Cholangiocarcinoma--current treatment options

A novel and challenging EUS-guided bridging technique for hilar cholangiocarcinoma (Bismuth IV) after total gastrectomy

The incidence of hilar cholangiocarcinoma is (1-2) / 100,0001. Due to the high location of obstruction, the treatment of hilar cholangiocarcinoma is complicated, especially for patients with gastrointestinal surgery. The traditional ERCP technique is to find a way to place more stents to treat obstructive jaundice. When ERCP fails, (Percuteneous transhepatic cholangial drainage, PTCD) is often chosen, but the effect is not ideal. The reason is that patients do not want to carry a drainage tube, which affects the quality of life of patients. Secondly, PTCD technology is bile external drainage technology, which will affect the balance of water and electrolytes in the patient's body, and the patient's appetite will also decrease. Here, we provide a bridge technique of EUS-BD to solve the problem of simultaneous drainage of left liver and right liver with a stent, in order to provide a new treatment idea for endoscopists.

PLK1 inhibition leads to mitotic arrest and triggers apoptosis in cholangiocarcinoma cells

Cholangiocarcinoma (CCA) is a lethal cancer originating from the epithelial cells within the bile duct and ranks as the second most prevalent form of liver cancer in Thailand. Polo-like kinase 1 (PLK1), a protein serine/threonine kinase, regulates a number of steps in cell mitosis and is upregulated in several types of cancer, including CCA. Our previous study identified PLK1 as a biomarker of the C1 subtype, correlating with poor prognosis in intrahepatic CCA. The present study aimed to examine the effect of PLK1 inhibition on CCA cells. Different CCA cell lines developed from Thai patients, HuCCA1, KKU055, KKU100 and KKU213A, were treated with two PLK1 inhibitors, BI2536 and BI6727, and were transfected with small interfering RNA, followed by analysis of cell proliferation, cell cycle distribution and cell apoptosis. It was discovered that BI2536 and BI6727 inhibited cell proliferation and caused G2/M-phase arrest in CCA cells. Furthermore, the number of total apoptotic cells was increased in PLK1 inhibitor-treated CCA cells. The expression levels of mitotic proteins, aurora kinase A, phosphorylated PLK1 (T210) and cyclin B1, were augmented in PLK1-inhibited CCA cells. Additionally, inhibition of PLK1 led to increased DNA damage, as determined by the upregulated levels of γH2AX and increased cleavage of poly (ADP-ribose) polymerase, an apoptotic marker. These results suggested that inhibiting PLK1 prolonged mitotic arrest and subsequently triggered cell apoptosis. Validation of the antiproliferative effects of PLK1 inhibition was accomplished through silencing of the PLK1 gene. In conclusion, targeting PLK1 provided promising results for further study as a potential candidate for targeted therapy in CCA.

Diagnostic accuracy and interobserver agreement of cholangioscopy for indeterminate biliary strictures: A single-center experience

BACKGROUND AND STUDY AIMS

Characterization of indeterminate biliary strictures (IDBS) still represents a major challenge. Digital single-operator cholangioscopy (DSOC) could potentially overcome limits of conventional biopsy and brush sampling. The aim of this study was to compare diagnostic accuracy of visual evaluation and DSOC-guided biopsies to conventional trans-papillary sampling techniques and to evaluate the inter-observer agreement (IOA) on visual diagnosis.

PATIENTS AND METHODS

All consecutive patients undergoing DSOC-guided biopsy after conventional sampling techniques for IDBS during a six-year period were retrospectively evaluated. Final diagnosis was based on histological evaluation of the surgical specimen if available or a clinical follow-up of at least 6 months. For IOA, 20-second DSOC clips were retrospectively reviewed by 6 experts and 6 trainees and classified according to the Monaco Classification.

RESULTS

Thirty-five patients underwent DSOC for IDBS in the study period; 14 patients (F = 9) with a median age of 64 years (range 53-76) met the study aim. After DSOC, strictures location was changed in three patients (additional yield of 21.4 %). Intraductal DSOC-guided biopsy were technically successful in all cases, with an adequacy of 92.8 %. No adverse events were recorded. Final diagnosis was benign disease in five cases and cholangiocarcinoma in the others. For IOA, 29 videos were evaluated with almost perfect agreement for final diagnosis (kappa 0.871; agreement 93.1, p <0.001), although overall accuracy of DSOC visual finding was 73.6 % and 64.4 % for experts and trainees, respectively.

CONCLUSIONS

DSOC could improve diagnostic accuracy for IDBS, since it showed high sensitivity for visual finding and high specificity for DSOC guided-biopsy. Visual diagnosis seems reliable for diagnosis using the Monaco Classification.

Insight Into the Role of Alkaloids in the Different Signalling Pathways of Cholangiocarcinoma

Throughout the biliary tree, a variety of cells give rise to cholangiocarcinomas, a broad group of malignancies. The fact that these tumours are silent and asymptomatic, especially in their early stages, seriously impairs the effectiveness of available therapeutic options and contributes to their poor prognosis. Over the past few years, increased efforts have been made to identify the aetiology and signalling pathways of these tumours and to create more potent therapies. Since alkaloids are more potent and effective against cholangiocarcinoma cell lines, they have gained importance in the treatment of cholangiocarcinoma. In cell lines with cholangiocarcinoma, they promote apoptosis. and restrict the spread of cells, departure, and development. This review highlights the recent developments in the study of CCA, primarily concentrating on the regulation of the signalling pathway and revealing alkaloids demonstrating strong anti-cholangiocarcinoma efficacy, providing researchers with a rapid approach for the future development of powerful and efficient pharmaceutical compounds.

The contribution of new methods in cytology for increasing sensitivity in the diagnosis of extrahepatic bile duct lesions

The aim of this review is to provide a comprehensive analysis of the existing literature pertaining to cytology of extrahepatic bile ducts. A search using the keywords "biliary brush cytology" was conducted in the PubMed database, with a focus on recent articles. The inclusion criteria primarily encompassed publications addressing problematic biliary stenosis. Emphasis was placed on identifying articles that explored innovative or less-utilized examination techniques aimed at enhancing the sensitivity of cytological examination. This review presents a comprehensive overview of the various types of materials used in sampling and the corresponding sampling methods. Additionally, it explores cytological and cytogenetic techniques, such as fluorescence in situ hybridization (FISH) and genetic methods (miRNA, NGS, cfDNA). These techniques possess the potential to improve the accuracy of diagnosing bile duct tumors, although their sensitivity varies. Furthermore, their utilization can facilitate early therapy, which plays a crucial role in patient prognosis. Each examination is always dependent on the quality and quantity of material delivered. A higher sensitivity of these examinations can be achieved by combining biliary cytology and other complementary methods.

