Hepatolithiasis associated with cholangiocarcinoma. Possible etiologic significance

A reappraisal of cholangiocarcinoma in patient with hepatolithiasis

BACKGROUND

Hepatolithiasis associated with cholangiocarcinoma is not often encountered. During the past 3 years, an increased incidence of patients with hepatolithiasis associated with cholangiocarcinoma was noted. Data were needed to reliably determine the incidence of this disease.

METHODS

Data concerning the relationship between cholangiocarcinoma and hepatolithiasis are presented. The treatment modalities and factors that influence long-term survival are discussed.

RESULTS

The overall incidence of cholangiocarcinoma in association with hepatolithiasis was 5.0% (55 in 1105). Before 1987, 65% of cholangiocarcinoma in association with hepatolithiasis was diagnosed postoperatively. After 1987, the incidence of accurate preoperative diagnosis increased (22.8%), and in most of the other instances (62.8%), the diagnosis was made at laparotomy. Surgical procedures consisted of common bile duct exploration with T-tube drainage (100%) and hepatectomy (38.2%). Mortality for patients who underwent surgery was 5.4%; they died of recurrent cholangitis. The overall median survival time of patients with cholangiocarcinoma in association with hepatolithiasis was 10.4 months; the 1-, 2-, and 4-year cumulative survival rates were 30.0%, 12.7%, and 3.6%, respectively. Patients with hepatectomy or the presence of mucobilia had better survival rates (P < 0.05).

CONCLUSIONS

The overall incidence of hepatolithiasis associated with cholangiocarcinoma was 5%. In most patients with cholangiocarcinoma in association with hepatolithiasis, diagnosis can be made preoperatively and at laparotomy. Patients with hepatectomy or presence of mucobilia had better survival rates.

A reappraisal of cholangiocarcinoma in patient with hepatolithiasis

BACKGROUND

Hepatolithiasis associated with cholangiocarcinoma is not often encountered. During the past 3 years, an increased incidence of patients with hepatolithiasis associated with cholangiocarcinoma was noted. Data were needed to reliably determine the incidence of this disease.

METHODS

Data concerning the relationship between cholangiocarcinoma and hepatolithiasis are presented. The treatment modalities and factors that influence long-term survival are discussed.

RESULTS

The overall incidence of cholangiocarcinoma in association with hepatolithiasis was 5.0% (55 in 1105). Before 1987, 65% of cholangiocarcinoma in association with hepatolithiasis was diagnosed postoperatively. After 1987, the incidence of accurate preoperative diagnosis increased (22.8%), and in most of the other instances (62.8%), the diagnosis was made at laparotomy. Surgical procedures consisted of common bile duct exploration with T-tube drainage (100%) and hepatectomy (38.2%). Mortality for patients who underwent surgery was 5.4%; they died of recurrent cholangitis. The overall median survival time of patients with cholangiocarcinoma in association with hepatolithiasis was 10.4 months; the 1-, 2-, and 4-year cumulative survival rates were 30.0%, 12.7%, and 3.6%, respectively. Patients with hepatectomy or the presence of mucobilia had better survival rates (P < 0.05).

CONCLUSIONS

The overall incidence of hepatolithiasis associated with cholangiocarcinoma was 5%. In most patients with cholangiocarcinoma in association with hepatolithiasis, diagnosis can be made preoperatively and at laparotomy. Patients with hepatectomy or presence of mucobilia had better survival rates.

Precancerous lesions of the biliary tree

Malignant tumors may arise from any portion of the biliary tree. The term cholangiocarcinoma (CC) applies to both intra- and extrahepatic tumors. More than 95% of these tumors are adenocarcinomas. Differentiation between CC and metastatic adenocarcinoma represents a difficult task for the pathologist. The presence of an intratumoral mini-ductal plate, and in situ carcinoma in bile ducts near the tumor and modulation from the bile duct towards parenchymal liver cells represent the major criteria in assessing the identity of an adenocarcinoma as a primary CC. Primary sclerosing cholangitis and congenital bile duct cysts both put patients at risk of developing CC. Lithiasis, recurrent pyogenic cholangitis, and typhoid infection are suspected but not proven predisposing conditions. Fluke infestations (Clonorchis sinensis and Opisthorchis viverrini) play a role in Far Eastern countries. Bile duct adenoma and multiple biliary papillomatosis may carry a malignant transformation potential. Pseudopyloric metaplasia may be a precursor lesion of CC.

