Intrahepatic cholangiocarcinoma associated with intrahepatic duct stones

Predicting peritumoral Glisson's sheath invasion of intrahepatic cholangiocarcinoma with preoperative CT imaging

Background

To investigate the differences of clinicopathological characteristics and computed tomography (CT) features between intrahepatic cholangiocarcinomas (ICC) with and without peritumoral Glisson's sheath invasion (PGSI), and to construct a nomogram to predict PGSI of ICCs preoperatively.

Methods

The clinicopathological characteristics and CT features of 84 ICCs were retrospectively analyzed and compared between ICCs with (30/84, 35.7%) and without PGSI (54/84, 64.3%). Multivariate logistic regression analysis was used to identify preoperative independent predictors of PGSI in ICCs. A nomogram was constructed to predict PGSI preoperatively.

Results

ICCs with and without PGSI differed significantly in the presence of abdominal pain, serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels, TNM and T stages, tumor location, intratumoral calcifications, intrahepatic bile duct dilatation, intrahepatic bile duct calculus, morphologic type and dynamic enhancement pattern on CT images (all P<0.05). Abdominal pain, serum CEA level, intrahepatic bile duct dilatation, and morphologic type were independent predictors of PGSI in ICCs. A nomogram based on those predictors was constructed to predict PGSI preoperatively with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.908 (P<0.001).

Conclusions

Clinicopathological characteristics and CT features differed significantly between ICCs with and without PGSI. A nomogram including abdominal pain, serum CEA level, intrahepatic bile duct dilatation, and morphologic type could predict PGSI accurately.

Hepatolithiasis and intrahepatic cholangiocarcinoma: A review

Although the incidence of hepatolithiasis is decreasing as the pattern of gallstone disease changes in Asia, the prevalence of hepatolithiasis is persistently high, especially in Far Eastern countries. Hepatolithiasis is an established risk factor for cholangiocarcinoma (CCA), and chronic proliferative inflammation may be involved in biliary carcinogenesis and in inducing the upregulation of cell-proliferating factors. With the use of advanced imaging modalities, there has been much improvement in the management of hepatolithiasis and the diagnosis of hepatolithiasis-associated CCA (HL-CCA). However, there are many problems in managing the strictures in hepatolithiasis and differentiating them from infiltrating types of CCA. Surgical resection is recommended in cases of single lobe hepatolithiasis with atrophy, uncontrolled stricture, symptom duration of more than 10 years, and long history of biliary-enteric anastomosis. Even after resection, patients should be followed with caution for development of HL-CCA, because HL-CCA is an independent prognostic factor for survival. It is not yet clear whether hepatic resection can reduce the occurrence of subsequent HL-CCA. Furthermore, there are no consistent findings regarding prediction of subsequent HL-CCA in patients with hepatolithiasis. In the management of hepatolithiasis, important factors are the reduction of recurrence of cholangitis and suspicion of unrecognized HL-CCA.

Cholangiocarcinoma Risk as Long-term Outcome After Hepatic Resection in the Hepatolithiasis Patients

BACKGROUND

Hepatolithiasis is a well-known risk factor of cholangiocarcinoma. Despite advances in diagnostic modalities, diagnosing cholangiocarcinoma in patients with hepatolithiasis still challenging and there are not enough reports on the incidence of cholangiocarcinoma in patient with hepatolithiasis after treatment. We aimed to evaluate the incidence and clinical characteristics of cholangiocarcinoma in patients with hepatolithiasis who underwent liver resection or non-resection.

METHODS

Among a total of 257 patients who received treatment for hepatolithiasis, 236 patients were eligible for analysis. Exclusion criteria were follow-up period less than 9 months, preoperative diagnosis of cholangiocarcinoma, occurrence of cholangiocarcinoma within 1 year after treatment. Completeness of stone clearance was defined when there was no intrahepatic duct stone during whole follow-up period. A retrospective study was done to analyze the patients' characteristics, the results and complications of the procedure, and the long-term outcomes for these patients. Kaplan-Meier method and cox proportional regression were used for statistical analysis.

RESULTS

95 patients underwent hepatic resection (resection group) and 144 patients did not (non-resection group). Complete stone clearance was 71% (67/95) in resection group and 41% (58/141) in non-resection group (p < 0.001). The incidence of cholangiocarcinoma was 6.8% (16/236) during follow-up period (mean 41 ± 41 months). Cholangiocarcinoma occurred 6.3% (6/95) and 7.1% (10/141) in resection and non-resection group, respectively. There was no significant difference in survival between two groups (p = 0.254). In analysis of according to completeness of stone clearance regardless of treatment modality, cholangiocarcinoma incidence was higher in patients with residual stone (10.4%) than complete stone removal (3.3%) (p = 0.263). On multivariate analysis, none of the factors (age, gender, CA19-9, stone location, bile duct stenosis, liver atrophy, stone recurrence, residual stone, and hepatic resection) showed relationship with the incidence of cholangiocarcinoma.

