Quantitative magnetic resonance imaging predicts individual future liver performance after liver resection for cancer

The risk of poor post-operative outcome and the benefits of surgical resection as a curative therapy require careful assessment by the clinical care team for patients with primary and secondary liver cancer. Advances in surgical techniques have improved patient outcomes but identifying which individual patients are at greatest risk of poor post-operative liver performance remains a challenge. Here we report results from a multicentre observational clinical trial (ClinicalTrials.gov NCT03213314) which aimed to inform personalised pre-operative risk assessment in liver cancer surgery by evaluating liver health using quantitative multiparametric magnetic resonance imaging (MRI). We combined estimation of future liver remnant (FLR) volume with corrected T1 (cT1) of the liver parenchyma as a representation of liver health in 143 patients prior to treatment. Patients with an elevated preoperative liver cT1, indicative of fibroinflammation, had a longer post-operative hospital stay compared to those with a cT1 within the normal range (6.5 vs 5 days; p = 0.0053). A composite score combining FLR and cT1 predicted poor liver performance in the 5 days immediately following surgery (AUROC = 0.78). Furthermore, this composite score correlated with the regenerative performance of the liver in the 3 months following resection. This study highlights the utility of quantitative MRI for identifying patients at increased risk of poor post-operative liver performance and a longer stay in hospital. This approach has the potential to inform the assessment of individualised patient risk as part of the clinical decision-making process for liver cancer surgery.

Synchronous Double Bile Duct Cancers with Distinct Genetic Features

A 69-year-old man was referred to our hospital because of appetite loss. Imaging showed a nodular tumor in the perihilar bile duct and a second flat lesion in the distal bile duct. Right hepatopancreaticoduodenectomy was performed, and the histopathological findings demonstrated that the perihilar and distal lesions were moderately and poorly differentiated adenocarcinoma, respectively, and anatomically separated. Furthermore, the resected specimens showed no pancreaticobiliary maljunction. Histological and TP53 gene analyses in a rare case of synchronous double bile duct cancers suggest that there are various genetic pathways through which bile duct cancer develops, highlighting the complexity of its pathogenesis.

IgG4-related Sclerosing Cholangitis Mimicking Cholangiocarcinoma Diagnosed by Endoscopic Ultrasound-guided Fine-needle Aspiration

A 58-year-old man was referred for obstructive jaundice. Imaging modalities revealed the presence of multiple pancreatic tumors and the stenosis of the middle common bile duct due to a hypoenhanced localized tumor. The multiple pancreatic tumors were histopathologically diagnosed as autoimmune pancreatitis by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). To differentiate between IgG4-related sclerosing cholangitis (IgG4-SC) and cholangiocarcinoma, we diagnosed the biliary tumor as IgG4-SC by EUS-FNA because of insufficient pathological materials obtained in a transpapillary manner. We herein report a case of IgG4-SC diagnosed by EUS-FNA.

Neuroendocrine Changes in Cholangiocarcinoma Growth

Cholangiocarcinoma (CCA) is a highly aggressive malignancy that emerges from the biliary tree. There are three major classes of CCA-intrahepatic, hilar (perihilar), or distal (extrahepatic)-according to the location of tumor development. Although CCA tumors are mainly derived from biliary epithelia (i.e., cholangiocytes), CCA can be originated from other cells, such as hepatic progenitor cells and hepatocytes. This heterogeneity of CCA may be responsible for poor survival rates of patients, limited effects of chemotherapy and radiotherapy, and the lack of treatment options and novel therapies. Previous studies have identified a number of neuroendocrine mediators, such as hormones, neuropeptides, and neurotransmitters, as well as corresponding receptors. The mediator/receptor signaling pathways play a vital role in cholangiocyte proliferation, as well as CCA progression and metastases. Agonists or antagonists for candidate pathways may lead to the development of novel therapies for CCA patients. However, effects of mediators may differ between healthy or cancerous cholangiocytes, or between different subtypes of receptors. This review summarizes current understandings of neuroendocrine mediators and their functional roles in CCA.

The tumour microenvironment and immune milieu of cholangiocarcinoma

Tumour microenvironment is a complex, multicellular functional compartment that, particularly when assembled as an abundant desmoplastic reaction, may profoundly affect the proliferative and invasive abilities of epithelial cancer cells. Tumour microenvironment comprises not only stromal cells, mainly cancer-associated fibroblasts, but also immune cells of both the innate and adaptive system (tumour-associated macrophages, neutrophils, natural killer cells, and T and B lymphocytes), and endothelial cells. This results in an intricate web of mutual communications regulated by an extensively remodelled extracellular matrix, where the tumour cells are centrally engaged. In this regard, cholangiocarcinoma, in particular the intrahepatic variant, has become the focus of mounting interest in the last years, largely because of the lack of effective therapies despite its rising incidence and high mortality rates worldwide. On the other hand, recent studies in pancreatic cancer, which similarly to cholangiocarcinoma, is highly desmoplastic, have argued against a tumour-promoting function of the tumour microenvironment. In this review, we will discuss recent developments concerning the role of each cellular population and their multifaceted interplay with the malignant biliary epithelial counterpart. We ultimately hope to provide the working knowledge on how their manipulation may lead to a therapeutic gain in cholangiocarcinoma.

Investigation of Factors Affecting the Sensitivity of Bile Duct Brush Cytology

Objectives While bile duct brush cytology during endoscopic retrograde cholangiopancreatography (ERCP) is a well-established procedure for detecting malignant biliary stricture, its sensitivity is reportedly low. We aimed to determine the pre-ERCP factors affecting brush cytology sensitivity. Methods We retrospectively analyzed 185 patients who underwent brush cytology during the first ERCP for undiagnosed biliary stricture at our institution between January 2014 and December 2016. We analyzed the relationship of age, sex, final diagnosis, stricture location, tumor size, stricture length, total bilirubin level, white blood cell count, and C-reactive protein level with brush cytology sensitivity. Results The following conditions were established as final diagnoses: benign disease, 19 cases (10.3%); intrahepatic cholangiocarcinoma, 10 cases (5.4%); hilar cholangiocarcinoma, 38 cases (20.5%); extrahepatic cholangiocarcinoma, 44 cases (23.8%); pancreatic cancer, 55 cases (29.7%); other malignant tumors, 19 cases (10.3%). The sensitivity and specificity of brush cytology were 60.8% and 94.7%, respectively. The stricture length, total bilirubin level, and white blood cell count in true-positive cases were significantly higher than those in false-negative cases. Furthermore, a stratified analysis of the bilirubin levels demonstrated that sensitivity was highest in patients with moderate jaundice (80% for a total bilirubin level of 10-20 mg/dL), but significantly lower in patients with severe jaundice (total bilirubin level ≥20 mg/dL). Conclusion While the sensitivity of brush cytology increases with bilirubin levels of up to 20 mg/dL, severe jaundice has a negative effect on sensitivity, warranting additional pathological examinations according to the pre-ERCP bilirubin level.

The Role of Stroma in Cholangiocarcinoma: The Intriguing Interplay between Fibroblastic Component, Immune Cell Subsets and Tumor Epithelium

Cholangiocarcinoma (CCA) is a severe and mostly intractable adenocarcinoma of biliary epithelial cells. A typical feature of CCA is its highly desmoplastic microenvironment containing fibrogenic connective tissue and an abundance of immune cells (T lymphocytes, Natural Killer (NK) cells, and macrophages) infiltrating tumor epithelium. This strong desmoplasia is orchestrated by various soluble factors and signals, suggesting a critical role in shaping a tumor growth-permissive microenvironment that is responsible for CCA poor clinical outcome. Indeed stroma not only provides an abundance of factors that facilitate CCA initiation, growth and progression, but also a prejudicial impact on therapeutic outcome. This review will give an overview of tumor-stroma signaling in a microenvironment critically regulating CCA development and progression. Identification of CCA secreted factors by both the fibroblast component and immune cell subsets might provide ample opportunities for pharmacological targeting of this type of cancer.

