Cholangiocarcinoma: principles and current trends

Post-operative Rehabilitation in Klatskin Tumor: A Rare Case Report

Cholangiocarcinoma (CCA), commonly referred to as Klatskin tumor (KT), is a rare cancer that develops from the epithelium of the intra- or extrahepatic bile duct. This case outlines the impact of physiotherapy rehabilitation in a post-operative case of a KT in a 58-year-old male who presented with complaints of abdominal pain, nausea, constipation, and difficulty in urinating and reportedly exhibited generalized weakness, weight loss, and dyspnea. Following investigations such as computed tomography (CT) scan, the patient was diagnosed with a KT for which he underwent hepaticojejunostomy and was kept under observation, following which supervised physiotherapy intervention (PI) commenced from post-operative day (POD) 3. The outcome measure was peak expiratory flow rate (PEFR), whereas the intervention involved diaphragmatic breathing exercises (DBEs), thoracic expansion exercises (TEEs), incentive spirometry (IS), range of motion (ROM) exercises, active cycle of breathing technique (ACBT), and ambulation. After two weeks of treatment, there were an improvement in cough frequency and an appreciable change in vital capacity (VC), and a significant increase in PEFR values was observed.

Efficacy of Endobiliary Radiofrequency Ablation in Preserving Survival, Performance Status and Chemotherapy Eligibility of Patients with Unresectable Distal Cholangiocarcinoma: A Case-Control Study

Background: Cholangiocarcinoma is the most common malignancy of the bile ducts causing intrahepatic, hilar, or distal bile duct obstruction. Most jaundiced patients are diagnosed with unresectable tumors in need for palliative bile duct drainage and chemotherapy. Endobiliary radiofrequency ablation (RFA) is an adjuvant technique that may be applied prior to biliary stenting. The aim of our study was to assess the efficacy of endobiliary RFA prior to stent insertion in patients with unresectable distal cholangiocarcinomas. Methods: Twenty-five patients (eight treated with RFA and stenting and 17 treated with stenting alone) were included in a case-controlled study. We prospectively assessed the impact of RFA on the survival rate, the patient performance status, and the preservation of eligibility for chemotherapy based on the patient laboratory profile. Results: Patients treated with RFA prior to stenting proved to have a significantly longer survival interval (19 vs. 16 months, p = 0.04, 95% CI) and significantly better performance status. Moreover, the laboratory profiles of patients treated with RFA has been proven superior in terms of total bilirubin, liver enzymes, and kidney function, thus making patients likely eligible for palliative chemotherapy. Post-ERCP adverse events were scarce in both the study group and the control group. Conclusion: Given the isolated adverse events and the impact on the patient survival, performance, and laboratory profile, RFA can be considered safe and efficient in the management of patients with unresectable distal cholangiocarcinomas.

Comparison of Intraductal RFA Plus Stent versus Stent-Only Treatment for Unresectable Perihilar Cholangiocarcinoma—A Systematic Review and Meta-Analysis

Simple Summary

In patients with unresectable perihilar cholangiocarcinoma, adequate biliary drainage is essential. Stent patency remains a challenge in these complex patients, as both plastic and metal stent occlusion may occur, necessitating additional drainage procedures. Radiofrequency ablation (RFA) is a promising local treatment that has already proven its usefulness in other malignancies, such as hepatocellular carcinoma. In this meta-analysis and systematic review, we aimed to compare intraductal RFA with stent placement to stent placement alone in patients with unresectable perihilar cholangiocarcinoma. We found that RFA + stent treatment showed a significantly longer overall survival, in comparison to stent-only treatment. Further research is necessary in order to validate these findings to support the implementation of this promising strategy in clinical practice.

Abstract

Background: One of the cornerstones of palliative treatment for unresectable perihilar cholangiocarcinoma is biliary stent placement in order to restore biliary drainage. In this review, the potential added value of RFA with stent placement in comparison to stent placement alone in patients with unresectable perihilar cholangiocarcinoma is analyzed. Methods: We performed a comprehensive online search for relevant articles in November 2021 (PROSPERO ID: CRD42021288180). The primary endpoint was difference in overall survival. Secondary endpoints included overall survival, stent patency and complications. Only studies comparing survival after RFA + stent placement with stent placement alone were included in the meta-analysis. Non-comparative studies or comparative studies describing stent patency only were included in the systematic review. Results: A total of nine studies, including 217 patients with pCCA who underwent RFA + stent placement and 294 patients who underwent stent-only treatment, met the inclusion criteria for the primary endpoint analysis. Direct comparison between the two treatment groups showed a significantly longer overall survival for RFA + stent treatment, with a pooled HR of 0.65 [95% CI, 0.50–0.84, I² = 38%]. When all eligible studies were included, RFA + stent treatment revealed an overall survival of 9.5 months [95% CI, 6.3–12.6], whereas survival for stent-only treatment was 7.0 months [95% CI, 5.7–8.2]. Due to the heterogeneity of the data, no pooled data analysis could be performed on stent patency or complications. Conclusions: RFA + stent placement displays promising potential to prolong survival. However, further research incorporating confounding factors like use of palliative chemotherapy is necessary in order to validate these findings.