Solanum nigrum Linn.: Advances in anti-cancer activity and mechanism in digestive system tumors

Cancer has currently become a serious public health issue in many countries worldwide, and tumors of the digestive system have attracted an increasing number of researchers' due to their numerous types, high proportion and wide area of occurrence. While tumors of the digestive system suffer from high mortality rates, leading to untimely diagnosis and a poor prognosis, making it necessary to update current treatment approaches such as surgery, radiation therapy, and chemotherapy. This highlights the importance of exploring novel therapeutic ideas and targets. Traditional Chinese medicine has a long history of clinical use due to its low toxicity and multi-factor targeting of multiple pathways. As a kind of traditional Chinese herb, S. nigrum Linn. is highly regarded for its proven antitumor activity. The aim of this study was to comprehensively recapitulate and analyze the anti-cancer effects and molecular mechanisms of treatment of gastrointestinal tumors with S. nigrum Linn. extracts and related compounds, including classical signaling pathways mediated by them as well as noncoding RNA pathways associated with tumor suppression. Components that have been found to be responsible for the anti-cancer activity of S. nigrum Linn. include solanine, solasonine, solamargine, a-L-rhhamnopyranose, uttroside B, degalactotigonin, glycoprotein, and other compounds. The underlying mechanisms of anti-cancer activity reflected in this study include apoptosis, cell cycle arrest, autophagy, anti-angiogenesis, suppression of metastasis and invasion, immune escape, and increased sensitivity to radiotherapy. S. nigrum Linn. has great potential in the treatment of tumors of the digestive system, and through further clinical trials and pharmacological mechanisms it has the potential to become a uniform and standardized anti-tumor drug.

The Role of Fluorescence In Situ Hybridization in Pancreatobiliary Brushing Cytology: A Large Retrospective Review with Histologic Correlation

(1) Background: Although the specificity of brush cytology for the detection of malignant pancreaticobiliary strictures is high, its sensitivity is low. Fluorescence in situ hybridization (FISH) can be used to detect chromosomal aneuploidy in biliary brushing specimens, and when used as an adjunct to routine cytology, it significantly improves diagnostic sensitivity. (2) Methods: We searched our laboratory information system to identify all bile duct brush cytology cases with follow-up surgical pathology between January 2001 and September 2019. Cytologic diagnoses were classified as negative, atypical, suspicious, or malignant. Correlated surgical pathological diagnoses were classified as benign or malignant. FISH test results were obtained for a subset of cytology cases with concurrent FISH testing, and the sensitivity, specificity, positive predictive value, and negative predictive value in identifying malignancy for cytology alone, FISH alone, and combined cytology and FISH were calculated. (3) Results: A total of 1017 brushing cytology cases with histologic correlation were identified. A total of 193 FISH tests were performed concurrently with cytological specimens. Malignant diagnoses were identified in 623 of 1017 patients, while 394 patients had benign strictures. The sensitivity, specificity, positive predictive, and negative predictive rate were 65%, 78%, 83%, and 49% for cytology alone; 72%, 67%, 63%, and 68% for FISH alone; and 85%, 42%, 60%, and 74% for combined cytology and FISH, respectively. Among FISH-positive cases, the risk of malignancy for polysomy was 82% and 32% for trisomy. (4) Conclusions: FISH improves the sensitivity and negative predictive rate of bile duct brush cytology. The combination of cytology and FISH has increased the sensitivity from 65% to 85% and the negative predictive rate from 49% to 74% when compared to cytology alone. A patient with a polysomy FISH result had a significantly higher risk of malignancy than a patient with a trisomy 7 result (82% vs. 32%, p < 0.00001).

Post-operative Rehabilitation in Klatskin Tumor: A Rare Case Report

Cholangiocarcinoma (CCA), commonly referred to as Klatskin tumor (KT), is a rare cancer that develops from the epithelium of the intra- or extrahepatic bile duct. This case outlines the impact of physiotherapy rehabilitation in a post-operative case of a KT in a 58-year-old male who presented with complaints of abdominal pain, nausea, constipation, and difficulty in urinating and reportedly exhibited generalized weakness, weight loss, and dyspnea. Following investigations such as computed tomography (CT) scan, the patient was diagnosed with a KT for which he underwent hepaticojejunostomy and was kept under observation, following which supervised physiotherapy intervention (PI) commenced from post-operative day (POD) 3. The outcome measure was peak expiratory flow rate (PEFR), whereas the intervention involved diaphragmatic breathing exercises (DBEs), thoracic expansion exercises (TEEs), incentive spirometry (IS), range of motion (ROM) exercises, active cycle of breathing technique (ACBT), and ambulation. After two weeks of treatment, there were an improvement in cough frequency and an appreciable change in vital capacity (VC), and a significant increase in PEFR values was observed.

Inhibition of ClC-5 suppresses proliferation and induces apoptosis in cholangiocarcinoma cells through the Wnt/β-catenin signaling pathway

Chloride channel-5 (ClC-5), an important branch of the ClC family, is involved in the regulation of the proliferation and cell-fate of a variety of cells, including tumor cells. However, its function in cholangiocarcinoma (CCA) cells remains enigmatic. Here, we discovered that ClC-5 was up-regulated in CCA tissues and CCA cell lines, while ClC-5 silencing inhibited CCA cell proliferation and induced apoptosis. Further mechanism studies revealed that ClC-5 inhibition could inhibit Wnt/β-catenin signaling activity and further activate the mitochondria apoptotic pathway in CCA cells. Furthermore, rescuing Wnt/β-catenin signaling activation eliminated the anti-tumor function of ClC-5 knockdown. Together, our research findings illustrated that ClC-5 inhibition plays an anti-tumor role in CCA cells via inhibiting the activity of the Wnt/β-catenin pathway, which in turn activates the mitochondrial apoptotic pathway.

Cullin3 deficiency shapes tumor microenvironment and promotes cholangiocarcinoma in liver-specific Smad4/Pten mutant mice

Cholangiocarcinoma (CC), the most lethal type of liver cancer, remains very difficult to treat due to an incomplete understanding of the cancer initiation and progression mechanisms and no effective therapeutic drugs. Thus, identification of genomic drivers and delineation of the underlying mechanisms are urgently needed. Here, we conducted a genome-wide CRISPR-Cas9 screening in liver-specific Smad4/Pten knockout mice (Smad4co/co;Ptenco/co;Alb-Cre, abbreviated as SPC), and identified 15 putative tumor suppressor genes, including Cullin3 (Cul3), whose deficiency increases protein levels of Nrf2 and Cyclin D1 that accelerate cholangiocytes expansion leading to the initiation of CC. Meanwhile, Cul3 deficiency also increases the secretion of Cxcl9 in stromal cells to attract T cells infiltration, and increases the production of Amphiregulin (Areg) mediated by Nrf2, which paracrinely induces inflammation in the liver, and promotes accumulation of exhausted PD1high CD8 T cells at the expenses of their cytotoxic activity, allowing CC progression. We demonstrate that the anti-PD1/PD-L1 blockade inhibits CC growth, and the effect is enhanced by combining with sorafenib selected from organoid mediated drug sensitive test. This model makes it possible to further identify more liver cancer suppressors, study molecular mechanisms, and develop effective therapeutic strategies.

Biomarkers in Hepatobiliary Cancers: What is Useful in Clinical Practice?

Hepatocellular carcinoma (HCC) and biliary tract cancers (BTC) exhibit a poor prognosis with 5-year overall survival rates around 15%, all stages combined. Most of these primary liver malignancies are metastatic at diagnostic, with only limited therapeutic options, relying mainly on systemic therapies. Treatment modalities are different yet partially overlapping between HCC and BTC. The complex molecular profile of BTC yields to several actionable therapeutic targets, contrary to HCC that remains the field of antiangiogenic drugs in non-molecularly selected patients. Immunotherapy is now validated in the first line in HCC in combination with bevacizumab, while clinical activity of single agent immunotherapy appears limited to a subset of patients in BTC, still poorly characterized, and combinations are currently under investigation. In this review, we provide a critical evaluation and grading of clinical relevance on (i) the main prognostic biomarkers in HCC and BTC, (ii) the main theragnostic biomarkers in both tumors, and lastly (iii) what is recommended in clinical practice.