CONCLUSION

Hepatic resection for hepatolithiasis is considered to have a limited value in preventing cholangiocarcinoma and the patients should be carefully followed even after hepatic resection. A combination of different treatment modalities is necessary to decrease the residual stone and improve the outcome of the patients with hepatolithiasis.

Complete radiofrequency ablation of hepatolithiasis-associated cholangiocarcinoma and successful management of post-ablation bronchobiliary fistula

This report documented the use of radiofrequency ablation (RFA) in the treatment of hepatolithiasis-associated cholangiocarcinoma and cyanoacrylate glue in the management of post-ablation bronchobiliary fistula. A 47-year-old Chinese woman with 20 years history of extrahepatic and intrahepatic cholangiolithiasis and multiple hepatic segmentectomy, developed hepatolithiasis-associated cholangiocarcinoma. The tumor was successfully treated with RFA but patient developed bronchobiliary fistula. Cyanoacrylate glue was used for occluding the bronchobiliary fistula. CT scan at 3 months showed complete restoration of physiological separation between the biliary and bronchial system. Repeat CT scan showed complete tumor ablation with no signs of tumor recurrence 10 months after RFA. In conclusion, RFA may be a safe and effective treatment option for patients with hepatolithiasis-associated cholangiocarcinoma who are poor candidates for surgical resection. Protection of the integrity of the bile duct and diaphragm during RFA can minimize postoperative complications. In case of development of post-ablation bronchobiliary fistula, cyanoacrylate glue can be used to occlude the fistula, before surgical resection is considered.

Effect of the GLP-1 analog exendin-4 and oxaliplatin on intrahepatic cholangiocarcinoma cell line and mouse model

The influence of Glucagon-like peptide-1 (GLP-1) and Exendin-4 on development of intrahepatic cholangiocarcinoma (ICC) is evaluated in the study. In vitro tests, including acute toxicity test, cell colony formation assays, cells proliferation and apoptosis, transwell assay, were performed. An ICC in situ tumor animal model was established. Then, animals were randomly divided into four groups (n = 6): control, Exendin-4 treatment, oxaliplatin treatment and Exendin-4-oxaliplatin treatment. Animals in the Exendin-4 treatment and Exendin-4-oxaliplatin treatment groups received a subcutaneous injection of Exendin-4 (100 μg/kg/day) for 1 week, and then received oxaliplatin (10 mg/kg/week) by tail vein injection. Animals in the control group received PBS. Immunohistochemistry tests were used for PCNA, Ki67, Caspase 3 expression in tumor tissue. Results show that that, after incubation of human cholangiocarcinoma cell lines, HuCCTI and GLP-1, or HuCCTI and Exendin-4, colony formation number was sharply decreased. However, GLP-1, HuCCTI or Exendin-4 did not affect the colony of normal cells. Combination treatment with oxaliplatin and Exendin-4 can significantly inhibit tumor cells’ proliferation and promote apoptosis. The combined effect is stronger than that of oxaliplatin or Exendin-4. Combination treatment with oxaliplatin and Exendin4 can significantly decrease Ki67 and PCNA proteins’ expression in subcutaneous tumors of nude mice. The inhibitory effect of Combination treatment with oxaliplatin and Exendin4 is clearly stronger than that of oxaliplatin. In addition, Combination treatment with oxaliplatin and Exendin4 can significantly increase Caspase3 protein positive expression. In short, these results show that combination treatment with oxaliplatin and Exendin4 can inhibit tumor cells’ proliferation, and promote apoptosis.

Diagnosis and treatment of cholangiocarcinoma in bile duct reoperation

AIM: To investigate the key points to the diagnosis and treatment of cholangiocarcinoma in bile duct reoperation.

METHODS: The clinical data for 26 patients who underwent bile duct reoperation and were finally diagnosed with cholangiocarcinoma from November 2006 to December 2011 were retrospectively analyzed.

