Cholangiocarcinoma: Epidemiology and risk factors

Classification of intrahepatic cholangiocarcinoma

Cholangiocarcinoma is a heterogenous malignancy with various classifications based on location, morphological features, histological features, and actionable genetic mutations. Intrahepatic cholangiocarcinoma (ICC), which arises in and proximal to second order bile ducts, is the second most common primary liver malignancy after hepatocellular carcinoma. In this review, we will discuss ICC risk factors, precursor lesions, various growth, anatomic, morphologic, and histologic classifications, rare variants, and differential diagnoses.

Lipid Metabolism Reprogramming in Tumor-Associated Macrophages Modulates Their Function in Primary Liver Cancers

Lipids are a complex class of biomolecules with pivotal roles in the onset, progression, and maintenance of cancers. Lipids, derived from the tumor microenvironment (TME) or synthesized by cancer cells themselves, govern a large variety of pro-tumorigenic functions. In recent years, lipid metabolism and the reprogramming of liver cancer cells have received increasing attention, revealing that altered regulation of diverse lipid species, including triacylglycerols, phospholipids, sphingolipids, ceramides, fatty acids, and cholesterol, actively contributes to the initiation and progression of primary liver cancer. Lipid metabolic reprogramming also modifies the TME by influencing the recruitment, activation, and function of immune cells. Tumor-associated macrophages (TAM) are essential components of TME that sustain cancer growth, promoting invasion and mediating immune evasion. Macrophage polarization toward a tumor-supportive phenotype is associated with metabolic reprogramming. Indeed, lipid accumulation and enhanced fatty acid oxidation in TAM contribute to polarization to a M2 phenotype. In this review, we examine lipid metabolism in hepatocellular carcinoma and cholangiocarcinoma, focusing on TAM lipid metabolic reprogramming.

ANXA1 promotes intrahepatic cholangiocarcinoma proliferation and growth by regulating glutamine metabolism through GOT1 stabilization

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is a malignant tumor with a poor prognosis, marked by a postoperative recurrence rate of 50-60% and a 5-year survival rate of 8-30%. Abnormal tumor metabolism, particularly, amino acid metabolism, plays a key role in malignant progression. However, the molecular mechanisms linking amino acid metabolism to ICC progression remain unclear.

METHODS

Bioinformatics was used to identity the key amino acid metabolism related gene in ICC, qRT-PCR, western blotting and immunohistochemical (IHC) were used to detect the expression of ANXA1 in normal tissues or ICC tissues and cells at mRNA and protein levels. The effects of ANXA1 on the proliferation ability of ICC in vitro and in vivo were investigated using CCK8, cloning formation experiment, EdU, IHC, nude mice subcutaneous tumorigenesis model. Immunoprecipitation, mass spectrometry analysis, protein ubiquitin level detection test, immunofluorescence co-localization, and redox stress metabolite detection test were used to explore the metabolism-related regulatory mechanism of ANXA1.

RESULTS

we employed bioinformatics analysis to classify ICC into metabolic subgroups with distinct prognoses and identified the associated biomarker Annexin A1(ANXA1), whose high expression is correlated with poor prognosis and promotes ICC development. Mass spectrometry analysis revealed that ANXA1 interacts with the key enzyme in glutamine metabolism, glutamic-oxaloacetic transaminase 1(GOT1). Through in vitro and in vivo experiments, overexpressed ANXA1 stabilizes GOT1 by recruiting the deubiquitinase USP5. This stabilization enhances glutamine uptake, as well as the production of aspartate and glutamate, which in turn reduces oxidative stress, thereby promoting tumor cell growth. Moreover, knockdown of ANXA1 combined with glutamine uptake inhibition significantly suppressed ICC cell proliferation and Inhibited subcutaneous tumor formation and growth.

CONCLUSIONS

These results suggest that the ANXA1/USP5/GOT1 axis promotes glutamine metabolism and ICC proliferation and growth. Inhibiting ANXA1 alongside glutamine uptake inhibition offers a promising strategy for treating ICC.

Epidemiological trends of cholangiocarcinoma and gallbladder cancer in Northeastern Italy: Administrative analysis over a 17-year period (2007-2023)

BACKGROUND

Cholangiocarcinoma (CCA) is a heterogeneous group of aggressive malignancies arising from the biliary tree. Epidemiological data show an increase in the incidence of intrahepatic CCA in Western countries and a stable or decrease in the incidence of extrahepatic CCA. There are conflicting results in literature regarding the trend of the incidence of gallbladder cancer. However, most studies refer to a time period before 2000.

AIM

To investigate the recent epidemiology of CCA and gallbladder cancer in Northeast Italy using regional data of hospital admissions.

METHODS

We performed a 17-year (2007-2023) retrospective analysis of hospital discharge records of the Veneto Region. During the period 10778 first hospital admissions for biliary tract cancers in the main or secondary diagnosis were recorded. Data were analyzed by the χ² test for categorical data and the Student’s t-test for continuous data to assess differences in percentages and averages, respectively. Trends in the age-standardized hospitalization rate were evaluated using Joinpoint regression, estimating annual percentage changes (APC).

RESULTS

The total number of hospitalizations for biliary tract cancers remained stable over the past 17 years (186 hospitalizations/year for intrahepatic CCA, 211 for extrahepatic CCA, and 237 for gallbladder cancer/unspecified biliary tract). Age-standardized hospitalization rates for intrahepatic and extrahepatic CCA decreased respectively from 4.9 cases to 3.4 per 100000 inhabitants (APC = -2.0, 95% confidence interval: -3.2 to -0.7, P < 0.001) and from 6.7 to 3.8 cases per 100000 inhabitants (APC = -3.2, 95% confidence interval: -4.2 to -2.1, P < 0.001). Instead, hospitalizations for gallbladder cancer remained stable, with an average rate of 5.5 per 100000 inhabitants. Overall, hospitalization rates for biliary tract cancers increased with age in both genders.

CONCLUSION

Our study reported a decreasing hospitalization rate for CCA and a stable trend for gallbladder cancer over a 17-year period, suggesting a change in the epidemiology of these tumors.

Prognosis of cholangiocarcinoma patients based on multiple patterns of programmed cell death, integrated analysis of the immune microenvironment and drug sensitivity

Background

Cholangiocarcinoma (CHOL) is a highly malignant bile duct cancer with a poor prognosis and rising incidence. Programmed cell death (PCD) plays a crucial role in cancer biology, influencing tumor immunity and treatment response. This study analyzes the impact of multiple PCD patterns on CHOL prognosis, tumor microenvironment (TME) and drug sensitivity.

Methods

RNA sequencing data from TCGA-CHOL and GSE107943 were analyzed to identify PCD-related genes. A PCD-associated Risk Score was constructed using Cox and Lasso regression analyses. The score's prognostic value was assessed through survival analysis, ROC curves, and functional annotation.

Results

We identified 111 differentially expressed PCD-related genes, including NCK2, BNIP3 and BIK, that constituted PCD-associated Risk Score and correlated with prognosis of CHOL. Functional analyses indicated enrichment in immune-related processes. High-risk patients showed increased immune cell infiltration and higher immune checkpoint expression, suggesting a benefit from immunotherapy. They also demonstrated greater sensitivity to several chemotherapeutic and targeted agents.

Conclusion

PCD-associated Risk Score is a robust prognostic tool for CHOL, influencing TME modulation and therapeutic response, and may guide personalized treatment strategies.

Oncologic impact of statin use on patients treated with hepatectomy for intrahepatic cholangiocarcinoma

AIM

Currently, the only recognized curative treatment for intrahepatic cholangiocarcinoma (ICC) is surgical resection. However, the impact of various clinical factors, including patient history and pharmacological interventions, on survival outcomes is still not fully understood. We aimed to bridge this knowledge gap by identifying clinical determinants that may influence the prognosis of ICC after surgical resection.

METHODS

We conducted a study on 172 patients who underwent hepatectomy for ICC between 2010 and 2019. We evaluated patient demographics, tumor characteristics, and whether patients were on statin therapy. Kaplan-Meier methods were used to analyze overall survival (OS) and recurrence-free survival (RFS), whereas multivariate analysis was utilized to identify prognostic factors.

RESULTS

Statin use was associated with significantly improved OS and RFS. The mean OS was 90.5 months in the statin group compared to 59.9 months in the statin-naive group (p = 0.001). Similarly, RFS was longer in the statin group (77.3 vs. 48.1 months; p = 0.006). Subgroup analyses demonstrated consistent benefits of statin use across different age groups and genders. Multivariate analysis identified statin use as an independent prognostic factor for OS (HR: 0.49, 95% CI: 0.29-0.82, p = 0.007) and RFS (HR: 0.60, 95% CI: 0.36-0.98, p = 0.043).

CONCLUSIONS

Statin therapy may be a potentially favorable medication for patients undergoing hepatectomy for ICC. However, further evaluation of its clinical benefits is required, and additional studies are recommended.

