepatic resections (n=68) for benign lesions or metastatic colonic carcinoma and 15 cases with cirrhosis without any cancer were used as controls.

RESULTS

A total of 118 cases of CC (88 I-CC, 30 H-CC) were identified. Of these, 61 (52%) patients had no known background liver disease, and 20 (17%) had cirrhosis. Associated liver disorders included metabolic dysfunction-associated steatohepatitis (23), chronic viral hepatitis B or C (13), biliary disease (primary or secondary sclerosing cholangitis) (8), polycystic kidney disease (6), cryptogenic cirrhosis (5) and others miscellaneous disorders (7). VMCs were present in 34 (39%) of 88 I-CC cases and 7 (23%) of 30 H-CC cases. VMCs were present within the tumour (20 cases), outside the cancer (21 cases) or at both locations (10 cases). VMCs with dysplasia/carcinoma in situ were seen in 19 of 41 (46%) cases with CC and VMCs. In addition, bile duct adenomas were identified in 6 (5%) of CC. 7% of controls showed the presence of VMCs compared with 35% of CC cases (p<0.05).

CONCLUSIONS

VMCs are seen far more frequently in patients with CC than in the control group. The findings support the hypothesis that VMCs could represent a precursor of CC or a marker for a higher risk of developing CC.

Predictive factors for subsequent intrahepatic cholangiocarcinoma associated with hepatolithiasis: Japanese National Cohort Study for 18 years

BACKGROUND

Predictive factors for intrahepatic cholangiocarcinoma in long-term follow-up of hepatolithiasis are unknown. We thus conducted a cohort study to investigate the predictive factors for developing intrahepatic cholangiocarcinoma in hepatolithiasis.

METHODS

This cohort is comprised of 401 patients registered in a nationwide survey of hepatolithiasis for 18 years of follow-up. Cox regression analysis was used to elucidate predictive factors for developing intrahepatic cholangiocarcinoma.

RESULTS

The median follow-up period of patients was 134 months. Twenty-two patients developed intrahepatic cholangiocarcinoma and all died. Identified independent significant factors were as follows: age 63 years or older (hazard ratio [HR] 3.344), residual stones at the end of treatment (HR 2.445), and biliary stricture during follow-up (HR 4.350). The incidence of intrahepatic cholangiocarcinoma in patients with three factors was significantly higher than that in patients with one or two factors. The incidence in the groups with one or two predictive factors was not different. In 88.9% of patients with both biliary stricture and intrahepatic cholangiocarcinoma, the duration between the diagnoses of biliary stricture and intrahepatic cholangiocarcinoma was ≥ 5 years. However, once intrahepatic cholangiocarcinoma developed, 77.8% of patients died within 1 year. Of 24 patients with no symptoms, no previous choledocoenterostomy, no signs of malignancy, no biliary stricture, and no treatment for hepatolithiasis during follow-up, only one developed intrahepatic cholangiocarcinoma.

CONCLUSIONS

Regarding carcinogenesis, complete stone clearance and releasing biliary stricture can prevent the development of intrahepatic cholangiocarcinoma and improve the prognosis of hepatolithiasis.

Cystic biliary tumors of the liver: diagnostic criteria and common pitfalls

With major advancements and frequent use of abdominal imaging techniques, hepatic cysts are increasingly encountered in clinical practice. Although the majority of cysts are benign, a small subset represents neoplastic precursors to cholangiocarcinoma. These cystic precursors include intraductal papillary neoplasms of the bile duct (IPNB) and mucinous cystic neoplasms of the liver (MCN-L), and bear striking pathologic resemblance to corresponding cystic neoplastic precursors within the pancreas. This review examines the salient clinical, gross, microscopic and molecular features of IPNBs and MCN-Ls, and, in particular, provides histopathologic comparison to their pancreatic counterparts. Considering these neoplasms may be diagnostically challenging, we also discuss other hepatic lesions within the differential diagnosis, and the potential for molecular methods to improve their preoperative evaluation and the early detection of cholangiocarcinoma.

Spontaneous Biloma Resulting from Intrahepatic Bile Duct Perforation Coexisting with Intrahepatic Cholelithiasis and Cholangiocarcinoma: A Case Report and Literature Review

Patient: Female, 74-year-old

Final Diagnosis: Biloma

Symptoms: Epigastralgia • fever • nausea

Medication: —

Clinical Procedure: —

Specialty: Surgery

Management of Hepatolithiasis: Review of the Literature

PURPOSE OF REVIEW

Hepatolithiasis is a disease characterized by intrahepatic stone formation. In this article, we review the features of this disease and explore the established and emerging treatment modalities.

RECENT FINDINGS

Recent reports show an increasing prevalence of hepatolithiasis, likely owed to increased immigration and shifts in the Western diet. New pharmacotherapy options are limited and are often only supportive. Endoscopic intervention still cruxes on removal of impacted stones, though new techniques such as bile duct exploratory lithotomy and lithotripsy continue to advance management. Although hepatectomy of the effected portion of the liver offers definitive therapy, alternative less invasive modalities such as combined endoscopic/interventional radiology modalities have been utilized in select patients. Additionally, liver transplant serves as an option for otherwise incurable hepatolithiasis with coexisting liver dysfunction. Multiple emerging pharmacologic and procedural interventions may provide novel treatment for hepatolithiasis. While definitive therapy remains resection of affected liver segments, these modalities offer hope for less invasive approaches in the future.

Successful treatment of colorectal liver metastasis harboring intrahepatic cholangiocarcinoma: A case report

RATIONALE

Colorectal liver metastasis develops in 50% of patients diagnosed with colorectal cancer, whereas concurrent intrahepatic cholangiocarcinoma (ICC) and colorectal liver metastases is extremely rare.

PATIENT CONCERNS

A 72-year-old man was referred to our hospital complaining of abdominal discomfort, diarrhea, and weakness over the last month.

DIAGNOSES

Colorectal liver metastases concurrent intrahepatic cholangiocarcinoma (ICC).

INTERVENTIONS

The patient was treated with mFOLFOX6 (5-fluorouracil 2400 mg/m, leucovorin 400 mg/m, and oxaliplatin 85 mg/m) plus bevacizumab 5 mg/kg every 2 weeks for 2 months. However, chemotherapy was not effective for the liver S3 lesion in our case. The possibility of ICC was considered based on the multidisciplinary team (MDT) mode, together with an anomalous increase in cancer antigen 19-9 and a history of hepatolithiasis.

OUTCOMES

Simultaneous resection of the colon cancer and liver tumors was performed at 6 weeks after discontinuing bevacizumab. Colorectal liver metastases concurrent ICC was confirmed by postoperative pathology. The patient's disease-free survival time is currently >14 months.

LESSONS

This is the first case report of the diagnosis and timely treatment of colorectal liver metastases harboring ICC. These results suggest that multiple primary tumors should be considered as a differential diagnosis when imaging or laboratory test results are abnormal.

The role of diffusion-weighted MR imaging for differentiating benign from malignant bile duct strictures

OBJECTIVES

To assess the added value of diffusion-weighted imaging (DWI) to conventional magnetic resonance imaging (MRI) for differentiating benign from malignant bile duct strictures.

METHODS

Twenty-seven patients with a benign stricture and 42 patients with a malignant stricture who had undergone gadoxetic acid-enhanced MRI with DWI were enrolled. Qualitative (signal intensity, dynamic enhancement pattern) and quantitative (wall thickness and length) analyses were performed. Two observers independently reviewed a set of conventional MRI and a combined set of conventional MRI and DWI, and receiver operating characteristic (ROC) curve analysis was assessed.

RESULTS

Benign strictures showed isointensity (18.5-70.4 %) and a similar enhancement pattern (22.2 %) to that of normal bile duct more frequently than malignant strictures (0-40.5 % and 0 %) on conventional MRI (P < 0.05). Malignant strictures (90.5-92.9 %) showed hypervascularity on arterial and portal venous phase images more frequently than benign strictures (37.0-70.4 %) (P < 0.01) On DWI, all malignant strictures showed hyperintensity compared with benign cases (70.4 %) (P < 0.001). Malignant strictures were significantly thicker and longer than benign strictures (P < 0.001). The diagnostic performance of both observers improved significantly after additional review of DWI.

CONCLUSIONS

Adding DWI to conventional MRI is more helpful for differentiating benign from malignant bile duct strictures than conventional MRI alone.