Survival Benefit of Intraductal Radiofrequency Ablation for Malignant Biliary Obstruction: A Systematic Review with Meta-Analysis

BACKGROUND/AIMS

Cholangiocarcinoma (CCA) is a rare but aggressive disease with a poor survival. Recent trials have shown improved survival with intraductal radiofrequency ablation (RFA) therapy. We performed a systematic review with meta-analysis to determine the survival benefit of endoscopic RFA for unresectable extrahepatic CCA with malignant biliary obstruction (MBO).

METHODS

A systematic search from 1970 to 2020 was performed in MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials. gov. We selected eligible studies reporting relative risks, hazard ratios (HRs), or odds ratios, adjusted by controlling for confounding factors of survival rate and stent patency duration, among patients with extrahepatic CCA with MBO treated with RFA with stent insertion or stent insertion only.

RESULTS

A total of eight trials (three randomized and five nonrandomized) with a total of 420 patients were included in the metaanalysis. Pooled overall survival analysis favored RFA treatment with stent insertion (HR, 0.47; 95% confidence interval [CI], 0.34- 0.64; I2=47%; p=0.09); however, no significant difference was found in the duration of stent patency between the groups (HR, 0.79; 95% CI, 0.57-1.09; I2=7%; p=0.36).

CONCLUSION

RFA therapy with stent insertion may confer a survival benefit compared with stent insertion only in patients with CCA and MBO.

Diagnostic accuracy of administrative database for bile duct cancer by ICD-10 code in a tertiary institute in Korea

BACKGROUND

Administrative database provides valuable information for large cohort studies, especially when tissue diagnosis is rather difficult such as the diagnosis for bile duct cancer (BDC). The aim of this study was to evaluate the diagnostic accuracy of administrative database for BDC by International Classification of Diseases (ICD)-10 codes in a tertiary institute.

METHODS

BDC and control groups were collected from 2003 to 2016 at Seoul National University Bundang Hospital. Cases of BDC were identified in the National Health Insurance Service (NHIS) database by ICD 10-code supported by V code. The control group was selected from cases without ICD-10 codes for BDC. A definite or possible diagnosis was defined according to pathologic reports. Medical records, images, and pathology reports were analyzed to evaluate ICD-10 codes for BDC. Sensitivity, specificity, positive predictive value, and negative predictive value for BDC were analyzed according to diagnostic criteria and cancer locations.

RESULTS

A total of 1707 patients with BDC and 1707 controls were collected. Among those with BDC, 1320 (77.3%) were diagnosed by definite criteria. Most (99.4%) of them had adenocarcinoma. Rate of definite diagnosis was the highest for ampulla of Vater (88.9%), followed by that for extrahepatic (84.9%) and intrahepatic (68.3%) BDCs. False positive cases commonly had hepatocellular carcinomas. For overall diagnosis of BDC, sensitivity, specificity, positive predictive value, and negative predictive value were 99.94%, 98.33%, 98.30%, and 99.94%, respectively. Diagnostic accuracies were similar regardless of diagnostic criteria or tumor locations.

CONCLUSIONS

Administrative database for BDC collected according to ICD-10 code with V code shows good accuracy.

High glucose-ROS conditions enhance the progression in cholangiocarcinoma via upregulation of MAN2A2 and CHD8

Diabetes is a major risk factor in the development and progression of several cancers including cholangiocarcinoma (CCA). However, the molecular mechanism by which hyperglycemia potentiates progression of CCA is not clearly understood. Here, we showed that a high glucose condition significantly increased reactive oxygen species (ROS) production and promoted aggressive phenotypes of CCA cells, including proliferation and migration activities. Mannosidase alpha class 2a member 2 (MAN2A2), was upregulated at both mRNA and protein levels in a high glucose‐ and ROS‐dependent manner. In addition, cell proliferation and migration were significantly reduced by MAN2A2 knockdown. Based on our proteome and in silico analyses, we further found that chromodomain helicase DNA‐binding protein 8 (CHD8) was induced by ROS signaling and regulated MAN2A2 expression. Overexpression of CHD8 increased MAN2A2 expression, while CHD8 knockdown dramatically reduced proliferation and migration as well as MAN2A2 expression in CCA cells. Moreover, both MAN2A2 and CHD8 were highly expressed with positive correlation in CCA tumor tissues. Collectively, these data suggested that high glucose conditions promote CCA progression through ROS‐mediated upregulation of MAN2A2 and CHD8. Thus, glucose metabolism is a promising therapeutic target to control tumor progression in patients with CCA and diabetes.

Serum KIAA1199 is an advanced-stage prognostic biomarker and metastatic oncogene in cholangiocarcinoma

BACKGROUND

Cell proliferation and migration are the determinants of malignant tumor progression, and a better understanding of related genes will lead to the identification of new targets aimed at preventing the spread of cancer. Some studies have shown that KIAA1199 (CEMIP) is a transmembrane protein expressed in many types of noncancerous cells and cancer cells. However, the potential role of KIAA1199 in the progression of cholangiocarcinoma (CCA) remains unclear.