Sarcomatous intrahepatic cholangiocarcinoma: Case report and literature review

RATIONALE

Sarcomatous intrahepatic cholangiocarcinoma is a rare histological variant of cholangiocarcinoma (ICC). Previous medical literature has not mentioned the prevalence of this kind of disease, but a poorer prognosis than that of ordinary ICC was indicated. The diagnosis of the sarcomatous ICC is established on histopathological and immunohistochemical examinations. In this article, we present a new case of a patient with sarcomatous ICC who had no radiographic sign of intrahepatic tumor preoperatively.

PATIENT CONCERNS

A 63-year-old man was noted with cholecystolithiasis and right upper abdominal pain. Liver function was within normal limits, although the gamma-glutamyl transpeptidase level was elevated. Serum carbohydrate antigen 19-9 level was elevated. Radiography showed atrophy of the left lobe of the liver, high-intensity signals on T1 weighted images, and low/high-intensity signals on T2 weighted images in hepatic ducts.

DIAGNOSES

The preoperative diagnoses were hepatolithiasis, choledocholithiasis, and cholecystolithiasis.

INTERVENTIONS

Exploratory laparotomy, adhesion release, cholecystectomy, choledocholithotomy, and T tube drainage were performed. During the surgery, an ill-defined tumor was detected on the atrophic left lateral lobe of the liver. Hepatic left lateral lobectomy was performed to remove the mass.

OUTCOMES

The final diagnosis of sarcomatous ICC was made by histopathology after surgery. No evidence of local recurrence or distant metastasis was noted on imaging during follow-up.

LESSONS

Although rare, sarcomatous ICC does exist in patients presented with cholecystolithiasis and liver atrophy. Surgeons should be aware of the existence of sarcomatous ICC due to the poor prognosis. We recommend that multidisciplinary approaches may be key to improve prognosis, including adjuvant chemotherapy or radiotherapy.

Sumoylation in p27kip1 via RanBP2 promotes cancer cell growth in cholangiocarcinoma cell line QBC939

BACKGROUND

Cholangiocarcinoma is one of the deadly disease with poor 5-year survival and poor response to conventional therapies. Previously, we found that p27kip1 nuclear-cytoplasmic translocation confers proliferation potential to cholangiocarcinoma cell line QBC939 and this process is mediated by crm-1. However, no other post-transcriptional regulation was found in this process including sumoylation in cholangiocarcinoma.

RESULTS

In this study, we explored the role of sumoylation in the nuclear-cytoplasmic translocation of p27kip1 and its involvement of QBC939 cells' proliferation. First, we identified K73 as the sumoylation site in p27kip1. By utilizing plasmid flag-p27kip1, HA-RanBP2, GST-RanBP2 and His-p27kip1 and immunoprecipitation assay, we validated that p27kip1 can serve as the sumoylation target of RanBP2 in QBC939. Furthermore, we confirmed crm-1's role in promoting nuclear-cytoplasmic translocation of p27kip1 and found that RanBP2's function relies on crm-1. However, K73R mutated p27kip1 can't be identified by crm-1 or RanBP2 in p27kip1 translocation process, suggesting sumoylation of p27kip1 via K73 site is necessary in this process by RanBP2 and crm-1. Phenotypically, the overexpression of either RanBP2 or crm-1 can partially rescue the anti-proliferative effect brought by p27kip1 overexpression in both the MTS and EdU assay. For the first time, we identified and validated the K73 sumoylation site in p27kip1, which is critical to RanBP2 and crm-1 in p27kip1 nuclear-cytoplasmic translocation process.

CONCLUSION

Taken together, targeted inhibition of sumoylation of p27kip1 may serve as a potentially potent therapeutic target in the eradication of cholangiocarcinoma development and relapses.

FEATURES OF THE ADAPTATION STATUS OF THE PATIENTS WITH DIFFERENCES IN THE PREVALENCE OF CANCER PROCESS IN BILIOPANCREATICODUODENAL ZONE AND IN THE VOLUME OF A SURGICAL INTERVENTION

The differences in the type and tension of the general unspecific adaptational reactions in cancer patients with varying prevalence of the process in biliopancreaticoduodenal zone and volume of surgical intervention were revealed. It was shown prognostic significance of the numerical score of the type and tension of the adaptational reaction a day after pancreatoduodenal resection for the development of postoperative complications.

Current diagnostic and management options in perihilar cholangiocarcinoma

Cholangiocarcinomas (CCAs) are heterogeneous biliary tract tumors with dismal prognosis. Perihilar CCA (pCCA) involves the large bile ducts of the hepatic hilum, and is the most common type of CCA. Primary sclerosing cholangitis (PSC) is an established risk factor for pCCA. Although the diagnosis of pCCA is challenging, recent advances have been made including cytologic techniques such as fluorescence in situ hybridization. Endoscopic ultrasound with sampling of regional lymph nodes is emerging as a valuable diagnostic modality in the diagnosis and staging of pCCA. Curative treatment options are limited to early stage disease, and include surgical resection and liver transplantation after neoadjuvant therapy. This underscores the importance of early detection, and the need for development of innovative diagnostic tools such as biomarkers. A dense desmoplastic tumor stroma plays an integral role in pCCA progression. The tumor stroma represents an additional target for development of new therapies. Herein, we discuss these advances in the diagnosis and treatment of pCCA.

[Correction of hepatic dysfunction as pre-treatment before systemic chemotherapy in patients with bile duct neoplasms]

This prospective randomized study incorporates 141 surgical department patients with hepatobiliary tumors. The 1st group patients received 800 ml/day of remaxol. The 2nd1 group patients received Ringer solution and 10% glucose at 1:1 ratio. The subgroups included: 1 subgroup-with pre-operative cholecysto- or choledochostomia and B-subgroup-without pre-operative interventions. The combined surgical and pharmaceutical correction of bile passage, bilirubinemia, cholestasis and cytolysis by remaxole leads to better hepatic dysfunction correction and allows better timing of chemotherapy in bile passage tumors.

Endoscopic retrograde cholangiopancreatography in the diagnosis and management of cholangiocarcinoma

Cholangiocarcinomas (CCAs) are rare malignancies that arise from the biliary epithelium. Intrahepatic CCAs usually present as mass lesions that are asymptomatic or cause nonspecific systemic symptoms such as fatigue, fever, and weight loss. Hilar and extrahepatic tumors most commonly present with jaundice, though cholangitis also can be seen. Tumor markers such as carbohydrate antigen 19-9 and carcinoembryonic antigen have been used to diagnose CCA, but these are nonspecific and may be elevated in infection, inflammation, or any obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) has been used for the diagnosis and management of CCA for many years. This article summarizes the data regarding the application of ERCP in the diagnosis and management of CCA.

Is an estimation of physiologic ability and surgical stress able to predict operative morbidity after pancreaticoduodenectomy?

BACKGROUND

Mortality rates after pancreaticoduodenectomy (PD) are below 4% in high volume centers, although morbidity rates still remain high. Therefore, it is important to clarify a predictor associated with operative morbidity after PD. The estimation of physiologic ability and surgical stress (E-PASS) score has been developed for comparative audit in general surgical patients.

OBJECTIVE

To evaluate whether E-PASS scoring system could predict the occurrence of complications after PD.

METHODS

We performed retrospective analysis of 69 patients (42.0% pancreatic cancer, 31.9% bile duct cancer, and others) who underwent PD using the E-PASS as a predictor of morbidity. Correlations between the incidence rates of postoperative complications and the preoperative risk score (PRS), surgical stress score (SSS) and comprehensive risk score (CRS) of the E-PASS scoring system were evaluated.