KEY POINTS

• Accurate diagnosis and exclusion of benign strictures of bile duct are important. • Diffusion-weighted MRI helps to distinguish benign from malignant bile duct strictures. • DWI plus conventional MRI provides superior diagnostic accuracy to conventional MRI alone.

Gross pathological classification of peripheral cholangiocarcinoma determines the efficacy of hepatectomy

BACKGROUND

Peripheral cholangiocarcinoma (PCC) can be grossly classified as mass-forming (MF), periductal-infiltrating (PI), and intraductal papillary (IP) types. IP-PCC should be distinguished from other types of PCC because patients with IP-PCC have a more favorable prognosis. We hypothesized that gross pathological classification of non-IP-PCC could determine the efficacy of hepatectomy.

METHODS

We retrospectively reviewed 224 histologically proven PCCs (including 172 PCCs from patients having non-IP type tumors) from patients who underwent hepatectomy between 1977 and 2007. Non-IP-PCCs were further classified as MF, MF mixed with PI (MF-PI), and PI for comparison.

RESULTS

Of the 224 patients with PCC, 52 had IP-PCC (23.2 %), and 172 had non-IP-PCC (76.8 %). One hundred one of the 172 non-IP-PCC patients had a curative resection (curative resection rate 58.7 %). The follow-up duration ranged from 1.1 to 193.1 months (median 13.4 months). Overall survival (OS) rates for the non-IP-PCC patients at 1 and 5 years were 58.4 and 15.1 %, respectively. Absence of symptoms, lower alkaline phosphatase levels, normal carcinoembryonic antigen (CEA), and presence of MF-type PCC independently and favorably affected OS for the non-IP-PCC patients following hepatectomy. Independent factors favorably predicting OS for the MF-PCC patients were the absence of symptoms, hepatolithiasis, normal CEA levels, successful curative hepatectomy, and negative lymph node metastasis, while for the MF-PI-PCC patients following hepatectomy, one independent factor, successful curative hepatectomy, favorably predicted OS. For the PI-PCC patients, the independent factors favorably predicting OS were normal albumin levels and negative lymph node metastasis.

CONCLUSIONS

It is important to correctly differentiate between the gross pathological classifications of non-IP-PCC because of their distinct characteristics and outcomes following hepatectomy. Correct gross pathological classification is essential for further translational investigations.

Management hepatolithiasis with operative choledochoscopic FREDDY laser lithotripsy combined with or without hepatectomy

BACKGROUND

Hepatolithiasis is very common in East Asia. It is benign in nature, but has a high recurrence rate. It is likely to lead to biliary cirrhosis and increase the risk of cholangiocarcinoma. Hence, the treatment of hepatolithiasis is difficult but vital. In this report, we present a novel approach to manage hepatolithiasis using the choledochoscopic Frequency-Doubled Double pulse Nd:YAG (FREDDY) laser lithotripsy combined with or without hepatectomy.

METHODS

Between July 2009 and October 2012, 45 patients underwent choledochoscopic FREDDY laser lithotripsy combined with or without hepatectomy (laser lithotripsy group). Forty-eight patients underwent a traditional operation (traditional method group) from January 2009 to June 2009. Comparative analysis was made of demographic and clinical characteristics of the two groups.

RESULTS

The final stone clearance rate of the laser lithotripsy group was 93.3%, whereas that of the traditional method group was 85.4% (P=0.22). In the laser lithotripsy group, 2 patients experienced hemobilia and 3 patients had acute cholangitis. In the traditional method group, 3 patients had intraoperative hemorrhage, 1 patient had bile leakage, 6 patients had acute cholangitis, and 1 patient died of liver failure. Moreover, the operative time in the traditional method group was significantly longer than that in the laser lithotripsy group (P=0.01). The mean hospital stay of the patients in the traditional method group was longer than that in the laser lithotripsy group (9.8 vs 8.2 days, P=0.17). Recurrent intrahepatic bile duct stones were not found during the follow-up period in the two groups.

CONCLUSION

Operative choledochoscopic FREDDY laser lithotripsy combined with or without hepatectomy may be an effective and safe treatment for hepatolithiasis.

The metabolic syndrome and risk factors for biliary tract cancer: a case-control study in China

OBJECTIVES

Recent data show that the metabolic syndrome may play a role in several cancers, but the etiology for biliary tract cancer is incompletely defined. The present aim was to evaluate risk factors for biliary tract cancer in China.

METHODS

A case-control study in which cases were biliary tract cancer patients referred to Peking Union Medical College Hospital (PUMCH). Controls were randomly selected from an existing database of healthy individuals at the Health Screening Center of PUMCH. Data on the metabolic syndrome, liver diseases, family history, and history of diabetes and hypertension were collected by retrospective review of the patients' records and health examination reports or by interview.

RESULTS

A total of 281 patients (102 intrahepatic cholangiocarcinoma (ICC), 86 extrahepatic cholangiocarcinoma (ECC) and 93 gallbladder carcinoma (GC)) and 835 age- and sex-matched controls were enrolled. HBsAg+/anti-HBc+ (P=0.002), history of diabetes (P=0.000), cholelithiasis (P=0.000), TC (P=0.003), and HDL (P=0.000) were significantly related to ICC. Cholelithiasis (P=0.000), Tri (P=0.001), LDL (P=0.000), diabetes (P=0.000), Apo A (P=0.000) and Apo B (P=0.012) were significantly associated with ECC. Diabetes (P=0.017), cholelithiasis (P=0.000) and Apo A (P=0.000) were strongly inversely correlated with GC.

CONCLUSION

Cholelithiasis, HBV infection and metabolic symptoms may be potential risk factors for the development of biliary tract cancer.

Comparison of concomitant and subsequent cholangiocarcinomas associated with hepatolithiasis: Clinical implications

AIM: To compare the outcomes of concomitant cholangiocarcinoma (C-CCA) and subsequent cholangiocarcinoma (S-CCA) associated with hepatolithiasis.

METHODS: From December 1987 to December 2007, 276 patients underwent hepatic resection for hepatolithiasis in Changhua Christian Hospital. Sixty-five patients were excluded due to incomplete medical records and the remaining 211 patients constituted our study population base. Ten patients were diagnosed with C-CCA based on the preoperative biopsy or postoperative pathology. During the follow-up period, 12 patients developed S-CCA. The diagnosis of S-CCA was made by image-guided biopsy or by pathology if surgical intervention was carried out. Patient charts were reviewed to collect clinical information. Parameters such as CCA incidence, interval from operation to CCA diagnosis, interval from CCA diagnosis to disease-related death, follow-up time, and mortality rate were calculated for both the C-CCA and S-CCA groups. The outcomes of the C-CCA and S-CCA groups were mathematically compared and analysed.

RESULTS: Our study demonstrates the clinical implications and the survival outcomes of C-CCA and S-CCA. Among the patients with unilateral hepatolithiasis, the incidence rates of C-CCA and S-CCA were fairly similar (4.8% vs 4.5%, respectively, P = 0.906). However, for the patients with bilateral hepatolithiasis, the incidence rate of S-CCA (12.2%) was higher than that of C-CCA (4.7%), although the sample size was limited and the difference between two groups was not statistically significant (P = 0.211). The average follow-up time was 56 mo for the C-CCA group and 71 mo for the S-CCA group. Regard to the average time intervals from operation to CCA diagnosis, S-CCA was diagnosed after 67 mo from the initial hepatectomy. The average time intervals from the diagnoses of CCA to disease-related death was 41 mo for the C-CCA group and 4 mo for the S-CCA group, this difference approached statistical significance (P = 0.075). Regarding the rates of overall and disease-related mortality, the C-CCA group had significantly lower overall mortality (70% vs 100%, P = 0.041) and disease-related mortality (60% vs 100%, P = 0.015) than the S-CCA group. For the survival outcomes of two groups, the Kaplan-Meier curves corresponding to each group also demonstrated better survival outcomes for the C-CCA group (log rank P = 0.005). In the C-CCA group, three patients were still alive at the time of data analysis, all of them had free surgical margins and did not have pathologically proven lymph node metastasis at the time of the initial hepatectomy. In the S-CCA group, only one patient had chance to undergo a second hepatectomy, and all 12 S-CCA patients had died at the time of data analysis.

CONCLUSION: C-CCA has better outcomes than S-CCA. The first hepatectomy is crucial because most patients with recurrent CCA or S-CCA are not eligible for repeated surgical intervention.

Neoplasia of gallbladder and biliary epithelium

CONTEXT

Diagnosis of biliary neoplasia can be challenging but is essential for the appropriate clinical management of patients. Therefore, it is important to recognize the morphologic features of the biliary neoplasms to report a correct diagnosis.