RESULTS

Analysis of cancer-related databases showed that KIAA1199 is overexpressed in CCA. ELISA, immunohistochemistry, Western blotting and qPCR indicated high expression levels of KIAA1199 in serum, CCA tissues and CCA cell lines. In the serum (n = 41) and large sample validation (n = 177) cohorts, higher KIAA1199 expression was associated with shorter overall survival and disease-free survival times. At the cellular level, KIAA1199 overexpression (OE) promoted CCA growth and metastasis. Subcutaneous tumor xenograft experiments showed that KIAA1199 enhances CCA cell proliferation. Additionally, the expression levels of components in the EMT-related TGF-β pathway changed significantly after KIAA1199 upregulation and silencing.

CONCLUSION

KIAA1199 is a promising new diagnostic molecule and therapeutic target in CCA. The serum KIAA1199 level can be used as a promising clinical tool for predicting the overall postoperative outcomes of patients with CCA.

METHODS

CCA-related KIAA1199 data were downloaded from the Gene Expression Omnibus (GEO) and The Cancer Genome Atlas (TCGA) databases. To assess the prognostic impact of KIAA1199, an enzyme-linked immunosorbent assay (ELISA) was used to measure the serum level of KIAA1199 in 41 patients who underwent surgical resection. Immunohistochemical staining, Western blotting and qPCR were used to verify and retrospectively review the expression levels of KIAA1199 in cancer tissue specimens from 177 CCA patients. The effect of KIAA1199 on CCA was evaluated by cell-based functional assays and subcutaneous tumor xenograft experiments. The expression levels of proteins associated with epithelial-mesenchymal transition (EMT) and activation of relevant signaling pathways were measured via Western blotting.

Effect of Combining EGFR Tyrosine Kinase Inhibitors and Cytotoxic Agents on Cholangiocarcinoma Cells

Purpose

The potential of members of the epidermal growth factor receptor (ErbB) family as drug targets in cholangiocarcinoma (CCA) has not been extensively addressed. Although phase III clinical trials showed no survival benefits of erlotinib in patients with advanced CCA, the outcome of the standard-of-care chemotherapy treatment for CCA, gemcitabine/cisplatin, is discouraging so we determined the effect of other ErbB receptor inhibitors alone or in conjunction with chemotherapy in CCA cells.

Materials and Methods

ErbB receptor expression was determined in CCA patient tissues by immunohistochemistry and digital-droplet polymerase chain reaction, and in primary cells and cell lines by immunoblot. Effects on cell viability and cell cycle distribution of combination therapy using ErbB inhibitors with chemotherapeutic drugs was carried out in CCA cell lines. 3D culture of primary CCA cells was then adopted to evaluate the drug effect in a setting that more closely resembles in vivo cell environments.

Results

CCA tumors showed higher expression of all ErbB receptors compared with resection margins. Primary and CCA cell lines had variable expression of erbB receptors. CCA cell lines showed decreased cell viability when treated with chemotherapeutic drugs (gemcitabine and 5-fluorouracil) but also with ErbB inhibitors, particularly afatinib, and with a combination. Sequential treatment of gemcitabine with afatinib was particularly effective. Co-culture of CCA primary cells with cancer-associated fibroblasts decreased sensitivity to chemotherapies, but sensitized to afatinib.

Conclusion

Afatinib is a potential epidermal growth factor receptor targeted drug for CCA treatment and sequential treatment schedule of gemcitabine and afatinib could be explored in CCA patients.

High Beclin-1 and ARID1A expression corelates with poor survival and high recurrence in intrahepatic cholangiocarcinoma: a histopathological retrospective study

Background

Although surgical resection provides a cure for patients with intrahepatic cholangiocarcinoma (ICC), the risk of mortality and recurrence remains high. Several biomarkers are reported to be associated with the prognosis of ICC, including Beclin-1, ARID1A, carbonic anhydrase IX (CA9) and isocitrate dehydrogenase 1 (IDH1), but results are inconsistent. Therefore, a histopathological retrospective study was performed to simultaneously investigate the relationship of these four potential biomarkers with clinicopathological parameters and their prognostic values in patients with ICC.

Methods

A total of 113 patients with ICC were enrolled from Cancer Hospital of Chinese Academy of Medical Sciences between January 1999 and June 2015. The expression of Beclin-1, ARID1A, IDH1 and CA9 were determined by immunohistochemical staining. The prognostic values of the four biomarkers were analyzed by Cox regression and the Kaplan-Meier method.

Results

Beclin-1, ARID1A, CA9 and IDH1 were highly expressed in ICC tumor tissues. Higher mortality was positively associated with Beclin-1 expression (HR = 2.39, 95% CI = 1.09–5.24) and higher recurrence was positively associated with ARID1A expression (HR = 1.71, 95% CI = 1.06–2.78). Neither CA9 nor IDH1 expression was significantly associated with mortality or disease recurrence. Kaplan-Meier survival curves showed that ICC patients with higher Beclin-1 and ARID1A expression had a lower survival rate and a worse recurrence rate than patients with low Beclin-1 and ARID1A expression (p < 0.05).