Melatonin attenuates Helicobacter pylori-mediated cholangiocarcinoma-associated fibroblast activation via modulating integrin/FAK signaling pathway

The interaction of Helicobacter pylori with cancer-associated fibroblasts (CAFs) to promote cholangiocarcinoma (CCA) genesis is unclear. We aimed to demonstrate the effect and mechanism of H. pylori on function of CAFs in vitro as well as the role of melatonin as an anti-fibrotic agent capable of modulating CAFs. CAF cells were generated by co-culture of human fibroblasts (OUMS cell line) with O. viverrini-associated CCA cells (KKU-100 cell line). In the presence of H. pylori lysate, these CAF cells exhibited increased proliferation and migration. The interaction of CAFs and H. pylori lysate also promoted KKU-100 cell migration. Proteomic analysis revealed that the fibrosis-associated integrin signaling pathway was enriched in CAFs stimulated by H. pylori lysate. Expression of focal adhesion kinase (FAK), a molecule that plays a pivotal role in cell proliferation and migration and known to be a downstream target of integrin, was upregulated in CAFs exposed to H. pylori lysate. Interestingly, melatonin treatment significantly attenuated both proliferation and migration of CAFs by reducing FAK phosphorylation and its downstream PI3K and β-catenin. These results suggest that H. pylori promotes proliferation and migration of CAFs cells and possibly fibrosis via the integrin/FAK signaling pathway, which could be attenuated by melatonin treatment.

The Application Status of Radiomics-Based Machine Learning in Intrahepatic Cholangiocarcinoma: Systematic Review and Meta-Analysis

BACKGROUND

Over the past few years, radiomics for the detection of intrahepatic cholangiocarcinoma (ICC) has been extensively studied. However, systematic evidence is lacking in the use of radiomics in this domain, which hinders its further development.

OBJECTIVE

To address this gap, our study delved into the status quo and application value of radiomics in ICC and aimed to offer evidence-based support to promote its systematic application in this field.

METHODS

PubMed, Web of Science, Cochrane Library, and Embase were comprehensively retrieved to determine relevant original studies. The study quality was appraised through the Radiomics Quality Score. In addition, subgroup analyses were undertaken according to datasets (training and validation sets), imaging sources, and model types.

RESULTS

Fifty-eight studies encompassing 12,903 patients were eligible, with an average Radiomics Quality Score of 9.21. Radiomics-based machine learning (ML) was mainly used to diagnose ICC (n=30), microvascular invasion (n=8), gene mutations (n=5), perineural invasion (PNI; n=2), lymph node (LN) positivity (n=2), and tertiary lymphoid structures (TLSs; n=2), and predict overall survival (n=6) and recurrence (n=9). The C-index, sensitivity (SEN), and specificity (SPC) of the ML model developed using clinical features (CFs) for ICC detection were 0.762 (95% CI 0.728-0.796), 0.72 (95% CI 0.66-0.77), and 0.72 (95% CI 0.66-0.78), respectively, in the validation dataset. In contrast, the C-index, SEN, and SPC of the radiomics-based ML model for detecting ICC were 0.853 (95% CI 0.824-0.882), 0.80 (95% CI 0.73-0.85), and 0.88 (95% CI 0.83-0.92), respectively. The C-index, SEN, and SPC of ML constructed using both radiomics and CFs for diagnosing ICC were 0.912 (95% CI 0.889-0.935), 0.77 (95% CI 0.72-0.81), and 0.90 (95% CI 0.86-0.92). The deep learning-based model that integrated both radiomics and CFs yielded a notably higher C-index of 0.924 (0.863-0.984) in the task of detecting ICC. Additional analyses showed that radiomics demonstrated promising accuracy in predicting overall survival and recurrence, as well as in diagnosing microvascular invasion, gene mutations, PNI, LN positivity, and TLSs.

CONCLUSIONS

Radiomics-based ML demonstrates excellent accuracy in the clinical diagnosis of ICC. However, studies involving specific tasks, such as diagnosing PNI and TLSs, are still scarce. The limited research on deep learning has hindered both further analysis and the development of subgroup analyses across various models. Furthermore, challenges such as data heterogeneity and interpretability caused by segmentation and imaging parameter variations require further optimization and refinement. Future research should delve into the application of radiomics to enhance its clinical use. Its integration into clinical practice holds great promise for improving decision-making, boosting diagnostic and treatment accuracy, minimizing unnecessary tests, and optimizing health care resource usage.

Global trends and disparities in gallbladder and biliary tract cancers: insights from the global burden of disease study 2021

BACKGROUND

Gallbladder and biliary tract cancers (GBC and BTC) are highly malignant, with poor prognoses and substantial regional variability in the disease burden. Although advances in medical science have improved outcomes in high-income regions, low- and middle-income regions continue to face rising incidence and mortality rates owing to delayed detection and treatment. Understanding the global trends and risk factors of GBC and BTC is essential for targeted interventions to reduce disease burden.

METHODS

A retrospective analysis of GBC and BTC was conducted using the 2021 Global Burden of Disease study. Data from 204 countries and territories between 1990 and 2021 were analyzed for incidence, mortality, and disability-adjusted life years stratified by age, sex, and sociodemographic index (SDI). Trends were quantified using age-standardized rates and estimated annual percentage changes.

RESULTS

In 2021, 216,768 new cases and 171,961 deaths were reported globally, with age-standardized incidence and mortality rates of 2.6 and 2.0 per 100,000, respectively. The high-income Asia-Pacific and Latin American regions exhibited the highest disease burdens. While global age-standardized rates declined estimated annual percentage changes for incidence: -0.44; mortality: -0.97), low-SDI regions experienced increases. High BMI emerged as the leading risk factor, contributing to 12% of the disability-adjusted life years. Projections indicate a stable incidence but rising mortality by 2036.

CONCLUSION

Although the global age-standardized rates of GBC and BTC are decreasing, disparities persist, with low-SDI regions experiencing increasing burdens. Targeted interventions addressing modifiable risk factors such as obesity, along with improved healthcare infrastructure and early detection, are critical for mitigating this global health challenge.

Pharmacologic features, clinical applications, and drug safety evaluation of futibatinib in the treatment of biliary tract cancer (BTC)

INTRODUCTION

Futibatinib is a small, potent, covalent, irreversible fibroblast growth factor receptor (FGFR) 1-4 inhibitor that has been added as a new standard of care for previously treated unresectable and/or advanced FGFR2 fusion/rearrangement-positive BTC. FGFR2 fusions/rearrangements play a key role in BTC survival, proliferation, invasion, and development of distant metastasis. The inhibition of this pathway is an important target in the treatment of BTC.

AREAS COVERED

The article covers the development of futibatinib for the treatment of refractory unresectable/advanced BTC, its mechanism of action, and key pharmacodynamic/pharmacokinetic data with a focus on the safety profile. Data are based on published clinical trials, pooled analysis, and retrospective studies indexed in PubMed (2010-2024).

EXPERT OPINION

Futibatinib is an FDA and EMA approved FGFR2 inhibitor for the treatment of patients with refractory BTC with FGFR2 fusions/rearrangements. Ongoing drug development strategies are centered on designing new FGFR2 fusion inhibitors able to overcome on-target and off-target resistances coupled with a high target selectivity to spare the most common treatment-related adverse events (hyperphosphatemia, stomatitis, alopecia, nail toxicity, skin reactions, eye toxicity).

EASL Clinical Practice Guidelines on the management of extrahepatic cholangiocarcinoma

Recent years have witnessed significant advances in the imaging, molecular profiling, and systemic treatment of cholangiocarcinoma (CCA). Despite this progress, the early detection, precise classification, and effective management of CCA remain challenging. Owing to recent developments and the significant differences in CCA subtypes, EASL commissioned a panel of experts to draft evidence-based recommendations on the management of extrahepatic CCA, comprising distal and perihilar CCA. Particular attention is given to the need for accurate classification systems, the integration of emerging molecular insights, and practical strategies for diagnosis and treatment that reflect real-world clinical scenarios.

The IL-6/JAK/STAT3 Axis in Cholangiocarcinoma and Primary Sclerosing Cholangitis: Unlocking Therapeutic Strategies Through Patient-Derived Organoids

Background/Objectives: Primary sclerosing cholangitis (PSC) is a rare, incurable liver disease characterized by chronic biliary inflammation and fibrosis. PSC is a significant risk factor for biliary tract cancer (BTC). This study aims to evaluate STAT3 expression in BTC and its prognostic significance as well as explore the potential of organoids derived from PSC and liver tumor patients as an in vitro model for testing novel therapeutic strategies in both PSC and BTC. Methods: Fresh tissue samples obtained from 10 PSC patients through targeted endoscopic retrograde cholangiography (ERC) and biopsy samples from liver tumor patients were used to establish organoid cultures. Organoids were treated with different agents and the therapeutic effect was measured by CellTiterGlo. Treatment with the JAK inhibitor baricitinib was followed by the measurement of cytokine concentrations in the supernatant. Archived formalin-fixed paraffin-embedded (FFPE) samples from 55 surgically resected BTC tumors were analyzed for STAT3 expression using immunohistochemistry. Results: We successfully established organoid cultures from all ERC samples. STAT3 protein expression was detected in 56% of tumor samples and 69% of the immune microenvironment. STAT3 positivity in the immune cell compartment was associated with longer disease-free survival, although the multivariate analysis could not confirm its value as an independent prognostic factor. Chemotherapy testing on liver tumor organoids showed various degrees of decreases in viability after treatment with gemcitabine, cisplatin, and cabozantinib. Baricitinib treatment significantly reduced IL-6 and MCP-1 secretion in cholangiocarcinoma Conclusions: The patient-derived organoid model of PSC and liver tumors is a valuable tool for testing novel and established therapeutic strategies, including JAK inhibitors and chemotherapy regimens. STAT3 expression in the immune microenvironment of BTC may serve as a prognostic marker. Further studies are needed to explore the integration of co-cultured organoid systems with stromal and immune components to improve physiological relevance.