OBJECTIVES

(1) To discuss the differential diagnosis of dysplasia in the gallbladder and differentiate dysplasia from reactive atypia and invasive carcinoma, (2) review the histologic features of adenoma and polypoid biliary lesions, (3) highlight the differential diagnosis of adenocarcinoma in liver biopsy, and (4) discuss the differential diagnosis of atypical biliary glandular lesions.

DATA SOURCES

Current English literature related to gallbladder and biliary neoplasia.

CONCLUSIONS

Biliary glandular neoplasms show a wide spectrum of morphology and have many mimics. Careful examination of the histologic features of these lesions and familiarity with their morphology can help to achieve the correct diagnosis.

Molecular evidence for the neoplastic potential of hepatic Von-Meyenburg complexes

Von-Meyenburg complexes (VMCs) have been shown to progress to cholangiocarcinoma (CC) in some cases. Histologic examination in such cases reveals a gradual transition of VMCs to intermediate lesions and finally to CC. The goal of this study was to determine if this histologic progression was also accompanied by sequential genetic alterations. Two cases that showed many VMCs with a transition to cholangiocarcinoma through intermediate lesions were analyzed. Multiple VMCs (away from the tumor), intermediate lesions and areas of frank CC were microdissected under stereoscopic guidance and were analyzed for allelic imbalance [loss of heterozygosity (LOH)] using a panel of 20 polymorphic microsatellite markers by polymerase chain reaction/electrophoresis. The 2 cases of CCs revealed LOH at 5 and 7 different genomic loci specific for each patient, respectively. Coexisting VMCs also exhibited LOH ranging from 0 to 3 loci in each case. Intermediate lesions showed LOH at a single locus in case 1, whereas the assay could not be performed in case 2 due to inadequate DNA yield. In case 2, the earliest acquired mutations were present in the VMCs supporting a causal relationship for neoplastic progression. Discordant LOH mutations were also present in the VMCs and the adenomatous lesions providing support that LOH detected at these sites did not passively migrate or reflect contamination. The results of the present study show that the histologic progression observed through these stages is also accompanied by LOH at loci harboring key oncogenes. The findings also support that VMCs are preneoplastic lesions that could progress to CC with time.

Intrahepatic cholangiocarcinoma associated with intrahepatic duct stones

OBJECTIVE

It has been well established that the long-term prognosis of intrahepatic duct stones (IHDS) is complicated by the late development of biliary cirrhosis with associated intrahepatic cholangiocarcinoma (IHCC). Despite recent improvements in imaging studies, accurate preoperative diagnosis of IHCC is difficult. Therefore, we attempted to elucidate the clinical features of patients with IHDS with IHCC.

METHODS

We reviewed 80 patients with IHDS and divided them into two groups. The DS group included 72 patients who had only IHDS. The second group was defined as the CC group and included eight patients who had IHDS and IHCC. For diagnosis of IHDS and confirmation of coexisting IHCC, patients underwent various radiological evaluations and additional laboratory tests, such as serum carbohydrate antigen 19-9 (CA 19-9).

RESULTS

There was no significant difference in the symptoms and stone characteristics between the two groups. For the CC group, liver resection was performed in four patients. Three patients underwent curative resection, but only one of these patients was alive at 36 months without recurrence.

CONCLUSION

IHCC with IHDS was difficult to diagnose in the early phase. Therefore, while performing diagnostic studies and surgery for IHDS, one should always consider the possibility of coexisting cholangiocarcinoma.

Diagnosis and surgical treatment of intrahepatic hepatolithiasis associated cholangiocarcinoma

Liver malignancy is known to be associated with hepatolithiasis. The present report summarises the results and our experience for management of 23 patients with intrahepatic hepatolithiasis associated cholangiocarcinoma (IHHCC). The correct diagnosis rates of US (ultrasonography), CT (computed tomography), and MRCP (magnetic resonance cholangiopancreatography) were 82.6% (19/23), 95.7% (22/23), and 91.7% (11/12), respectively. Carbohydrate antigen 19-9 (CA 19-9) was helpful in the diagnosis of IHHCC. All 23 patients with IHHCC underwent laparotomy. The surgical procedure consisted hepatectomy with a bile duct exploration in 16 patients (69.6%), a hepatectomy and drainage procedure such as sphincteroplasty and choledo-jejunostomy in three patients (13.0%), a bile duct exploration with biopsy in two patients (8.7%), and simple laparotomy and biopsy in two patients (8.7%). All the IHHCC patients who underwent a palliative procedure or laparotomy died within 1 year, and the overall cumulative survival rates at 1, 3, and 5 years were 43.8% (10/23), 13.0% (3/23), and 4.3% (1/23), respectively, and those patients who underwent curative resection were 88.9% (8/9), 33.3% (3/9), and 11.1% (1/9), respectively, which significantly longer than those (20.0%, 2/10; 0.0%, 0/10; and 0.0%, 0/10) patients who underwent palliative resection, respectively (p < 0.05). A suspicion of malignancy is necessary when managing patients with long-term hepatolithiasis. Hepatic resection with postoperative treatment is the treatment of choice for cholangiocarcinoma when it is resectable.

A comparison of hepatic mucinous cystic neoplasms with biliary intraductal papillary neoplasms

BACKGROUND & AIMS

There is controversy regarding the term biliary intraductal papillary neoplasms (IPN-B) and their pathology, which frequently are confused with hepatic mucinous cystic neoplasms (MCN). We aimed to summarize the clinicopathologic features of IPN-B and differentiate them from MCN.

METHODS

From January 1998 to December 2007, there were 19 patients with intrahepatic IPN-B and 13 patients with MCN who underwent surgical treatment at Zhongshan Hospital. Multiple demographic and clinicopathologic parameters were reviewed retrospectively and compared between the groups.

RESULTS

The mean ages of patients with IPN-B and MCN were 59.5 +/- 11.1 and 44.4 +/- 9.7 years, respectively (P = .0004); the male:female ratios also differed (11:8 vs 2:11; P = .028). Tumors were significantly smaller (6.0 vs 11.2 cm; P = .006) in patients with IPN-B than in those with MCN. More patients with IPN-B also had hepatolithiasis (47.4% vs 0%, P = .004); cholangiectasis and communication between the cyst and main bile duct were more frequent in patients with IPN-B than in those with MCN (P < .001). The IPN-B consisted of 4 subtypes--the gastric subtype was the least invasive. Malignant lesions were more common in patients with IPN-B than in those with MCN (78.9% vs 38.5%; P = .03). The overall 5-year survival rates of patients with IPN-B and MCN were 82% and 100%, respectively.

CONCLUSIONS

Intrahepatic IPN-B represents a distinct clinicopathologic entity that differs clinically, histologically, and radiologically from MCN. Curative resection has a favorable prognosis for patients with IPN-B, but further studies of its subtype are required.

Outcomes of hepatic resection for hepatolithiasis

BACKGROUND

Hepatic resection is main approach to treatment of hepatolithiasis, but the long-term follow-up results of hepatic resection for hepatolithiasis are rarely reported.

METHODS

A retrospective study was conducted of 87 patients with hepatolithiasis who underwent hepatic resection.

RESULTS

The final stone clearance rates were 95%. There was a significant difference in the incidence of recurrent stones between patients with and without remaining biliary strictures. On multivariate analysis, the presence of residual or recurrent stones was an independent risk factor associated with recurrent cholangitis. The 10-year overall survival rate was 80.3%. On multivariate analysis, the development of cholangiocarcinoma was an independent predictor of survival in patients who underwent hepatic resection for hepatolithiasis.

CONCLUSIONS

The long-term outcomes after hepatic resection were satisfactory in patients whose intrahepatic stones and strictures were completely removed. Cholangiocarcinoma associated with hepatolithiasis was an independent prognostic factor in patients with hepatolithiasis who underwent hepatic resection.

Contrast-enhanced MRI combined with MR cholangiopancreatography for the evaluation of patients with biliary strictures: differentiation of malignant from benign bile duct strictures

PURPOSE

To determine imaging criteria for the combined use of contrast-enhanced (CE)-MRI and MR cholangiopancreatography (MRCP) to differentiate malignant from benign biliary strictures.