Proliferative activity of bile duct epithelium after bacterial infection in dogs

To clarify the relationship between proliferative activity in bile duct epithelia and bacterial infection in the dog, we induced obstructive cholestasis with a bacterial infection in two lobes of the liver. The bile duct branch draining the left lateral lobes of the liver was cannulated in all mongrel dogs. The dogs were divided into three groups and treated as follows: in group 1 the cannula was clamped after the injection of 10(7) Escherichia coli (aerobic bacteria) and 10(7) Bacteroides fragilis (anaerobic bacteria) cells; in group 2 the cannula was clamped after the injection of 10(7) E. coli cells; and in group 3 the cannula was clamped without the injection of any bacteria. Three months and 9 months later dogs from each group were killed, and their livers were examined. In the group 1 dogs papillary hyperplasia and severe dysplasia were noted in association with chronic cholangitis at 3 months and 9 months, respectively, after operation. In the group 2 dogs periductal fibrosis was severe, but epithelial papillary hyperplasia was less pronounced than in the group 1 dogs at each period. In the group 3 dogs no periductal fibrosis or epithelial papillary hyperplasia was seen at either 3 or 9 months postoperatively. These findings suggest that papillary hyperplasia and/or severe dysplasia of the bile duct epithelium may be caused by aerobic and anaerobic bacterial infection of the biliary tract in combination with bile stasis.

Histomorphological characteristics of cholangiocellular carcinomas in northeast Thailand, where a region infection with the liver fluke, Opisthorchis viverrini is endemic

Northeast Thailand has a very high incidence rate of intrahepatic biliary tumors which is believed to closely related to infestation with the liver fluke, Opisthorchis viverrini. This study was conducted to ascertain whether there are any phenotypic differences in such tumors between northeast Thailand and Japan, a country free of liver flukes. Forty one intrahepatic cholangiocarcinomas from patients in northeast Thailand were histopathologically compared with 39 lesions collected in Japan. The proportions of each type of adenocarcinoma in the Thailand cases were similar to those of the Japanese cases except that medullary type poorly differentiated tubular adenocarcinoma was only found in the series from Thailand. Whether the presence of medullary lesions only in the cases from the area of endemic fluke infection implies differences in etiology remains in question. The similarity in the majority of histological types, the inflammatory reactions observed in the bile ducts and the earlier development of tumors in association with parasites suggests that tumor promotion resulting from liver fluke infection rather than quantitative or qualitative differences in genetic alterations is responsible for the high frequency of cholangiocellular carcinomas in northeast Thailand.

A morphologic and immunocytochemical study of hepatic neoplasms in cats

A retrospective study was done of 47 neoplasms of the hepatic and biliary systems from 47 cats brought to The Animal Medical Center over a period of 10 years (1980 to 1989). Histologic examination of specimens taken at necropsy revealed that 87% (41/47) of the hepatic neoplasms were epithelial and 13% (6/47) were nonepithelial. Of the epithelial tumors, 25/47 (53%) were of intrahepatic bile duct origin, 9/47 (19%) were of hepatocellular origin, 5/47 (11%) involved the extrahepatic bile ducts, and 2/47 (4%) were adenocarcinomas of the gall bladder. Of the nonepithelial neoplasms, hemangiosarcomas were more common, 5/47 (11%), than leiomyosarcomas, 1/47 (2%). Multiple liver lobes were involved in 21/34 (62%) of the epithelial and all six of the nonepithelial intrahepatic neoplasms. Most of the bile duct adenocarcinomas (6/9) were predominantly characterized by acinar structures with mucin production, diffuse necrosis, and little desmoplasia. The hepatocellular carcinomas were characterized by three patterns-trabecular (five tumors), pseudoglandular pattern (two tumors), and anaplastic (one tumor). The hepatic carcinoid was characterized by various-sized groups of acinar and rosettelike structures, some with lumens, separated by thin fibrovascular stroma. The extrahepatic bile duct adenocarcinomas (4/4) were acinopapillary with moderate desmosplasia, whereas the adenocarcinomas of the gall bladder had elongated tubular structures lined by anaplastic cells and a severe desmoplastic reaction. The neuroendocrine carcinoma of the extrahepatic bile duct, the hemangiosarcomas, and the leiomyosarcoma had morphologic features characteristic of these neoplasms. Two of the 16 (13%) bile duct adenomas had anaplastic and precancerous changes. Residual benign components were seen in 10/15 (67%) of the biliary adenocarcinomas, 4/9 (44%) of the intrahepatic bile duct adenocarcinomas, and all of the extrahepatic bile duct adenocarcinomas and gall bladder adenocarcinomas. Results of immunohistochemical studies of the biliary neoplasms were similar to those described in studies of biliary neoplasms in human beings. Results of this study revealed that the frequency of different types of hepatic neoplasms in cats varied from that seen in dogs and human beings, but the morphologic features were comparable.