Prognostic impact of albumin-bilirubin score in predicting the long-term survival of distal cholangiocarcinoma after radical surgery

BACKGROUND

The Albumin-Bilirubin Score (ALBI) serves as an indicator of nutritional status and is a widely recognized prognostic biomarker in cancer patients. The purpose of this research is to evaluate the association between ALBI and survival outcomes in patients with distal cholangiocarcinoma (dCCA) after radical surgery, and develop a nomogram model based on the ALBI to predict individual survival.

METHODS

A total of 177 individuals with dCCA receiving surgery from Jan 2011 to Jan 2022 were enrolled in the research. The association between ALBI and clinicopathologic factors was investigated. The impact of ALBI on recurrence-free survival (RFS) and overall survival (OS) was evaluated by Kaplan-Meier curves and Cox proportional hazards models. Nomograms based on ALBI and other prognostic variables screened by multivariate analysis were produced in predicting RFS and OS of dCCA patients following radical surgery, and the nomograms were evaluated by the consistency index (C-index), calibration curve and decision curve analysis (DCA) curve.

RESULTS

The optimal cut-off value for ALBI was -1.67, and the area under the ROC curve (AUC) was 0.71. The High-ALBI group had a considerably shorter RFS and OS (P < 0.001). Multivariate analysis revealed that the ALBI, degree of differentiation, portal vein invasion, and lymph node invasion were significant prognostic factors for RFS, and that the ALBI, CA19-9, degree of differentiation, lymph node invasion, and portal vein invasion were significant prognostic factors for OS. The nomograms were constructed based on these significant prognostic factors. The calibration curves displayed good consistency between actual and predicted probability. Nomograms based on these variables have better discriminant ability in predicting RFS and OS compared with the American Joint Committee on Cancer (AJCC) TNM stage. Moreover, the scores predicted by the nomogram enabled patient stratification into low-points and high-points groups. Kaplan-Meier curves demonstrated that patients in the high-points group had considerably better prognoses than those in the low-points group (p < 0.001).

CONCLUSION

ALBI was an independent prognostic factor in predicting RFS and OS of dCCA patients after radical surgery. The nomograms based on ALBI can provide reliable, personalized survival prediction for dCCA.

Conversion treatment for advanced intrahepatic cholangiocarcinoma: Opportunities and challenges

The prevalence of intrahepatic cholangiocarcinoma (ICC) is increasing globally. Despite advancements in comprehending this intricate malignancy and formulating novel therapeutic approaches over the past few decades, the prognosis for ICC remains poor. Owing to the high degree of malignancy and insidious onset of ICC, numerous cases are detected at intermediate or advanced stages of the disease, hence eliminating the chance for surgical intervention. Moreover, because of the highly invasive characteristics of ICC, recurrence and metastasis postresection are prevalent, leading to a 5-year survival rate of only 20%-35% following surgery. In the past decade, different methods of treatment have been investigated, including transarterial chemoembolization, transarterial radioembolization, radiotherapy, systemic therapy, and combination therapies. For certain patients with advanced ICC, conversion treatment may be utilized to facilitate surgical resection and manage disease progression. This review summarizes the definition of downstaging conversion treatment and presents the clinical experience and evidence concerning conversion treatment for advanced ICC.

Combined analysis of albumin in situ hybridisation and C reactive protein immunohistochemistry for the diagnosis of intrahepatic cholangiocarcinoma: towards a molecular classification paradigm

AIMS

Intrahepatic cholangiocarcinoma (iCCA) is a diagnosis of exclusion that can pose a challenge to the pathologist despite thorough clinical workup. Although several immunohistochemical markers have been proposed for iCCA, none of them reached clinical practice. We here assessed the combined usage of two promising diagnostic approaches, albumin in situ hybridisation (Alb-ISH) and C reactive protein (CRP) immunohistochemistry, for distinguishing iCCA from other adenocarcinoma primaries.

METHODS

We conducted Alb-ISH and CRP immunohistochemistry in a large European iCCA cohort (n=153) and compared the results with a spectrum of other glandular adenocarcinomas of different origin (n=885). In addition, we correlated expression patterns with clinicopathological information and mutation data.

RESULTS

Alb-ISH was highly specific for iCCA (specificity 98.8%) with almost complete negativity in perihilar CCA and only rare positives among other adenocarcinomas (sensitivity 69.5%). CRP identified the vast majority of iCCA cases (sensitivity 84.1%) at a lower specificity of 86.4%. Strikingly, the combination of CRP and Alb-ISH boosted the diagnostic sensitivity to 88.0% while retaining a considerable specificity of 86.1%. Alb-ISH significantly correlated with CRP expression, specific tumour morphologies and small or large duct iCCA subtypes. Neither Alb-ISH nor CRP was associated with iCCA patient survival. 16 of 17 recurrent mutations in either IDH1, IDH2 and FGFR2 affected Alb-ISH positive cases, while the only KRAS mutation corresponded to an Alb-ISH negative case.

CONCLUSIONS

In conclusion, we propose a sequential diagnostic approach for iCCA, integrating CRP immunohistochemistry and Alb-ISH. This may improve the accuracy of CCA classification and pave the way towards a molecular-guided CCA classification.

Idarubicin-transarterial chemoembolization combined with gemcitabine plus cisplatin for unresectable intrahepatic cholangiocarcinoma

BACKGROUND

Intrahepatic cholangiocarcinoma (iCCA) is the second most common liver malignancy with poor prognosis and limited treatment options.

AIM

To identify the most effective drug for transarterial chemoembolization (TACE) in cholangiocarcinoma and evaluate the efficacy and safety of combining it with gemcitabine and cisplatin (GemCis) for unresectable iCCA.

METHODS

Cholangiocarcinoma cell lines (RBE, HuCC-T1) were treated with 10 chemotherapeutic drugs, and cytotoxicity was assessed by cell counting kit-8 assays. Tumor-bearing nude mice were treated with idarubicin or GemCis, and tumor growth was monitored. Clinical data from 85 iCCA patients were analyzed to evaluate the efficacy and safety of idarubicin-TACE combined with GemCis.

RESULTS

Idarubicin demonstrated the highest cytotoxicity, significantly outperforming GemCis, the standard first-line therapies. In tumor-bearing mouse models, idarubicin and GemCis treatments significantly slowed tumor growth, with idarubicin showing particularly pronounced effects on days 12 and 15 (P < 0.05). In retrospective analysis, the median overall survival (OS) and progression-free survival (PFS) in the combination therapy group were significantly longer than those in the GemCis alone group (median OS, 16.23 months vs 10.07 months, P = 0.042; median PFS, 7.73 months vs 6.30 months, P = 0.023). Additionally, major grade 3/4 adverse events (AEs) in the combination therapy group were abdominal pain (26.3% vs 6.5%, P = 0.049) and elevated transaminases (42.1% vs 12.9%, P = 0.038). Most AEs were mild to moderate and manageable.

CONCLUSION

Idarubicin demonstrated higher cytotoxicity than GemCis, significantly inhibiting tumor growth in tumor-bearing mouse models. Preliminary clinical results suggest that local idarubicin-TACE combined with GemCis may offer improved survival outcomes for iCCA patients with a manageable safety profile.

Characterization and clinical outcomes of rare biliary adenosquamous carcinoma

BACKGROUND

Data are scarce regarding biliary adenosquamous carcinoma (BASC) due to its low incidence. BASC displays a worse prognosis than adenocarcinoma and its specific treatment is still an unmet medical need. We conducted a description analysis of BASC including clinicopathologic parameters and treatment outcomes.

METHODS

All consecutive patients with histologically proven BASC diagnosed in six French hospitals between 2000 and 2022 were enrolled and described.

RESULTS

A total of 16 BASC, accounting for 1.4 % of all biliary tract carcinoma, were included and the BASC incidence increased steadily over the past 22 years. The median age at diagnosis was 70.7 years (min-max 31.4-82.0 years) with most women (62.5 %). At diagnosis, half of BASC patients had a localized stage. The primary tumor locations were shared between gallbladder cancers (n = 7) and cholangiocarcinoma (n = 7), with mainly an extra-hepatic disease (71.4 %). Median overall survival was 9.5 months (95 % CI = 2.1-14.8 months). A total of 13 (81.6 %) patients had undergone surgery with a median relapse-free survival of 3.8 months (95 % CI = 0.0-10.5 months). Five (38.5 %) patients received an adjuvant chemotherapy. A total of seven (43.8 %) patients were treated with chemotherapy for the occurrence of metastases with a median progression-free survival of 2.8 months (95 % CI = 0.8-4.1 months). No objective response was observed and stable disease was achieved in two patients (28.6 %).