MATERIALS AND METHODS

A total of 44 patients with biliary stricture who had undergone unenhanced, MRCP, and dynamic MRI were identified from radiological and surgical databases. Two radiologists analyzed MR features for asymmetry, luminal irregularity, abrupt narrowing, outer margin, signal intensity (SI) on T2-weighted (T2W) images, and hyperenhancement relative to liver parenchyma during portal phase. The wall thickness and length of the narrowed segment were measured. MR findings relevant as predictors were identified using a Chi-square or Fisher's exact test and the odds ratio (OR).

RESULTS

The presence of hyperenhancement relative to liver parenchyma, length > 12 mm, wall thickness > 3 mm, indistinct outer margin, luminal irregularity, and asymmetry of strictured bile duct were significant factors for malignancy (P < 0.05). Malignant strictures were significantly thicker (5.0 +/- 2.0 mm) and longer (27.0 +/- 13.6 mm) than benign strictures. When any three or more of these six criteria were used in combination, we could identify 100% of malignant strictures and 87.0% of benign strictures.

CONCLUSION

The combined use of CE-MRI and MRCP helped to define the criteria for differentiating malignant from benign biliary strictures in our data.

Interaction of Toll-like receptors with bacterial components induces expression of CDX2 and MUC2 in rat biliary epithelium in vivo and in culture

The mechanism of transformation of biliary epithelium leading to intestinal metaplasia, which is significantly involved in biliary diseases, remains unclear. CDX2, an intestine-specific transcription factor, is thought to regulate intestinal mucin MUC2 (mucus core protein) expression. We took advantage of polycystic kidney (PCK) rats as a model of chronic suppurative cholangitis with intestinal metaplasia and of cultured biliary epithelial cells (BECs) from PCK rats to clarify the causal relation between bacterial components such as pathogen-associated molecular patterns (PAMPs) and the development of intestinal metaplasia of bile ducts. Histological, immunohistochemical, and in situ hybridization studies were conducted in PCK rat livers. In cultured BECs, CDX2 and MUC2 were expressed following treatment with PAMPs and inhibitors (anti-Toll-like receptor (TLR)2/TLR4 antibody, nuclear factor-kappaB (NF-kappaB) inhibitor MG132). Chronic suppurative cholangitis with intestinal metaplasia developed as the PCK rats aged, and intestinal metaplasia and aberrant CDX2 and MUC2 expression developed in parallel. Intraluminal bacteria and the expression of TLR2 and TLR4 in BECs were demonstrated in the bile ducts, showing chronic suppurative cholangitis. In cultured BECs, treatment with PAMPs induced upregulation of CDX2 and MUC2 expression, and this effect was abolished by pretreatment with anti-TLR2 and anti-TLR4 antibody and MG132. A knockdown of CDX2 by CDX2 small interfering RNA inhibited MUC2 expression in cultured BECs induced by PAMPs, and transfection of CDX2 expression vector induced MUC2 expression. In conclusion, bacterial components may induce upregulation of the CDX2 expression followed by MUC2 expression via TLR and the NF-kappaB system in cultured BECs, and could be related to the development of intestinal metaplasia of the bile ducts.

Outcomes of Hepatectomy for Hepatolithiasis

AIM

Surgical and nonsurgical procedures for management of hepatolithiasis have been reported. The aim of this study was to evaluate immediate and long-term results of hepatectomy as treatment for hepatolithiasis.

MATERIALS AND METHODS

Immediate and long-term outcomes of 123 consecutive patients who underwent hepatectomy for hepatolithiasis at our institution from 2000 to 2005 were analyzed retrospectively. Acute cholangitis was the major presenting symptom (in 106 out of 123, 86.2% of cases).

RESULTS

The immediate stone clearance rate was 92.7% (114 out of 123) and final stone clearance rate was 96% (118 out of 123) after subsequent T-tube route or endoscopic retrograde cholangiopancreatography (ERCP). Residual stones were identified in 5 patients (4%). The surgical morbidity and mortality rates were 33.3% (41 out of 123) and 1.6% (2 out of 123) respectively. Of the 123 patients, 3 (2.4%) had associated cholangiocarcinoma at the time of hepatectomy. With a median follow-up of 40.3 months (range 5-58), a recurrent stone developed in 7 patients (5.7%) and cholangiocarcinoma in 2 (1.6%). Ten patients died during the follow-up period, with 4 of them (out of 123, 3.2%) due to recurrent stone with sepsis.

CONCLUSION

Hepatectomy is a safe and effective treatment for hepatolithiasis, with a high stone clearance rate and fair rate of surgical complications. Recurrent stone-induced sepsis and cholangiocarcinoma are the major factors compromising long-term survival in these patients.

CT Findings of Cholangiocarcinoma Associated with Recurrent Pyogenic Cholangitis

OBJECTIVE

The purpose of our study was to determine the characteristic CT findings of cholangiocarcinoma associated with recurrent pyogenic cholangitis.

CONCLUSION

CT findings of cholangiocarcinoma associated with recurrent pyogenic cholangitis are important in order to improve early diagnosis and proper treatment. Cholangiocarcinoma associated with recurrent pyogenic cholangitis is predominantly located in the atrophic hepatic lobes and in the hepatic lobes of biliary calculi and is associated with the narrowing or obliteration of the portal vein.

Treatment of non-endemic hepatolithiasis in a Western country. The role of hepatic resection

INTRODUCTION

The aim of this study was to assess the safety and the efficacy of hepatic resective surgery in the treatment of single lobe hepatolithiasis.

PATIENTS AND METHODS

Retrospective analysis and comparison between hepatic resections in patients with hepatolithiasis (hepatolithiasis group [HG]) and liver masses (control group [CG]). Seventeen consecutive Caucasian patients with single lobe hepatolithiasis (HG) and 30 patients with liver masses without chronic liver disease and previous chemotherapy (CG), were operated during the 5-year period 2000-2005, inclusive. Major hepatic resections including 4 right hepatectomies, 10 left hepatectomies, and 3 left lateral sectionectomy in HG, and 12 right hepatectomies, 3 extended right hepatectomy, 5 left hepatectomies, 4 left lateral sectionectomy, 5 bisegmentectomy, and 1 mesohepatectomy in CG. The main outcome measures were: type and length of surgical procedures, intra- and postoperative blood losses and transfusions (packed red blood cells [PRBC] and fresh frozen plasma [FFP]), intra- and postoperative course and complications (within 30 days of the operation), length of hospitalisation, histopathology, and recurrence of hepatolithiasis.

RESULTS

Mean operation time was 6.21 +/- 2.38 h in HG versus 7.10 +/- 2.21 h in CG (P = 0.33). Mean intra-operative blood loss in CG was higher than in HG (1010 +/- 550 ml versus 560 +/- 459 ml; P = 0.035). The other variables considered in the two groups were not statistically different. Intra-operative transfusion were 0.50 +/- 0.85 units in HG versus 1.35 +/- 2.25 units of PRBC in CG (P = 0.06), and 0.66 +/- 1.34 units in HG versus 0.68 +/- 1.20 units of FFP in CG (P = 0.44), respectively. No cases of death were registered. Postoperative complications occurred in 12 patients (25.5%) - 5 cases (10.6%) in HG and 7 cases (14.8%) in CG (P = 0.18). Mean postoperative transfusions were 0.47 +/- 1.24 units in HG versus 1.10 +/- 1.18 units of PRBC in CG (P = 0.35), and 0.65 +/- 1.40 units in HG versus 0.46 +/- 0.82 units of FFP in CG (P = 0.25), respectively. Difference in median hospitalisation was not statistically significant (14 +/- 10 days versus 12 +/- 9 days; P = 0.28). Histopathology showed cholangiocarcinoma in 2 cases (11.7%). During the follow-up period (range, 5-127 months; mean, 50.4 +/- 41.9 months), 1 patient had lithiasis recurrence and 1 patient died for the co-existing cholangiocarcinoma.

CONCLUSIONS

Hepatic resection is the treatment of choice in patients with single lobe hepatolithiasis. An early indication for surgery may reduce the mortality/morbidity rates of hepatic resection for hepatolithiasis.

CT Differentiation of cholangiocarcinoma from periductal fibrosis in patients with hepatolithiasis

OBJECTIVE

The objective of our study was to determine useful CT findings for differentiating cholangiocarcinoma from periductal fibrosis in patients with hepatolithiasis.