Conclusions

High Beclin-1 and ARIDIA expression are strongly associated with poor prognosis in ICC patients, and thus Beclin-1 and ARID1A should be simultaneously considered as potential prognostic biomarkers for ICC patients.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5429-3) contains supplementary material, which is available to authorized users.

Case: Authentic multimodal therapy and liver resection for an initially unresectable intrahepatic cholangiocarcinoma

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Certain segments of intrahepatic cholangiocarcinoma (ICC) remain unresectable.

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Curative resection is a prominent prognostic factor for ICC.

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Multimodal chemotherapy and R0 resection could cur initially unresectable ICC.

Introduction

Although curative resection is an outstanding prognostic factor of intrahepatic cholangiocarcinoma (ICC), certain segments remain unresectable. The standard therapy for initially unresectable ICC is uncertain. In this case report, we reported the feasibility of multimodal chemotherapy and curative resection.

Case

A 59-year-old Asian woman with back pain was referred to the hospital by her family physician regarding liver mass visible on ultrasonography. At admission, the carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels were high, and images showed characteristic signs of ICC with intrahepatic metastases and invasions to on the right Glisson's sheath. Multimodal therapy was applied to the ICC, which could not be resected at first. The therapy comprised hepatic arterial chemoembolization with drug-eluting beads (DEB-TACE), angiographic subsegmentectomy (AS), and systemic chemotherapy. Downstaging of the ICC, which results in curative resection, was planned due to non-normalization of the tumor markers, and pathological analysis revealed complete remission. At 34 months after the surgery, the patient was alive without relapse.

Discussion

Recently, chemotherapy and/or an interventional approach were reported to be feasible, although unresectable advanced ICC has a poor prognosis. Some studies have reported that multimodal chemotherapy and R0 resection of initially unresectable ICC can prolong survival time. However, some reports have shown high morbidity and mortality associated with initially unresectable ICC treated with multimodal chemotherapy and R0 resection. Our study resulted in complete remission without complications.

Conclusion

Multimodal chemotherapy and hepatic curative resection on locally advanced ICC are feasible treatment approaches for initially unresectable ICC.

Sulfated galactans from the red seaweed Gracilaria fisheri exerts anti-migration effect on cholangiocarcinoma cells

BACKGROUND

Seaweeds have a long history of use in Asian countries as functional foods, medicinal herbs, and the treatment of cancer. Polysaccharides from various seaweeds have shown anti-tumor activity. Cholangiocarcinoma (CCA), often with metastatic disease, is highly prevalent in Thailand as a consequence of liver fluke infection. Recently, we extracted sulfated galactans (SG) from Gracilaria fisheri (G. fisheri), a south east Asian seaweed, and found it exhibited anti-proliferation effect on CCA cells.

PURPOSE

In the present study, we evaluated the anti-migration activity of SG on CCA cells and its underlined mechanism.

METHODS

CCA cells were treated with SG alone or drugs targeting to epidermal growth factor (EGF) receptor (EGFR) or pretreated with SG prior to incubation with EGF. Anti-migration activity was determined using a scratch wound-healing assay and zymography. Immunofluorescence staining and western blotting were used to investigate EGFR signaling mediators.

RESULTS

Under basal condition, SG reduced the migration rate of CCA, which was correlated with a decrease in the active-form of matrix metalloproteinases-9. SG decreased expression of phosphorylated focal adhesion kinase (FAK), but increased expression of E-cadherin to promote cells stasis. Moreover, phosphorylation of EGFR and extracellular signal-regulated kinases (ERK), known to stimulate growth of cancer cells, was blocked in a comparable way to EGFR inhibitors Cetuximab and Erlotinib. Pretreatment cells with SG attenuated EGF induced phosphorylation of EGFR, ERK and FAK.

CONCLUSION

This study reveals that SG from G. fisheri retards migration of CCA cells, and its mechanism of inhibition is mediated, to some extent, by inhibitory effects on MAPK/ERK signal transduction pathway. Our findings suggest that there may be a therapeutic potential of SG in CCA treatment.

High glucose levels boost the aggressiveness of highly metastatic cholangiocarcinoma cells via O-GlcNAcylation

Increased glucose utilization is a feature of cancer cells to support cell survival, proliferation, and metastasis. An association between diabetes mellitus and cancer progression was previously demonstrated in cancers including cholangiocarcinoma (CCA). This study was aimed to determine the effects of high glucose on protein O-GlcNAcylation and metastatic potentials of CCA cells. Two pairs each of the parental low metastatic and highly metastatic CCA sublines were cultured in normal (5.6 mM) or high (25 mM) glucose media. The migration and invasion abilities were determined and underlying mechanisms were explored. Results revealed that high glucose promoted migration and invasion of CCA cells that were more pronounced in the highly metastatic sublines. Concomitantly, high glucose increased global O-GlcNAcylated proteins, the expressions of vimentin, hexokinase, glucosamine-fructose-6-phosphate amidotransferase (GFAT) and O-GlcNAc transferase of CCA cells. The glucose level that promoted migration/invasion was shown to be potentiated by the induction of GFAT, O-GlcNAcylation and an increase of O-GlcNAcylated vimentin and vimentin expression. Treatment with a GFAT inhibitor reduced global O-GlcNAcylated proteins, vimentin expression, and alleviated cell migration. Altogether, these results suggested the role of high glucose enhanced CCA metastasis via modulation of O-GlcNAcylation, through the expressions of GFAT and vimentin.

