Curative resection of gallbladder cancer with liver invasion and hepatic metastasis after chemotherapy with gemcitabine plus S-1: report of a case

Exosomal long non-coding RNA TRPM2-AS promotes angiogenesis in gallbladder cancer through interacting with PABPC1 to activate NOTCH1 signaling pathway

BACKGROUND

Abnormal angiogenesis is crucial for gallbladder cancer (GBC) tumor growth and invasion, highlighting the importance of elucidating the mechanisms underlying this process. LncRNA (long non-coding RNA) is widely involved in the malignancy of GBC. However, conclusive evidence confirming the correlation between lncRNAs and angiogenesis in GBC is lacking.

METHODS

LncRNA sequencing was performed to identify the differentially expressed lncRNAs. RT-qPCR, western blot, FISH, and immunofluorescence were used to measure TRPM2-AS and NOTCH1 signaling pathway expression in vitro. Mouse xenograft and lung metastasis models were used to evaluate the biological function of TRPM2-AS during angiogenesis in vivo. EDU, transwell, and tube formation assays were used to detect the angiogenic ability of HUVECs. RIP, RAP, RNA pull-down, dual-luciferase reporter system, and mass spectrometry were used to confirm the interaction between TRPM2-AS, IGF2BP2, NUMB, and PABPC1.

RESULTS

TRPM2-AS was upregulated in GBC tissues and was closely related to angiogenesis and poor prognosis in patients with GBC. The high expression level and stability of TRPM2-AS benefited from m6A modification, which is recognized by IGF2BP2. In terms of exerting pro-angiogenic effects, TRPM2-AS loaded with exosomes transported from GBC cells to HUVECs enhanced PABPC1-mediated NUMB expression inhibition, ultimately promoting the activation of the NOTCH1 signaling pathway. PABPC1 inhibited NUMB mRNA expression through interacting with AGO2 and promoted miR-31-5p and miR-146a-5p-mediated the degradation of NUMB mRNA. The NOTCH signaling pathway inhibitor DAPT inhibited GBC tumor angiogenesis, and TRPM2-AS knockdown enhanced this effect.

CONCLUSIONS

TRPM2-AS is a novel and promising biomarker for GBC angiogenesis that promotes angiogenesis by facilitating the activation of the NOTCH1 signaling pathway. Targeting TRPM2-AS opens further opportunities for future GBC treatments.

Effects of surgery on survival of elderly patients with gallbladder cancer: A propensity score matching analysis of the SEER database

Background

Surgery is the sole curative therapy for gallbladder cancer (GBC) patients. Confronting an aging society, the demand to treat elderly patients with GBC is increasing. But there are few reports on survival benefit in elderly GBC patients treated with surgery. Therefore, we designed this population-based study to assess the survival benefit of surgery in GBC patients aged 70 years or older.

Methods

GBC patients aged 70 years or older were identified in the surveillance, epidemiology, and end results cancer (SEER) database from 2010 to 2017. A 1:1 propensity score matching (PSM) analysis was conducted to balance the baseline data of patients. Overall survival (OS) and cancer-specific survival (CSS) of patients were evaluated by Kaplan-Meier analysis and compared with log-rank test. Independent risk factors associated with OS and CSS were determined by univariate and multivariate Cox proportional hazard regression analyses and subgroup analysis were performed.

Results

A total of 2055 GBC patients aged 70 years or older were included in our study, with 1734 patients underwent surgery. Before PSM, the age, AJCC stage, TNM stage, and chemotherapy were significantly different between the surgery and no-surgery group (all P<0.05). Patients with surgery had significantly longer OS and CSS than those without surgery (P<0.0001). After 1:1 PSM, the differences in clinicopathological characteristics were reduced (all P>0.05). Kaplan-Meier analysis also showed patients received surgery had significantly better OS and CSS (P<0.0001). Subgroup analysis further indicated that almost all subgroups received surgery had OS and CSS advantage, especially patients aged 70-84 years old. Finally, univariate and multivariate COX regression analyses showed that age, AJCC stage and T stage were independent prognostic factors for OS and CSS in patients undergoing surgery.

Conclusion

Our study found that surgery significantly improved OS and CSS in GBC patients aged 70-84 years, but more prospective studies are needed to prove our findings.

Curative surgical resection for initially unresectable metastatic gallbladder cancer following neoadjuvant chemotherapy: Case report and review of literature

Background

Gallbladder cancer is a rare type of malignancy with overall poor prognosis. It represents the most common type of biliary tract cancer. Surgical resection can provide cure for those presenting in early stages. However, patients presenting with locally advanced or metastatic disease are considered unresectable and the first line of management in such cases is chemotherapy.