MATERIALS AND METHODS

CT images of 30 patients with hepatolithiasis and pathologically proven cholangiocarcinoma (n = 14) or periductal fibrosis (n = 16) were retrospectively reviewed. Helical CT scans were obtained before, 30 seconds after, and 65 seconds after the start of contrast material injection. Analysis of CT findings included evaluation for the presence of periductal soft-tissue density, bile duct wall thickening at the stricture site, ascites, portal vein obliteration, lymph node enlargement, and a duct stone; assessment of the degree of ductal dilatation; and evaluation of the enhancement pattern of periductal lesions, thickened ductal wall, and hepatic parenchyma. The CT attenuation coefficients of the thickened ductal wall and adjacent normal-looking bile duct were measured on images obtained during each phase. Among these findings, statistically significant variables were determined using the Fisher's exact test and Student's t test. Sensitivity and specificity values of the CT criteria were also calculated.

RESULTS

The presence of periductal soft-tissue density (p = 0.002), higher enhancement of the duct than adjacent bile duct on portal venous phase images (p = 0.008), ductal wall thickening (p = 0.026), portal vein obliteration (p = 0.031), and lymph node enlargement (p = 0.031) were found to be the significant findings for differentiating cholangiocarcinoma from fibrosis in patients with hepatolithiasis. When any two or more of these five criteria were used in combination, we could identify 100% of the patients with cholangiocarcinoma but only 12.5% of the patients with fibrosis.

CONCLUSION

Cholangiocarcinoma in patients with hepatolithiasis can be diagnosed using specific CT criteria.

Hepatic resection of the intraductal papillary type of peripheral cholangiocarcinoma

BACKGROUND

Peripheral cholangiocarcinoma (PCC) can be grossly classified into mass-forming, periductal-infiltrating, and intraductal papillary (IP) types. Information on IP-PCC patients undergoing hepatectomy is sparse because of the small number of cases.

METHODS

The clinical features of 40 IP-PCC patients undergoing hepatectomy between 1977 and 2000 were reviewed. The clinical features of 94 PCC patients without IP growth undergoing hepatectomy were used for comparison.

RESULTS

IP-PCC and non-IP-PCC groups had similar age distributions (P =.674), sex ratios (P =.079), and positive rates for serum carcinoembryonic antigen and CA 19-9 (P =.121 and.795, respectively). The two groups also exhibited similar rates of association between hepatolithiasis and PCC (P =.230). However, more IP-PCC patients exhibited signs during admission, and more had ALT values >36 IU/L; they also had smaller tumors, more mucobilia association, and tumors in earlier stages and had undergone more postoperative chemotherapy. Multivariate logistic regression analysis showed that only ALT >36 IU/L differentiated IP-PCC from non-IP-PCC patients. The two groups exhibited similar operative mortality (P = 1.0). Follow-up ranged from 1.6 to 125.2 months (mean and median, 44.6 and 5.7 months, respectively). The 1-, 3-, and 5-year overall survival rates were 72.9%, 41.2%, and 24.7%, respectively, in the IP-PCC group and 43.3, 6.03%, and 2.01% in the non-IP-PCC group. The prognosis was favorable for the IP-PCC patients (P <.00001), particularly for IP-PCC patients who received curative hepatectomy (P =.013).

CONCLUSIONS

IP-PCC patients had significantly better survival than non-IP-PCC patients, and aggressive curative hepatic resection is associated with a longer survival.

Influence of age on surgical treatment of peripheral cholangiocarcinoma

BACKGROUND

Peripheral cholangiocarcinoma (PCC) constitutes the second most common primary liver cancer. Information is lacking on patients with PCC <40 years old undergoing surgical treatment. The aim of this study was to evaluate the influence of age on surgical treatment of patients with PCC based on reviewing the clinicopathologic features and survival rate of 23 patients with PCC <40 years old who received surgical treatment.

METHODS

The clinical features of 23 younger patients with PCC (<40 years old) who underwent surgical treatment between 1977 and 2000 were reviewed. Clinical features of 284 patients with PCC >40 years old were used for comparison.

RESULTS

Three hundred seven patients with PCC with an age range between 28 and 93 years (mean 57.2, median 56.0) were investigated. The fiftieth decade was the peak PCC age in the series. Clinical presentations and physical findings were similar between younger and older PCC groups. Similar positive serum carcinoembryonic antigen and carbohydrate antigen 19-9 rates (42.9% and 66.7% vs 41.2% and 74.4%, respectively) and a similar rate of hepatolithiasis associated with PCC were also observed between the 2 groups (43.5% vs 48.9%). Younger patients with PCC tended to show less mucobilia, less papillary-type PCC, and a more advanced stage of tumor compared with older patients with PCC. However, postoperative adjuvant chemotherapy and radiotherapy were used more frequently in the older patients with PCC. Operative morbidity and mortality were similar between the 2 groups (surgical mortality rate 7.8%). Follow-up ranged from 1.0 to 167.6 months (mean 13.0, median 5.7). The 1- and 2-year actuarial survival rates were 6.3% and 0% in the younger PCC group and 31.3% and 15.0% in the older PCC group, respectively. Prognosis was dismal for the younger patients with PCC (P = 0.0008), but they may benefit from hepatic resection.

CONCLUSIONS

Younger patients with PCC had a significantly worse survival rate than older patients with PCC. Hepatectomy is rational and may benefit younger patients with PCC.

Immediate and long-term outcomes of hepatectomy for hepatolithiasis

OBJECTIVE

The aim of this study was to evaluate the perioperative and long-term results of hepatectomy for hepatolithiasis.

PATIENTS AND METHODS

Immediate and long-term outcomes of 103 consecutive patients with hepatolithiasis who underwent hepatectomy from 1989 to 2001 were analyzed. Immediate outcomes included stone clearance rate, operative morbidity, and mortality. Long-term results included stone recurrence rate and survival.

RESULTS

The immediate stone clearance rate was 90%, and the final stone clearance rate was 98% after subsequent choledochoscopic lithotripsy by cutaneous stoma or T-tube route. The operative morbidity and hospital mortality rates were 28% and 2%, respectively. Multivariate analysis showed that right hepatectomy (P=.006) and preoperative hyperbilirubinemia (P=.038) were predictive of postoperative complications. Ten patients (10%) had associated cholangiocarcinoma (four known preoperatively) at the time of hepatectomy. With a median follow-up of 56 months (range 6-158), recurrent stones developed in eight patients and cholangiocarcinoma developed in three patients (range: 7-30 months postoperatively). Sixteen patients had died during the follow-up period, none of recurrent cholangitis. Cholangiocarcinoma was the only significant prognostic factor of long-term survival by Cox regression analysis.

CONCLUSIONS

Hepatectomy is a safe and effective treatment for hepatolithiasis, with a high immediate stone clearance rate and a low long-term stone recurrence rate. The presence of associated cholangiocarcinoma is the main factor compromising long-term survival in patients with hepatolithiasis.

Expression of cytokeratin 7 and 20 in pathological conditions of the bile tract

Expression of cytokeratin 7 (CK7) and cytokeratin 20 (CK20) helps to establish the origin of biliary and metastatic carcinomas. We investigated the expression of CK7 and CK20 in inflammatory, metaplastic and neoplastic conditions of the bile ducts, and evaluated possible relationships between the CK expression pattern and extrahepatic bile duct/gallbladder carcinomas (EBDCs) or intrahepatic bile duct carcinomas (IBDCs). We used immunohistochemistry for the investigation of 48 formalin-fixed, paraffin-embedded specimens grouped as: A) lithiasic or inflamed surgically resected extrahepatic bile ducts/gallbladders: all were CK7+/CK20+; B) percutaneous liver biopsies from patients with chronic hepatitis C primary biliary cirrhosis and primary sclerosing cholangitis: all were CK7+/CK20-; C) EBDCs: all were CK7+/CK20+, except for two cases which were CK7-/CK20-; D) IBDCs: all were CK7+/CK20-, except for one case showing CK20 positivity. Metaplastic changes were seen only among specimens in groups A and C: in these cases, CK20 was either focally or diffusely expressed. Our study suggests that the expression of cytokeratins under specific stimuli can be different from normal tissues, and that sometimes CK20 expression can be related to and precede the occurrence of metaplastic alterations.

Cholangiocarcinoma: recent progress. Part 1: epidemiology and etiology

An attempt is made in this review to update the reader on recent developments and progress in the study of cholangiocarcinoma: a major primary carcinoma of the liver with a very poor prognosis. Knowledge of the cell biology and physiological functions of the cholangiocyte has recently so progressed that our understanding of cholangiocarcinogenetic mechanism is expected to follow. The first part of the review deals with semantic problems, temporal changes in the incidence of cholangiocarcinoma and geographic differences in epidemiology, etiologic factors (particularly opistorchiasis in Thailand and hepatolithiasis in the Far East), and discusses a recently disclosed role of hepatitis C virus infection (30% of cholangiocarcinoma patients have antibodies against hepatitis C virus in Japan).