Digital single-operator peroral cholangioscopy-guided biopsy sampling versus ERCP-guided brushing for indeterminate biliary strictures: a prospective, randomized, multicenter trial (with video)

BACKGROUND AND AIMS

Accurately diagnosing indeterminate biliary strictures is challenging but important for patient prognostication and further management. Biopsy sampling under direct cholangioscopic vision might be superior to standard ERCP techniques such as brushing or biopsy sampling. Our aim was to investigate whether digital single-operator cholangioscopy (DSOC) compared with standard ERCP workup improves the diagnostic yield in patients with indeterminate biliary strictures.

METHODS

Patients with an indeterminate biliary stricture on the basis of MRCP were randomized to standard ERCP visualization with tissue brushing (control arm [CA]) or DSOC visualization and DSOC-guided biopsy sampling (study arm [SA]). This was a prospective, international, multicenter trial with a procedure-blinded pathologist.

RESULTS

The first sample sensitivity of DSOC-guided biopsy samples was significantly higher than ERCP-guided brushing (SA 68.2% vs CA 21.4%, P < .01). The sensitivity of visualization (SA 95.5% vs CA 66.7%, P = .02) and overall accuracy (SA 87.1% vs CA 65.5%, P = .05) were significantly higher in the SA compared with the CA, whereas specificity, positive predictive value, and negative predictive value showed no significant difference. Adverse events were equally low in both arms.

CONCLUSIONS

DSOC-guided biopsy sampling was shown to be safe and effective with a higher sensitivity compared with standard ERCP techniques in the visual and histopathologic diagnosis of indeterminate biliary strictures. (Clinical trial registration number: NCT03140007.).

Correlation of apparent diffusion coefficient and intravoxel incoherent motion imaging parameters with Ki-67 expression in extrahepatic cholangiocarcinoma

PURPOSE

To investigate the correlation of magnetic resonance imaging (MRI), apparent diffusion coefficient (ADC) and intravoxel incoherent motion imaging parameters with Ki-67 expression in cholangiocarcinoma.

METHODS

A total of 42 extrahepatic cholangiocarcinoma (EHCC) cases confirmed by surgical pathology were analyzed retrospectively. Subjects underwent MRI at 3.0 T and intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI) sequential scanning prior to surgery, and postoperative Ki-67 expression was recorded by immunohistochemistry (IHC). The patients were divided into 4 groups (I-IV) based on increasing Ki-67 expression from - to +++. ADC values and IVIM-DWI parameters were calculated, including true diffusion coefficient (D), perfusion fraction (f), and pseudo-diffusion coefficient (D*). The comparison among groups was analyzed by univariate ANOVA (normal distribution) or Kruskal-Wallis H (non-normal distribution). Spearman correlation analysis was used to analyze the correlation of each parameter with Ki-67 expression. The diagnostic efficiency of each parameter was compared using the area under the curve (AUC) of the receiver operating characteristic (ROC) curve.

RESULTS

Except for D*, other values had statistically significant differences between groups (P < 0.05). ADC, D and f values had negative correlations with Ki-67 expression (r values were -0.607, -0.795, -0.531, respectively, P < 0.05). The AUCs were 0.701, 0.880, 0.623, respectively (P < 0.0001).

CONCLUSION

IVIM-DWI technology can reflect the proliferative activity of EHCC cells to a certain extent, and has clinical value for predicting the degree of malignancy of a tumor.

Targeted Therapies in Cholangiocarcinoma: Emerging Evidence from Clinical Trials

Cholangiocarcinoma (CCA) is a highly-aggressive malignancy arising from the biliary tree, characterized by a steady increase in incidence globally and a high mortality rate. Most CCAs are diagnosed in the advanced and metastatic phases of the disease, due to the paucity of signs and symptoms in the early stages. This fact, along with the poor results of the local and systemic therapies currently employed, is responsible for the poor outcome of CCA patients and strongly supports the need for novel therapeutic agents and strategies. In recent years, the introduction of next-generation sequencing technologies has opened new horizons for a better understanding of the genetic pathophysiology of CCA and, consequently, for the identification and evaluation of new treatments tailored to the molecular features or alterations progressively elucidated. In this review article, we describe the potential targets under investigation and the current molecular therapies employed in biliary tract cancers. In addition, we summarize the main drugs against CCA under evaluation in ongoing trials and describe the preliminary data coming from these pioneering studies.

Decreased argininosuccinate synthetase expression in Thai patients with cholangiocarcinoma and the effects of ADI-PEG20 treatment in CCA cell lines

Cholangiocarcinoma (CCA) is a severe cancer with poor prognosis. The aim of the present study was to explore the expression of argininosuccinate synthetase (ASS), as well as the possibility of using pegylated arginine deiminase (ADI-PEG20) for the treatment of CCA. ASS expression was determined in CCA specimens from 40 patients in Thailand. Immunohistochemical detection of ASS and determination of the proliferative index, Ki-67, were carried out in paraffin-embedded sections of these specimens, as well as in two CCA cell lines, HuCCA and RmCCA-1, derived from CCA samples from patients in Thailand. In total, ~45% of the CCA specimens had low ASS expression, and the level of expression was significantly negatively associated with cell differentiation (P<0.05) and Ki-67 expression (P<0.05). The level of ASS expression in tumor cells was significantly lower than that in non-tumor cells (1.3-fold, P<0.05). The HuCCA cell line had significantly lower levels (P<0.05) of ASS expression at the mRNA and protein levels relative to those of normal human immortalized fibroblast cells (BJ-1). By contrast, the RmCCA-1 cell line showed no significant difference. In addition, the effects of ADI-PEG20 on growth inhibition, apoptosis and cell cycle arrest were determined in HuCCA and RmCCA-1 cells. ADI-PEG20 treatment reduced cell viability and cell proliferation in the two CCA cell lines, though it had no effect in immortalized BJ-1 cells. Furthermore, ADI-PEG20 treatment significantly increased G0/G1 cell cycle arrest in HuCCA, though not in RmCCA-1 cells. ASS silencing in the RmCCA-1 cell line significantly enhanced its sensitivity to ADI-PEG20 treatment. Results from the in vitro study demonstrated that ADI-PEG20 has antitumor activity against CCA with low ASS expression.

The cholangiocyte primary cilium in health and disease

Cholangiocytes, like most cells, express primary cilia extending from their membranes. These organelles function as antennae which detect stimuli from bile and transmit the information into cells regulating several signaling pathways involved in secretion, proliferation and apoptosis. The ability of primary cilia to detect different signals is provided by ciliary associated proteins which are expressed in its membrane. Defects in the structure and/or function of these organelles lead to cholangiociliopathies that result in cholangiocyte hyperproliferation, altered fluid secretion and absorption. Since primary cilia dysfunction has been observed in several epithelial tumors, including cholangiocarcinoma (CCA), primary cilia have been proposed as tumor suppressor organelles. In addition, the loss of cilia is associated with dysregulation of several molecular pathways resulting in CCA development and progression. Thus, restoration of the primary cilia may be a potential therapeutic approach for several ciliopathies and CCA.

The diagnostic value of five serum tumor markers for patients with cholangiocarcinoma

OBJECTIVE

To assess the clinical significance and diagnostic value of the single and combined detection of five tumor markers in patients with cholangiocarcinoma.