Case presentation

60 years old Saudi female with no previous medical background who was diagnosed at local hospital to have unresectable metastatic gallbladder cancer to the liver. She received 6 cycles of neoadjuvant chemotherapy as the standard protocol (Gemcitabin + Cisplatin). She showed a good response and after a multidisciplinary tumor board decision was then taken for a successful curative surgical resection (R0). Post operatively, she had another 4 cycles adjuvant chemotherapy of the same regimen. She is still on active surveillance, alive in a good condition with no local recurrence or distant metastasis after 42 months post operatively.

Discussion

Patients with gallbladder cancer are often diagnosed at late stages and those with locally advanced or metastatic gallbladder cancer are not candidates for surgical resection, even though it is a principal part of management to achieve cure. A conversion surgical resection is yet possible in selected patients initially labeled as having unresectable gallbladder cancer following neoadjuvant chemotherapy.

Conclusion

A conversion surgical resection can achieve cure in appropriately selected candidates initially labeled as unresectable gallbladder cancer following good response to neoadjuvant chemotherapy. Careful patient selection and multidisciplinary team management is recommended. Further studies are needed to standardized the management approach regarding criteria for eligible candidates, timing before considering conversion, and extent of resection.

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Patients with gallbladder cancer are often diagnosed at late stages and those with locally advanced or metastatic gallbladder cancer are not candidates for surgical resection, even though it is a principal part of management to achieve cure.

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The management approach for such tumor stages is a palliative systemic chemotherapy using the standard protocols of Gemcitabin + Cisplatin or clinical trial along with supportive care. Palliative radiotherapy may also play a role

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The limit of surgical resection can be variable depending on the pre- and intra- operative findings ranging from only radical cholecystectomy to more aggressive procedures including major hepatic resection, extra-hepatic biliary duct resection, or adjacent organs resection depending on the tumor extensions aiming to achieve R0 resection.

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Surgical resection for gallbladder cancer can be potentially curative, is not always feasible especially in locally advanced or metastatic cases. However, it should be considered whenever possible following good response to neoadjuvant chemotherapy in appropriate candidates.

KIF11 promotes cell proliferation via ERBB2/PI3K/AKT signaling pathway in gallbladder cancer

Proliferation is one of the significant hallmarks of gallbladder cancer, which is a relatively rare but fatal malignance. Aim of this study was to examine the biological impact and molecular mechanism of the candidate hub-gene on the proliferation and tumorigenesis of gallbladder cancer. We analyzed the differentially expressed genes and the correlation between these genes with MKI67, and showed that KIF11 is one of the major upregulated regulators of proliferation in gallbladder cancer (GBC). The Gene Ontology, Gene Sets Enrichment Analysis and KEGG Pathway analysis indicated that KIF11 may promote GBC cell proliferation through the ERBB2/PI3K/AKT signaling pathway. Gain-of-function and loss-of-function assay demonstrated that KIF11 regulated GBC cell cycle and cancer cell proliferation in vitro. GBC cells exhibited G2M phase cell cycle arrest, cell proliferation and clone formation ability reduction after treatment with Monastrol, a specific inhibitor of KIF11. Xenograft model showed that KIF11 promotes GBC growth in vivo. Rescue experiments showed that KIF11-induced GBC cell proliferation dependented on ERBB2/PI3K/AKT pathway. Moreover, we found that H3K27ac signals are enriched among the promoter region of KIF11 in the UCSC Genome Browser Database. Differentially expressed analysis showed that EP300, a major histone acetyltransferase modifying H3K27ac signal, is highly expressed in gallbladder cancer and correlation analysis illustrated that EP300 is positively related with KIF11 in almost all the cancer types. We further found that KIF11 was significantly downregulated in a dose-dependent and time-dependent manner after histone acetylation inhibitor treatment. The present results highlight that high KIF11 expression promotes GBC cell proliferation through the ERBB2/PI3K/AKT signaling pathway. The findings may help deepen our understanding of mechanism underlying GBC cancer development and development of novel diagnostic and therapeutic target.

Salvage Surgery for Metastatic Gall Bladder Cancer with Vanishing Liver Metastasis Following Palliative 5-Fluorouracil Metronomic Chemotherapy

Gall Bladder Cancer (GBC) is an aggressive malignancy. The prognosis of metastatic GBC is dismal. Until recently, there are no standard treatment guidelines for management of patients with metastatic GBC. But the ultimate aim of any treatment modality is to improve the overall survival with good quality of life. We hereby report a long term survivor of metastatic GBC treated with initial six cycles of gemcitabine + cisplatin combination chemotherapy, but did not show any response. In view of chemotoxicity and as a matter of physician preference patient was started on low dose weekly 5- Fluorouracil monotherapy based on a metronomic chemotherapy principle. There was complete resolution of all the liver metastasis and salvage radical cholecystectomy was done. The patient is disease free on imaging at eight months of follow up. A very few such cases have been reported in the world literature, till date. Metastatic disease must not be considered incurable as there are no objective measures to predict tumour biology. Further research on metronomic chemotherapy and tumour genetics in such patients will open a new era of individualised cancer therapy based on objective measures that will predict tumour biology.