CONCLUSIONS

BASC is a rare disease with an increased incidence, highlighting the diagnostic challenges. BASC population was associated with a poor prognostic and limited therapeutic response. Further molecular investigations should be performed to investigate new therapeutic options.

EBV enhances immunotherapy sensitivity in intrahepatic cholangiocarcinoma through cGAS-STING pathway activation

BACKGROUND

The absence of representative Epstein-Barr virus-associated intrahepatic cholangiocarcinoma (EBVaICC) cell lines has limited our understanding of the molecular and immunological characteristics of this cancer subtype.

METHODS

We reviewed patients with metastatic cholangiocarcinoma at Sun Yat-sen University Cancer Center from January 2015 to August 2023. Among them, 22 patients with EBVaICC and 66 patients with non-EBVaICC who received anti-PD1 treatment were included. Additionally, 2 EBV-positive ICC cell lines, RBE-EBV and HuH28-EBV, were developed through cell-to-cell infection. Stable EBV infection and responsiveness to viral reactivation were confirmed. Transcriptomic and bioinformatics analyses were performed, and in vitro experiments examined the immune effects of EBV-positive ICC. Key immune-related genes and cytokines were validated by reverse transcription quantitative polymerase chain reaction and ELISA in cell lines and patient plasma samples.

RESULTS

In this study, we found that patients with EBVaICC showed enhanced immune responses and improved overall and progression-free survival compared to patients with non-EBVaICC. We first successfully established and validated 2 EBV-positive ICC cell lines (RBE-EBV and HuH28-EBV). These cell lines were confirmed for stable EBV infection and displayed responsiveness to viral reactivation, making them suitable for future studies. Transcriptomic analyses and in vitro studies revealed that EBV activated the cGAS-STING pathway, resulting in MHC-I upregulation and CXCL10 secretion in ICC cells, which collectively enhanced CD8+ T cell chemotaxis and cytotoxicity. Furthermore, ELISA analysis showed higher plasma levels of CXCL10 and IFN-γ in patients with EBVaICC, suggesting a potential role for EBV in enhancing immunotherapy sensitivity in this subtype.

CONCLUSIONS

The established EBV-positive ICC cell lines revealed enhanced immunogenicity driven by cGAS-STING pathway activation, providing valuable models for future research and insights into the mechanisms of improved immunotherapy sensitivity in EBVaICC.

Updated cholangiocarcinoma incidence trends and projections in Thailand by region based on data from four population-based cancer registries

Background

Cholangiocarcinoma (CCA) is a significant health concern in Thailand, as the age-standardized rates (ASR) and other trends fluctuate across different regions. However, comprehensive national estimates are lacking. This study examined the Thai ASR of CCA trends from 2012 to 2021 and projected the incidence rates to 2026.

Methods

This retrospective cohort analysis examined 6379 CCA cases from population-based cancer registries (PBCRs) in the northern, central, northeastern, and southern regions for the time period January 1, 2012, to December 31, 2021. The Joinpoint, age-period-cohort, and Nordpred models were used to assess CCA incidence trends and predictions.

Findings

CCA incidence trends in Thailand showed a decrease, with an average annual percentage change (AAPC) of -7.20% (95% CI: -11.04 to -3.19) for males, and -5.81% (95% CI: -10.81 to -0.54) for females. The projected incidence rate per 100,000 person-years for 2026 varied slightly according to the model: Joinpoint (males: 6.1, females: 3.4), age-period-cohort (males: 6.0, females: 3.3), and Nordpred (males: 5.5, females: 3.4). Regional analyses revealed decreasing trends in the northern and northeastern regions, with 2026 projections indicating further declines exceeding the 10-year trends. Owing to the small sample size, trends in the central and southern regions could not be determined.

Interpretation

Thailand's CCA rate has generally decreased but varies geographically; the northern and northeastern regions remain at high risk. To minimize CCA nationally, initiatives should be maintained, new risk factors explored, diagnostics improved, and regional variances addressed.

Funding

The Graduate School of Khon Kaen University.

Acceptable number of cholangioscopy-guided biopsies for diagnosing perihilar cholangiocarcinoma

INTRODUCTION

diagnosing perihilar cholangiocarcinoma can be challenging. Previous studies suggest that the sensitivity of taking three cholangioscopy-guided biopsies is approximately 70 %. We hypothesized that obtaining four or more biopsies might improve the sensitivity for diagnosing perihilar cholangiocarcinoma.

OBJECTIVE

to determine the acceptable number of cholangioscopy-guided biopsies to improve sensitivity for diagnosing perihilar cholangiocarcinoma.

METHODS

this retrospective study analyzed clinical records of adults with perihilar stenosis who underwent cholangioscopy-guided biopsies. Patients with gallbladder cancer or metastatic bile duct obstruction were excluded. Data were grouped based on the number of biopsies taken: group A (one to three biopsies), group B (four to six biopsies), and group C (seven to ten biopsies). Results from each group were compared against a composite standard, including clinical follow-up and/or biopsies performed by alternative methods.

RESULTS

the group that underwent 4-6 biopsies had a sensitivity of 77.4 %, while the group with 7-10 biopsies had a sensitivity of 70.8 %. The group with 1-3 biopsies had a sensitivity of 34.5 %. Statistically significant differences were observed between the groups, with comparisons showing improved sensitivity in the 4-6 biopsy group versus the 1-3 biopsy group (χ² = 14.42, p = 0.0001), and the 7-10 biopsy group versus the 1-3 biopsy group (χ² = 6.56, p = 0.010).

CONCLUSIONS

performing four to six cholangioscopy-guided biopsies significantly improves sensitivity for diagnosing perihilar cholangiocarcinoma compared to one to three biopsies. Further studies are needed to validate these findings.

Current status and prospects of targeted therapy for cholangiocarcinoma based on molecular characteristics

Cholangiocarcinoma (CCA) is a serious public health issue due to its insidious onset and dismal prognosis. The past few years have witnessed and highlighted the development of understanding and management of CCA. The combination of gemcitabine and cisplatin (GP) chemotherapy regimen with immunotherapy using immune checkpoint inhibitors has been considered the new standard first-line treatment alternative for advanced CCA. Notably, the proportion of patients with advanced CCA with targetable genetic mutations is approximately 40 %, and these patients may be considered for molecularly targeted therapy in the second-line treatment. In this review, we highlight the advances and progress in targeted therapies for advanced CCA, with special attention to data from Asian populations, including Chinese. In addition, we present in detail the phosphatase tension homolog (PTEN), a novel biomarker for both of first-line chemotherapy and second-line targeted therapy in advanced CCA, and its ability to forecast prognosis in patients with CCA. The mechanisms of rapid resistance to targeted agents warrant further investigation and address in light of the development of new targeted therapies. Precision medicine is gradually playing an increasing role in achieving optimal therapeutic outcomes.

Artificial intelligence for detection and characterization of focal hepatic lesions: a review

Focal liver lesions (FLL) are common incidental findings in abdominal imaging. While the majority of FLLs are benign and asymptomatic, some can be malignant or pre-malignant, and need accurate detection and classification. Current imaging techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI), play a crucial role in assessing these lesions. Artificial intelligence (AI), particularly deep learning (DL), offers potential solutions by analyzing large data to identify patterns and extract clinical features that aid in the early detection and classification of FLLs. This manuscript reviews the diagnostic capacity of AI-based algorithms in processing CT and MRIs to detect benign and malignant FLLs, with an emphasis in the characterization and classification of these lesions and focusing on differentiating benign from pre-malignant and potentially malignant lesions. A comprehensive literature search from January 2010 to April 2024 identified 45 relevant studies. The majority of AI systems employed convolutional neural networks (CNNs), with expert radiologists providing reference standards through manual lesion delineation, and histology as the gold standard. The studies reviewed indicate that AI-based algorithms demonstrate high accuracy, sensitivity, specificity, and AUCs in detecting and characterizing FLLs. These algorithms excel in differentiating between benign and malignant lesions, optimizing diagnostic protocols, and reducing the needs of invasive procedures. Future research should concentrate on the expansion of data sets, the improvement of model explainability, and the validation of AI tools across a range of clinical setting to ensure the applicability and reliability of such tools.