METHODS

In total, 296 patients with biliary tract disease who were diagnosed and received treatment at Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University (17113011) during April 2011 to Dec 2017 were chosen for this study. Patients were divided into a cholangiocarcinoma group and a benign biliary tract disease group. Serum was collected from the patients, and the concentrations of AFP, CEA, CA125, CA19-9, CA72-4 and total bilirubin (TBIL) were tested. BM SPSS Statistics 22.0 was used to analyze the data. Receiver-operating characteristic (ROC) curves for the single and combined detection of five tumor markers were generated, and the sensitivity, specificity, and area under ROC curve (AUC) were calculated.

RESULTS

The concentrations of serum tumor markers in the cholangiocarcinoma group were higher than those in the benign biliary tract disease group. The AUCs for the single detections of the AFP, CEA, CA125, CA19-9, CA72-4 were 0.654, 0.808, 0.772, 0.833, and 0.743, and the optimal cutoffs were 2.58 ng/mL, 2.85 ng/mL, 23.85 U/mL, 46.75 U/mL, and 2.46 U/mL respectively. The combined detection of CEA, CA125 and CA19-9 had great diagnostic value. Its AUC was 0.888, its sensitivity was 85.1%, and its specificity was 83.1%.

CONCLUSIONS

The levels of CEA, CA125, CA19-9 and CA72-4 had a different diagnostic value for cholangiocarcinoma, and combined serum CEA, CA125 and CA19-9 would have the best clinical diagnostic effect of cholangiocarcinoma.

Hepatoduodenal lymph node metastasis mimicking Klatskin tumor in a patient with sigmoid colon mucinous cancer

We report a case of a 48-year-old female patient, who presented with abdominal pain, jaundice, and lack of appetite. Ultrasound showed intrahepatic biliary dilatation with retroperitoneal lymphadenopathy. Further magnetic resonance cholangiopancreatography detected Klatskin tumor. Computed tomography (CT) confirmed the Klatskin tumor with liver metastases and retroperitoneal lymphadenopathy. Biopsy from the hepatic lesion identified mucinous adenocarcinoma, likely originating from bile ducts. Endoscopic retrograde cholangiopancreatography was performed 3 times with stents placed in the left and right hepatic bile ducts. Later the patient had hematochezia and was referred to colonoscopy. Tubulovillous adenoma with dysplasia was diagnosed with signs of in situ cancer. Preoperative CT was done for further staging: new pulmonary metastases were discovered. Sigmoid colon was resected. Histopathology verified a poorly differentiated mucinous adenocarcinoma within the tubulovillous adenoma. Intraoperative biopsies of porta hepatis mass resembled metastatic lymph nodes in hepatoduodenal ligament, mimicking Klatskin tumor. Retrospective analysis of CT data demonstrated presence of sigmoid colon tumor.

Opisthorchiasis and cholangiocarcinoma in Southeast Asia: an unresolved problem

The prevalence of cholangiocarcinoma (CCA) in Southeast Asia is much higher than other areas of the world. Eating raw, fermented, or undercooked cyprinid fish, infected with the liver fluke, Opisthorchis viverrini sensu lato (sl), results in chronic biliary inflammation, periductal fibrosis, and increased cancer risk. There may be associated glomerulonephritis. The process of infection is difficult to disrupt because eating practices have proven extremely difficult to change, and the life cycle of the fluke cannot be broken due to high prevalence in canine and feline reservoir hosts. Fecal analysis and enzyme-linked immunosorbent assay tests can be used to diagnose opisthorchiasis. Diagnosis of CCA is complex, partly due to the lack of definitive imaging characteristics but also due to the difficulty of obtaining samples for cytology or histology. This cancer has proven to be resistant to common chemotherapy treatments and so the two avenues of treatment available are surgical resection and liver transplantation, both requiring early detection of the tumor for the best chances of success. Late presentation of symptoms reduces the chances of successful surgical intervention. While liver fluke infections can be treated with praziquantel, individuals will often become reinfected, and multiple reinfections can be more harmful than a singular, long-term infection. A key research on the detection and characterization of novel biomarkers in all parts of the carcinogenic pathway for early diagnosis is needed.

Overexpression of karyopherin-α2 in cholangiocarcinoma correlates with poor prognosis and gemcitabine sensitivity via nuclear translocation of DNA repair proteins

Cholangiocarcinoma is a highly malignant tumor, and the development of new therapeutic strategies is critical. Karyopherin-α2 (KPNA2) functions as an adaptor that mediates nucleocytoplasmic transport. Specifically, KPNA2 transports one of the important DNA repair machineries, the MRE11-RAD50-NBS1 (MRN) complex, to the nucleus. In this study, we clarified the significance of KPNA2 in cholangiocarcinoma. KPNA2 expression evaluated by immunohistochemical analysis was common in malignant tissue but rare in adjacent noncancerous tissues. KPNA2 overexpression was significantly correlated with poor prognosis and was an independent prognostic factor after surgery. In patients with cholangiocarcinoma who received gemcitabine after surgery, KPNA2 overexpression tended to be a prognostic indicator of poor overall survival. In KPNA2-depleted cholangiocarcinoma cells, proliferation was significantly decreased and gemcitabine sensitivity was enhanced in vitro and in vivo. Expression of KPNA2 and the MRN complex displayed colocalization in the nucleus. In addition, nuclear localization of the MRN complex was regulated by KPNA2 in vitro. These results suggest that KPNA2 expression may be a useful prognostic and predictive marker of gemcitabine sensitivity and survival. The regulation of KPNA2 expression may be a new therapeutic strategy for cholangiocarcinoma.

Molecular profiling of intrahepatic cholangiocarcinoma: the search for new therapeutic targets

Intrahepatic cholangiocarcinoma (iCCA) is the second most frequent primary tumor of the liver and a highly lethal disease. Therapeutic options for advanced iCCA are limited and ineffective due to the largely incomplete understanding of the molecular pathogenesis of this deadly tumor. Areas covered: The present review article outlines the main studies and resulting discoveries on the molecular profiling of iCCA, with a special emphasis on the different techniques used for this purpose, the diagnostic and prognostic markers identified, as well as the genes and pathways that could be potentially targeted with innovative therapies. Expert commentary: Molecular profiling has led to the identification of distinct iCCA subtypes, characterized by peculiar genetic alterations and transcriptomic features. Targeted therapies against some of the identified genes are ongoing and hold great promise to improve the prognosis of iCCA patients.

miR-124 targets GATA6 to suppress cholangiocarcinoma cell invasion and metastasis

Background

Our previous study showed that GATA6 plays important roles in cholangiocarcinoma (CCA) cell invasion and metastasis. However, the regulation mechanism of GATA6 in CCA is not clear. In this study, we studied the potential function of miR-124 in CCA and the mechanism of GATA6 regulation.

Methods

The expression levels of miR-124 and GATA6 in cancerous tissues from 57 CCA patients was detected by RT-PCR and IHC. The impact of miR-124 on GATA6 expression in CCA cells was evaluated using cell transfection, xenotransplantation into nude mice and a luciferase reporter assay.

Results

miR-124 was decreased in 57 cancerous tissue samples compared with 38 matched paracancerous samples. The miR-124 level was inversely associated with lymph node involvement and distant metastasis. miR-124 significantly inhibited invasion and migration of CCA cells in vitro. Furthermore, miR-124 inhibited CCA cell metastasis in nude mice. miR-124 inhibited the luciferase activity of reporter genes containing the wild-type GATA6 3′-UTR, which was abrogated by mutation of the binding site. The protein levels of GATA6 were negatively regulated by miR-124. miR-124 expression was inversely associated with GATA6 in 57 cancerous samples. The miR-124-induced suppression of CCA invasion was abrogated by remedial expression of GATA6. GATA6 expression was decreased by miR-124 overexpression in liver masses from nude mice.