Poly(styrenesulfonate)-Modified Ni-Ti Layered Double Hydroxide Film: A Smart Drug-Eluting Platform

Drug-eluting stents (DESs) are widely used in the palliative treatment of many kinds of cancers. However, the covered polymers used in DESs are usually associated with stent migration and acute cholecystitis. Therefore, developing noncovered drug-loading layers on metal stents is of great importance. In this work, Ni-Ti layered double hydroxide (Ni-Ti LDH) films were prepared on the surface of nitinol via hydrothermal treatment, and the LDH films were further modified by poly(styrenesulfonate) (PSS). The anticancer drug doxorubicin could be effectively loaded onto the modified films, and drug release could be smartly controlled by the pH. Besides, the drug absorption amounts of cancer cells cultured on the films could be effectively improved. These results indicate that the PSS-modified LDH film may become a promising drug-loading platform that can be used in the design of DESs.

Total serum bile acid as a potential marker for the diagnosis of cholangiocarcinoma without jaundice

Diagnosis of cholangiocarcinoma (CCA) is difficult when patients do not show jaundice. The aim of this study was to examine the feasibility of using the total serum bile acid (TSBA) level as an aid for the diagnosis of CCA in patients without jaundice. For this purpose, TSBA of the following groups were measured using a Beckman Synchron CX4 clinical chemistry analyzer: 60 cases of CCA with total serum bilirubin ≤2 mg/dL (low total bilirubin group, LTB); 32 cases of CCA with total serum bilirubin >2 mg/dL (high total bilirubin group, HTB); and 115 healthy controls. Liver function parameters such as serum cholesterol, albumin, alanine aminotransferase (ALT), aspartate aminotransferase (AST) and alkaline phosphatase (ALP) were also examined. The results showed that the TSBA of both LTB and HTB groups of the CCA patients were significantly higher than that of the healthy controls. Also, significant correlation was observed between TSBA and total bilirubin levels in the HTB group of CCA patients. However, no such correlation was seen in the LTB group. The cut-off value of TSBA was determined for the LTB group of CCA patients using the receiver operating characteristic curve analysis, and it was 6.05 μmol/L with the sensitivity and specificity of 46.7% and 84.4%, respectively. In addition, the ALP level was correlated well with the TSBA level and ALP in HTB group was significantly higher than that of LTB group. Moreover, the combination of high TSBA and high ALP levels gave higher specificity up to 97.4%. TSBA might be useful for the diagnosis of CCA patients without jaundice.

Cell-SELEX based selection and optimization of DNA aptamers for specific recognition of human cholangiocarcinoma QBC-939 cells

Cholangiocarcinoma (CCA) is a very aggressive biliary tract malignancy with no efficient early diagnosis and therapeutics available, so there is a call for effective molecular probes. Herein, we performed cell-based systematic evolution of ligands by exponential enrichment (cell-SELEX) to obtain aptamers for the specific recognition of human cholangiocarcinoma QBC-939 cells. By coordinating sequence homology analysis and secondary structure analysis, we successfully obtained two aptamers with dissociation constants (Kd) in the low nanomolar range. A 23 nt truncated sequence was identified after further analysis on the secondary structure. More importantly, because hepatocellular carcinoma SMMC-7721 cells were employed as the control in the counter selection, the obtained aptamers demonstrated excellent specificity to the target cells, and no binding to several other hepatocellular carcinoma cell lines was observed. Moreover, the aptamers were initially found to recognize membrane proteins, giving them great potential in the field of biomarker discovery. These newly generated aptamers may play a key role in the early diagnosis and clinical treatment of CCA.

Hypoxia enhances cholangiocarcinoma invasion through activation of hepatocyte growth factor receptor and the extracellular signal‑regulated kinase signaling pathway

Hypoxia is associated with tumor progression and poor prognosis in several cancer types. The present study aimed to examine the contribution of hypoxia (1% O₂) to cancer progression in a cholangiocarcinoma cell line, RMCCA-1. The molecular basis of the hypoxic response pathway was investigated. The results showed that hypoxia significantly accelerated cancer cell proliferation and enhanced cell invasion (P<0.05). By using receptor tyrosine kinase and intracellular signaling antibody array kits, an increased phosphorylation/activation of a number of signaling molecules, particularly hepatocyte growth factor receptor (Met) and extracellular signal-regulated kinase (ERK) 1/2, was identified. Inhibition of Met and ERK by small hairpin RNA and U0126, respectively, significantly inhibited hypoxia-induced the invasive potential of RMCCA-1 cells (P<0.05). However, according to immunohistochemical analysis, hypoxia-inducible factor-1α expression was not correlated with cancer staging or tumor differentiation in 44 samples of cholangicarcinoma cases. The findings of the present study emphasized the importance of Met/ERK pathway activation as a key molecular event that may be responsible for a more invasive phenotype in hypoxic tumors and suggest Met as a potential target for the treatment of cholangiocarcinoma.

