Clinical experience of intrahepatic cholangiocarcinoma associated with hepatolithiasis

Liver resection for hepatolithiasis: A multicenter experience in Latin America

BACKGROUND

Hepatolithiasis is a prevalent disease in Asia but rare in Western countries. An increasing number of cases have been reported in Latin America. Liver resection has been proposed as a definitive treatment for complete stone clearance. The aim of this study was to evaluate the postoperative outcomes of liver resection for the treatment of hepatolithiasis in 2 large hepatobiliary reference centers from South America.

METHODS

We conducted a retrospective descriptive analysis from patients with hepatolithiasis who underwent liver resection between November 1986 and December 2018, in 2 Latin-American centers in Chile and Brazil.

RESULTS

One hundred forty-nine patients underwent liver resection for hepatolithiasis (72 in Chile, 77 in Brazil). The mean age was 49 years and most patients were female (62.4%). Hepatolithiasis was localized in the left lobe (61.7%), right lobe (24.2%), and bilateral lobe (14.1%). Bilateral lithiasis was associated with higher incidence of preoperative and postoperative cholangitis (81% vs 46.9% and 28.6% vs 6.1%) and need for hepaticojejunostomy (52.4%). In total, 38.9% of patients underwent major hepatectomy and 14.1% were laparoscopic. The postoperative stone clearance was 100%. The 30-day morbidity and mortality rates were 30.9% and 0.7%, respectively. Cholangiocarcinoma was seen in 2 specimens, and no postoperative malignancy were seen after a median follow-up of 38 months. Fourteen patients (9.4%) had intrahepatic stones recurrence.

CONCLUSIONS

Liver resection is an effective and definitive treatment for patients with hepatolithiasis. Bilateral hepatolithiasis was associated with perioperative cholangitis, the need for hepaticojejunostomy, and recurrent disease. Resection presents a high rate of biliary tree stone clearance and excellent long-term results, with low recurrence rates and low risk of malignancy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Discovery of Serotransferrin Glycoforms: Novel Markers for Diagnosis of Liver Periductal Fibrosis and Prediction of Cholangiocarcinoma

Cholangiocarcinoma (CCA) caused by chronic liver fluke infection is a major public health problem in Northeast Thailand. Identification of CCA risk groups is urgently needed for the control of CCA in this region. Periductal fibrosis (PDF) induced by chronic inflammation of bile ducts is known as a pre-neoplastic lesion of CCA. We aimed to identify the serum CCA and PDF biomarkers using mass spectrometry (UPLC-ESI-QqQ) with multiple reaction mode (MRM) analysis. Here, serum levels of serotransferrin glycoforms at the glycopeptide level were measured in the sera of CCA (n = 100), PDF (n = 50), and healthy control (n = 100) subjects. The results indicated that serotransferrin peptide levels were generally the same between the control and PDF groups, whereas CCA patients had reduced levels. Moreover, 56 serotransferrin glycoforms were detected, with nine increased in CCA compared to control subjects. Among them, the serum levels of four glycoforms were increased in PDF and CCA patients compared to control subjects. In particular, highly sialylated multi-branched glycans of serotransferrin serum were significantly correlated with poor prognosis and tumor stage in CCA patients. Taken together, these glycoforms could be used as risk biomarkers and prognosis and diagnosis markers of CCA.

Intrahepatic cholangiocarcinoma prognostic determination using pre-operative serum C-reactive protein levels

Background

Serum C-reactive protein (CRP), an acute inflammatory response biomarker, has been recognized as an indicator of malignant disease progression. However, the prognostic significance of CRP levels collected before tumor removal in intrahepatic cholangiocarcinoma requires further investigation.

Methods

We sampled the CRP levels in 140 patients with intrahepatic cholangiocarcinoma who underwent hepatectomies with regional lymphadenectomies between 2006 and 2013. A retrospective analysis of the clinicopathological data was performed. We focused on the impact of serum CRP on the patients’ cancer-specific survival and recurrence-free survival rates.

Results

High levels of preoperative serum CRP were significantly associated with well-established clinicopathologic features, including gender, advanced tumor stage, and elevated carcinoembryonic antigen and carbohydrate antigen 19-9 levels (P < 0.05). Univariate analysis demonstrated a significant association between high levels of serum CRP and adverse cancer-specific survival (P = 0.001) and recurrence-free survival (P < 0.001). In patients with stage I/II intrahepatic cholangiocarcinoma, the serum CRP level was a prognostic indicator for cancer-specific survival. In patients with stage I/II or stage III/IV, the serum CRP level was a prognostic indicator for recurrence-free survival (P < 0.05). Additionally, multivariate analysis identified serum CRP level in intrahepatic cholangiocarcinoma as an independent prognostic factor (P < 0.05).