What is the impact of coexistence of hepatolithiasis on cholangiocarcinoma?

BACKGROUND

Hepatolithiasis is a well-known etiology of cholangiocarcinoma. However, whether or not hepatolithiasis influences the presentation of cholangiocarcinoma is not very clear. To help clarify this, we conducted the present study to investigate the clinicopathological characteristics of cholangiocarcinoma with hepatolithiasis. As well, we made a comparison between the presence and absence of hepatolithiasis in patients with cholangiocarcinoma to determine the impact of hepatolithiasis.

METHODS

Among 140 patients with histologically proven cholangiocarcinoma at the Taichung Veteran General Hospital between October 1982 and December 2000, 38 were found to have concomitant hepatolithiasis. Patients were evaluated on the basis of age, gender, presenting symptom, laboratory data, preoperative liver function (indocyanine green test), tumor markers, histological differentiation, lymph node involvement, and organ metastasis. Data were statistically analyzed using the chi-squared test and Student's t-test. Analysis of survival was performed using the Kaplan-Meier method, and univariate analysis and multivariate analyses for survival were performed by Cox proportional hazard model.

RESULTS

The cholangiocarcinoma with hepatolithiasis group (CC + HL) was found to be predominantly female, with more common presentation of fever and less presentation of jaundice (P < 0.05). In addition, patients with cholangiocarcinoma without hepatolithiasis (CC - HL group) had higher serum bilirubin levels and more advanced histological differentiation (P < 0.05). As well, the percentage of resectability of the CC + HL group was higher than that of the CC - HL group, although it was not statistically significant. Univariate and multivariate analyses for overall survival showed that those patients with an age older than 65 years, hypoalbuminemia, poor histological differentiation, and a presence of hepatolithiasis were prone to a graver prognosis, albeit none of them were statistically significant. Resectability was the only independent predictor of a favorable prognosis with significant difference.

CONCLUSIONS

The clinicopathological features of cholangiocarcinoma with concomitant hepatolithiasis showed few differences from that without hepatolithiasis. Resectability was the only predictor that favored a good prognosis.

Peroral cholangioscopic treatment of hepatolithiasis: Long-term results

BACKGROUND

Peroral cholangioscopic lithotomy is an effective treatment for extrahepatic bile duct stones. However, an evaluation of the usefulness and long-term results of peroral cholangioscopic lithotomy for hepatolithiasis has not been reported. The aim of this study was to evaluate the usefulness and long-term results of peroral cholangioscopic lithotomy for hepatolithiasis.

METHODS

From August 1987 to July 1998, 36 consecutive patients underwent peroral cholangioscopic lithotomy for hepatolithiasis; 34 were followed for a mean of 93 months (range, 14 to 164 months).

RESULTS

The rate of complete stone removal was 64%; the morbidity rate was 2.8%. The recurrence rate for patients in whom stones were completely removed was 21.7%. Two patients (5.9%) had cholangiocarcinoma develop during follow-up.

CONCLUSION

Although incomplete stone removal and recurrence are common, peroral cholangioscopic lithotomy is a sufficiently safe and effective method for the treatment of hepatolithiasis.

Gene amplification and mRNA and protein overexpression of c-erbB-2 (HER-2/neu) in human intrahepatic cholangiocarcinoma as detected by fluorescence in situ hybridization, in situ hybridization, and immunohistochemistry

BACKGROUND/AIMS

The human proto-oncogene c-erbB-2 (also called HER-2/neu) is located on chromosome 17q21-22. There have been no studies on gene amplification or mRNA expression of c-erbB-2 in human intrahepatic cholangiocarcinoma (CC) hitherto.

METHODS

We investigated c-erbB-2 gene amplification by fluorescence in situ hybridization (FISH), c-erbB2 mRNA expression by ISH, and c-erbB-2 protein expression by immunohistochemistry in 22 archival cases of CC.

RESULTS

FISH revealed that c-erbB-2 gene signals were increased in CC. ISH showed that c-erbB-2 mRNA signals were located in the nuclei and cytoplasms of cancer cells and were increased in cancer cells compared with non-cancerous bile ducts where no signals were present. Immunohistochemistry showed that the c-erbB-2 protein was expressed in the cell membrane of cancer cells, and was increased compared with non-cancerous bile ducts where no expression was found. There was a positive significant correlation between c-erbB-2 mRNA and protein expression. Clinicopathologically, there were no correlations between the c-erbB-2 expression and various pathological features.

CONCLUSIONS

These data suggest that c-erbB-2 gene amplification does occur in CC, and that there is an overexpressed c-erbB-2 protein through the enhanced mRNA expression. The c-erbB-2 gene amplification may be related to the oncogenesis or tumor progression of CC.

c-erbB-2 and c-Met expression relates to cholangiocarcinogenesis and progression of intrahepatic cholangiocarcinoma

AIMS

The c-erbB-2 and c-Met proto-oncogenes are important for tumour invasiveness and metastasis in many types of malignant tumours. Previous studies have indicated that these proteins are associated with carcinogenesis in intrahepatic cholangiocarcinoma. In this study, we examined c-erbB-2 and c-Met expression by immunohistochemistry in hepatolithiasis, intrahepatic cholangiocarcinoma and metastatic lymph node, in order to clarify whether these proteins play a role in carcinogenesis and tumour metastasis in intrahepatic cholangiocarcinoma.

METHODS AND RESULTS

In hepatolithiasis, the staining for c-erbB-2 was positive in 14 of the 23 (61%) cases, while staining for c-Met was positive in eight of the 23 (35%) cases. In intrahepatic cholangiocarcinoma, staining for c-erbB-2 was positive in 45 of the 81 (55%) cases, while staining for c-Met was positive in 28 (35%) cases. The positivity of c-Met staining in intrahepatic cholangiocarcinoma was significantly higher in the differentiated type of cholangiocarcinoma than in the undifferentiated type. In addition, c-Met-positive staining had an inverted correlation with tumour size, the presence of perineural invasion and the presence of lymph node metastasis. c-Met staining had a significantly higher positivity in cases at an early stage of intrahepatic cholangiocarcinoma. In contrast, the positivity of c-erbB-2 staining in intrahepatic cholangiocarcinoma was significantly higher in cases with lymph node metastasis than in cases without. In metastatic lymph nodes, the staining for c-erbB-2 was positive in 20 of the 25 (80%) cases, while staining for c-Met was positive in six of the 25 (24%) cases. There was no difference in survival between c-erbB-2-positive and negative patients. However, the patients with c-Met-positive tumours had a significantly longer survival than those with c-Met-negative tumours in the medium survival term. The multivariate analysis showed the presence of lymph node metastasis, lymphatic permeation and histological differentiation to be independent prognostic factors.

CONCLUSION

These results indicate that increased c-Met expression participates in cholangiocarcinogenesis and in the early developmental stages of intrahepatic cholangiocarcinoma, while increased c-erbB-2 expression contributes to the development of cholangiocarcinogenesis into an advanced stage associated with tumour metastasis.

Late development of bile duct cancer in patients who had biliary-enteric drainage for benign disease: a follow-up study of more than 1,000 patients

OBJECTIVE

To evaluate the correlation between biliary-enteric surgical drainage and the late development of cholangiocarcinoma of the biliary tract.

SUMMARY BACKGROUND DATA

In patients with biliary-enteric drainage, reflux of intestinal contents into the bile duct may occur and cause cholangitis, which is regarded as the most serious complication of these procedures. Lithiasis of the biliary tract and a previous biliary-enteric anastomosis have both been suggested to favor the late onset of cholangiocarcinoma.

METHODS

Consecutive patients (n = 1,003) undergoing three different procedures of biliary-enteric anastomosis (transduodenal sphincteroplasty, choledochoduodenostomy, and hepaticojejunostomy) between 1967 and 1997 were included in this study. The postoperative clinical course and long-term outcome were evaluated by a retrospective review of the hospital records and follow-up. Mean follow-up was 129.6 months.