RESULTS

Of the 69 patients 30 (43.5%) experienced a total of 54 postoperative complications. All E-PASS scores, especially PRS and CRS were significantly higher in the patients with postoperative complications than in the patients without complication. The complication rate gradually increased as the PRS, SSS and CRS score increased. Under receiver operating characteristic analysis, if a cut-off point of CRS was 0.75, sensitivity and specificity for the prediction of operative morbidity after PD was 80.0 and 79.5%, respectively. Neoadjuvant chemotherapy and intraoperative radiation therapy (IORT) did not influenced on operative morbidity after PD.

CONCLUSION

E-PASS scoring system is useful to evaluate for morbidity after PD. Neoadjuvant chemotherapy and IORT could be adapted without significant extra risk for surgical complication.

Lessons from the toxic bile concept for the pathogenesis and treatment of cholestatic liver diseases

Alterations in bile secretion at the hepatocellular and cholangiocellular levels may cause cholestasis. Formation of 'toxic bile' may be the consequence of abnormal bile composition and can result in hepatocellular and/or bile duct injury. The canalicular phospholipid flippase (Mdr2/MDR3) normally mediates biliary excretion of phospholipids, which normally form mixed micelles with bile acids and cholesterol to protect the bile duct epithelium from the detergent properties of bile acids. Mdr2 knockout mice are not capable of excreting phospholipids into bile and spontaneously develop bile duct injury with macroscopic and microscopic features closely resembling human sclerosing cholangitis. MDR3 mutations have been linked to a broad spectrum of hepatobiliary disorders in humans ranging from progressive familial intrahepatic cholestasis in neonates to intrahepatic cholestasis of pregnancy, drug-induced cholestasis, intrahepatic cholelithiasis, sclerosing cholangitis and biliary cirrhosis in adults. Other examples for bile injury due to the formation of toxic bile include the cholangiopathy seen in cystic fibrosis, after lithocholate feeding (in mice) and vanishing bile duct syndromes induced by drugs and xenobiotics. Therapeutic strategies for cholangiopathies may target bile composition/toxicity and the affected bile duct epithelium itself, and ideally should also have anti-cholestatic, anti-fibrotic and anti-neoplastic properties. Ursodeoxycholic acid (UDCA) shows some of these properties, but is of limited efficacy in the treatment of human cholangiopathies. By contrast to UDCA, its side chain-shortened homologue norUDCA undergoes cholehepatic shunting leading to a bicarbonate-rich hypercholeresis. Moreover, norUDCA has anti-inflammatory, anti-fibrotic and anti-proliferative effects, and stimulates bile acid detoxification. Upcoming clinical trials will have to demonstrate whether norUDCA or other side chain-modified bile acids are also clinically effective in humans. Finally, drugs for the treatment of cholangiopathies may target bile toxicity via nuclear receptors (FXR, PPARalpha) regulating biliary phospholipid and bile acid excretion.

AKT and ERK1/2 signaling in intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinomas (ICC) are neoplasms that originate from cholangiocytes and can occur at any level of the biliary tree. Surgical resection is the current therapy of choice for this highly aggressive cancer. However, the 5-year survival still is poor, with high recurrence rates. Due to the intrahepatic growth a significant proportion of patients present with advanced disease and are not candidates for curative surgery or transplantation. The existing palliative options are of limited benefit and there is a great necessity for novel therapeutic options. In this article we review the role of the phosphoinositide 3-kinase(PI3K)/AKT and extracellular regulated kinase (ERK) signaling pathways in ICC and present new data on the prognostic value of these protein kinases. Finally, we discuss future upcoming therapeutic options based on targeting these signaling pathways.

Enhanced detection of cholangiocarcinoma with serum trypsinogen-2 in patients with severe bile duct strictures

BACKGROUND/AIMS

Primary sclerosing cholangitis (PSC) is associated with a high risk of cholangiocarcinoma. Our aim was to evaluate the diagnostic value of trypsinogen-1, trypsinogen-2, tumour-associated trypsin inhibitor, human chorionic gonadotropin beta and trypsin-2-alpha(1)-antitrypsin for cholangiocarcinoma and to compare them with CA19-9 and CEA.

METHODS

The study consisted of 84 patients with either PSC or cholangiocarcinoma or both referred for liver transplantation or other liver surgery. The serum concentrations were determined by time-resolved immunofluorometric assays.

RESULTS

Forty-six patients were transplanted due to PSC; in 3 of the explanted livers cholangiocarcinoma was found incidentally. All transplanted patients had severe biliary strictures together with cirrhosis or pre-cirrhosis. Twenty-nine of 38 patients with cholangiocarcinoma were candidates for intervention. In all, 8 patients had both PSC and cholangiocarcinoma. Receiver-operating characteristics curve analysis showed that serum trypsinogen-2 had the highest accuracy in differentiating between cholangiocarcinoma and PSC. The area under the curve (AUC) value was 0.804 for trypsinogen-2 and 0.613 for CA19-9. Serum trypsinogen-2 also showed the highest accuracy for differentiation between PSC and PSC with simultaneous cholangiocarcinoma with an AUC value of 0.759.

CONCLUSIONS

Our results suggest that serum trypsinogen-2 is a most useful marker for diagnosing patients with cholangiocarcinoma, and it is superior to serum CA19-9 and CEA.

Helical CT assessment on hilar cholangiocarcinoma: comparison value of arterial phase and portovenous phase correlation

OBJECTIVE

To study the correlation between the findings of hilar cholangiocarcinoma in hepatic arterial phase and portal venous phase. Attention will focus on whether the arterial phase imaging shows more detail than portal phase imaging.

MATERIAL AND METHOD

Descriptive study design with retrospective data collection in Srinagarind Hospital, Khon Kaen University. CT scans of the upper abdomen of 34 patients with pathologically proven hilar cholangiocarcinoma between 2002 and 2004 were reviewed for: (1) characteristic of the tumor; (2) adenopathy, (3) arterial involvement, (4) venous involvement, and (5) degree of biliary involvement on both the hepatic arterial and portal venous phases.

RESULTS

The correlation was high for characteristics of the tumor, the tumor enhancement pattern, and detection of adenopathy, degree of biliary involvement, and arterial involvement, but low for portal venous involvement which the portal venous phase detected better than the hepatic arterial phase.

CONCLUSION

In hilar type cholangiocarcinoma, the portal venous phase yielded the best findings. Furthermore, it showed all findings that were seen in the hepatic arterial phase. According to the present study, the authors suggest doing a pre-contrast study then a portal venous phase imaging for evaluation and diagnosis of hilar type cholangiocarcinoma. There is no necessity to perform hepatic arterial phase in hilar cholangiocarcinoma.

Clinical Utility of Coaxial Reservoir System for Hepatic Arterial Infusion Chemotherapy

PURPOSE

To test the feasibility and clinical utility of a reservoir with coaxial catheters (a 2.9-F microcatheter and a 5-F catheter) and a port (ie, coaxial reservoir) that was developed to perform repeated hepatic arterial infusion chemotherapy (HAIC) in patients with unresectable liver neoplasms.

MATERIALS AND METHODS

The coaxial reservoir was implanted in 64 patients with unresectable liver neoplasms as a result of difficulty in implanting a conventional reservoir with a 5-F catheter. The 2.9-F microcatheter tip was inserted into the gastroduodenal artery (n = 22), pancreaticoduodenal arcade (n = 20), or peripheral hepatic artery (n = 22) through the 5-F catheter, and a side hole created in the leading end of the microcatheter was oriented toward the proper hepatic artery. Technical success was defined by implantation of the coaxial reservoir and initiation of HAIC. The study endpoint was interruption of HAIC or death. Technical success and early and delayed complications were recorded.