RESULTS: There were 15 cases of intrahepatic cholangiocarcinoma and 11 cases of extrahepatic cholangiocarcinoma. For extrahepatic cholangiocarcinomas, 5 were located around the site of biliary-enteric anastomosis, and one was located within the choledochol cyst. Fifteen patients had cholelithiasis. Abdominal pain and obstructive jaundice were the most common symptom for intrahepatic cholangiocarcinomas and extrahepatic cholangiocarcinomas, respectively. Eight patients revealed atypical imaging findings, including inflammatory biliary strictures in 5 cases, atrophy of the liver in 2 cases and residual choledochol cyst in 1 case. Fourteen patients received en-bloc tumor resection.

CONCLUSION: Laboratory tests, imaging studies and frozen-section examinations should be combined to improve the diagnosis of cholangiocarcinomas in bile duct reoperation. The tumor and the residual lesion of the bile duct which causes the tumor should be removed completely.

Comparison of concomitant and subsequent cholangiocarcinomas associated with hepatolithiasis: Clinical implications

AIM: To compare the outcomes of concomitant cholangiocarcinoma (C-CCA) and subsequent cholangiocarcinoma (S-CCA) associated with hepatolithiasis.

METHODS: From December 1987 to December 2007, 276 patients underwent hepatic resection for hepatolithiasis in Changhua Christian Hospital. Sixty-five patients were excluded due to incomplete medical records and the remaining 211 patients constituted our study population base. Ten patients were diagnosed with C-CCA based on the preoperative biopsy or postoperative pathology. During the follow-up period, 12 patients developed S-CCA. The diagnosis of S-CCA was made by image-guided biopsy or by pathology if surgical intervention was carried out. Patient charts were reviewed to collect clinical information. Parameters such as CCA incidence, interval from operation to CCA diagnosis, interval from CCA diagnosis to disease-related death, follow-up time, and mortality rate were calculated for both the C-CCA and S-CCA groups. The outcomes of the C-CCA and S-CCA groups were mathematically compared and analysed.

RESULTS: Our study demonstrates the clinical implications and the survival outcomes of C-CCA and S-CCA. Among the patients with unilateral hepatolithiasis, the incidence rates of C-CCA and S-CCA were fairly similar (4.8% vs 4.5%, respectively, P = 0.906). However, for the patients with bilateral hepatolithiasis, the incidence rate of S-CCA (12.2%) was higher than that of C-CCA (4.7%), although the sample size was limited and the difference between two groups was not statistically significant (P = 0.211). The average follow-up time was 56 mo for the C-CCA group and 71 mo for the S-CCA group. Regard to the average time intervals from operation to CCA diagnosis, S-CCA was diagnosed after 67 mo from the initial hepatectomy. The average time intervals from the diagnoses of CCA to disease-related death was 41 mo for the C-CCA group and 4 mo for the S-CCA group, this difference approached statistical significance (P = 0.075). Regarding the rates of overall and disease-related mortality, the C-CCA group had significantly lower overall mortality (70% vs 100%, P = 0.041) and disease-related mortality (60% vs 100%, P = 0.015) than the S-CCA group. For the survival outcomes of two groups, the Kaplan-Meier curves corresponding to each group also demonstrated better survival outcomes for the C-CCA group (log rank P = 0.005). In the C-CCA group, three patients were still alive at the time of data analysis, all of them had free surgical margins and did not have pathologically proven lymph node metastasis at the time of the initial hepatectomy. In the S-CCA group, only one patient had chance to undergo a second hepatectomy, and all 12 S-CCA patients had died at the time of data analysis.

CONCLUSION: C-CCA has better outcomes than S-CCA. The first hepatectomy is crucial because most patients with recurrent CCA or S-CCA are not eligible for repeated surgical intervention.

Expression of HBx protein in hepatitis B virus-infected intrahepatic cholangiocarcinoma

BACKGROUND

Hepatitis B virus (HBV) is an etiological factor of intrahepatic cholangiocarcinoma (ICC), but the pathogenic mechanisms remain unclear. This study aimed to investigate the expression and possible role of HBx, an HBV-encoded potentially oncogenic protein, in HBV-infected ICC.

METHODS

Tissue samples were obtained from 54 specimens of HBV-infected ICC. Forty-four specimens were of peripheral type and 10 hilar type. Formalin-fixed, paraffin-embedded sections of the specimens were immunohistochemically stained for HBx and p53.

RESULTS

HBx expression was found in 70.4% (38/54) of the specimens, and it was more frequently seen in the peripheral type than in the hilar type (79.5% vs 30.0%, P=0.002). All three well-differentiated ICCs expressed HBx, whereas 76.9% (30/39) moderately-differentiated and 41.7% (5/12) poorly-differentiated ICCs had HBx expression (P=0.033). Patients with HBx expression had a significantly higher prevalence of elevated serum alpha-fetoprotein (P=0.033). p53 protein expression was found in 18 of 54 cases (33.3%), and was not correlated with that of HBx.