Conclusions

Our data suggested that miR-124 decreases GATA6 expression by targeting its 3′-UTR, which in turn inhibits CCA invasion and metastasis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3166-z) contains supplementary material, which is available to authorized users.

Hospital-based Population of Elderly Cancer Cases in Northeastern Thailand

BACKGROUND

The proportion of aged Thais (≥65 years old) is expected to be 30% by 2030, leading to an increased number of elderly cancer cases. Older individuals have distinct patterns of cancer and treatment needs. We therefore conducted the present study of new cancer cases and trends to get a perspective on the elderly cancer situation in Northeast Thailand.

MATERIALS AND METHODS

All new elderly cancer cases (≥65 years) registered in the hospital-based cancer registry at the Faculty of Medicine, Srinagarind Hospital, Khon Kaen University during 1993-2012 were included in the study.

RESULTS

Elderly patients accounted for 31.6% of all cancer patients and new cancer cases in the older age group increased 46% from the first to second decades. The absolute number of oldest old (80+ years) doubled. The top three cancers in males were liver and bile duct, lung, and colorectal. In females, the three most common cancers were liver and bile duct, oral cavity, and cervix. Cancers with the highest percentages of increase were thyroid, prostate, and colorectal.

CONCLUSIONS

Elderly cancer cases are increasing. Treatment modalities and palliative care for older populations are urgently needed.

Cholangiocarcinoma associated with limbic encephalitis and early cerebral abnormalities detected by 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography-positron emission tomography: a case report

Background

Limbic encephalitis was originally described as a rare clinical neuropathological entity involving seizures and neuropsychological disturbances. In this report, we describe cerebral patterns visualized by positron emission tomography in a patient with limbic encephalitis and cholangiocarcinoma. To our knowledge, there is no other description in the literature of cerebral positron emission tomography findings in the setting of limbic encephalitis and subsequent diagnosis of cholangiocarcinoma.

Case presentation

We describe a case of a 77-year-old Caucasian man who exhibited persistent cognitive changes 2 years before his death. A cerebral scan obtained at that time by 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography-positron emission tomography showed low radiotracer uptake in the frontal and temporal lobes. Cerebrospinal fluid analysis indicated the presence of voltage-gated potassium channel antibodies. Three months before the patient’s death, a lymph node biopsy indicated a cholangiocarcinoma, and a new cerebral scan obtained by 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography-positron emission tomography showed an increment in the severity of metabolic deficit in the frontal and parietal lobes, as well as hypometabolism involving the temporal lobes. Two months before the patient’s death, cerebral metastases were detected on a contrast-enhanced computed tomographic scan. Postmortem examination revealed a cholangiocarcinoma with multiple metastases including the lungs and lymph nodes. The patient’s brain weighed 1300 g, and mild cortical atrophy, ex vacuo dilation of the ventricles, and mild focal thickening of the cerebellar leptomeninges, which were infiltrated by neoplastic epithelial cells, were observed.

Conclusions

These findings support the need for continued vigilance in malignancy surveillance in patients with limbic encephalitis and early cerebral positron emission tomographic scan abnormalities. The difficulty in early diagnosis of small tumors, such as a cholangiocarcinoma, is discussed in the context of the clinical utility of early cerebral hypometabolism detected by 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography-positron emission tomography in patients with rapidly progressive dementia.

A Promising Serum Autoantibody Marker, Anti-Heat Shock Protein 90α, for Cholangiocarcinoma

The present study was designed to investigate cholangiocarcinoma (CCA) antibodies in hamster serum. Hamster CCA cell lines were processed using sodium dodecyl sulfate-polyacrylamide gel electrophoresis and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. A candidate biomarker was confirmed by immunoprecipitation and western blot, and was further analyzed using ELISA and sera from normal control hamsters, hamsters with opisthorchiasis and hamsters with various stages of CCA, as well as from CCA patients and healthy individuals. One candidate marker was identified as HSP90α, as indicated by a high level of anti-HSP90α in hamster CCA sera. It was found that the levels of anti-HSP90α were specifically elevated in the sera of hamsters with CCA compared with other groups and progressively increased with the clinical stage. At the cut-off point of 0.4850 on the receiver operating characteristic curve, anti-HSP90α could discriminate CCA from healthy control groups with a sensitivity of 76.2%, specificity of 71.4% and total accuracy 75.5%. In the present study, we have shown that anti-HSP90α may be a potential useful serum biomarker to discriminate CCA cases from healthy persons.

Evaluation and validation of suitable reference genes for reverse transcription-quantitative polymerase chain reaction studies in cholangiocarcinoma patients and cell lines

Reverse transcription-quantitative polymerase chain reaction (RT-qPCR) has become a frequently used method in gene expression studies. The relative quantification method is an important and common method for the evaluation of RT-qPCR data. One of the key requirements of this method is to identify an applicable internal reference gene. However, to the best of our knowledge, no suitable reference genes have been identified for the genetic analysis of cholangiocarcinoma (CCA) in humans and cell lines. In the present study, screening was conducted using 12 common reference genes, which were selected in order to provide an experimental basis for the study of the gene expression in CCA patients and cell lines. Tumor samples and adjacent non-neoplastic tissues from 20 patients with CCA were obtained for the present study. The stability and applicability of the 12 reference gene candidates were validated using GeNorm, NormFinder and BestKeeper software. Based on a comparison of the results, the following reference genes are recommended for various tissue groups: Total sample group, ribosomal protein L29; CCA tissue group, TATA-box binding protein; CCA cell line and tissue group, actin-β; CCA cell line group, 18S ribosomal RNA; CCA tissue and adjacent non-neoplastic tissue group, 5'-aminolevulinate synthase 1; and adjacent non-neoplastic tissue group, hypoxanthine phosphoribosyltransferase 1. The results of the search also clearly reveal that a systematic study regarding the selection of suitable reference genes for studying the target gene profiling in CCA tissues and cell lines has not been previously published. The present study may provide useful information for future studies that examine the gene expression of CCA for choosing suitable reference genes.

Cholangiocarcinoma: from molecular biology to treatment

Cholangiocarcinoma is a rare tumor originating in the bile ducts, which, according to their anatomical location, is classified as intrahepatic, extrahepatic and hilar. Nevertheless, incidence rates have increased markedly in recent decades. With respect to tumor biology, several genetic alterations correlated with resistance to chemotherapy and radiotherapy have been identified. Here, we highlight changes in KRAS and TP53 genes that are normally associated with a more aggressive phenotype. Also IL-6 and some proteins of the BCL-2 family appear to be involved in the resistance that the cholangiocarcinoma presents toward conventional therapies. With regard to diagnosis, tumor markers most commonly used are CEA and CA 19-9, and although its use isolated appears controversial, their combined value has been increasingly advocated. In imaging terms, various methods are needed, such as abdominal ultrasound, computed tomography and cholangiopancreatography. Regarding therapy, surgical modalities are the only ones that offer chance of cure; however, due to late diagnosis, most patients cannot take advantage of them. Thus, the majority of patients are directed to other therapeutic modalities like chemotherapy, which, in this context, assumes a purely palliative role. Thus, it becomes urgent to investigate new therapeutic options for this highly aggressive type of tumor.