RESULTS

Fifty-five (5.5%) cases of primary bile duct cancer were found among the 1,003 patients at intervals of 132 to 218 months from biliary-enteric anastomosis. The incidence of cholangiocarcinoma in the three groups was 5.8% in transduodenal sphincteroplasty patients, 7.6% in choledochoduodenostomy patients, and 1.9% in hepaticojejunostomy patients. The incidence of malignancy related to the different underlying diagnosis was 5.9%, 7.2%, and 1.9% in patients with choledocholithiasis, sphincter of Oddi stenosis, and postoperative benign stricture, respectively. Although only one patient who developed cholangiocarcinoma had previous concurrent lithiasis of the biliary tract, 40 patients had experienced mostly severe, recurrent cholangitis. No case of malignancy occurred in patients scored as having no cholangitis in the early and long-term postoperative outcome. Univariate and multivariate analyses have shown the presence of cholangitis as the only factor affecting the incidence of cholangiocarcinoma.

CONCLUSIONS

Chronic inflammatory changes consequent to biliary-enteric drainage should be closely monitored for the late development of biliary tract malignancies.

Radiologic manifestations of sclerosing cholangitis with emphasis on MR cholangiopancreatography

Magnetic resonance cholangiopancreatography (MRCP) is a relatively new, noninvasive cholangiographic technique that is comparable with invasive endoscopic retrograde cholangiopancreatography (ERCP) in the detection and characterization of extrahepatic bile duct abnormalities. The role of MRCP in evaluation of the intrahepatic bile ducts, especially in patients with primary or secondary sclerosing cholangitis, is under investigation. The key cholangiographic features of primary sclerosing cholangitis are randomly distributed annular strictures out of proportion to upstream dilatation. As the fibrosing process worsens, strictures increase and the ducts become obliterated, and the peripheral ducts cannot be visualized to the periphery of the liver at ERCP. In addition, the acute angles formed with the central ducts become more obtuse. With further progression, strictures of the central ducts prevent peripheral ductal opacification at ERCP. Cholangiocarcinoma occurs in 10%-15% of patients with primary sclerosing cholangitis; cholangiographic features that suggest cholangiocarcinoma include irregular high-grade ductal narrowing with shouldered margins, rapid progression of strictures, marked ductal dilatation proximal to strictures, and polypoid lesions. Secondary sclerosing and nonsclerosing processes can mimic primary sclerosing cholangitis at cholangiography. These processes include ascending cholangitis, oriental cholangiohepatitis, acquired immunodeficiency syndrome-related cholangitis, chemotherapy-induced cholangitis, ischemic cholangitis after liver transplantation, eosinophilic cholangitis, and metastases.

The significance of hepatectomy for primary intrahepatic stones

The objective of this study was to evaluate the significance of performing hepatectomy for primary intrahepatic stones. Observations on the morphology of the bile ducts, histopathological findings of the excised liver, and treatment results were reviewed in 29 of 35 patients with primary intrahepatic stones. The remaining 6 patients (17.1%) were excluded because they had intrahepatic cholangiocarcinoma. The subjects were classified into two groups according to the morphological characteristics of the bile ducts; one group comprised 25 patients having strictures in the central bile duct, and another group comprised 4 patients having no biliary stricture, but a localized dilatation in the distal bile duct. Calcium bilirubinate stones were found in all the patients with a biliary stricture, whereas cholesterol stones were found in those without a biliary stricture. Hepatectomy was performed in 25 of the 29 patients (86.2%), the results of which were excellent. In fact, during the past 10 years, no postoperative complications have occurred, nor have there been any retained or recurrent stones. Moreover, the postoperative hospitalization period was as short as 15.3 days. The findings of this study indicate that hepatectomy allows treatment for primary intrahepatic stones to be completed within a short period of time without incurring serious postoperative complications, and serves as a useful prophylactic technique for recurrent stones.

Peripheral cholangiocarcinoma (cholangiocellular carcinoma): clinical features, diagnosis and treatment

Peripheral cholangiocarcinoma is a relatively rare cancer. However, it is known to have an unfavourable prognosis compared with that of hepatocellular carcinoma. Little is known about its aetiology, clinical or pathological features. Recently, with the development of imaging modalities, early staged cholangiocarcinoma has been diagnosed with relative ease. Surgery is the optimal therapy. Total hepatectomy does not provide survival benefit. Conventional surgery remains the only effective treatment, even for patients with advanced-stage tumours. Factors influencing survival after hepatectomy were tumour-free margin, lymphnodes metastasis and histopathology of tumour. Palliative intrahepatic tubing or percutaneous transhepatic biliary drainage and brachytherapy can alleviate jaundice and cholangitis, thereby prolonging survival in some cases.

c-erbB-2 protein is expressed in hepatolithiasis and cholangiocarcinoma

AIMS

The c-erbB-2 proto-oncogene encodes a transmembrane protein which is highly homologous to epidermal growth factor receptor. Overexpression of this c-erbB-2 protein has been reported in many human carcinomas, including breast carcinoma. However, there have been few studies of the expression of c-erbB-2 in cholangiocarcinoma and hepatolithiasis, a condition occasionally associated with cholangiocarcinoma.

METHODS AND RESULTS

In this study, we evaluated immunoreactivity for the c-erbB-2 protein in human cholangiocarcinomas (n = 47), hepatolithiasis (n = 20), fetal livers (n = 36) and normal adult livers (n = 6). In normal adult livers and fetal livers, expression of c-erbB-2 protein could not be detected in hepatocytes or intrahepatic biliary cells. In hepatolithiasis, there was overexpression of c-erbB-2 in 15/20 (75%). The expression was found with a membranous pattern on the proliferated intrahepatic bile ducts and proliferated intrahepatic peribiliary glands around the bile ducts containing stones. Hepatocytes were negative for c-erbB-2 protein. Moreover, the biliary cell expression of the c-erbB-2 protein correlated significantly with Ki67 labelling index. On the other hand, aberrant expression of c-erbB-2 was found in 33/47 (70%) cholangiocarcinomas. The c-erbB-2 expression in cholangiocarcinomas did not correlate with Ki67 labelling index or p53 expression.

CONCLUSIONS

These results indicate that aberrant expression of c-erbB-2 protein is found in cholangiocarcinoma and also in noncancerous biliary proliferative lesions such as hepatolithiasis. These findings also suggest that c-erbB-2 oncogene participates not only in cholangiocarcinogenesis but also in biliary cell proliferation in non-neoplastic conditions.

Clinical studies of mucin-producing cholangiocellular carcinoma: a study of 22 histopathology-proven cases

OBJECTIVE

We present the clinical features and outcomes of 22 surgically treated and histopathology-proven cases of mucin-producing cholangiocellular carcinoma (MPCCC).

BACKGROUND

Cholangiocellular carcinoma (CCC) is an uncommon malignancy. Unlike hepatocellular carcinoma, it is difficult to set up a high-risk group, and a specific tumor marker has yet to be found. Chronic liver disease is usually not found to be associated with CCC. Information about patients with MPCCC is limited, and the frequency of MPCCC in all patients with CCC has not been reported.

METHODS

The clinical features of 22 surgically treated and histopathology-proven cases of MPCCC were reviewed, including morbidity, mortality, and follow-up results. Factors that may influence the outcomes were also analyzed. Clinical features and outcomes of 148 patients with non-mucin-producing cholangiocellular carcinoma (non-MPCCC) were also summarized for comparison.

RESULTS

Of 170 cases of CCC, 22 (12.9%) were MPCCC. Imaging studies were important in the differential diagnosis of CCC. Operative findings (e.g., gross appearance of the liver, mucobilia found by common bile duct exploration, choledochoscopic findings, and frozen section) were useful in the diagnosis of MPCCC. Surgical procedures included common bile duct exploration, or hepaticostomy, and intraoperative choledochoscopy in all 22 patients. Hepatic resection was done in 14 of the 22 cases (63.6%). No early surgical mortality was noted. Wound infections (two patients), bile leak (one patient), and intraabdominal abscess (one patient) were the postoperative complications. The 1-, 2-, 3-, 4-, and 5-year survival rates were 86.5%, 68.5%, 59.0%, 38.5%, and 31.0%, respectively. A significant difference in survival pattern was found between the MPCCC and non-MPCCC patient groups. Patients with hepatic resection had a significantly better prognosis than those without resection. Although patients with hepatolithiasis had a better survival pattern than those without hepatolithiasis, the difference was not statistically significant.

CONCLUSIONS

We present the clinical features and outcomes of 22 surgically treated and histopathology-proven cases of MPCCC. Patients with hepatic resection were found to have better survival rates.

Hepatolithiasis associated with cholangiocarcinoma

BACKGROUND

Intrahepatic stone is common in East Asia. Hepatolithiasis is a risk factor for cholangiocarcinoma but it is difficult to make an accurate diagnosis before operation. The effect of intrahepatic stone on diagnosis, treatment and survival in patients with coexistent cholangiocarcinoma was investigated.