Conclusions

We confirmed a significant association of elevated pre-operative CRP levels with poor clinical outcomes for the tested patients with intrahepatic cholangiocarcinoma. Our results indicate that the serum CRP level may represent a useful factor for patient stratification in intrahepatic cholangiocarcinoma management.

Incidence of Cholangiocarcinoma with or without Previous Resection of Liver for Hepatolithiasis

BACKGROUND/AIMS

To investigate the incidence of cholangiocarcinoma in patients with hepatolithiasis with or without previous resection of liver.

METHODS

From 2002 to 2009, we retrospectively reviewed 117 patients who were diagnosed and treated for hepatolithiasis in Korea University Guro Hospital. Among the 117 patients, 55 patients who were lost during follow-up were excluded, and 62 patients were eligible for analysis. The hepatic resection group (n=25) included patients who underwent left hemihepatectomy (n=2); left lateral segmentectomy (n=10); left lobectomy (n=9); right lobectomy (n=3); or wedge resection (n=1). The nonhepatic resection group (n=37) included transhepatic cholangiographic lithotomy and endoscopic retrograde cholangiopancreatography-treated patients. The mean follow-up period was 47 months.

RESULTS

The incidence of cholangiocarcinoma while patients were followed for hepatolithiasis was 12.9% (8/62) (hepatic resection group, three cases [12%] vs nonhepatic resection group, five cases [13.5%]; p=1.000). The mean follow-up period was 53 months (47±11 months) until the diagnosis of cholangiocarcinoma.

CONCLUSIONS

There was no difference in the incidence of cholangiocarcinoma according to previous liver resections. Patients with hepatolithiasis should be carefully followed up for detection of cholangiocarcinoma even after a previous liver resection.

Intrahepatic cholangiocarcinoma associated with intrahepatic duct stones

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Unusual cases of acute cholecystitis and cholangitis: Tokyo Guidelines

Unusual cases of acute cholecystitis and cholangitis include (1) pediatric biliary tract infections, (2) geriatric biliary tract infections, (3) acalculous cholecystitis, (4) acute and intrahepatic cholangitis accompanying hepatolithiasis (5) acute biliary tract infection accompanying malignant pancreatic-biliary tumor, (6) postoperative biliary tract infection, (7) acute biliary tract infection accompanying congenital biliary dilatation and pancreaticobiliary maljunction, and (8) primary sclerosing cholangitis. Pediatric biliary tract infection is characterized by great differences in causes from those of adult acute biliary tract infection, and severe cases should be immediately referred to a specialist pediatric surgical unit. Because biliary tract infection in elderly patients, who often have serious systemic conditions and complications, is likely to progress to a serious form, early surgery or biliary drainage is necessary. Acalculous cholangitis, which often occurs in patients with serious concomitant conditions, such as those in intensive care units (ICUs) and those with disturbed cardiac, pulmonary, and nephric function, has a high mortality and poor prognosis. Cholangitis accompanying hepatolithiasis includes recurrent pyogenic cholangitis, an epidemic disease in Southeast Asia. Biliary tract infections, which often occur after a biliary tract operation and treatment of the biliary tract, may have a fatal outcome, and should be carefully observed. The causes of acute cholangitis associated with pancreaticobiliary maljunction differ before and after operation. Direct cholangiography is most useful in the diagnosis of primary sclerosing cholangitis. If cholangiography visualizes a typical bile duct, differentiation from acute pyogenic cholangitis is easy. This article discusses the individual characteristics, diagnostic criteria, treatment guidelines, and prognosis of these unusual types of biliary tract infection.