Volatile Organic Compounds in Urine for Noninvasive Diagnosis of Malignant Biliary Strictures: A Pilot Study

BACKGROUND

The use of volatile organic compounds (VOCs) in bile was recently studied and appeared promising for diagnosis of malignancy. Noninvasive diagnosis of malignant biliary strictures by using VOCs in urine has not been studied.

AIM

To identify potential VOCs in urine to diagnose malignant biliary strictures.

METHODS

In this prospective cross-sectional study, urine was obtained immediately prior to ERCP from consecutive patients with biliary strictures. Selected-ion flow-tube mass spectrometry was used to analyze the concentration of VOCs in urine samples.

RESULTS

Fifty-four patients with biliary strictures were enrolled. Fifteen patients had malignant stricture [six cholangiocarcinoma (CCA) and nine pancreatic cancer], and 39 patients had benign strictures [10 primary sclerosing cholangitis (PSC) and 29 with benign biliary conditions including chronic pancreatitis and papillary stenosis]. The concentration of several compounds (ethanol and 2-propanol) was significantly different in patients with malignant compared with benign biliary strictures (p < 0.05). Using receiver operating characteristic curve analysis, we developed a model for the diagnosis of malignant biliary strictures adjusted for age and gender based on VOC levels of 2-propranol, carbon disulfide, and trimethyl amine (TMA). The model [-2.4191 * log(2-propanol) + 1.1617 * log(TMA) - 1.2172 * log(carbon disulfide)] ≥ 7.73 identified the patients with malignant biliary stricture [area under the curve (AUC = 0.83)], with 93.3 % sensitivity and 61.5 % specificity (p = 0.009). Comparing patients with CCA and PSC, the model [38.864 * log(ethane) - 3.989 * log(1-octene)] ≤ 169.9 could identify CCA with 80 % sensitivity and 100 % specificity (AUC = 0.9).

CONCLUSIONS

Measurement of VOCs in urine may diagnose malignant biliary strictures noninvasively.

Hypoxia enhances cholangiocarcinoma invasion through activation of hepatocyte growth factor receptor and the extracellular signal‑regulated kinase signaling pathway

Hypoxia is associated with tumor progression and poor prognosis in several cancer types. The present study aimed to examine the contribution of hypoxia (1% O₂) to cancer progression in a cholangiocarcinoma cell line, RMCCA-1. The molecular basis of the hypoxic response pathway was investigated. The results showed that hypoxia significantly accelerated cancer cell proliferation and enhanced cell invasion (P<0.05). By using receptor tyrosine kinase and intracellular signaling antibody array kits, an increased phosphorylation/activation of a number of signaling molecules, particularly hepatocyte growth factor receptor (Met) and extracellular signal-regulated kinase (ERK) 1/2, was identified. Inhibition of Met and ERK by small hairpin RNA and U0126, respectively, significantly inhibited hypoxia-induced the invasive potential of RMCCA-1 cells (P<0.05). However, according to immunohistochemical analysis, hypoxia-inducible factor-1α expression was not correlated with cancer staging or tumor differentiation in 44 samples of cholangicarcinoma cases. The findings of the present study emphasized the importance of Met/ERK pathway activation as a key molecular event that may be responsible for a more invasive phenotype in hypoxic tumors and suggest Met as a potential target for the treatment of cholangiocarcinoma.

Bile proteomics for differentiation of malignant from benign biliary strictures: a pilot study

BACKGROUND

Determining the etiology of biliary strictures is challenging, and the sensitivities of the current tests to diagnose them are low. Protein biomarkers in bile, in combination with other tests, may improve sensitivity in diagnosing biliary strictures.

OBJECTIVE

To analyse the differential abundance of proteins in benign and malignant biliary strictures through proteomic analysis of bile.

METHODS

In this prospective, cross-sectional study, bile was aspirated in 24 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) including six patients with primary sclerosing cholangitis (PSC), three with cholangiocarcinoma (CCA), ten with pancreatic cancer, and five with benign biliary conditions. Liquid chromatography/mass spectrometry was used to examine the bile for differential abundance of protein biomarkers. The relative abundance of various proteins was compared in the malignant vs. benign groups and in CCA vs. PSC.

RESULTS

The majority of the proteins identified in bile were similar to those of the plasma (plasma proteins) and certain proteins were differentially expressed among the different groups (CCA, pancreatic cancer, PSC or benign). A total of 18 proteins were identified as being more abundant in the malignant group (CCA and pancreatic cancer) than in the benign strictures group, including myeloperoxidase, complement C3, inter-alpha-trypsin inhibitor heavy chain H4, apolipoprotein B-100, and kininogen-1 isoform 2. A total of 30 proteins were identified to be less abundant in the malignant group than in the benign group, including trefoil factor 2, superoxide dismutase [Cu-Zn], kallikrein-1, carboxypeptidase B and trefoil factor 1.

CONCLUSIONS

Protein biomarkers in bile may differentiate malignant from benign biliary strictures. Larger studies are warranted to validate these observations.

Role of surgery in cholangiocarcinoma: From resection to transplantation

The treatment of cholangiocarcinoma (CCA) represents a major challenge to modern medicine. Diagnostics and treatment modalities are complex and require close interdisciplinary work-up. However, surgical resection currently offers the only potentially curative treatment option. Improved peri-operative strategies as well as optimized surgical techniques have generated significantly increased survival chances for patients in recent years. Complete tumor resection is the key parameter to long-term survival. In spite of expanded surgical limits R0 resection cannot be achieved in some cases as parenchymal disease may limit the extent of resection. Although liver transplantation (LT) is not a standard therapy for CCA today, it may be an option in such selected cases. Protocols including neo-adjuvant radio-chemotherapy and staging-lymphadenectomy before LT have generated impressive results in the recent past. Since palliative options generate only short-term survival extension LT for CCA has lately been discussed more extensively after the procedure had been abandoned due to dismal survival data in the 1990-years. This review offers a comprehensive picture of the current surgical treatment option for cholangiocarcinoma.

Epidemiology of cholangiocarcinoma

Cholangiocarcinoma (CCA) is a cancer arising from the intra- or extrahepatic bile ducts and mainly characterized by its late diagnosis and fatal outcome. CCA is the second most common primary liver tumour and accounts for approximately 10-15% of all hepatobiliary malignancies. The development of CCA is linked to a wide spectrum of conditions causing biliary inflammation, cholestasis and inflammation of the liver. The geographic diversity of risk factors is reflected in considerable differences in incidence worldwide. Although data are not consistent, incidence seems to be rising in the Western World. Given the limited opportunities of treating advanced CCA, surveillance has been suggested as a strategy for detection of early disease in the high-risk group of patients with primary sclerosing cholangitis (PSC). In this review we present an updated overview of the epidemiology of CCA. We also highlight the risk of CCA in PSC with special focus on surveillance strategies.