Downregulation of FOXP3 inhibits invasion and immune escape in cholangiocarcinoma

FOXP3 is known as a master control of regulatory T cells with recently studies indicating its expression in several tumor cells. In order to study the precise role of FOXP3 in cholangiocarcinoma, FOXP3 was knocked down in cholangiocarcinoma cell lines. Down regulation of FOXP3 inhibits tumor cell invasion by reducing the quantity of MMP-9 and MMP-2. With FOXP3 knocking down, IL-10 and TGF-β1 secreted by cancer cells diminishes and the cell survival of T cells is significant up-regulation. These results suggest that FOXP3 plays an important role in tumor malignant phenotype, especially the invasion and immune escape.

Surgical and combined treatment of patients with cholangiocellular carcinoma

INTRODUCTION

Liver resection is the essential method of cholangiocellular carcinoma treatment. However due to low resectability and high incidence of recurrences search for additional curative methods is necessary.

AIM

To improve the results of surgical treatment of patients with cholangiocellular carcinoma especially with complications and poor prognosis.

MATERIAL AND METHODS

A total of 95 surgical procedures for intrahepatic cholangiocarcinoma have been performed in the department of liver andpancreatic tumors at N.N. Blokhin Russian Cancer Research Center since 1998 to 2014. 11 patients had obstructive jaundice as the first symptom of the disease. Extended liver resections were done in most cases (84.2%). Preoperative treatment was performed in 3 patients. Adjuvant chemotherapy after R0-resection was applied in 15 patients.

RESULTS

The postoperative mortality rate was 4.2%. Postoperative complications were observed in 51 (53.7%) patients. Complication grade III after adjuvant chemotherapy was observed in one (6.7%) patient. Median survival after liver resection was 25 months, 5-year survival rate - 25.3%. In stage I-II five-year survival reached 66.7%. In patients with obstructive jaundice 5-year survival rate was 26.7%, median survival - 37 months. There was no improvement of survival in case of adjuvant therapy.

CONCLUSION

Liver resection remains essential treatment of cholangiocellular carcinoma including patients with obstructive jaundice. Additional curative methods are necessary to increase resectability and decrease the risk of recurrence.

Association between cellular radiosensitivity and G1/G2 checkpoint proficiencies in human cholangiocarcinoma cell lines

Cholangiocarcinoma is a destructive malignancy with a poor prognosis and lack of effective medical treatment. Radiotherapy is an alternative treatment for patients with unresectable cholangiocarcinoma. However, there are limited data on the radiation responsiveness of individual cholangiocarcinoma cells, which is a key factor that influences radiation treatment outcome. In this study, we found that cholangiocarcinoma cell lines differ remarkably in their radiosensitivity. The variation of radiosensitivity of cholangiocarcinoma cells correlates with their p53 status and existing G1 and/or G2 checkpoint defects. We also demonstrated the potential of checkpoint kinase Chk1/2 inhibition on the enhancement of the radiosensitivity of cholangiocarcinoma cells. Thus, this study provides useful information for predicting radiation response and provides evidence for the enchantment of radiotherapeutic efficiency by targeting checkpoint kinase Chk1/2 in some subpopulations of cholangiocarcinoma patients.

Clinicopathological analysis and prognosis of extrahepatic bile duct cancer with a microscopic positive ductal margin

BACKGROUND

The fate of a microscopic positive ductal margin (MPDM) of extrahepatic bile duct (EHBD) cancer is unclear. The purpose of this study was to analyse the clinicopathological features of EHBD cancer with MPDM and to identify the prognostic factors associated with survival.

METHODS

Between 1995 and 2007, a retrospective analysis of 464 patients who had undergone surgical resection for EHBD cancer was conducted. Clinicopathological factors likely to influence survival were assessed using univariate and multivariate analysis.

RESULTS

One hundred twenty-four patients had MPDM which included invasive carcinoma (IC) (n =85) and carcinoma in situ (CIS)/ high-grade dysplasia (HGD) (n = 39). The median survival (MS) of R0, R1 as CIS/ HGD, and R1 as IC were 41 months, 29 months, and 18 months, respectively. Adverse prognostic factors were 'IC' on the resection margin [HR = 1.66, 95% confidence intervals (CIs) 1.06-2.59, P = 0.026], and no use of adjuvant chemoradiotherapy (HR = 1.57, 95% CIs 1.04-2.39, P = 0.033). Adjuvant chemoradiotherapy was beneficial in patients with MPDM as IC (5-year survival rate 19.7 compared with 2.8%, P = 0.011).

CONCLUSIONS

The presence of MPDM is an important prognostic factor in EHBD cancer. When a ductal resection margin is positive, discrimination between 'IC' and 'CIS/ HGD' is important.

Analysis of microscopic tumor spread patterns according to gross morphologies and suggestions for optimal resection margins in bile duct cancer

BACKGROUND/PURPOSE

Surgical resection is the only curative treatment for extrahepatic bile duct (EHBD) cancer, but guidelines for optimal resection margins have not yet been established. Therefore, the purpose of this study is to analyze the patterns of microscopic tumor spreads and their lengths according to gross morphology and to suggest optimal resection margins for EHBD cancer.