Histological features and interphase nucleolar organizer regions in hyperplastic, dysplastic and neoplastic epithelium of intrahepatic bile ducts in hepatolithiasis

Neoplastic transformation occurs in the intrahepatic biliary tree in hepatolithiasis. The present study aimed to clarify the neoplastic processes by correlating the histological features of the bile duct lesions with counts of interphase argyrophilic nucleolar organizer regions (AgNORs), which reflect cell proliferative activity. We studied 55 cases of hepatolithiasis and 25 normal autopsy livers. The biliary epithelial lesions in hepatolithiasis were divisible into hyperplasia, dysplasia and neoplasia. These lesions were found in bile ducts containing calculi. All cases of hepatolithiasis showed a varied degree of hyperplasia. Additionally, eight cases showed dysplasia, five non-invasive intraductal adenocarcinoma and 10 invasive adenocarcinoma. Cases of non-invasive and invasive carcinoma frequently harboured areas of dysplasia, and areas of dysplasia and non-invasive carcinoma, respectively. The mean and standard deviation of the number of interphase AgNORs in the normal and abnormal biliary epithelium showed a step-wise increase in the following order: normal (1.32 +/- 0.36), hyperplasia (1.52 +/- 0.37), dysplasia (2.28 +/- 0.56), non-invasive carcinoma (3.23 +/- 1.00), and invasive carcinoma (3.72 +/- 0.77). These histological and cell kinetic observations suggest that, in hepatolithiasis, carcinogenesis in bile duct epithelial cells progresses in a multi-step manner, through hyperplasia, dysplasia, non-invasive adenocarcinoma and invasive adenocarcinoma.

Cell kinetic analyses and expression of carcinoembryonic antigen, carbohydrate antigen 19-9 and DU-PAN-2 in hyperplastic, pre-neoplastic and neoplastic lesions of intrahepatic bile ducts in livers with hepatoliths

We evaluated cell proliferative activity and expression of carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9) and DU-PAN-2 in various bile duct lesions in livers with hepatoliths, using histochemical and immunohistochemical methods. Histologically, the bile duct lesions were divisible into hyperplasia, dysplasia, adenocarcinoma in situ and invasive adenocarcinoma. All cases showed mucosal hyperplasia in stone-bearing bile ducts. Livers with invasive adenocarcinoma frequently contained adenocarcinoma in situ and dysplasia, and livers with adenocarcinoma in situ occasionally harboured dysplasia. Proliferating cell nuclear antigen (PCNA) labelling index was low in hyperplasia (mean +/- SD = 20.5 +/- 8.7%), intermediate in dysplasia (35.4 +/- 15.9%), and high in adenocarcinoma in situ (46.4 +/- 9.3%). The mean number of argyrophilic nucleolar organizer regions (AgNORs) was low in hyperplasia (1.52), intermediate in dysplasia (2.26) and high in adenocarcinoma in situ (2.69). There was a significant positive correlation between PCNA labelling index and AgNORs count. CEA was expressed on invasive adenocarcinoma cells and adenocarcinoma in situ cells in most cases and on dysplastic cells in about a half, while CEA was never present in hyperplastic epithelia. Expression of CA 19-9 was low in adenocarcinoma, intermediate in dysplasia and rather high in hyperplasia. There was no significant difference in DU-PAN-2 expression among these bile duct lesions. These data suggest that cell replicative activity is low in hyperplasia, intermediate in dysplasia and high in adenocarcinoma in situ, and that CEA appears in the following order: dysplasia, adenocarcinoma in situ, invasive adenocarcinoma. We suggest that carcinogenesis in biliary epithelial in livers with stones is a multi-step process through hyperplasia, dysplasia and adenocarcinoma in situ to invasive adenocarcinoma.