Factors Contributing to the High Malignancy Level of Cholangiocarcinoma and Its Epidemiology: Literature Review and Data

CCA is a highly desmoplastic malignant cancer and is the second most common primary liver malignancy after hepatocellular carcinoma (HCC), accounting for approximately 15% of all primary liver tumors. CCA has a poor prognosis, with an average five-year survival rate of 9%, which is lower than that of pancreatic cancer. Although considerable efforts have been invested into the genomics, epigenetics, and risk factors, very little is known about what might have been the key causes for the high malignancy level of CCA. In this review, we analyze the incidence and mortality of CCA in different regions based on data from 1994 to 2022 obtained from the International Agency for Research on Cancer (IARC), discuss the current status of treatment of the disease, and focus on what might be the main factors contributing to the high malignancy level of CCA: alkalosis caused by the Fenton reaction, hypoxia, and the TIME. The review includes studies published from 1979 to 2024, aiming to provide an updated synthesis of basic early classical theoretical knowledge and current knowledge about CCA. By revealing the epidemiological characteristics of CCA, the potential mechanisms of high malignancy, and the current challenges of treatment, this review aims to provide new directions for future cancer research, promote the development of personalized treatment strategies, and facilitate a deeper understanding and the more effective management of CCA worldwide.

CLDN18.2: a potential nanotherapeutic target for cholangiocarcinoma

Cholangiocarcinoma (CCA) is an extremely malignant and aggressive primary liver tumor that has become increasingly prevalent in recent years. Unfortunately, the prognosis for patients diagnosed with CCA remains exceptionally poor. Currently, the primary treatment options include surgery and chemotherapy. However, the effectiveness of postoperative chemotherapy is limited, characterized by a brief duration of remission and high rates of recurrence and metastasis, resulting in minimal survival benefits for patients. Therefore, there is an urgent need to develop new therapeutic strategies that are both safer and more effective. In recent years, as oncology research has progressed, Claudin 18.2 (CLDN18.2)-targeted therapy has emerged, showing promise for improving the survival of patients with CLDN18.2-positive cancers. Studies suggest that combining new agents targeting CLDN18.2 with standard cytotoxic therapies offers significant survival benefits in CLDN18.2-positive solid tumors, which is expected to provide a more effective treatment option for patients with advanced cholangiocarcinoma. While existing immune checkpoints or therapeutic targets have limitations, such as low positivity rates and minimal absolute improvement in patient survival time, drugs that target FGFR, IDH, and Her-2, along with antiangiogenic agents, have shown promise for patients with advanced malignancies affecting the bile ducts. Therefore, exploring these novel therapeutic strategies may yield new insights for precision treatment of cholangiocarcinoma in the future. This review aims to focus on the potential application of CLDN18.2 in treating solid tumors, particularly cholangiocarcinoma, to systematically summarize research progress related to this target and thoroughly examine its value in diagnosing, treating, and assessing the prognosis of cholangiocarcinoma.

Cholangiocarcinoma: The era of liquid biopsy

Cholangiocarcinoma (CCA) is a highly aggressive and heterogeneous malignancy arising from the epithelial cells of the biliary tract. The limitations of the current methods in the diagnosis of CCA highlight the urgent need for new, accurate tools for early cancer detection, better prognostication and patient monitoring. Liquid biopsy (LB) is a modern and non-invasive technique comprising a diverse group of methodologies aiming to detect tumour biomarkers from body fluids. These biomarkers include circulating tumour cells, cell-free DNA, circulating tumour DNA, RNA and extracellular vesicles. The aim of this review is to explore the current and potential future applications of LB in CCA management, with a focus on diagnosis, prognostication and monitoring. We examine both its significant potential and the inevitable limitations associated with this technology. We conclude that LB holds considerable promise, but further research is necessary to fully integrate it into precision oncology for CCA.

IL-22/IL-22R1 pathway enhances cholangiocarcinoma progression via ERK1/2 activation

BACKGROUND

IL-22 plays a pivotal role in the processes of inflammation and tissue healing., but its role in cholangiocarcinoma (CCA) remains unclear. our study explored the IL-22/IL-22R1 pathway and its impact on CCA progression through the ERK1/2 signaling cascade.

AIM

To determine the mechanism of the IL-22/IL-22R1 pathway in CCA and provide new directions for its clinical treatment.

METHODS

IL-22R1 expression was assessed in human and rat CCA tissues utilizing immunohistochemical techniques, Western blot analysis, and quantitative reverse transcription PCR. The impact of IL-22 on CCA cells was assessed in vitro via tests for proliferation, migration, invasion, and apoptosis assays. The rat models of thioacetamide-induced CCA and subcutaneous xenografts in nude mice were used to assess the in vivo effects. ERK1/2 inhibitors were applied to elucidate the mechanistic role of the pathway.

RESULTS

IL-22R1 was overexpressed in CCA cell lines and tissues. IL-22 treatment increased the phosphorylation of ERK1/2, promoting tumor cell proliferation, migration, invasion, and resistance to apoptosis. ERK1/2 inhibition considerably reversed these effects both in vitro and in vivo.

CONCLUSION

The IL-22/IL-22R1 axis promotes CCA progression by activating ERK1/2 signaling. Targeting this pathway with ERK1/2 inhibitors offers potential therapeutic strategies for CCA.

Establishment and genomic profiling of cholangiocarcinoma cells with functional characterization

Cholangiocarcinoma (CCA) is a highly lethal hepatobiliary malignancy, with prognosis is influenced by anatomical subtypes and etiological factors. This study successfully established three CCA cell lines: KKU-097, KKU-466, and KKU-610, from the primary tumors of patients in liver fluke-endemic areas. These cells represent the perihilar CCA (pCCA) and intrahepatic CCA (iCCA) subtypes. Comprehensive analyses, including histopathology, molecular profiling, biomarkers, cancer phenotype characterization, and drug sensitivity testing with standard chemotherapeutics, were conducted. Whole-exome sequencing was performed to explore genetic alterations. All three cell lines exhibited adherent growth with an epithelial morphology and positive expression of the bile duct epithelial markers CK-7 and CK-19. Cytogenetic analysis revealed highly complex hypertriploid karyotypes with multiple chromosomal aberrations. Among the cell lines, KKU-610 demonstrated higher growth and invasion rates, whereas KKU-466 and KKU-097 cells exhibited less aggressive phenotypes. Drug sensitivity testing demonstrated relative resistance to gemcitabine as a monotherapy and in combination with cisplatin in all three cells. Genomic profiling identified targetable mutations, highlighting these new cell lines as valuable models for investigating the pathogenesis of CCA and evaluating therapeutic strategies.

Western and Eastern experience in treating perihilar cholangiocarcinoma: retrospective bi-centre study

BACKGROUND

Resection outcomes for perihilar cholangiocarcinoma differ between Western and Eastern centres, but reasons behind these disparities remain unclear. This study aimed to compare current outcomes between a Western and an Eastern expert centre to identify prognostic factors.

METHODS

Patients who underwent hepatobiliary resection for perihilar cholangiocarcinoma between 2010 and 2022 at Karolinska University Hospital (Stockholm, Sweden) and Cancer Institute Hospital (Tokyo, Japan) were retrospectively included. Primary outcome was overall survival. Secondary outcomes were disease-free survival, postoperative complications and 90-day mortality rate.

RESULTS

Two hundred and forty-nine patients were included (Cancer Institute Hospital n = 159, Karolinska n = 90). Median overall survival was 20.4 months at Karolinska and 52.0 months at Cancer Institute Hospital (P < 0.001). Median disease-free survival was 11.9 months at Karolinska and 32.4 months at Cancer Institute Hospital (P < 0.001). Advanced tumours, ASA class ≥III, poor differentiation and radial margin positivity were more common in the Western cohort. Treatment centre, T-status, N1-status, resection side, R1-status, age and carbohydrate antigen 19-9 were prognostic for overall survival. The Eastern cohort had a lower rate of postoperative complications (24.5%) and a lower mortality rate (2.5%) compared with the Western cohort (51.1% and 10.0%).

CONCLUSION

Advanced tumour stage and radial margin positivity contributed to poor long-term survival in the Western cohort. A higher burden of co-morbidity and a higher rate of extended resections with smaller remnant liver volume influenced the Western postoperative mortality rate.

Transplantation for Peri-Hilar and Intrahepatic Cholangiocarcinoma With mTOR Immunosuppression

BACKGROUND

Cholangiocarcinoma (CCA) has rising incidence and mortality rates. Outcomes from combination systemic, loco-regional therapy (LRT) and liver transplantation (LT) are improving, but more granular data are needed to inform evidence-based management, including patient selection and immunosuppression.

METHODS

Patients with peri-hilar (PH) and intrahepatic (IH) CCA who underwent LT at a single center between January 2008 and February 2023 were reviewed retrospectively. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS) with significance determined by Cox proportional hazards model.

RESULTS

During the study period, 53 patients underwent LT for either PH (n = 27), or IH (26). Cohort had mean age 58.5 years old (IQR, 47.0-63.0), body mass index (BMI) 25.9 (IQR, 22.9-30.0) kg/m2, and mean biologic MELD 9 (IQR, 7-17). Most frequent etiology was PSC (n = 12, 22.6%). Forty-nine patients (92.5%) received neoadjuvant therapy, including systemic (n = 48, 90.6%) and locoregional therapy (LRT) (n = 22, 41.5%), to which PH tumors were both most and least responsive (P = .03). On explant pathology, tumor were a median size of 3.5 cm and lympho-vascular invasion (LVI) was present in 13 (24.5%) cases. Median follow-up post-transplant was 910 days (IQR, 407-1509). Probabilities of OS and RFS at 3-years post-LT were 69.2% (95% CI, 56.9%-84.2%) and 57.4% (95% CI, 43.7%-75.4%). In multivariable analysis, OS was associated with tumor type and LVI, and RFS with age, BMI, PSC and LRT. After a median post-LT period of 38 days (IQR, 27-79.5), 39 (71.7%) patients started mTOR inhibition with lowered tacrolimus goal. Cox proportional hazard model showed significant association of OS with mTOR inhibition, though this was not validated by a time-dependent co-variate approach.