METHODS

A total of 79 patients with EHBD cancers who underwent curative resection at Seoul National University Hospital between 2007 and 2010 were reviewed. Pathologic findings were reviewed by a single specialized pathologist.

RESULTS

Mucosal and mural/perimural spreads were seen in 37.3 and 62.3 %, respectively. The mean length of tumor spreads in the papillary (n = 13), nodular/nodular infiltrative (n = 43), and sclerosing types (n = 23) were 4.5 ± 6.3, 1.8 ± 6.4, and 6.4 ± 6.7 mm, respectively. Spread patterns correlated with gross morphologies (P < 0.001). The lengths of tumor spreads at the 90th percentile were 15.6, 10.0, and 15.6 mm, respectively.

CONCLUSIONS

The patterns of tumor spreads correlated with gross morphologies. Optimal resection margins in EHBD cancers should be 16 mm in the papillary and sclerosing types and 10 mm in the nodular/nodular infiltrative type.

Adjuvant chemotherapy in resectable cholangiocarcinoma patients

BACKGROUND AND AIM

Cholangiocarcinoma patients usually have poor treatment outcome and a high mortality rate. The role of adjuvant chemotherapy (AC) is controversial. Our study aimed to evaluate benefits of AC in resectable cholangiocarcinoma patients.

METHODS

A retrospective study included 263 patients who underwent curative resection in Srinakarind University Hospital. These patients had pathological reports showing a clear margin (R0) or microscopic margin (R1) of lesion-free tissue.

RESULTS

There were 138 patients who received AC. This group had a significantly lower mean age than patients not receiving adjuvant chemotherapy (NAC) group (57.7 ± 8.5 vs 60.4 ± 9.0 years, P = 0.01). The level of serum albumin above 3 g/dL was more common in AC group than the NAC one (87.7% vs 79.2%, P = 0.04). Patients who received AC had significantly longer overall median survival time (21.6 vs 13.4 months, P = 0.01). Patients with a combination of gemcitabine and capecitabine regimen had the longest survival time (median overall survival time of gemcitabine and capecitabine 31.5, 5-fluorouracil and mitomycin 17.3, 5-fluorouracil alone 22.2, capecitabine alone 21.6, and gemcitabine alone 7.9 months, P = 0.02). Benefits of AC were likely to be found in patients who had high-risk features, that is, high level of carbohydrate antigen 19-9, advanced stage, T4 stage, lymph node involvement, and R1 margin.

CONCLUSIONS

AC significantly prolongs survival time in resectable cholangiocarcinoma patients, particularly in the high risk group.

Skull metastasis from intrahepatic cholangiocarcinoma: report of 3 cases and review of the literature

Skull metastases occur in patients with various malignancies; however, those resulting from intrahepatic cholangiocarcinoma (ICC) have been rarely reported. In our hospital, 324 patients were diagnosed with metastatic brain or skull tumors from June 1969 to June 2011, but only 3 of them (0.9%) developed skull metastases from ICC. We report the case of 3 patients with skull metastases from ICC. A combination of computed tomography (CT), contrast-enhanced magnetic resonance imaging (MRI), 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), and methionine-PET were used for imaging. Sites of tumors were the lateral left orbit and right parietal bone in case 1, the left parietal bone, left temporal bone, and lateral left orbit in case 2, the right petrous bone, right occipital bone, and upper cervical vertebra in case 3. The metastases were confirmed to have originated from ICC by biopsy in two of the cases and diagnosed by MRI and FDG-PET in case 2. Radiosurgery and radiotherapy had positive effects on symptom improvement and cosmetic problems.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Silencing of miR-370 in human cholangiocarcinoma by allelic loss and interleukin-6 induced maternal to paternal epigenotype switch

Cholangiocarcinoma (CCA) is a highly lethal malignant tumor arising from the biliary tract epithelium. Interleukin-6 (IL-6) is a major mediator of inflammation and contributor to carcinogenesis within the biliary tree. Previous studies suggested that enforced IL-6 contributes to cholangiocarcinogenesis through hypermethylation of several genes implicated in CCA. However, the precise mechanisms of IL-6 effects in CCA remain unclear. We now demonstrate that microRNA (miR)-370 is underexpressed in a large cohort of human CCA vs. normal liver tissues. In addition, we show that IL-6 induces a time-dependent silencing of miR-370. In addition, demethylation of CCA cells results in upregulation of miR-370. Furthermore, we demonstrate that miR-370 is imprinted, and that the Intergenic Differentially Methylated Region (IG-DMR) responsible for imprinting regulation of this genomic locus is hypermethylated in response to IL-6 treatment. In addition, the IG-DMR is hypermethylated in human CCA specimens compared to normal matched controls, in the same location as the IL-6 induced hypermethylation. Finally, miR-370 was found to regulate WNT10B in luciferase as well as western blotting experiments. Our data indicate that the paternal allele of miR-370 is normally silenced through genomic imprinting and that the overexpression of IL-6 in CCA effectively suppresses the expression of miR-370 from the maternal allele, lending support to the theory that miR-370 silencing in human CCA follows a classic two-hit mechanism.