Alteration in N -acetylglucosaminyltransferase activities and glycan structure in tissue and bile glycoproteins from extrahepatic bile duct carcinoma

The activities of three N -acetylglucosaminyltransferases (GnT)-III, IV and V, as well as the structural alterations of N-glycans on the glycoproteins in cancer tissues and bile specimens from 28 cases of extrahepatic bile duct carcinoma (EBDC) were compared with those from 18 cases of benign biliary duct diseases (BBDD). GnT activities were determined with fluorescence-labeled substrate using a HPLC method. It was found that GnT-III and GnT-V activities in EBDC were increased to 3.14 and 15.96 times respectively of the mean BBDD values, but GnT-IV remained unchanged. The activity of GnT-V was correlated with the grade of differentiation and TMN stage of EBDC. The up-regulation of GnT-III resulted in the increased bisecting-GlcNAc on the N-glycans of glycoproteins in cancer tissues and a 201 kDa bile glycoprotein when analyzed with HRP-labeled E(4)-PHA. The increased GnT-V activity led to the elevation of the beta1,6GlcNAc branch (or antennary number) on the N-glycans in cancer tissue glycoproteins and 201, 163, 122 kDa proteins in the bile as probed with HRP-labeled DSA. These findings suggest that the alteration in GnT activities may be involved in the malignant transformation and development of EBDC, resulting in the aberrant glycosylation of some tissue and bile proteins. The latter was expected to be used in the clinical diagnosis and prognosis evaluation in EBDC patients.

Relation of hepatolithiasis to helminthic infestation

BACKGROUND AND AIM

The relation of helminthic infestation to hepatolithiasis is a subject of dispute. This case-control study was undertaken to evaluate the prevalence of helminthiasis in hepatolithiasis patients and to compare the clinicopathological features of hepatolithiasis between patients with and without helminthiasis.

METHODS

The prevalence of ascariasis or clonorchiasis was evaluated using ELISA in 131 patients with hepatolithiasis who were treated at Show-Chwan Memorial Hospital and 121 subjects who constituted a control group. The patients' detailed histories and medical charts were reviewed.

RESULTS

The prevalence of positive immunodiagnosis of ascariasis and clonorchiasis was higher in patients with hepatolithiasis than in control subjects (33.6%, 44/131 vs 17.4%, 21/121, odds ratio [OR] = 2.41, 95% confidence interval [CI] = 1.28-4.56, P = 0.005; and 6.9%, 9/131 v 0.8%, 1/121, OR = 8.85, 95% CI = 1.12-188.69, P = 0.02). Patients with helminthiasis rarely had concurrent gallbladder stones (26%, 12/47 vs 55%, 46/84, OR = 0.28, 95% CI = 0.12-0.66, P = 0.002). Prior to the diagnosis of hepatolithiasis in adulthood, most of the patients with helminthiasis tended to have a history of recurrent abdominal pain in their childhood and an asymptomatic 'lucid interval' during their teenage years (70.2%, 33/47 vs 39.3%, 33/84, OR = 3.64, 95% CI = 1.59-8.42, P = 0.0005). However, the prevalence of intrahepatic duct stricture (38.3%, 18/47 vs 40.5%, 34/84, OR = 0.91, 95% CI = 0.41-2.02, P > 0.05), secondary biliary cirrhosis (6.4%, 3/47 vs 3.6%, 3/84, OR = 1.84, 95% CI = 0.28-12.03, P > 0.05), cholangiocarcinoma (2.1%, 1/47 vs 0%, 0/84, OR = approximately , P > 0.05), and stone recurrence (54.8%, 24/42 vs 50.0%, 38/76, OR = 1.33, 95% CI = 0.58-3.06, P > 0.05) did not significantly increase.

CONCLUSIONS

Helminthiasis is a possible risk factor for hepatolithiasis, although it is unlikely to increase the incidence of complications, including bile duct stricture, secondary biliary cirrhosis, and cholangiocarcinoma. Patients with helminthiasis tend to have a history of an asymptomatic 'lucid interval' between the periods of recurrent abdominal pain in their childhood and the diagnosis of hepatolithiasis in their adulthood.

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

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

Long-term outcome of percutaneous transhepatic cholangioscopic lithotomy for hepatolithiasis

OBJECTIVES

Percutaneous transhepatic cholangioscopic lithotomy (PTCSL) for the treatment of hepatolithiasis is particularly suited for those patients who are poor surgical risks or who refuse surgery and those with previous biliary surgery or stones distributed in multiple segments. However, hepatolithiasis is characterized by high rates of treatment failure and recurrence. We examined the long-term results of 245 patients with hepatolithiasis treated by PTCSL.

METHODS

This was a retrospective study of 245 patients who underwent PTCSL for hepatolithiasis; the patients were followed for 1-22 yr to evaluate the immediate and long-term results. Sonography was used to search for stone recurrence every year or whenever the patients presented symptoms suggestive of cholangitis. Cholangiography and/or CT were performed to verify recurrence.