Immunohistochemically detected expression of Skp2, p27 kip1, and p-p27 (Thr187) in patients with cholangiocarcinoma

The paper was aimed to detect the expression of Skp2, p27(kip1) (p27), and p-p27 (Thr187) in patients with cholangiocarcinoma (CCA). Western blot and immunohistochemistry were used to analyze the expression and subcellular localization of p27, Skp2, and p-p27 (Thr187) in tissue specimens of 53 patients with CCA and 10 with chronic proliferative cholangitis (CPC). Besides, the relationships of p27, Skp2, and p-p27 (Thr187) with clinicopathologic findings were examined, followed by analysis of the relationships of p27 expression with p-p27 (Thr187) and Skp2 in CCA tissue. The expression of p27 was lower in CCA than CPC tissue, and the expression of Skp2 and p-p27 (Thr187) was higher in CCA than CPC tissue (P < 0.05). The positive p27 and Skp2 proteins were mainly expressed in nucleus and cytoplasm of CCA, and p-p27 (Thr187) was only observed in nucleus. The expression of p27, Skp2, and p-p27 (Thr187) was closely associated with tumor grade and TNM stage (P < 0.05). A significantly negative correlation between the expression of p27 and Skp2 (r = -0.480, P < 0.05) and between the expression of p27 and p-p27 (Thr187) (r = -0.387, P < 0.05) was observed. Skp2-dependent proteasomal degradation of p27 plays role in the malignant transformation of CCA. Besides, the expression of p27, Skp2, and p-p27 (Thr187) may serve as markers for the progression of CCA.

Inhibition of the AKT pathway in cholangiocarcinoma by MK2206 reduces cellular viability via induction of apoptosis

Introduction

Cholangiocarcinoma (CCA) is an aggressive disease with limited effective treatment options. The PI3K/Akt/mTOR pathway represents an attractive therapeutic target due to its frequent dysregulation in CCA. MK2206, an allosteric Akt inhibitor, has been shown to reduce cellular proliferation in other cancers. We hypothesized that MK2206 mediated inhibition of Akt would impact CCA cellular viability.

Study methods

Post treatment with MK2206 (0-2 μM), cellular viability was assessed in two human CCA cell lines—CCLP-1 and SG231—using an MTT assay. Lysates from the MK2206 treated CCA cells were then examined for apoptotic marker expression levels using Western blot analysis. Additionally, the effect on cellular proliferation of MK2206 treatment on survivin depleted cells was determined.

Results

CCLP-1 and SG231 viability was significantly reduced at MK2206 concentrations of 0.5, 1, and 2 μM by approximately 44%, 53%, and 64% (CCLP-1; p = 0.01) and 32%, 32%, and 42% (SG231; p < 0.00005) respectively. Western analysis revealed a decrease in AKT^Ser473, while AKT^Thr308 expression was unchanged. In addition, cleaved PARP as well as survivin expression increased while pro-caspase 3 and 9 levels decreased with treatment. Depletion of survivin in CCLP-1 cells resulted in apoptosis as evidenced by increased cleaved PARP. In addition, survivin siRNA further enhanced the antitumor activity of MK2206.

Conclusions

This study demonstrates that by blocking phosphorylation of Akt at serine473, CCA cellular growth is reduced. The growth suppression appears to be mediated via apoptosis. Importantly, combination of survivin siRNA transfection and MK2206 treatment significantly decreased cell viability.

Downregulation of FOXP3 inhibits invasion and immune escape in cholangiocarcinoma

FOXP3 is known as a master control of regulatory T cells with recently studies indicating its expression in several tumor cells. In order to study the precise role of FOXP3 in cholangiocarcinoma, FOXP3 was knocked down in cholangiocarcinoma cell lines. Down regulation of FOXP3 inhibits tumor cell invasion by reducing the quantity of MMP-9 and MMP-2. With FOXP3 knocking down, IL-10 and TGF-β1 secreted by cancer cells diminishes and the cell survival of T cells is significant up-regulation. These results suggest that FOXP3 plays an important role in tumor malignant phenotype, especially the invasion and immune escape.

Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis

BACKGROUND

Evaluation of indeterminate biliary strictures typically involves collection and analysis of tissue or cells. Brush cytology and intraductal biopsies that are routinely performed during ERCP to assess malignant-appearing biliary strictures are limited by relatively low sensitivity.

OBJECTIVE

To study the comparative effectiveness of brushings for cytology and intraductal biopsies in the etiology of biliary strictures.

DESIGN

Meta-analysis.

SETTING

Referral center.

PATIENTS

PUBMED and Embase databases were reviewed for studies published to April 2014 where diagnostic correlation of histology was available.

INTERVENTION

Database and review of study findings.

MAIN OUTCOME MEASUREMENTS

Sensitivity and specificity.

RESULTS

The pooled sensitivity and specificity of brushings for the diagnosis of malignant biliary strictures was 45% (95% confidence interval [CI], 40%-50%) and 99% (95% CI, 98%-100%), respectively. The pooled diagnostic odds ratio to detect malignant biliary strictures was 33.43 (95% CI, 14.29-78.24). For intraductal biopsies, the pooled sensitivity and specificity were 48.1% (95% CI, 42.8%-53.4%) and 99.2% (95% CI, 97.6%-99.8%), respectively. The pooled diagnostic odds ratio to detect malignant biliary strictures was 43.18 (95% CI, 19.39-95.83). A combination of both modalities only modestly increased the sensitivity (59.4%; 95% CI, 53.7%-64.8%) with a specificity of 100% (95% CI, 98.8%-100.0%). The Begg-Mazumdar and Egger tests indicated a low potential for publication bias.

LIMITATIONS

Inclusion of low-quality studies.

CONCLUSION

Our study suggests that both brushings and biopsy are comparable and have limited sensitivity for the diagnosis of malignant biliary strictures. A combination of both only modestly increases the sensitivity.

Fragile histidine triad (FHIT) suppresses proliferation and promotes apoptosis in cholangiocarcinoma cells by blocking PI3K-Akt pathway

Fragile histidine triad (FHIT) is a tumor suppressor protein that regulates cancer cell proliferation and apoptosis. However, its exact mechanism of action is poorly understood. Phosphatidylinositol 3-OH kinase (PI3K)-Akt-survivin is an important signaling pathway that was regulated by FHIT in lung cancer cells. To determine whether FHIT can regulate this pathway in cholangiocarcinoma QBC939 cells, we constructed an FHIT expression plasmid and used it to transfect QBC939 cells. Protein and mRNA expression were measured by western blotting and qRT-PCR, respectively. The viability and apoptosis of QBC939 cells were then assessed using MTT assays and flow cytometry. Our results revealed that the expression of survivin and Bcl-2 was downregulated, and caspase 3 was upregulated, in cells overexpressing FHIT. In addition, FHIT suppressed the phosphorylation of Akt. The changes in cell proliferation and apoptosis were obvious in cells overexpressing FHIT which parallels that of treatment with LY294002, a potent inhibitor of phosphoinositide 3-kinases. Treatment with LY294002 further decreased the expression of survivin and Bcl-2 and increased caspase-3 levels. These results suggest that FHIT can block the PI3K-Akt-survivin pathway by suppressing the phosphorylation of Akt and the expression of survivin and Bcl-2 and upregulating caspase 3.

Adjuvant chemotherapy in resectable cholangiocarcinoma patients

BACKGROUND AND AIM

Cholangiocarcinoma patients usually have poor treatment outcome and a high mortality rate. The role of adjuvant chemotherapy (AC) is controversial. Our study aimed to evaluate benefits of AC in resectable cholangiocarcinoma patients.

METHODS

A retrospective study included 263 patients who underwent curative resection in Srinakarind University Hospital. These patients had pathological reports showing a clear margin (R0) or microscopic margin (R1) of lesion-free tissue.