RESULTS

The technical success rate was 100%. HAIC was repeated every 1-4 weeks during the mean follow-up period of 14.1 months. Arterial infusion chemotherapy was interrupted in 17 patients (27%) as a result of hepatic arterial occlusion (16%, n = 10), catheter dislocation (3%, n = 2), catheter occlusion (3%, n = 2), wound infection (3%, n = 2), or breakage of the port (2%, n = 1). Patency rates of the hepatic artery were 96%, 82%, and 50% at 6 months, 1 year, and 2 years after reservoir implantation, respectively.

CONCLUSION

Implantation of the coaxial reservoir is feasible, safe, and useful in expanding the indication of HAIC to patients with unresectable liver neoplasms.

Hepatitis B virus and intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is a rare type of primary liver cancer that arises from intrahepatic bile ducts. Its etiopathogenesis has been considered to be independent of the presence of chronic viral hepatitis infections or cirrhosis. These factors, particularly the hepatitis C virus, have been reported to play a role in the development of cholangiocarcinoma in a few studies, with inconclusive results. We report 2 cases of ICC that presented with a background of hepatitis B virus (HBV) infection and discuss the possible pathophysiological relationships between ICC and HBV infection, with an emphasis on the x gene of HBV.

Evaluation of VEGF A expression and microvascular density as prognostic factors in extrahepatic cholangiocarcinoma

OBJECTIVES

Angiogenesis is essential for tumor growth and metastasis. An association between microvessel density, a measure of tumor angiogenesis, and conventional prognostic variables has been shown for many different tumor entities. In extrahepatic cholangiocarcinoma, the VEGF expression and microvessel density have rarely been investigated.

METHODS

Paraffin-embedded specimens from 51 resected adenocarcinomas of the extrahepatic bile duct were immunostained for vascular endothelial growth factor A (VEGF A) and CD 34 to evaluate the microvessel density (MVD). VEGF A staining was evaluated by combining intensity and percentage of positive tumor cells, as low (expression equal or below the median), or high (above the median). Microvessel density was assessed using a method published by Weidner et al.

RESULTS

Median disease free survival (DFS) of the study group was 12.5 months (range, 1-66.3 months). DFS was calculated in the 39 patients with complete resection. It was significantly better in patients with low microvessel density than DFS in patients with high microvessel density (33 months (range, 3-66.3 months) vs. 21.8 months (range, 1.6-31.6 months); p=0.022). In contrast, VEGF A expression did not correlate with survival. There was a trend toward a higher VEGF A expression in highly vascularized tumors (p=0.08), but failed to reach statistic significance.

CONCLUSIONS

The present study indicates, that vascularisation has an important impact on survival of extrahepatic cholangiocarcinoma patients. Other molecules than VEGF A are probably involved in neovascularization in extrahepatic cholangiocarcinoma.

Roles of the MEK1/2 and AKT pathways in CXCL12/CXCR4 induced cholangiocarcinoma cell invasion

AIM: To evaluate the expression of C-X-C motif chemokine receptor 4 (CXCR4) and its signaling cascades, which were previously identified as a key factor for cancer cell progression and metastasis, in cholangiocarcinoma cell lines.

METHODS: The expression of CXCR4 and its signaling cascades were determined in the cholangiocarcinoma cell lines (RMCCA1 and KKU100) by Western blotting. The invasion assays and the detection of actin polymerization were tested in these cholangiocarcinoma cells treated with CXC chemokine ligand -12 (CXCL12).

RESULTS: Expression of CXCR4 was detected in both cholangiocarcinoma cell lines and activation of CXCR4 with CXCL12 triggered the signaling via the extracellular signal-regulated kinase-1/2 (ERK1/2) and phosphoinositide 3-kinase (PI3K) and induction of cholangiocarcinoma cell invasion, and displayed high levels of actin polymerization. Addition of CXCR4 inhibitor (AMD3100) abrogated CXCL12-induced phosphorylation of MEK1/2 and Akt in these cells. Moreover, treatment with MEK1/2 inhibitor (U0126) or PI3K inhibitor (LY294002) also attenuated the effect of CXCL12-induced cholangiocarcinoma cell invasion.

CONCLUSION: These results indicated that the activation of CXCR4 and its signaling pathways (MEK1/2 and Akt) are essential for CXCL12-induced cholangiocarcinoma cell invasion. This rises Implications on a potential role for the inhibition of CXCR4 or its signal cascades in the treatment of cholangiocarcinoma.

Proteasome inhibition-induces endoplasmic reticulum dysfunction and cell death of human cholangiocarcinoma cells

AIM: To determine if proteasome inhibition induces apoptosis in human cholangiocarcinoma cells, and if so, to elucidate the cellular mechanisms.

METHODS: Studies were performed in the human KMCH, KMBC, and Mz-ChA-1 cholangiocarcinoma, and normal rat cell lines. MG132, a peptide aldehyde, which inhibits the chymotrypsin-like activity of the proteaosome was employed for this study. Apoptosis was assessed morphologically by 4’-6-Diamidino-2-phenylindole (DAPI) nuclear staining and fluorescence microscopy. Mitochondrial membrane potential was examined using a fluorescent unquenching assay. Ultrastructural changes during cell death were examined using transmission electron microscopy (TEM). Caspase 3/7 activity was assessed using an enzymatic-based fluorescent assay. Cytosolic-free calcium concentrations were measured using Fura-2 and digitized fluorescent microscopy.

RESULTS: MG132, a proteasome inhibitor, induced apoptosis in all the cholangiocarcinoma cell lines examined. In contrast, minimal cytotoxicity was observed in normal rat cholangiocytes. Apoptosis was time- and -concentration-dependent. There was no change in the mitochondrial membrane potential between treated and untreated cells. Ultrastructural examination by transmission electron microscopy displayed the classic features of apoptosis, but in addition, there was also dramatic vacuolization of the endoplasmic reticulum (ER). Unexpectedly, no increase in caspase 3/7 activity was observed in MG132 treated cells, nor did the pancaspase inhibitor, Q-VD-OPh prevent cell death. The protein synthesis inhibitor, cycloheximide, blocked apoptosis induced by proteosome inhibitor indicating that ER dysfunction was dependent upon the formation of new proteins.

CONCLUSION: Proteosome inhibition induces ER dysfunction and caspase-independent cell death selectively in human cholangiocarcinoma cells. Proteasome inhibitors warrant evaluation as anticancer agents for the treatment of human cholangiocarcinoma.

Establishment and characterization of a cholangiocarcinoma cell line (RMCCA-1) from a Thai patient

AIM

To establish and characterize a new cell line derived from peripheral cholangiocarcinoma of a Thai patient.

METHODS

The peripheral cholangiocarcinoma specimen surgically obtained from the patient was aseptically processed by washing and mincing before culturing in Ham's F12 medium containing 10% fetal bovine serum. After 3 mo, when the cell line has become homogeneous and stabilized, several features were investigated, including growth characteristics, immunofluorescence staining for cytokeratins, expression of tumor markers, chromosomal analysis by G-banding and multicolour fluorescence in situ hybridization (mFISH), in vitro migration and invasion characteristics.

RESULTS

The RMCCA-1 cell line has been established. These cells proliferated as a monolayer with a population doubling time of 48 h. Immunofluorescence staining showed positive staining for human cytokeratin 7 and 19 verifying the biliary epithelial origin. RMCCA-1 secreted carbohydrate antigen 19-9 (CA19-9), but insignificant levels of carcinoembryonic antigen (CEA) and alpha-fetoprotein (AFP). Chromosome analysis identified aneuploidy karyotypes with a modal chromosome number of 59. RMCCA-1 exhibited a low level of in vitro invasiveness, but a high degree of motility. The cell line exhibited a significant number of chromosomal aberrations as shown by mFISH and G-banding methods.

CONCLUSION

A new cell line derived from peripheral cholangiocarcinoma of a Thai patient has been established. This cell line shows a low level of in vitro invasiveness, but a high degree of motility. It will serve as a valuable tool for further studies on tumor biology, molecular pathogenesis, metastatic mechanism and response to therapeutic drugs of cholangiocarcinoma.