Mucosal dysplasia of the liver and the intraductal variant of peripheral cholangiocarcinoma in hepatolithiasis

Four cases are reported of the intraductal variant of peripheral cholangiocarcinoma among surgical specimens from 32 cases of hepatolithiasis. The cancers arose from the periphery of the stone-containing bile duct and spread chiefly along the luminal surface. Microscopically, these tumors showed papillary proliferation and therefore were diagnosed as the intraductal spreading type of peripheral cholangiocarcinoma. Mucosal dysplasia also was noticed in the vicinity of the tumors. In six other cases, mucosal dysplasia was observed in the periphery of the stone. Immunohistochemically, anti-CA 19-9 staining was observed diffusely in the cytoplasm of dysplastic lesions and carcinomas. Anti-carcinoembryonic antigen staining was restricted to the luminal surface and/or the supranuclear region of the cytoplasm in carcinomas. It was not identified in dysplastic cells. These results suggest that the mucosal dysplasia occasionally observed near stones is a precursor of the intraductal spreading type of peripheral cholangiocarcinoma in the presence of hepatolithiasis. The authors hypothesize that the lining epithelium of the large bile duct, when persistently exposed to biochemically altered bile, may undergo a carcinomatous transformation through a stage of mucosal dysplasia.

Mucosal dysplasia of the liver and the intraductal variant of peripheral cholangiocarcinoma in hepatolithiasis

Four cases are reported of the intraductal variant of peripheral cholangiocarcinoma among surgical specimens from 32 cases of hepatolithiasis. The cancers arose from the periphery of the stone-containing bile duct and spread chiefly along the luminal surface. Microscopically, these tumors showed papillary proliferation and therefore were diagnosed as the intraductal spreading type of peripheral cholangiocarcinoma. Mucosal dysplasia also was noticed in the vicinity of the tumors. In six other cases, mucosal dysplasia was observed in the periphery of the stone. Immunohistochemically, anti-CA 19-9 staining was observed diffusely in the cytoplasm of dysplastic lesions and carcinomas. Anti-carcinoembryonic antigen staining was restricted to the luminal surface and/or the supranuclear region of the cytoplasm in carcinomas. It was not identified in dysplastic cells. These results suggest that the mucosal dysplasia occasionally observed near stones is a precursor of the intraductal spreading type of peripheral cholangiocarcinoma in the presence of hepatolithiasis. The authors hypothesize that the lining epithelium of the large bile duct, when persistently exposed to biochemically altered bile, may undergo a carcinomatous transformation through a stage of mucosal dysplasia.

Intrahepatic cholangiocarcinoma in hepatolithiasis: A frequently overlooked disease

Five cases of intrahepatic cholangiocarcinoma were found among 101 cases of hepatolithiasis. There was no definite sign of cholangiocarcinoma in ERCP and image studies of four cases. The possibility of the existence of occult cholangiocarcinoma should be kept in mind, especially when unusual presentations, such as body weight loss, anemia, palpable abdominal mass, and intractable pain, appear. An intraoperative frozen-section examination should be considered under the following circumstances: (1) whitish nodular mass over liver, (2) mucinous substance within bile duct, and (3) enlarged, firm lymph nodes clustered along the hepatic arteries and/or celiac arteries.