RESULTS

There were 138 patients who received AC. This group had a significantly lower mean age than patients not receiving adjuvant chemotherapy (NAC) group (57.7 ± 8.5 vs 60.4 ± 9.0 years, P = 0.01). The level of serum albumin above 3 g/dL was more common in AC group than the NAC one (87.7% vs 79.2%, P = 0.04). Patients who received AC had significantly longer overall median survival time (21.6 vs 13.4 months, P = 0.01). Patients with a combination of gemcitabine and capecitabine regimen had the longest survival time (median overall survival time of gemcitabine and capecitabine 31.5, 5-fluorouracil and mitomycin 17.3, 5-fluorouracil alone 22.2, capecitabine alone 21.6, and gemcitabine alone 7.9 months, P = 0.02). Benefits of AC were likely to be found in patients who had high-risk features, that is, high level of carbohydrate antigen 19-9, advanced stage, T4 stage, lymph node involvement, and R1 margin.

CONCLUSIONS

AC significantly prolongs survival time in resectable cholangiocarcinoma patients, particularly in the high risk group.

Patient selection for liver transplantation

Improved outcomes in liver transplant recipients reflect advances in surgical technique, post-operative care, immunosuppression as well as better selection of potential candidates. The pre-transplant evaluation is a multidisciplinary process intended to recognize and treat important comorbid conditions that may impair outcomes during the peri- and post-transplant periods. Important psychosocial issues should also be ascertained and tackled early during the pre-transplant evaluation with an overarching intention to improve the success of liver transplantation.

Humerus Metastasis From Cholangiocarcinoma: A Case Report

Cholangiocarcinoma is a malignant disease of the epithelial cells in the intra- and extrahepatic bile ducts. It is the most frequent biliary malignancy. The lack of effective medical treatment makes a radical surgical resection the only therapeutic option. However, frequently Intrahepatic cholangiocarcinoma metastasize in lymphatic chains, including the hepatoduodenal ligament, and it often invades adjacent organs or metastasizes to other visceral organs such as the lungs, bones, adrenal glands, and brain and the prognosis remains poor. We present a case of elderly patient with a severe and progressive pain due to a pathologic fracture of humerus. The medical investigations revealed the presence of an intrahepatic cholangiocarcinoma.

The challenge of cholangiocarcinoma: dissecting the molecular mechanisms of an insidious cancer

Cholangiocarcinoma is a fatal cancer of the biliary epithelium and has an incidence that is increasing worldwide. Survival beyond a year of diagnosis is less than 5%, and therapeutic options are few. Known risk factors include biliary diseases such as primary sclerosing cholangitis and parasitic infestation of the biliary tree, but most cases are not associated with any of these underlying diseases. Numerous in vitro and in vivo models, as well as novel analytical techniques for human samples, are helping to delineate the many pathways implicated in this disease, albeit at a frustratingly slow pace. As yet, however, none of these studies has been translated into improved patient outcome and, overall, the pathophysiology of cholangiocarcinoma is still poorly understood. There remains an urgent need for new approaches and models to improve management of this insidious and devastating disease. In this review, we take a bedside-to-bench approach to discussing cholangiocarcinoma and outline research opportunities for the future in this field.

Patterns of initial disease recurrence after resection of biliary tract cancer

OBJECTIVES

This study aimed to provide further insights into the indications for adjuvant therapeutic strategies via analysis of the sites of initial recurrence after resection of gallbladder cancer (GBC) and intrahepatic (IHC) and extrahepatic cholangiocarcinoma (EHC).

METHODS

Patients with biliary tract cancer who underwent potentially curative resection were identified from the database. Sites of initial disease recurrence were categorized as locoregional or distant.

RESULTS

Between March 2001 and April 2009, 231 patients underwent curative resection. Initial GBC and IHC recurrence involving a distant site occurred in 70.8 and 86.8% patients, respectively, compared to 56.9% patients with EHC (p = 0.002). The median time to disease recurrence (TTR) was shorter among the GBC and IHC groups compared with that in EHC patients (6.3 and 6.7 vs. 13.1 months, respectively; p = 0.003). Moreover, median times to distant recurrence in GBC and IHC groups were shorter than that in EHC (5.8 and 6.5 vs. 14.1 months, respectively; p = 0.002).

CONCLUSIONS

After resection, recurrent GBC and IHC are more likely to involve a distant site and are associated with significantly shorter TTR than recurrent EHC. These findings suggest that an adjuvant therapeutic strategy targeting distant disease is likely to have a significant impact on the overall management of GBC and IHC.

Impaired degradation followed by enhanced recycling of epidermal growth factor receptor caused by hypo-phosphorylation of tyrosine 1045 in RBE cells

Background

Since cholangiocarcinoma has a poor prognosis, several epidermal growth factor receptor (EGFR)-targeted therapies with antibody or small molecule inhibitor treatment have been proposed. However, their effect remains limited. The present study sought to understand the molecular genetic characteristics of cholangiocarcinoma related to EGFR, with emphasis on its degradation and recycling.

Methods

We evaluated EGFR expression and colocalization by immunoblotting and immunofluorescence, cell surface EGFR expression by fluorescence-activated cell sorting (FACS), and EGFR ubiquitination and protein binding by immunoprecipitation in the human cholangiocarcinoma RBE and immortalized cholangiocyte MMNK-1 cell lines. Monensin treatment and Rab11a depletion by siRNA were adopted for inhibition of EGFR recycling.

Results

Upon stimulation with EGF, ligand-induced EGFR degradation was impaired and the expression of phospho-tyrosine 1068 and phospho-p44/42 MAPK was sustained in RBE cells as compared with MMNK-1 cells. In RBE cells, the process of EGFR sorting for lysosomal degradation was blocked at the early endosome stage, and non-degradated EGFR was recycled to the cell surface. A disrupted association between EGFR and the E3 ubiquitin ligase c-Cbl, as well as hypo-phosphorylation of EGFR at tyrosine 1045 (Tyr1045), were also observed in RBE cells.

Conclusion

In RBE cells, up-regulation of EGFR Tyr1045 phosphorylation is a potentially useful molecular alteration in EGFR-targeted therapy. The combination of molecular-targeted therapy determined by the characteristics of individual EGFR phosphorylation events and EGFR recycling inhibition show promise in future treatments of cholangiocarcinoma.

Upregulated expression of Mina53 in cholangiocarcinoma and its clinical significance

The aim of this study was to determine the level of expression of Mina53 in human cholangiocarcinoma (CCA) and to explore the role of Mina53 in carcinogenesis and tumor progression and its clinical significance in CCA. The level of expression of Mina53, p53 and Ki67 was investigated by immunohistochemistry in 69 surgically resected CCA tissues and 21 adjacent non-cancerous tissues. The correlation between Mina53 expression and clinicopathological characteristics and the expression of p53 and Ki67 was examined. Positive expression of Mina53 was observed in 61 of 69 CCA cases (88.4%) and 1 case (4.8%) of adjacent non-cancerous tissue. The level of expression of Mina53 in CCA was markedly higher than in the adjacent non-cancerous tissues. An increased level of expression of Mina53 in CCA was significantly associated with histological differentiation (P<0.01), TNM stage (P<0.05) and lymph node metastasis (P<0.01). There was no significant correlation between the level of Mina53 expression and gender, age or distant metastasis (P>0.05). However, the expression of Mina53 was associated with the expression of p53 in CCA (P<0.05). In addition, increased levels of expression of Mina53 in CCA were positively associated with Ki67 levels (r=0.801, P<0.01, as calculated by association analysis). Therefore, the upregulation of Mina53 expression may be significant in the carcinogenesis and development of human CCA and could have significant clinical value.