Nervous and Neuroendocrine regulation of the pathophysiology of cholestasis and of biliary carcinogenesis

Cholangiocytes, the epithelial cells lining the biliary ducts, are the target cells in several liver diseases. Cholangiopathies and cholangiocarcinoma generate interest in many scientists since the genesis. The developing mechanisms, and the therapeutic tools of these diseases are still undefined. Several studies demonstrate that many hormones, neuropeptides and neurotransmitters regulate malignant and non-malignant cholangiocyte pathophysiology in the course of chronic biliary diseases. The aim of this review is to present the findings of several studies published in the recent years that contributed to clarifying the role of nervous and neuroendocrine regulation of the pathophysiologic events associated with cholestasis and cholangiocarcinoma development. This manuscript is organized into two parts. The first part offers an overview of the innervation of the liver and the origin of neuroendocrine hormones, neurotransmitters and neuropeptides affecting cholangiocyte function and metabolism. The first section also reviews the effects played by several neuroendocrine hormones and nervous system on cholangiocyte growth, survival and functional activity in the course of cholestasis. In the second section, we summarize the results of some studies describing the role of nervous system and neuroendocrine hormones in the regulation of malignant cholangiocyte growth.

Estrogens and the pathophysiology of the biliary tree

The scientific framework concerning estrogen effects on different tissues has expanded enormously during the last decades, when estrogen receptor (ER) subtypes were identified. Estrogens are not only essential for the female reproductive system, but they also control fundamental functions in other tissues including the cardiovascular system, bone, brain and liver. Recently, estrogens have been shown to target the biliary tree, where they modulate the proliferative and secretory activities of cholangiocytes, the epithelial cells lining bile ducts. By acting on both estrogen receptors (ER-α) and (ER-β) subtypes, and by activating either genomic or non-genomic pathways, estrogens play a key role in the complex loop of growth factors and cytokines, which modulates the proliferative response of cholangiocytes to damage. Specifically, estrogens activate intracellular signalling cascades [ERK1/2 (extracellular regulated kinases 1/2, PI3- kinase/AKT (phosphatidylinositol-3’ kinase/AKT)] typical of growth factors such as insulin like growth factor (IGF1), nerve growth factor (NGF) and vascular endothelial growth factor (VEGF), thus potentiating their action. In addition, estrogens stimulate the secretion of different growth factors in proliferating cholangiocytes. This review specifically deals with the recent advances related to the role and mechanisms by which estrogens modulate cholangiocyte functions in normal and pathological conditions.

Cyclooxygenase-2 and prostaglandin signaling in cholangiocarcinoma

Cholangiocarcinoma is a highly malignant epithelial neoplasm arising within the biliary tract and its incidence and mortality is rising. Early diagnosis is difficult and there is presently no effective treatment. Significant progress has been made over the past several years in defining the link between COX-2 and cholangiocarcinogenesis. Selective COX-2 inhibitors have been shown to inhibit cholangiocarcinoma cell growth in vitro and in animal models. However, recently, concerns have been raised about the cardiovascular side effect associated with some COX-2 inhibitors utilized at relatively high dose for antitumor chemoprevention, despite that these inhibitors have a proven safety profile when given as monotherapy to arthritis patients. Therefore, there is an urgent and practical need to develop novel chemopreventive strategy that simultaneously targets COX-2 signaling and other related key molecules in cholangiocarcinogenesis, such as EGFR or utilization of agents inhibiting COX-2 signaling in conjunction with other standard chemotherapy or radiation therapy; these approaches are expected to provide synergistic anti-tumor effect with lesser side effect. In this context, the recently delineated interplay between COX-2-derived PG signaling and other growth-regulatory pathways, such as EGFR, ErbB2, IL-6/GP130, HGF/Met, TGF-beta/Smad, and iNOS is expected to provide important therapeutic implications. This review will summarize the recent advances in understanding the mechanisms for COX-2-derived PG signaling in cholangiocarcinogenesis and focus on the newly unveiled interactions between PG cascade and other key signaling pathways that coordinately regulate cholangiocarcinoma growth. Knowledge on these aspects will help develop more effective therapeutic strategy targeting COX-2 and related key signaling molecules.

MUC1 and MUC5AC mucin expression in liver fluke-associated intrahepatic cholangiocarcinoma

AIM: To investigate the expressions of MUC1 and MUC5AC in intrahepatic cholangiocarcinoma (ICC). Association of expressions of mucins MUC1 and MUC5AC with clinical findings, metastasis, and survival of the liver fluke-associated ICC patients was determined.

METHODS: The expressions of MUC1 and MUC5AC mucins were examined by immunohistochemical staining in 87 cases of histologically-proven ICC. The expressions of mucins in relationship between clinicopathological significance and prognosis of the patients were evaluated.

RESULTS: Fifty-two patients (60%) exhibited both MUC1 and MUC5AC expressions, whereas 31% expressed either MUC1 or MUC5AC, and 9% expressed neither. High MUC1 immunoreactivity displayed a significant correlation with tumor progression as reflected by vascular invasion (P<0.001), whereas high expression of MUC5AC significantly correlated with neural invasion (P = 0.022) and advanced ICC stage (P = 0.008). Patients with high expression of MUC1 had a significantly shorter survival (P = 0.0002). According to multivariate analyses, MUC1 reactivity (P = 0.026), histological grading and stage of tumor represented the least probability of survival.

CONCLUSION: MUC1 is overexpressed in liver fluke-associated cholangiocarcinoma and relates to vascular invasion and poor prognosis, whereas MUC5AC mucin is neoexpressed and relates to neural invasion and advanced ICC stage. High MUC1 expression in tumor may be useful for predicting the poor outcome of ICC patients.

The delta opioid receptor 1 is expressed by proliferating bile ductules in rats with cholestasis: implications for the study of liver regeneration and malignant transformation of biliary epithelium

In sharp contrast with the normal adult liver, the fetal human and rat livers and the liver of rats with cholestasis secondary to bile duct resection express the preproenkephalin mRNA, which codes for the endogenous opioid peptide Met-enkephalin. Furthermore, Met-enkephalin immunoreactivity is detected in hepatocytes and in proliferating bile ductules in the cholestatic rat liver. These data suggest that in cholestasis endogenous opioids may have a local effect in the cholestatic liver. As endogenous opioids exert their effect by binding to opioid receptors, the presence of opioid receptors in the cholestatic livers would support the hypothesis that Met-enkephalin plays a role in situ. Preliminary data presented in this manuscript reveals the expression of the delta opioid receptor in the liver of rats with cholestasis. This finding suggests that there is a scenario in which Met-enkephalin can bind to opioid receptors in the liver in cholestasis to exert a local effect. In vivo studies in this model of cholestasis with the use of opioid agonist and antagonist will shed light on the possible role of opioidergic regulation of liver regeneration. Studies on the effect of opiate antagonists on the evolution of cholestasis in this animal model may provide insight into the mechanisms of liver regeneration. In addition, as some conditions associated with cholestasis and bile ductular proliferation can be complicated by malignancy, the expression of the delta opioid receptor in malignant tumors of the biliary tree merits research.

Inducible nitric oxide synthase up-regulates Notch-1 in mouse cholangiocytes: implications for carcinogenesis

BACKGROUND & AIMS

Inflammatory mediators and cell fate genes, such as the Notch gene family, both have been implicated in cancer biology. Because cholangiocarcinomas arise in a background of inflammation and express the inflammatory mediator inducible nitric oxide synthase (iNOS), we aimed to determine whether iNOS expression alters Notch expression and signaling.

METHODS

Notch receptor and ligand expression in human liver was evaluated by immunohistochemistry. The effect of iNOS and NO on Notch-1 expression was examined in cell lines.