METHODS

Between 1981 and 1994, 33 patients with hepatolithiasis and associated cholangiocarcinoma were identified and compared respectively to 18 patients with intrahepatic cholangiocarcinoma alone.

RESULTS

Patients with intrahepatic stones had a significantly longer duration of symptoms, a higher frequency of previous biliary surgery but a lower rate of preoperative diagnosis. Surgical resection was the treatment of choice and was performed in 18 of 33 patients with cholangiocarcinoma and stones and in nine of 18 with intrahepatic cholangiocarcinoma alone. Significantly inferior 5-year survival rates were found in patients with hepatolithiasis: two of 32 versus four of 14 for all cases and two of 17 versus four of nine for resectable cases (P < 0.05).

CONCLUSION

These survival differences may be attributed to delayed diagnosis, lower diagnostic rate and relatively fewer curative resections in the patients with stone-containing cholangiocarcinoma.

Late development of bile duct cancer after sphincteroplasty: a ten- to twenty-two-year follow-up study

BACKGROUND

Transduodenal sphincteroplasty is designed to destroy the sphincteric muscle fibers, producing a terminal choledochoduodenostomy. In the absence of Oddi's sphincter, intestinal contents with both activated pancreatic juice and bacterial flora are refluxed into the bile duct and remain there for a prolonged time. The long-term effect of producing the reflux has not been evaluated to date.

METHODS

One hundred nineteen consecutive patients undergoing transduodenal sphincteroplasty between February 1973 and July 1984 were included in this study. Postoperative clinical courses of 108 patients could be evaluated by means of a retrospective review of the hospital records. Median follow-up was 18 years.

RESULTS

Eight cases (7.4%) of primary bile duct cancer were found among the 108 cases at intervals of 1 to 20 years after sphincteroplasty. Two patients had concurrent hepatolithiasis. The patency of sphincteroplasty was confirmed in all cases, and the bile was infected in seven cases. Pathologic specimens obtained demonstrated cholangiocarcinomas and various degrees of atypical hyperplastic lesions under the background of chronic cholangitis.

CONCLUSIONS

Chronic cholangitis can be an important causative factor in late development of bile duct cancer after sphincteroplasty. Any patients treated with choledochoduodenostomy should be closely monitored for late cholangiocarcinoma.

Clinicopathologic spectrum of resected extraductal mass-forming intrahepatic cholangiocarcinoma

BACKGROUND

The mode of tumor growth of intrahepatic cholangiocarcinoma (CC) varies considerably from patient to patient. This study describes the clinicopathologic variety of the extraductal mass-forming type of CC.

METHODS

Patients with CC characterized by an extraductal mass (n = 26) who underwent hepatectomy from 1976 through 1992 were clinicopathologically classified into three types: Type I (n = 7), no biliary stricture; Type II (n = 13), biliary stricture without jaundice; and Type III (n = 6), biliary stricture with jaundice.

RESULTS

Type I included three patients with microductular-trabecular arrangement and behavior reminiscent of hepatocellular carcinoma (high association with chronic liver disease, mild positivity for alpha-fetoprotein [AFP], no lymph node metastasis, but frequent intrahepatic metastasis), in contrast to the other typical cholangiocarcinoma. Hepatolithiasis was associated only with Type II CC: The serum positivity for AFP and carcinoembryonic antigen was much higher in Type I CC, whereas positivity of CA 19-9 was highest in Type III. Involvement of the portal vein, hepatic artery, or hepatic duct was most frequent in Type III CC, which necessitated resection of the extrahepatic bile duct and hepatectomy.

CONCLUSION

The clinicopathologic behavior of intrahepatic CC differs considerably according to the presence or absence of stricture of the biliary tree. Thus, CC without biliary stricture behaves more like hepatocellular carcinoma, whereas CC with biliary stricture is more like hilar or extrahepatic bile duct carcinoma.

Hepatolithiasis associated with cholangiocarcinoma

Hepatolithiasis is a risk factor for cholangiocarcinoma. It is difficult to make an accurate diagnosis before treatment. In a retrospective study, we identified characteristic clinical features of 103 patients with hepatolithiasis (group H) and 10 patients with hepatolithiasis associated with cholangiocarcinoma (group HC), and examined the methods for diagnosis and treatment. The main symptoms were abdominal pain, fever, and jaundice, although few patients in group HC had jaundice. The incidence of abnormal serum levels of carcinoembryonic antigen (CEA) in group HC was higher than in group H. The incidence of cholangiocarcinoma in cases in which most of the stones were present in the intrahepatic ducts of the left lobe (type I-L) was higher than the incidence in the other patients. Of the patients who underwent portography in group HC, portal veins in the portion of the liver containing the cholangiocarcinoma were not seen, and this region was atrophic in the operative specimens. The incidence of portal obstruction in portograms in group HC was higher than that in group H. The possibility of carcinoma should be kept in mind if there are high levels of CEA, if the location of the stones is classified as type I-L, or if portal veins cannot be seen on portograms. In such patients, liver resection should be considered because there may be undiagnosed cholangiocarcinoma.

Lectin histochemical study of cholangiocarcinoma arising from stone-bearing intrahepatic bile duct

With the purpose of studying changes in the expression of glycoconjugate structures in cholangiocarcinoma and the nonneoplastic epithelium of stone-bearing intrahepatic bile ducts, a panel of 12 biotinylated lectins were used on formalin-fixed, paraffin-embedded tissue sections from 13 patients who had undergone surgical resection of cholangiocarcinoma and on nonneoplastic stone-bearing intrahepatic bile ducts from 10 patients. Of the 13 patients with cholangiocarcinoma 10 had hepatolithiasis and 3 did not. Among the 12 lectins, only wheat germ agglutinin (WGA) stained the cholangiocarcinoma and nonneoplastic epithelium of the stone-bearing intrahepatic bile duct. All nonneoplastic epithelia of stone-bearing intrahepatic bile ducts were stained heavily and homogeneously by WGA, the GlcNAC-specific lectin. The high columnar epithelium of both intramural and extramural glands was stained in the supranuclear region, while the low columnar epithelium of serous acini was stained in the whole cytoplasm. cytoplasm. In the well-differentiated cholangiocarcinoma, the WGA weakly stained the neoplastic cells in the supranuclear region, while it stained the luminal cytoplasmic membrane heavily. In the poorly-differentiated cholangiocarcinoma, about 50% of cancer cells were stained with WGA. The carcinoma was moderately stained in the cytoplasm. Less reactivity and a lower percentage of cells stained with lectin were found in cholangiocarcinomas when compared to nonneoplastic epithelia. This led us to conclude that there is a dramatic decrease in lectin-binding carbohydrate structures associated with cholangiocarcinoma progression.

Immunohistochemical study of mucin carbohydrates and core proteins in hepatolithiasis and cholangiocarcinoma

The expression of mucin carbohydrates [Tn, sialosyl-Tn(STn), and T antigens] and core proteins [MUCI-apomucin-related antigen (ARA) and MUC2-ARA] was examined immunohistochemically in tissues from 40 patients with hepatolithiasis and 26 patients with intrahepatic bile-duct carcinoma. Tn and STn antigens were expressed in most of the carcinomas, and were also often expressed in the atypical bile-duct epithelium of the patients with hepatolithiasis or carcinoma, whereas they were rarely or never expressed in the normal bile duct, suggesting that they are effective tumor markers. T antigen was less useful as a marker for intrahepatic bile-duct carcinoma or the atypical epithelium, because it was expressed in normal bile-duct of some cases. Regarding the expression of ARAs in the carcinomas, non-invasive bile-duct cyst adenocarcinomas with favorable prognosis either expressed no MUCI-ARA with [DF3(-), MUSEII(-) and 139H2(-)] staining pattern or expressed MUCI-ARA with [DF3(-), MUSEII(+) and 139H2(+)] staining pattern. However these tumors often expressed MUC2-ARA with [anti-MRP(+) and CCP58(+)] staining pattern. In contrast, most invasive non-papillary cholangiocarcinomas with poor prognosis expressed MUCI-ARA with [DF3(+), MUSEII(+) and 139H2(+)] staining pattern, but expressed no MUC2-ARA with [anti-MRP(-) and CCP58(-)] staining pattern. These results suggests that different apomucins are produced by bile-duct cystadenocarcinomas and cholangiocarcinomas with differing prognosis. Furthermore, expression of Tn and STn antigens is a useful indicator of malignancy in the intrahepatic duct.