RESULTS

PTCSL achieved complete clearance of hepatolithiasis in 209 patients (85.3%); the rate of incomplete clearance was higher in patients with intrahepatic duct stricture (29/118, 24.6% vs 7/127, 5.5%; p = 0.002). The rate of major complications was 1.6% (4/245) and included liver laceration (n = 2), intra-abdominal abscess (n = 1), and disruption of the percutaneous transhepatic biliary drainage fistula (n = 1). The overall recurrence rate of hepatolithiasis and/or cholangitis was 63.2%. The absolute rate of stone recurrence was not significantly related to the presence of intrahepatic duct stricture (51/89, 56.2% vs 53/120, 44.4%; p = 0.08), although the median time to recurrence was less in those with stricture (11 vs 18 yr; p = 0.007). In the patients without intrahepatic duct stricture, the rate of complete stone clearance was not related to the presence of dilation (34/38, 89.5% vs 86/89, 96.6%; p = 0.196), but the recurrence rate was higher in those with dilation (20/34, 58.8% vs 33/86, 38.4%; p = 0.042). Among the 209 patients with a successful initial PTCSL, the incidence of recurrent cholangitis or cholangiocarcinoma was significantly higher in those with incompletely removed recurrent hepatolithiasis than in those without coexisting hepatolithiasis (44.3%, 27/61 vs 16.2%, 24/148; p < 0.001 and 6.6%, 4/61 vs 0.7%, 1/148; p = 0.026).

CONCLUSIONS

PTCSL is a relatively safe and effective procedure for treating hepatolithiasis. Long-term follow-up is required because the overall recurrence rate of hepatolithiasis and/or cholangitis is high. The rate of complete stone clearance and the median time to stone recurrence are less in the presence of stricture, but the absolute rate of stone recurrence is not significantly related to stricture. In the absence of stricture, the rate of stone recurrence is higher in patients with dilated intrahepatic duct. Complete stone clearance is necessary, because the incidence of recurrent cholangitis or cholangiocarcinoma is higher in patients with incomplete clearance of recurrent hepatolithiasis.

What is the impact of coexistence of hepatolithiasis on cholangiocarcinoma?

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The significance of hepatectomy for primary intrahepatic stones

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

Hepatolithiasis associated with cholangiocarcinoma

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Hepatolithiasis associated with cholangiocarcinoma

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

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

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

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

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

Histological evaluation of the intrahepatic biliary tree in intrahepatic cholesterol stones, including immunohistochemical staining against apolipoprotein A-1

Apolipoprotein A-1 is known to be one of inhibiting factors of cholesterol nucleation in bile, and decreased activity of apolipoprotein A-1 is considered to predispose cholesterol-supersaturated bile to formation of cholesterol crystals. To study the pathogenesis of the intrahepatic formation of cholesterol stones, we examined surgically resected liver specimens from six patients with intrahepatic cholesterol stones and compared the characteristic histopathological features with those of intrahepatic calcium bilirubinate stones, using morphological examination and immunohistochemical staining against apolipoprotein A-1. Morphologically, in all six patients with cholesterol stones the severity of chronic proliferative cholangitis with proliferation of the mucus-producing glandular elements in the walls of the large bile duct or periductal tissues was less extensive than that seen with calcium bilirubinate stones, and cholesterol crystals had formed in the septal and interlobular bile ducts. Immunohistochemically, unlike the normal liver and calcium bilirubinate stone-containing lobes, the hepatocytes and the epithelial lining of the bile ducts and peribiliary glands of the cholesterol stone-containing lobes did not react completely (some of the epithelial cells reacted only faintly) with apolipoprotein A-1 antibody. These findings suggest that an abundance of mucous substance and bacterial infection of the biliary tree may not be necessary for the formation of cholesterol stones, compared with findings in cases of calcium bilirubinate stones. We suggest that cholesterol crystals may be produced in the septal and interlobular bile ducts in the microenvironment of cholesterol-supersaturated bile and decreased activity of apolipoprotein A-1.

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.

Complications of hepatolithiasis

Hepatolithiasis or intrahepatic stone is associated with a variety of complications of which biliary sepsis is one. Left untreated, infection results in formation of micro-abscesses, portal thrombophlebitis and fistulation into adjacent structures. With repeated infection, biliary strictures and severe destruction of liver parenchyma occur. Biliary cirrhosis, portal hypertension and bleeding varices are the terminal manifestations. Early recognition and proper treatment are essential for the prevention of severe complications and functional deterioration.