RESULTS

Notch-1, but not other Notch receptors, were up-regulated by cholangiocytes in primary sclerosing cholangitis and cholangiocarcinoma. The colocalization of Notch-1 and iNOS also was observed in large bile ducts from the hilar region of primary sclerosing cholangitis patients. Notch-1 expression in murine cholangiocytes was iNOS dependent. iNOS expression also facilitated Notch signaling by inducing the nuclear translocation of its intracellular domain and the expression of a transcriptional target, hairy and enhancer of split (Hes)-1. The gamma-secretase inhibitor N-[N-(3,5-Difluorophenacetyl-L-alanyl)-S-phenylglycine]-t-butyl ester, which blocks Notch signaling, enhanced tumor necrosis factor-related apoptosis-inducing ligand-induced apoptosis in cholangiocarcinoma cells.

CONCLUSIONS

These data implicate a direct link between the inflammatory mediator iNOS and Notch signaling, and have implications for the development and progression of cholangiocarcinoma.

Mucin-producing cholangiocarcinoma: clinical experience of 24 cases in 16 years

OBJECTIVE

Mucin-producing cholangiocarcinoma (MPCC) is an uncommon biliary tract malignancy. This retrospective study was designed to investigate the clinical presentations, associated diseases, the value of tumor markers, and treatment and prognosis of MPCC.

MATERIAL AND METHODS

The study included 24 MPCC cases (7 M, 17 F) from 132 histopathology-proven cholangiocarcinoma patients seen between 1988 and 2003. MPCC and non-mucin-producing cholangiocarcinoma (non-MPCC) were compared.

RESULTS

Common clinical symptoms and signs included epigastric or right upper quadrant pain, fever and chills, jaundice, and anemia. Seventeen patients had mucobilia in surgical, cholangiographic, or CT findings. Biliary stones were found in 71% of MPCC patients. In detecting MPCC, a serum CA-19-9 level > 120 U/ml had 73% sensitivity, 41% specificity, 25% positive predictive value, 85% negative predictive value, and 48% accuracy in the 132 cholangiocarcinoma patients. The 1-, 2-, 3-, 4-, and 5-year survival rates were 44.3%, 33.8%, 28.1%, 21.1%, and 21.1%, respectively. Univariate analysis showed that tumor type (MPCC) was the only significant factor predicting survival when compared with non-MPCC patients in 5-year cumulative survival rates (21.1% versus 5.4%). MPCC patients receiving surgical resection had a prolonged median survival time (13 months versus 6 months) than those without resection.

CONCLUSIONS

MPCC clinical presentations were similar to non-MPCC in Taiwan except for more jaundice, fever and chills. The major factor predisposing to MPCC was biliary stones. Using serum CA19-9 levels greater than 120 U/ml was a diagnostic aid to detecting MPCC patients. MPCC patients had a better prognosis than non-MPCC patients. The recommended treatment for MPCC is surgical resection.

Granular cell tumor of the biliary system: a report of 2 cases with cytologic diagnosis on endoscopic brushing

BACKGROUND

Granular cell tumors (GCTs) of biliary system are rare. GCTs show a striking preponderance for young, black females, who generally present with obstructive jaundice. To our knowledge, these are the first 2 reports of GCT of biliary system identifed on endoscopic brushing cytology.

CASES

In case 1, a 24-year-old, black woman presented with a 5-month history of pruritus. Radiographic studies demonstrated a mass in the distal common bile duct. Endoscopic biopsy and bile duct brushing were diagnosed as GCT. A Whipple procedure was confirmatory of GCT. In case 2, a 38-year-old, black female presented with a 7-month history of pruritus and jaundice. Radiographic studies showed a stricture of the common hepatic duct at the hilum. Endoscopic brushing cytology of the stricture yielded only a few sheets of granular cells that were missed on initial screening. Suspicion of cholangiocarcinoma prompted surgery, and final histopathology showed GCT. Both patients were well 1 1/2 and 6 years after presentation.

CONCLUSION

GCT of the bile duct can be diagnosed on endoscopic brushing and should be considered in the cytologic differential diagnosis in the appropriate clinical settings.

Effect of mutated IκBα transfection on multidrug resistance in hilar cholangiocarcinoma cell lines

AIM: To explore the expression effect of mutated IκBα transfection on multidrug resistance gene (MDR-1) in hilar cholangiocarcinoma cells by inhibiting the activity of nuclear transcription factor-κB (NF-κB).

METHODS: We used the mutated IκBα plasmid to transfect QBC₉₃₉HCVC+ cells and QBC939 cells, and electrophoretic gel mobility shift assay (EMSA) to detect the binding activity of NF-κB DNA and the effect of the transfecting mutated IκBα plasmid on multidrug resistance gene (MDR-1) in hilar cholangiocarcinoma cells and its expression protein (P-GP).

RESULTS: Plasmid DNA was digested by restriction enzymes Xbal and Hand III, and its product after electrophoresis showed two bands with a big difference in molecular weight, with a size of 4.9 kb and 1.55 kb respectively, which indicated that the carrier was successfully constructed and digested with enzymes. The radioactivity accumulation of QBC₉₃₉HCVC+ and QBC939 cells transfected with mutated IκBα plasmid was significantly lower than that of the control group not transfected with mutated IκBα plasmid. Double densimeter scanning showed that the relative signal density between the tansfection group and non-transfection group was significantly different, which proved that the mutated IκBα plasmid could inhibit the binding activity of NF-κB DNA in hilar cholangiocarcinoma cells. Compared to control group not transfected with m IκBα plasmid, the expression level of MDR-1mRNA in the QBC939 and QBC939HCVC+ cells transfected with mutated IκBα plasmid was lower. The expression intensity of P-GP protein in QBC939 and QBC939HCVC+ cells transfected with mutated IκBα was significantly lower than that of the control group not transfected with mutated IκBα plasmid.

CONCLUSION: The mutated IκBα plasmid transfection can markedly reverse the multidrug resistance of hilar cholangiocarcinoma cells. Interruption of NF-κB activity may become a new target in gene therapy for hilar cholangiocar-cinogenesic carcinoma.

Neutrophils enhance invasion activity of human cholangiocellular carcinoma and hepatocellular carcinoma cells: an in vitro study

BACKGROUND AND AIM

Tumor-mesenchymal interactions are involved in the mechanism of tumor invasion in several types of carcinoma. Mutual interactions between carcinoma cells and neutrophils, however, have been poorly understood. In the present study we examined the effect of neutrophils on invasion activities of carcinoma cells in vitro. Role of hepatocyte growth factor (HGF) as a mediator was also evaluated.

METHODS

Using a Matrigel invasion chamber, invasion activities of HuCC-T1 human cholangiocellular carcinoma cells and HepG2 hepatocellular carcinoma cells in response to recombinant HGF or neutrophils were evaluated.

RESULTS

Recombinant HGF dose-dependently increased invasion activities of HuCC-T1 and HepG2 cells. Neutrophils significantly enhanced invasion activities of these cells, which were suppressed to the respective basal levels with anti-HGF antibody. The carcinoma cells did not secrete HGF. Neutrophils cultivated in tumor condition medium (TCM) of HuCC-T1 or HepG2 cells secreted a significant level of HGF protein without increasing HGF mRNA expression. Treatment with heat or ultrafiltration of TCM of HuCC-T1 or HepG2 cells suggested carcinoma cell-derived HGF inducer(s) to be certain protein(s) with a molecular weight of more than 30 000.

CONCLUSIONS

The present study suggests the presence of mutual interactions between HuCC-T1/HepG2 carcinoma cells and neutrophils in tumor invasion via paracrine regulation mediated by neutrophil-derived HGF.