'Metaplastic lesions' in intrahepatic bile ducts in hepatolithiasis: a histochemical and immunohistochemical study

Pathology of the intrahepatic bile ducts bearing calculi was examined with an emphasis on metaplasia in 22 cases of hepatolithiasis and in seven cases of normal livers. Normal livers contained few glandular elements within the bile duct walls and no metaplastic lesions or endocrine cells. In hepatolithiasis, a number of mucous glands resembling pyloric glands (pseudopyloric gland metaplasia) were seen within duct walls in all cases. The epithelial cells of the glands were positive for class III mucin with paradoxical concanavalin A staining which is known to be specific for pyloric glands. These cells were also positive for neutral, sialo- and sulfomucin to a variable extent. Intestinal metaplasia, including goblet cell and Paneth cell metaplasia, was found within duct walls and in covering epithelia in five (23%) cases. Endocrine cells, including argyrophil, argentaffin and gut hormone-containing cells were present in these metaplastic lesions in 13 (59%) cases. The occurrence of endocrine cells was closely associated with intestinal metaplasia, although there were a few endocrine cells in metaplastic pseudopyloric glands. These findings suggest that metaplastic lesions similar to the well-known metaplastic lesions in the gallbladder occur in the intrahepatic bile duct walls in hepatolithiasis. The appearance of metaplastic lesions and endocrine cells may be causally related to chronic inflammatory processes associated with hepatolithiasis.

Clinical experience in 20 hepatic resections for peripheral cholangiocarcinoma

During the 10-year period from 1978 to 1987, hepatic resections were performed on 20 patients with peripheral cholangiocarcinoma (PCC). Nine of these patients were men and 11 were women (mean age, 48.5 years). Among them, 80% had intrahepatic stones with recurrent cholangitis. The 20 patients were subdivided into the following three groups: Group I (12 patients with surgery for PCC); Group II (4 patients with surgery for chronic cholangitis [but the final pathologic diagnosis confirmed PCC]); and Group III (4 patients with surgery for space-occupying liver lesions). No early postoperative mortality was noticed. The few complications that occurred were related to surgery for hepatolithiasis. Postoperative wound infection was the most common complication. The overall mean survival time was 20.5 months. Four patients survived for more than 3 years; one was even alive for more than 5 years after surgery.

Intraoperative fiberoptic choledochoscopy for malignant biliary tract obstruction

A prospective study to determine the safety and effectiveness of intraoperative fiberoptic choledochoscopy in the management of malignant obstruction of the biliary tree was conducted in 44 patients. There were 12 patients with cancer of the pancreatic head, 9 with adenocarcinoma of the distal common bile duct, 4 with adenocarcinoma of the ampulla of Vater, 8 with cholangiocarcinoma of the common hepatic duct, 9 with intrahepatic bile duct carcinoma, and 2 with hepatocellular carcinoma. Five patients with intrahepatic bile duct carcinoma and two with hepatocellular carcinoma were found during a search for intrahepatic duct stones in patients with recurrent cholangitis. In nine patients with bile duct carcinoma (seven extrahepatic and two intrahepatic), histopathological diagnosis was made at operative endoscopy. Treatment strategy was altered in seven patients based on findings at operative choledochoscopy. Complications were few with no mortality. Intraoperative fiberoptic choledochoscopy was safe and useful in the management of malignant obstruction of the biliary tree.

Clinical experience of intrahepatic cholangiocarcinoma associated with hepatolithiasis

Between 1960 and 1986, seven patients with intrahepatic cholangiocarcinoma and one patient with intrahepatic bile duct adenoma, related to hepatolithiasis, were seen among 112 cases of hepatolithiasis. Histopathologically, the tumors associated with hepatolithiasis arose from the periphery of the stone-containing bile duct, spread chiefly along the luminal surface, and invaded the ductal wall or periductal tissue. The tumors showed papillary to papillo-tubular proliferation and were diagnosed as the intraductal or periductal spreading type of cholangiocarcinoma. In addition, atypical epithelial hyperplasia was noted in the vicinity of the tumor area. These findings suggest that chronic relapsing cholangitis in patients with hepatolithiasis can induce progressive changes to atypical epithelial hyperplasia which may develop into cholangiocarcinoma.

Intrahepatic calculi associated with cholangiocarcinoma

A unique case of hepatolithiasis associated with cholangiocarcinoma is described. The intrahepatic calculi consisted mainly of cholesterol rather than calcium bilirubinate. A bacteriological study of the intrahepatic and gallbladder bile was negative, though bacterial infection of the bile duct has been considered a main factor responsible for formation of intrahepatic calculi.