HPV prevalence and cervical intraepithelial neoplasia among HIV-infected women in Yunnan Province, China: a pilot study

OBJECTIVES

To determine the prevalence of HPV and cervical neoplasia among HIV-infected women in southwestern China.

METHODS

Cervical cytology, HPV detection by Hybrid Capture-2™ assay, and diagnostic colposcopy were followed by cervical biopsy if indicated. Logistic regression analysis was used to analyze associations between HPV co-infection and cervical intraepithelial neoplasia (CIN), and HIV-related clinical and laboratory parameters.

RESULTS

Colposcopic-histopathologically proven CIN2+ lesions were present in 7/83 (8.4%) HIV-infected women. Nearly half (41/83, 43%) were co-infected with carcinogenic HPV genotypes. HPV co-infection was higher in women with colposcopic-histopathologically proven CIN2+ lesions than women with <CIN1 after adjusting for age (OR: 8.3, 95% CI: 0.9, 73.4). Women with CD4+ cell counts less than 350 cells/μL had higher CIN2+ prevalence after adjusting for current ART status and age (adjusted OR: 6.3, 95% CI: 1.1, 36.5).

CONCLUSIONS

HIV/AIDS care and treatment programs should integrate effective cervical cancer prevention services to mitigate the risk of invasive cervical cancer among HIV-infected women in China.

Association of stem cell marker expression pattern and survival in human biliary tract cancer

The aim of this study was to investigate the molecular and protein expression pattern of markers of stemness phenotype and its clinicopathological significance in human biliary tract cancer (BTC). Human BTC cell lines (CCLP-1, Egi-1, MzChA-1, MzChA-2, SkChA-1, TFK-1 and GBC) were analyzed in vitro and in xenotransplanted animals for expression of markers of stemness and compared to tissue microarrays (TMA) of 34 cases of human BTC with complete pathomorphological and clinical data (survival). Molecular analyses on the mRNA and protein level included makers of stemness and progenitor (Bmi-1, Sox-2, Nestin, CD133, CD44 and Nanog), proliferation and differentiation (cell cycle proteins, intermediate filaments). The investigated BTC samples showed a low to moderate and partially significantly different expression pattern of the stem cell markers in vitro, in vivo and in TMA. Hierarchical cluster analysis identified subgroups with homogenous expression of stem cell markers significantly differing with respect to cytokeratin expression in xenografts and Ki67 proliferation marker in human TMA, respectively - thus indicating possible heterogeneous carcinogenesis pathways in BTC. Additionally, these stem cell markers could be linked to morphology and molecular markers of proliferation and differentiation on the mRNA and protein level. Finally, survival analysis identified the combination of CD133 and CD44 as an independent prognostic factor yet their value as prognostic factors need testing in prospective study design.

The role of cancer-associated myofibroblasts in intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma is typically characterized by a dense desmoplastic stroma, of which cancer-associated myofibroblasts (which express α-smooth muscle actin), are a major cellular component. These stromal myofibroblasts have a crucial role in accelerating the progression of intrahepatic cholangiocarcinoma and in promoting resistance to therapy through interactive autocrine and paracrine signaling pathways that promote malignant cell proliferation, migration, invasiveness, apoptosis resistance and/or epithelial-mesenchymal transition. These changes correlate with aggressive tumor behavior. Hypoxic desmoplasia and aberrant Hedgehog signaling between stromal myofibroblastic cells and cholangiocarcinoma cells are also critical modulators of intrahepatic cholangiocarcinoma progression and therapy resistance. A novel strategy has been developed to achieve improved therapeutic outcomes in patients with advanced intrahepatic cholangiocarcinoma, based on targeting of multiple interactive pathways between cancer-associated myofibroblasts and intrahepatic cholangiocarcinoma cells that are associated with disease progression and poor survival. Unique organotypic cell culture and orthotopic rat models of cholangiocarcinoma progression are well suited to the rapid preclinical testing of this potentially paradigm-shifting strategy.

The role of cancer-associated myofibroblasts in intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma is typically characterized by a dense desmoplastic stroma, of which cancer-associated myofibroblasts (which express α-smooth muscle actin), are a major cellular component. These stromal myofibroblasts have a crucial role in accelerating the progression of intrahepatic cholangiocarcinoma and in promoting resistance to therapy through interactive autocrine and paracrine signaling pathways that promote malignant cell proliferation, migration, invasiveness, apoptosis resistance and/or epithelial-mesenchymal transition. These changes correlate with aggressive tumor behavior. Hypoxic desmoplasia and aberrant Hedgehog signaling between stromal myofibroblastic cells and cholangiocarcinoma cells are also critical modulators of intrahepatic cholangiocarcinoma progression and therapy resistance. A novel strategy has been developed to achieve improved therapeutic outcomes in patients with advanced intrahepatic cholangiocarcinoma, based on targeting of multiple interactive pathways between cancer-associated myofibroblasts and intrahepatic cholangiocarcinoma cells that are associated with disease progression and poor survival. Unique organotypic cell culture and orthotopic rat models of cholangiocarcinoma progression are well suited to the rapid preclinical testing of this potentially paradigm-shifting strategy.