Detection of bcl-2 and bax expression and bcl-2/JH fusion gene in intrahepatic cholangiocarcinoma

AIM: To investigate the relationship between bcl-2 gene and its related protein bax and intrahepatic cholangiocellular carcinoma (CCC).

METHODS: Semi-nested in situ PCR (SNISPCR) and imm- unohistochemistry were performed to detect bcl-2/JH fusion gene and bcl-2, bax protein expression in 29 cases of CCC.

RESULTS: No bcl-2/JH fusion gene was found in all cases of CCC, 72.4% of 29 cases expressed bcl-2 protein. Bcl-2 protein expression was related to histopathological grades (P < 0.05). There was no corresponding relationship between bcl-2/JH fusion gene formation and bcl-2 protein expression in CCC (P < 0.05). Bax was expressed in 10.3% of 29 cases. The ratio of bcl-2 to bax in normal liver tissues (3.5 to 1) was different from that in tumor tissues (7.0 to 1).

CONCLUSION: It is suggested that bcl-2/JH fusion gene formation is not a frequent event and may not play an important role in the pathogenesis of CCC. However, aberrant ratio of bcl-2 to bax protein expression may be involved in the course of tumorigenesis of CCC. Abnormal bcl-2 protein expression may not be solely resulted from bcl-2/JH fusion gene.

[Liver regeneration after hepatectomy]

It is well known that the normal liver has enormous regenerative capacity. Despite years of effort by numerous investigators, there is still uncertainty about the signals of liver regeneration. Computed tomography (CT) is the most useful tool because it accurately measures human liver volume. Comparing the differences in regeneration after major resection of normal and injured livers, normal livers reached plateau levels within 1 to 2 months regardless of the extent of resection, whereas regeneration was retarded in injured liver. Human liver regeneration is influenced by the extent of resection. In biliary cancer, liver regeneration terminates when the liver has regained about three-quarters of its original size in about 1 year. The clinical significance of the observation that liver regeneration is an incomplete process is unclear. However, the strong correlation observed between body surface area and regenerated liver volume suggests that liver regeneration is a process of restoration of the liver to a volume suitable for body size. In living related-donor liver transplantation there is a tendency for the size of the transplanted liver to converge to the standard liver volume, regardless of whether the initial liver-graft volume was smaller or larger than the standard liver volume.

Hemodynamics of intrahepatic cholangiocarcinoma: evaluation with single-level dynamic CT during hepatic arteriography

BACKGROUND

We determined the radiologic characteristics of intrahepatic cholangicarcinoma (ICC) on single-level dynamic computed tomography during hepatic arteriography (CTHA) and assessed the hemodynamics of the tumor.

METHODS

Eleven patients with pathologically confirmed ICC underwent single-level dynamic CTHA. After placing the catheter tip in the proper hepatic artery and running a 30-s continuous scan, scanning was performed every 15 or 30 s for 120 s. The change of contrast-enhancement pattern of the ICCs were interpreted retrospectively.

RESULTS

The pattern of enhancement was classified into two types: vascular and hypovascular. In the vascular type, the contrast enhancement gradually spread from each intratum oral artery and became mottled. It changed from a mottled and hypoattenuated pattern to an even and hyperattenuated appearance in comparison with the adjacent liver approximately 120 s after the injection of contrast agent. In the hypovascular type, the tumor was barely enhanced and remained hypoattenuated compared with the adjacent liver at 120 s after the beginning of the injection. The 11 ICCs were classified into eight vascular types and three hypovascular types. Intratumoral arteries were visualized in nine tumors: eight vascular types and one hypovascular type.

CONCLUSION

The contrast-enhancement pattern of ICC on single-level dynamic CTHA is related to the intratumoral artery.

The molecular pathogenesis of cholangiocarcinoma

Cholangiocarcinoma is rising in clinical importance because of increasing incidence, poor prognosis, and suboptimal response to therapy. Recent investigations into the underlying molecular mechanisms involved in cholangiocarcinogenesis and tumor growth have contributed greatly to our understanding of this disease. To review this topic, we discuss the molecular mechanisms in sections reflecting the unique features that allow cancer cells to develop and maintain a growth advantage. Through a better understanding of these mechanisms, improved and more specific diagnostic, therapeutic, and preventative strategies may be developed and hopefully improve the outcome of this devastating disease.

Anatomic and molecular pathology of intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is the second most common malignant tumor of the liver, and ICC is reportedly increasing recently. ICC is usually adenocarcinoma with variable desmoplastic reaction, although there are several special or unusual histological features. ICC may arise at the large intrahepatic bile duct near the hepatic hilus and also from the bile ductules at the border of the hepatic parenchyma. On the anatomical level, the pathology of ICC differs depending on the region from which the ICC arises. At the large intrahepatic bile duct, ICC presents papillary growth and periductal infiltration. Some cases show extensive papillary growth and intraluminal spread with marked gastroenteric metaplasia. Mucus core protein 1 is expressed in aggressive ICC. ICC arising from ductules shares phenotypes of hepatocellular carcinoma. ICC in chronic biliary diseases, particularly arising in hepatolithiasis, presents precancerous lesions that include biliary epithelial dysplasia, as well as in-situ carcinoma. Chronic advanced hepatitis C is one of the background diseases of ICC. Chronic inflammation, with the upregulation of cyclooxygenase-2 and growth factors, and the formation of reactive oxygen species are one of the causative factors in the DNA damage of biliary epithelial cells. K- ras mutation and aberrant expression of p53 are found in one-third of ICCs. The latter may be due to mdm-2 upregulation. Hepatocyte growth factor/met and interleukin 6 (IL6)/IL6 receptor are involved in cell proliferation/mitoinhibition and apoptosis in ICC. Fibrous stroma formation and invasion involve the proliferation of Alpha-smooth muscle antigen-positive stromal cells, and cell-to-cell and cell-to-matrix interactions involving E-cadherin/catenin and CD44 and matrix proteinases may be involved in the invasion of ICC. Evasion of immune surveillance involving the Fas/FasL system is important in the malignant progression of ICC. Further molecular and genetic studies are mandatory to evaluate the pathogenesis and progression of ICC.

Diagnosis and management of cholangiocarcinomas: a comprehensive review

First described by Maximilian deStoll in 1777, cholangiocarcinoma remains to be a diagnostic and therapeutic challenge. The incidence of cholangiocarcinoma is of 2000-3000 cases a year in the US but much higher in Southeast Asia and Eastern Europe. Sclerosing cholangitis, ulcerative colitis, liver fluke infestations, hepatolithiasis, thorotrast exposure, choledochal cysts are associated with an increased risk. Recently, substantial progress has been achieved in the understanding of the cellular and molecular mechanisms playing a role in biliary carcinogenesis including oncogenes and tumor suppressor genes. Surgery alone can be a curative treatment in only a fraction of patients with a 5-year survival rate of 0-39%. The role of radiotherapy including intensification with intraoperative radiation therapy, brachytherapy or conformal external beam radiation therapy has not been proven. Experience with chemotherapy is not widespread in cholangiocarcinoma. Chemotherapy trials have mostly included small numbers of patients and there have been no large prospective randomized trials. Observed objective response rates have been between 0% and 40% with no complete remissions. Further studies are required to find out the impact of chemotherapy in the management of cholangiocarcinoma and search for newer agents with novel mechanisms of action that can be more active in cholangiocarcinoma should continue. Meanwhile prevention and early diagnosis of cholangiocarcinoma is essential. Efforts should also continue to discover means to detect high-risk patients with less invasive methods.

Successful photodynamic therapy for nonresectable cholangiocarcinoma: a randomized prospective study

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The role of preoperative phenylalanine breath test in hepatectomy

BACKGROUND/AIMS

The phenylalanine breath test may serve as a liver function test, although its clinical usefulness has never been clarified. This study aimed to evaluate the role of preoperative phenylalanine breath test in patients undergoing hepatectomy.