CONCLUSIONS

In this single center cohort of CCA, post-LT outcomes were significantly greater for patients with IH tumors and no LVI. Immunosuppression with mTOR inhibition was not consistently associated with outcomes.

Mapping the landscape of biliary tract cancer in Europe: challenges and controversies

Biliary tract cancer (BTC) is becoming more common worldwide, with geographic differences in incidence and risk factors. In Europe, BTC may be associated with primary sclerosing cholangitis, lithiasis, and liver cirrhosis, but is more frequently observed as a sporadic disease. BTC increasingly affects patients under 60 years, resulting in a significant social and economic burden. Early diagnosis remains challenging due to vague symptoms in 50% of patients with BTC, and lack of specific biomarkers, resulting in late presentation and poor prognosis. The identification of patients at increased risk and reliable biomarkers require collaborative efforts to make faster progress. This Series paper highlights the disparities in access to diagnostic tools and multidisciplinary care in Europe, particularly in economically disadvantaged regions, while identifying priority areas for improvement. Addressing these inequities requires harmonised guidelines, accelerated pathways to curative treatments, and improved awareness among healthcare professionals and the public. Multidisciplinary teams (MDTs) are crucial for the diagnosis of BTC and for improving patient outcomes, yet inconsistencies exist in their implementation not only between different countries, but also between different centres within a country. Collaboration and standardisation of diagnostic and treatment protocols across Europe are essential to effectively address the management of patients with BTC.

Cholangiocyte organoids for disease, cancer, and regenerative medicine

The biliary tract is a ductal network comprising the intrahepatic (IHBDs) and extrahepatic bile duct (EHBDs). Biliary duct disorders include cholangitis, neoplasms, and injury. However, the underlying mechanisms are not fully understood. With advancements in 3D culture technology, cholangiocyte organoids (COs) derived from primary tissues or induced pluripotent stem cells (iPSCs) can accurately replicate the structural and functional properties of biliary tissues. These organoids have become powerful tools for studying the pathogenesis of biliary diseases, such as cystic fibrosis and primary sclerosing cholangitis, and for developing new therapeutic strategies for cholangiocarcinoma. Additionally, COs have the potential to repair bile duct injuries and facilitate transplantation therapies. This review also discusses the use of organoids in genetically engineered mouse models to provide mechanistic insights into tumorigenesis and cancer progression. Continued innovation and standardization of organoid technology are crucial for advancing precision medicine for biliary diseases and cancer.

Epidemiology and genomic features of biliary tract cancer and its unique features in Korea

Biliary tract cancer (BTC) is a rare but highly aggressive malignancy that includes intrahepatic cholangiocarcinoma (ICC), extrahepatic cholangiocarcinoma, and gallbladder cancer (GBC). While BTC has a low global incidence, its regional variations are notable. Among nations, Korea has the second-highest incidence of BTC globally, with the highest mortality rate worldwide, underscoring the need for a deeper understanding of this cancer. Liver fluke infection and hepatitis B virus infection are key risk factors unique to Korea, contributing to regional differences in BTC incidence. Additionally, genomic alterations in Korean patients with BTC differ from those in other populations, including lower frequencies of IDH1 mutations and FGFR2 fusions in ICC and a higher prevalence of ERBB2 amplification in GBC. Recognizing the clinical significance of these alterations, ivosidenib and pemigatinib have been approved in Korea for BTC patients with IDH1 mutations and FGFR2 fusions, respectively. This review explores the epidemiology, risk factors, and molecular features of BTC, along with corresponding targeted therapies. Furthermore, we compare the unique characteristics of BTC in Korea with global data to inform future research and clinical practice.

A Novel 167-Amino Acid Protein Encoded by CircPCSK6 Inhibits Intrahepatic Cholangiocarcinoma Progression via IKBα Ubiquitination

Intrahepatic cholangiocarcinoma (ICC), a formidable challenge in oncology, demands innovative biomarkers and therapeutic targets. This research highlights the importance of the circular RNA (circRNA) circPCSK6 and its peptide derivative circPCSK6-167aa in ICC. CircPCSK6 is significantly downregulated in both ICC patients and mouse primary ICC models, and its lower expression is linked to adverse prognosis, highlighting its pivotal role in ICC pathogenesis. Functionally, this study elucidates the regulatory effect of circPCSK6-167aa on IκBα ubiquitination within the NF-κB pathway, which is mediated by its competitive binding to the E3 ligase RBBP6. This complex interaction leads to reduced activation of the NF-κB pathway, thereby curbing tumor cell proliferation, migration, invasion, stemness, and hepatic-lung metastasis in vivo. This groundbreaking discovery expands the understanding of circRNA-driven tumorigenesis through atypical signaling pathways. Additionally, this investigation identified EIF4A3 as a detrimental regulator of circPCSK6, exacerbating ICC malignancy. Importantly, by leveraging patient-derived xenograft (PDX), organoids, and organoid-derived PDX models, higher levels of circPCSK6-167aa enhance sensitivity to gemcitabine, indicating its potential to improve the effectiveness of chemotherapy. These insights emphasize the therapeutic promise of targeting circPCSK6-167aa, offering vital biological insights and clinical directions for developing cutting-edge therapeutic approaches, thus revealing innovative strategies and targets for future treatments.

Research trends and hotspots evolution of artificial intelligence for cholangiocarcinoma over the past 10 years: a bibliometric analysis

Objective

To analyze the research hotspots and potential of Artificial Intelligence (AI) in cholangiocarcinoma (CCA) through visualization.

Methods

A comprehensive search of publications on the application of AI in CCA from January 1, 2014, to December 31, 2023, within the Web of Science Core Collection, was conducted, and citation information was extracted. CiteSpace 6.2.R6 was used for the visualization analysis of citation information.

Results

A total of 736 publications were included in this study. Early research primarily focused on traditional treatment methods and care strategies for CCA, but since 2019, there has been a significant shift towards the development and optimization of AI algorithms and their application in early cancer diagnosis and treatment decision-making. China emerged as the country with the highest volume of publications, while Khon Kaen University in Thailand was the academic institution with the highest number of publications. A core group of authors involved in a dense network of international collaboration was identified. HEPATOLOGY was found to be the most influential journal in the field. The disciplinary development pattern in this domain exhibits the characteristic of multiple disciplines intersecting and integrating.

Conclusion

The current research hotspots primarily revolve around three directions: AI in the diagnosis and classification of CCA, AI in the preoperative assessment of cancer metastasis risk in CCA, and AI in the prediction of postoperative recurrence in CCA. The complementarity and interdependence among different AI applications will facilitate future applications of AI in the CCA field.

Recent progress in emerging molecular targeted therapies for intrahepatic cholangiocarcinoma

Cholangiocarcinoma (CCA) is a diverse group of epithelial malignant tumors arising from the biliary tract, characterized by high molecular heterogeneity. It is classified into intrahepatic (iCCA) and extrahepatic CCA (eCCA) based on the location of the primary tumor. CCA accounts for approximately 15% of all primary liver cancers, with iCCA comprising 10-20% of all CCAs. iCCA is especially known for its characteristic aggressiveness and refractoriness, leading to poor prognosis. Despite the increasing global incidence and mortality rates, surgery remains the only available standard treatment approach for a subset (25%) of patients with early-stage, resectable iCCA. The paucity of effective systemic medical therapies restricts therapeutic options for patients with advanced or metastatic iCCA. In the past decade, advances in the understanding of the molecular complexity of these tumors have provided fruitful insights for the identification of promising new druggable targets and the development of feasible therapeutic strategies that may improve treatment outcomes for patients with iCCA. In this review, we aim to highlight critical up-to-date studies and medicinal chemistry aspects, focusing on novel targeted approaches utilizing promising candidates for molecular targeted therapy in iCCA. These candidates include aberrations in isocitrate dehydrogenase (IDH) 1/2, fibroblast growth factor receptor (FGFR), B-Raf proto-oncogene (BRAF), neurotrophic tyrosine receptor kinase (NTRK), human epidermal growth factor receptor 2 (HER2), and programmed cell death protein 1 (PD-1)/programmed cell death-ligand 1 (PD-L1). Furthermore, this review provides an overview of potential inhibitors aimed at overcoming acquired drug resistance in these actionable targets for iCCA.