CONCLUSIONS

HBx may contribute to the pathogenesis of ICC, particularly the peripheral type. p53 abnormality may not play a significant role in HBx-mediated oncogenicity during ICC carcinogenesis.

Risk factors of intrahepatic cholangiocarcinoma in patients with hepatolithiasis: a case-control study

BACKGROUND

Why 3.3% to 10% of all patients with hepatolithiasis develop intrahepatic cholangiocarcinoma (ICC) remains unknown. We carried out a hospital-based case-control study to identify risk factors for the development of ICC in patients with hepatolithiasis in China.

METHODS

Eighty-seven patients with pathologically diagnosed hepatolithiasis associated with ICC and 228 with hepatolithiasis alone matched by sex, age (+/-2 years), hospital admittance and place of residence were interviewed during the period of 2000-2008. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for each risk factor.

RESULTS

Among the patients with hepatolithiasis associated with ICC, the mean age was 57.7 years and 61.0% were female. Univariate analysis showed that the significant risk factors for ICC development in hepatolithiasis were smoking, family history of cancer, appendectomy during childhood (under age 20), and duration of symptoms >10 years. In multivariate stepwise logistic regression analysis, smoking (OR=1.931, 95% CI: 1.000-3.731), family history of cancer (OR=5.175, 95% CI: 1.216-22.022), and duration of symptoms >10 years (OR=2.348, 95% CI: 1.394-3.952) were independent factors.

CONCLUSION

Smoking, family history of cancer and duration of symptoms >10 years may be risk factors for ICC in patients with hepatolithiasis.

Establishment and identification of the human multi-drug-resistant cholangiocarcinoma cell line QBC939/ADM

In this study, we aim to establish the human multi-drug-resistant cholangiocarcinoma cell line QBC939/ADM which can be grow and passaged steadily in 1 μg/ml concentration of adriamycin in appropriate medium. The human multi-drug-resistant cholangiocarcinoma cell line QBC939/ADM was established using the method of exposure to medium with adriamycin alternated between high and low concentration with gradually increasing concentration. Furthermore, QBC939 and QBC939/ADM were both treated with adriamycin, mitomycin and vindesine, and then detected by MTT assay, respectively. Growth cycle and intra-cellular concentrations of ADM within cells of each group were determined by flow cytometry. Expression levels of P-glycoprotein were detected by Western bolt and real-time PCR. Results showed that, compared with QBC939, the inhibitive rates of adriamycin, mitomycin and vindesine to QBC939/ADM were lower. Content of ADM in the QBC939/ADM was lower. Western bolt and real time PCR showed that P-glycoprotein in the QBC939/ADM group was over expressed. Therefore, QBC939/ADM was establish and identified as the multi-drug-resistant cell line, which can grow and be passaged steadily in 1 μg/ml concentration adriamycin in appropriate medium. And the multi-drug-resistant character of QBC939/ADM was indicated to be related to the over expression of P-glycoprotein induced by chemotherapeutic drugs.

The growth-inhibition effect of tamoxifen in the combination chemotherapeutics on the human cholangiocarcinoma cell line QBC939

In the individual application of adriamycin, mitomycin, vindesine and their combined application with tamoxifen for the pre-treatment of the human cholangiocarcinoma cell line QBC939, QBC939 was determined by MTT assay to investigate the inhibitive effect and its initial mechanism of TAM on cell growth. Growth cycle and apoptosis of each group were determined by flow cytometry. Concentration of ADM in QBC939 was detected by flow cytometry. The levels of their P-glycoprotein were detected by immunohistochemistry. The mRNA and protein levels of apoptotic-associated genes Bcl-2 and Bax were determined by western blot and real-time PCR. The inhibitive rates of adriamycin, mitomycin, vindesine to QBC939 and the apoptosis rates of QBC939 were enhanced after the pre-treatment of tamoxifen. Influence of tamoxifen in their growth cycle was not so obvious except vindesine group because of the increasing cell numbers of G (2)/M phase in which cells may be blocked. The contents of adriamycin in cells rose after the pre-treatment of tamoxifen. Expression level of the multi-drug resistant protein on cell surface was shown as (+). Furthermore, real-time PCR and Western blot analysis revealed an upregulation of Bcl-2 and a downregulation of Bax in QBC939 after the pre-treatment of tamoxifen. Therefore, tamoxifen may have the ability to enhance the relative sensitivity of QBC939 to chemotherapeutics.