METHODOLOGY

Twenty-seven patients undergoing hepatectomy were studied. The PBT30 (phenylalanine excretion ratio at 30 min) was measured after oral administration of 100 mg of L-[1-(13)C]-phenylalanine. Postoperative mortality and morbidity were compared with the value of PBT30, ICGR15 (plasma retention rate of indocyanine green at 15 min), Child-Pugh score, and other blood chemical tests together with operative factors. Independent factors contributing to postoperative mortality and morbidity were evaluated by multiple logistic regression analysis.

RESULTS

Postoperative mortality and morbidity rates were 0 and 25.9%, respectively. PBT30 and ICGR15 values were significantly different between the groups with and without postoperative complication, and these two parameters independently contributed to prediction of postoperative complication.

CONCLUSIONS

PBT30 is a clinically useful predictor for postoperative complication in patients undergoing hepatectomy.

Celecoxib inhibits proliferation and induces apoptosis via prostaglandin E2 pathway in human cholangiocarcinoma cell lines

AIM: To evaluate the roles and mechanisms of celecoxib in inducing proliferation inhibition and apoptosis of human cholangiocarcinoma cell lines.

METHODS: Cyclooxygenase-2-overexpressing human cholangiocarcinoma cell line QBC939 and cyclooxygenase-2-deficient human cholangiocarcinoma cell line SK-CHA-1 were used in the present study. The anti-proliferative effect was measured by methabenzthiazuron (MTT) assay; apoptosis was determined by transferase-mediated dUTP nick end labeling (TUNEL) detection and transmission electron microscopy (TEM). Cell cycle was analyzed by flow cytometry (FCM). The PGE₂ levels in the supernatant of cultured cholangiocarcinoma cells were quantitated by enzyme-linked immunoabsordent assay (ELISA).

RESULTS: Celecoxib suppressed the production of PGE₂ and inhibited the growth of QBC939 cells. Celecoxib at 10, 20, and 40 μmol/L inhibited PGE₂ production by 26%, 58%, and 74% in QBC939 cells. The PGE₂ level was much lower constitutively in SK-CHA-1 cells (18.6 ± 3.2) compared with that in QBC939 (121.9 ± 5.6) cells (P < 0.01) and celecoxib had no significant influence on PGE₂ level in the SK-CHA-1 cells. The PGE₂ concentration in SK-CHA-1 cells also reduced but not significantly after treatment with celecoxib. The PGE₂ concentration in SK-CHA-1 cells was (16.5 ± 2.9) ng/well, (14.8 ± 3.4) ng/well, (13.2 ± 2.0) ng/well and (12.6 ± 3.1) ng/well respectively, when pre-treated with 1 μmol/L, 10 μmol/L, 20 μmol/L and 40 μmol/L of celecoxib for 48 h (P > 0.05, vs control). The anti-proliferation effect of celecoxib (20 μmol/L) on QBC939 cells was time-dependent, it was noticeable on day 2 (OD490 = 0.23 ± 0.04) and became obvious on day 3 (OD₄₉₀ = 0.31 ± 0.07) to day 4 (OD490 = 0.25 ± 0.06), and the OD₄₉₀ in the control group (day 1) was 0.12 ± 0.03 (P < 0.01, vs control). The anti-proliferation effect of celecoxib could be abolished by the addition of 200 pg/mL PGE₂. The proliferation of SK-CHA-1 cells was inhibited slightly by celecoxib, the cell density OD490 in the presence of celecoxib and in control group was 0.31 ± 0.04 and 0.42 ± 0.03 respectively on day 2 (P > 0.05), 0.58 ± 0.07 and 0.67 ± 0.09 respectively on day 3 (P > 0.05), and 0.71 ± 0.08 and 0.78 ± 0.06 respectively on day 4 (P > 0.05). Celecoxib induced proliferation inhibition and apoptosis by G₁-S cell cycle arrest: the percentage of QBC939 cells in G₀-G₁phase after treatment with 40 μmol/L (74.6 ± 66.21) and 20 μmol/L (68.63 ± 4.36) celecoxib increased significantly compared with control cells (54.41 ± 5.12, P < 0.01). The percentage of SK-CHA-1 cells in G₀-G₁ phase after treatment with various concentrations of celecoxib didn't change significantly compared with control cells. The TUNEL index was much higher in QBC939 cells treated with 20 μmol/L celecoxib for 2 d (0.063 ± 0.018) and for 4 d (0.102 ± 0.037) compared with control cells (0.017 ± 0.004, P < 0.01).

CONCLUSION: The current in vitro study indicates that inhibition of proliferation and induction of apoptosis in human cholangiocarcinoma cells by cyclooxygenase-2 specific inhibitor celecoxib may involve in COX-dependent mechanisms and PGE₂pathway. Celecoxib as a chemopreventive and chemotherapeutic agent might be effective primarily on COX-2-expressing cholangiocarcinoma.

Hepatic resection under in situ hypothermic hepatic perfusion

BACKGROUND/AIMS

Temporary inflow occlusion of the portal triad has been used frequently in hepatectomy to minimize bleeding. On the other hand, Pringle's maneuver produces ischemic-reperfusion injury especially in patients with underlying liver disease.

METHODOLOGY

Thirty-seven cases of hepatic resections were performed with intermittent Pringle's maneuver (IP group; n = 17) and in situ hypothermic perfusion (CP group; n = 20). In the CP group, hepatic inflow was continuously occluded, and 4-degree Centigrade Ringer's lactate was administered by drip during resection. Hepatic outflow occlusion was not performed.

RESULTS

All patients tolerated the procedures well. Cold perfusion technique significantly decreased both the times required and the blood loss in hepatectomy (p < 0.05). Serum hyaluronic acid levels gradually increased after the induction of hepatectomy and peaked 10 minutes after reperfusion in the both groups. Thereafter, it decreased and showed a significantly lower level in the CP group until 60 minutes after reperfusion (p < 0.05). Hepaplastin levels remained significantly higher in the CP group one week after operation (p < 0.05).

CONCLUSIONS

Using the technique of in situ hypothermic perfusion, we can prolong the ischemic time safely with minimal systemic influence even in cases with underlying liver diseases. This may compare favorably with intermittent Pringle's maneuver in terms of reducing hepatic sinusoidal endothelial cell damage during hepatectomy and reperfusion.

Human WISP1v, a member of the CCN family, is associated with invasive cholangiocarcinoma

Family members of the connective tissue growth factor, cysteine-rich 61, nephroblastoma over-expressed gene (CCN) encode cysteine-rich secreted proteins with roles in human fibrotic disorders and tumor progression. In this study, we identified a CCN family member, WISP1v, as over-expressed in human cholangiocarcinomas. Genetic analysis of WISP1v was performed on surgically resected specimens of cholangiocarcinoma. The WISP1v biological effects were analyzed using the HuCCT1 human cholangiocarcinoma cell line. The WISP1v gene was expressed in 19 of 39 cholangiocarcinoma tissues (49%) but not in normal livers. Expression of WISP1v was significantly associated with lymphatic and perineural invasion of tumor cells (P <.05), as well as a poor clinical prognosis (P <.01). In the intraductal papillary cholangiocarcinomas, WISP1v was detected only in the cases with duct wall invasion but not in the cases without duct wall invasion (P <.05). No mutation of WISP1v gene was detected in the examined samples. In vitro analysis revealed that WISP1v stimulated the invasive phenotype of cholangiocarcinoma cells with activation of both p38 and p42/p44 mitogen-activated protein kinases (MAPKs). Furthermore, WISP1v-induced cholangiocarcinoma invasion was significantly suppressed by the p38 MAPK inhibitor SB203580 but not by the p42/p44 MAPK kinase (MEK) inhibitor PD98059. Our findings suggest that WISP1v-mediated signaling is involved in the generation of invasive cellular properties and leads to progression of cholangiocarcinoma.