Liver diseases: epidemiology, causes, trends and predictions

As a highly complex organ with digestive, endocrine, and immune-regulatory functions, the liver is pivotal in maintaining physiological homeostasis through its roles in metabolism, detoxification, and immune response. Various factors including viruses, alcohol, metabolites, toxins, and other pathogenic agents can compromise liver function, leading to acute or chronic injury that may progress to end-stage liver diseases. While sharing common features, liver diseases exhibit distinct pathophysiological, clinical, and therapeutic profiles. Currently, liver diseases contribute to approximately 2 million deaths globally each year, imposing significant economic and social burdens worldwide. However, there is no cure for many kinds of liver diseases, partly due to a lack of thorough understanding of the development of these liver diseases. Therefore, this review provides a comprehensive examination of the epidemiology and characteristics of liver diseases, covering a spectrum from acute and chronic conditions to end-stage manifestations. We also highlight the multifaceted mechanisms underlying the initiation and progression of liver diseases, spanning molecular and cellular levels to organ networks. Additionally, this review offers updates on innovative diagnostic techniques, current treatments, and potential therapeutic targets presently under clinical evaluation. Recent advances in understanding the pathogenesis of liver diseases hold critical implications and translational value for the development of novel therapeutic strategies.

LncRNA MIR17HG drives cisplatin resistance partially via miR-138-5p/AKAP9 axis in cholangiocarcinoma

OBJECTIVES

This study aims to discover the role of lncRNA MIR17HG, referred to as MIR17HG, in cisplatin resistance for cholangiocarcinoma (CCA).

METHODS

QRT-PCR was conducted to measure the expression of MIR17HG in cisplatin-resistant/sensitive CCA cells and clinical CCA specimens. Log-rank test was used to analyze the survival curve. Cck8-assay and flow cytometry were employed to detect the sensitivity of CCA cells to cisplatin and the apoptosis rate following different treatments, respectively. The next-generation sequencing was carried out to get gene transcripts after silencing MIR17HG in HCCC-9810 cells. The LncBase database was used to predict the target miRNA of MIR17HG, and MS2 RIP assay and dual luciferase assay were conducted to confirm their binding. MiRwalk database and the RNA sequencing data were utilized to screen the key genes regulated by MIR17HG/miR-138-5p axis and a dual luciferase assay was performed to confirm the binding site of miR-138-5p with AKAP9. Immunoblotting was further employed to give assistant evidence. Rescue experiments were performed to observe the function of miR-138-5p and AKAP9 in MIR17HG-induced cisplatin resistance.

RESULTS

MIR17HG overexpression predicts cisplatin resistance and poor prognosis in CCA. MIR17HG could bind with miR-138-5p to release AKAP9, thereby inhibiting cisplatin-induced apoptosis and promoting cisplatin resistance in CCA. MIR17HG silencing in CCA cells leads to expression alteration of genes, which are enriched in platinum resistance-related pathways.

CONCLUSIONS

LncRNA MIR17HG regulates platinum resistance-associated genes and promotes cisplatin resistance partially via the miR-138-5p/AKAP9 axis by inhibiting cisplatin-induced apoptosis in CCA.

An Unusual Case of Intrahepatic Stone Masquerading as Cholangiocarcinoma

A cancer of the biliary tree, cholangiocarcinoma (CCA) often presents with painless jaundice, right upper quadrant abdominal pain, and unintended weight loss. Serologic testing to include cancer antigen 19-9 (CA 19-9) is elevated in CCA but can also be elevated in inflammatory processes in the biliary system. Diagnosis is difficult and even with advanced imaging techniques false-positives may occur. We present a case of a patient with elevated CA 19-9 and biliary stricture concerning for CCA but was due to hepatic stone. It demonstrates the challenge of correctly diagnosing CCA and an instance of nonmalignant elevation of CA 19-9.

DNA damage response and repair gene mutations predict clinical outcomes in biliary tract cancer

BACKGROUND

This study aims to explore the genetic characteristics of biliary tract cancer (BTC), with a particular focus on the impact of DNA damage response and repair (DDR) genes on clinical outcomes.

METHODS

A total of 180 patients with BTC and next-generation sequencing data were retrospectively analyzed. Clinical outcomes were compared between DDR-positive and DDR-negative groups.

RESULTS

DDR mutations were found in 28.3% of patients, with ATM (7.8%), BAP1 (5.6%), and BRCA2 (3.3%) being the most common. DDR-positive patients receiving first-line platinum-based chemotherapy (n = 73) had a significantly higher objective response rate (50.0% vs. 14.9 %; p = .001), longer median progression-free survival (mPFS) (7.7 vs. 3.8 months; p = .001) and longer median overall survival (28.6 vs. 11.9 months; p < .001). Multivariate analysis confirmed that deleterious DDR gene mutations were independently associated with prolonged mPFS (hazard ratio [HR], 0.37; 95% CI, 0.20-0.67; p < .001) and median overall survival (mOS) (HR, 0.19; 95% CI, 0.08-0.46; p < .001). In 56 patients receiving immunotherapy combined with chemotherapy, DDR-positive patients had a significantly higher overall response rate (45% vs. 8.3%; p = .001), longer mPFS (7.7 vs. 3.8 months; p = .009), and longer mOS (12.7 vs. 8.8 months; p = .011). Multivariate analysis showed that the presence of deleterious DDR gene mutations was associated with significantly longer mPFS (HR, 0.34; 95% CI, 0.16-0.73); p = .005] and mOS (HR, 0.23; 95% CI, 0.08-0.62; p = .004).

CONCLUSION

Deleterious DDR gene mutations are associated with improved clinical outcomes in patients with BTC treated with platinum-based chemotherapy or immunotherapy combined with chemotherapy.

Molecular biology of cholangiocarcinoma and its implications for targeted therapy in patient management

Cholangiocarcinoma (CCA) remains a devastating malignancy and a significant challenge to treat. The majority of CCA patients are diagnosed at an advanced stage, making the disease incurable in most cases. The advent of high-throughput genetic sequencing has significantly improved our understanding of the molecular biology underpinning cancer. The identification of 'druggable' genetic aberrations and the development of novel targeted therapies against them is opening up new treatment strategies. Currently, 3 targeted therapies are approved for use in CCA; Ivosidenib in patients with IDH1 mutations and Infigratinib/Pemigatinib in those with FGFR2 fusions. As our understanding of the biology underpinning CCA continues to improve it is highly likely that additional targeted therapies will become available in the near future. This is important, as it is thought up to 40 % of CCA patients harbour a potentially actionable mutation. In this review we provide an overview of the molecular pathogenesis of CCA and highlight currently available and potential future targeted treatments.

Epidemiology of cholangiocarcinoma

Cholangiocarcinoma (CCA) represents a heterogenous set of malignancies arising from the biliary tract. Classification of CCA subdivides tumours into intrahepatic (iCCA) and extrahepatic (eCCA), with eCCA further categorised as perihilar (pCCA) and distal (dCCA) lesions. Tumour subtypes show distinct epidemiological, genetic and clinical characteristics. Global incidence and mortality are rising, with the highest rates seen in Asian populations compared to the West. There has been a divergence in recent mortality trends observed between CCA subtypes, with rising rates of iCCA seen compared with eCCA. There are several drivers for these differing trends, including specific risk factors, misclassification of CCA subtypes and variation in diagnosis and surveillance. Risk factors for CCA can be divided into hepatobiliary, extra-hepatic and environmental, with hepatobiliary diseases conferring the largest risk. Surgery represents the only curative treatment for CCA, but can only be offered to early-stage candidates who are otherwise fit; the majority of patients are therefore treated with chemotherapy and, recently, immunotherapy. Due to late-stage presentation of disease, prognosis is poor, with 5-year survival <20%.

Management of intrahepatic cholangiocarcinoma: a review for clinicians

Intrahepatic cholangiocarcinoma (iCCA) is an aggressive liver malignancy that arises from second-order biliary epithelial cells. Its incidence is gradually increasing worldwide. Well-known risk factors have been described, although in many cases, they are not identifiable. Treatment options are continuously expanding, but the prognosis of iCCA remains dismal. R0 liver resection remains the only curative treatment, but only a limited number of patients can benefit from it. Frequently, major hepatectomies are needed to completely remove the tumour. This could contraindicate surgery or increase postoperative morbidity in patients with chronic liver disease and small remnant liver volume. In cases of anticipated inadequate future liver remnant, regenerative techniques may be used to expand resectability. The role and extent of lymphadenectomy in iCCA are still matters of debate. Improvements in iCCA diagnosis and better understanding of genetic profiles might lead to optimized surgical approaches and drug therapies. The role of neoadjuvant and adjuvant therapies is broadening, gaining more and more acceptance in clinical practice. Combining surgery with locoregional therapies and novel drugs, such as checkpoint-inhibitors and molecular-targeted molecules, might improve treatment options and survival rates. Liver transplantation, after very poor initial results, is now receiving attention for the treatment of patients with unresectable very early iCCA (i.e. <2 cm) in cirrhotic livers, showing survival outcomes comparable to those of hepatocellular carcinoma. Ongoing prospective protocols are testing the efficacy of liver transplantation for patients with unresectable, advanced tumours confined to the liver, with sustained response to neoadjuvant treatment. In such a continuously changing landscape, the aim of our work is to review the state-of-the-art in the surgical and medical treatment of iCCA.

Digestive cancers: mechanisms, therapeutics and management

Cancers of the digestive system are major contributors to global cancer-associated morbidity and mortality, accounting for 35% of annual cases of cancer deaths. The etiologies, molecular features, and therapeutic management of these cancer entities are highly heterogeneous and complex. Over the last decade, genomic and functional studies have provided unprecedented insights into the biology of digestive cancers, identifying genetic drivers of tumor progression and key interaction points of tumor cells with the immune system. This knowledge is continuously translated into novel treatment concepts and targets, which are dynamically reshaping the therapeutic landscape of these tumors. In this review, we provide a concise overview of the etiology and molecular pathology of the six most common cancers of the digestive system, including esophageal, gastric, biliary tract, pancreatic, hepatocellular, and colorectal cancers. We comprehensively describe the current stage-dependent pharmacological management of these malignancies, including chemo-, targeted, and immunotherapy. For each cancer entity, we provide an overview of recent therapeutic advancements and research progress. Finally, we describe how novel insights into tumor heterogeneity and immune evasion deepen our understanding of therapy resistance and provide an outlook on innovative therapeutic strategies that will shape the future management of digestive cancers, including CAR-T cell therapy, novel antibody-drug conjugates and targeted therapies.

Conversion therapy for unresectable intrahepatic cholangiocarcinoma using gemcitabine plus S-1 combined with PD-1 inhibitors: a case report

Intrahepatic cholangiocarcinoma (iCCA) is a highly malignant tumor of the liver and gallbladder, which is usually diagnosed at an advanced stage and the opportunity for surgery is lost. Therefore, conversion therapy is important to convert the iCCA into a resectable state. In recent years, the conversion protocol of immuno-chemotherapy has been applied for advanced liver cancer. However, little has been reported about iCCA conversion therapy. The aim of this report is to present the results of conversion therapy with Gemcitabine plus S-1 (GS) combined with PD-1 inhibitors (Zimberelimab) in a 74-year-old female IIIB iCCA patient. After 6 cycles of conversion therapy, enhanced CT showed that the patient's tumor had shrunk to nearly half its original size, making radical resection possible. Postoperative pathology showed a complete pathological response. This provides a new way to convert advanced iCCA into resectable state.

OPTIMIZING PERIOPERATIVE CARE FOR PERIHILAR CHOLANGIOCARCINOMA: THE CRUCIAL ROLE OF MULTIDISCIPLINARY MANAGEMENT, NEOADJUVANT THERAPY, AND INTERVENTIONAL RADIOLOGY

BACKGROUND

Perihilar cholangiocarcinoma presents unique challenges in perioperative management, requiring a comprehensive approach to optimize patient outcomes.

AIMS

This case study focuses on the multidisciplinary management and innovative interventions performed in the perioperative care of a patient with hilar cholangiocarcinoma.

METHODS

A comprehensive assessment and treatment strategy involving neoadjuvant therapy and interventional radiology techniques were implemented. Neoadjuvant chemotherapy was administered to reduce tumor size and improve resectability. The crucial role of interventional radiology in managing postoperative complications is highlighted, particularly in the case of massive pulmonary embolism.

RESULTS

The neoadjuvant therapy successfully reduced tumor size, enabling an R0 surgical resection. Additionally, interventional radiology interventions, such as percutaneous pharmaco-mechanical thrombectomy, effectively addressed the life-threatening complication of massive pulmonary embolism.

CONCLUSIONS

This article highlights the importance of a collaborative, multidisciplinary approach in managing complex oncological surgeries, especially regarding the hospital's rescue capacity for severe postoperative complications. Emergent management with interventional radiology had a central role in resolving life-threatening complications.

CHOLANGIOCARCINOMA: EPIDEMIOLOGY, HISTOPATHOLOGY, AND POTENTIAL PROGNOSTIC AND THERAPEUTIC IMPLICATIONS IN A COHORT FROM A REFERENCE CENTER IN SOUTHERN BRAZIL

BACKGROUND

Cholangiocarcinoma (CCA) is a rare neoplasm, with high mortality, originating in the bile ducts. Its incidence is higher in Eastern countries due to the endemic prevalence of liver parasites. Factors such as metabolic syndrome, smoking, and pro-inflammatory conditions are also linked to the disease. Clinical features include asthenia, abdominal pain, cholestasis, and increased serum levels of CEA and CA19-9.

AIMS

The aim of this study was to evaluate CCA prevalence, survival, and potential prognostic and therapeutic implications in a patient cohort and assess correlations with clinical laboratory data and possible associated risk factors.

METHODS

This is a retrospective study of the clinical and histological data of patients diagnosed with CCA at Santa Casa de Misericórdia in Porto Alegre, Brazil, between 2016 and 2021.

RESULTS

There was a 56% prevalence of CCA in women, with intrahepatic localization in 55.4% of cases and unifocality in 85.6% of patients. The mean age of the patients was 63 years (26-89 years), with a mean tumor size of 5.5 cm. The median survival time was 7 months (0 to >50). CA19-9 was altered in 81% of patients, whereas GOT/GPT was altered in 62.5% and gamma-glutamyl transferase/alkaline phosphatase/bilirubin in 69.1% of patients. Mortality was higher among patients with extrahepatic CCA.

CONCLUSION

Risk factors such as smoking, cholecystectomy, cirrhosis, intrahepatic lithiasis, and transplantation should be considered individually by the attending physician for radiological monitoring and incidental discovery of the neoplasm. Lack of timely identification by the attending physician can delay diagnosis, increasing mortality.

Artificial Intelligence and Radiomics in Cholangiocarcinoma: A Comprehensive Review

Cholangiocarcinoma (CCA) is a malignant biliary system tumor and the second most common primary hepatic neoplasm, following hepatocellular carcinoma. CCA still has an extremely high unfavorable prognosis, regardless of type and location, and complete surgical resection remains the only curative therapeutic option; however, due to the underhanded onset and rapid progression of CCA, most patients present with advanced stages at first diagnosis, with only 30 to 60% of CCA patients eligible for surgery. Recent innovations in medical imaging combined with the use of radiomics and artificial intelligence (AI) can lead to improvements in the early detection, characterization, and pre-treatment staging of these tumors, guiding clinicians to make personalized therapeutic strategies. The aim of this review is to provide an overview of how radiological features of CCA can be analyzed through radiomics and with the help of AI for many different purposes, such as differential diagnosis, the prediction of lymph node metastasis, the defining of prognostic groups, and the prediction of early recurrence. The combination of radiomics with AI has immense potential. Still, its effectiveness in practice is yet to be validated by prospective multicentric studies that would allow for the development of standardized radiomics models.

Exploring the effects of gut microbiota on cholangiocarcinoma progression by patient-derived organoids

BACKGROUND

Recent research indicates a role of gut microbiota in development and progression of life-threatening diseases such as cancer. Carcinomas of the biliary ducts, the so-called cholangiocarcinomas, are known for their aggressive tumor biology, implying poor prognosis of affected patients. An impact of the gut microbiota on cholangiocarcinoma development and progression is plausible due to the enterohepatic circulation and is therefore the subject of scientific debate, however evidence is still lacking. This review aimed to discuss the suitability of complex cell culture models to investigate the role of gut microbiota in cholangiocarcinoma progression.

MAIN BODY

Clinical research in this area is challenging due to poor comparability of patients and feasibility reasons, which is why translational models are needed to understand the basis of tumor progression in cholangiocarcinoma. A promising approach to investigate the influence of gut microbiota could be an organoid model. Organoids are 3D cell models cultivated in a modifiable and controlled condition, which can be grown from tumor tissue. 3D cell models are able to imitate physiological and pathological processes in the human body and thus contribute to a better understanding of health and disease.

CONCLUSION

The use of complex cell cultures such as organoids and organoid co-cultures might be powerful and valuable tools to study not only the growth behavior and growth of cholangiocarcinoma cells, but also the interaction with the tumor microenvironment and with components of the gut microbiota.

Infiltrating T lymphocytes and tumor microenvironment within cholangiocarcinoma: immune heterogeneity, intercellular communication, immune checkpoints

Cholangiocarcinoma is the second most common primary liver cancer, and its global incidence has increased in recent years. Radical surgical resection and systemic chemotherapy have traditionally been the standard treatment options. However, the complexity of cholangiocarcinoma subtypes often presents a challenge for early diagnosis. Additionally, high recurrence rates following radical treatment and resistance to late-stage chemotherapy limit the benefits for patients. Immunotherapy has emerged as an effective strategy for treating various types of cancer, and has shown efficacy when combined with chemotherapy for cholangiocarcinoma. Current immunotherapies targeting cholangiocarcinoma have predominantly focused on T lymphocytes within the tumor microenvironment, and new immunotherapies have yielded unsatisfactory results in clinical trials. Therefore, it is essential to achieve a comprehensive understanding of the unique tumor microenvironment of cholangiocarcinoma and the pivotal role of T lymphocytes within it. In this review, we describe the heterogeneous immune landscape and intercellular communication in cholangiocarcinoma and summarize the specific distribution of T lymphocytes. Finally, we review potential immune checkpoints in cholangiocarcinoma.