Cholangiocarcinoma presenting as hemobilia and recurrent iron-deficiency anemia: a case report

The Emerging Role of Tumor Microenvironmental Stimuli in Regulating Metabolic Rewiring of Liver Cancer Stem Cells

Primary liver cancer (PLC) is one of the most devastating cancers worldwide. Extensive phenotypical and functional heterogeneity is a cardinal hallmark of cancer, including PLC, and is related to the cancer stem cell (CSC) concept. CSCs are responsible for tumor growth, progression, relapse and resistance to conventional therapies. Metabolic reprogramming represents an emerging hallmark of cancer. Cancer cells, including CSCs, are very plastic and possess the dynamic ability to constantly shift between different metabolic states depending on various intrinsic and extrinsic stimuli, therefore amplifying the complexity of understanding tumor heterogeneity. Besides the well-known Warburg effect, several other metabolic pathways including lipids and iron metabolism are altered in PLC. An increasing number of studies supports the role of the surrounding tumor microenvironment (TME) in the metabolic control of liver CSCs. In this review, we discuss the complex metabolic rewiring affecting liver cancer cells and, in particular, liver CSCs. Moreover, we highlight the role of TME cellular and noncellular components in regulating liver CSC metabolic plasticity. Deciphering the specific mechanisms regulating liver CSC-TME metabolic interplay could be very helpful with respect to the development of more effective and innovative combinatorial therapies for PLC treatment.

Establishment and verification of potential biomarkers for cholangiocarcinoma

Cholangiocarcinoma (CCA) is a malignancy arising from multiple locations along the biliary tree, which is still lacking effective diagnostic biomarkers. The present study aimed to provide a comprehensive differential gene expression profile for the disease. The differentially expressed genes (DEGs) for CCA were explored in-depth using a Gene Expression Omnibus (GEO) dataset, an internal cohort of clinical participants as well as in vitro experiments with the HUCCT1 cell line. Based on the GEO dataset, potential biomarker genes were proposed and the enriched biological processes as well as signaling pathways were further investigated. A protein-protein interaction network of target genes was established. In the clinical specimens, the functions of the primary candidate, FBJ murine osteosarcoma viral oncogene homolog B (FOSB), were evaluated by reverse transcription-quantitative (RT-q)PCR and western blot analysis. A Cell Counting Kit-8 (CCK-8) assay was used for a functional study on FOSB. The results indicated that, compared with non-tumor bile duct tissues, primary CCA samples had 676 differentially expressed genes, including 277 downregulated and 399 upregulated ones. Among these, HBD, FOSB, HBB, ITIH2, FCGBP, MT1JP, PIJR, SLC38A1, COL10A1 and MMP19 were determined to be the most significant DEGs. At the same time, upregulated genes were enriched in ‘vasculature development’ and ‘IL-17 signaling pathways’. Downregulated genes were enriched in ‘extracellular matrix progress’ and ‘glucuronate signaling pathway’. The patients with CCA displayed decreased levels of hemoglobin. Compared with paracancerous tissues, CCA cancerous tissues exhibited increased RNA and protein expression levels of FOSB according to RT-qPCR and western blot analysis, respectively. Furthermore, FOSB expression influenced the proliferation/viability of the CCA cell line HUCCT1. In conclusion, the present study suggested that the FOSB gene may serve as a primary biomarker candidate for CCA, providing a valuable reference for its clinical implementation.

Hemobilia: An Uncommon But Notable Cause of Upper Gastrointestinal Bleeding

GOAL AND BACKGROUND

A literature review to improve practitioners' knowledge and performance concerning the epidemiology, diagnosis, and management of hemobilia.

STUDY

A search of Pubmed, Google Scholar, and Medline was conducted using the keyword hemobilia and relevant articles were reviewed and analyzed. The findings pertaining to hemobilia etiology, investigation, and management techniques were considered and organized by clinicians practiced in hemobilia.

RESULTS

The majority of current hemobilia cases have an iatrogenic cause from either bile duct or liver manipulation. Blunt trauma is also a significant cause of hemobilia. The classic triad presentation of right upper quadrant pain, jaundice, and upper gastrointestinal bleeding is rarely seen. Computed tomography and magnetic resonance imaging are the preferred diagnostic modalities, and the preferred therapeutic management includes interventional radiology and endoscopic retrograde cholangiopancreatography. Surgery is rarely a therapeutic option.

CONCLUSIONS

With advances in computed tomography and magnetic resonance imaging technology, diagnosis with these less invasive investigations are the favored option. However, traditional catheter angiography is still the gold standard. The management of significant hemobilia is still centered on arterial embolization, but arterial and biliary stents have become accepted alternative therapies.

How to apply clinical cases and medical literature in the framework of a modified "failure mode and effects analysis" as a clinical reasoning tool--an illustration using the human biliary system

BACKGROUND

Clinicians use various clinical reasoning tools such as Ishikawa diagram to enhance their clinical experience and reasoning skills. Failure mode and effects analysis, which is an engineering methodology in origin, can be modified and applied to provide inputs into an Ishikawa diagram.

METHOD

The human biliary system is used to illustrate a modified failure mode and effects analysis. The anatomical and physiological processes of the biliary system are reviewed. Failure is defined as an abnormality caused by infective, inflammatory, obstructive, malignancy, autoimmune and other pathological processes. The potential failures, their effect(s), main clinical features, and investigation that can help a clinician to diagnose at each anatomical part and physiological process are reviewed and documented in a modified failure mode and effects analysis table. Relevant medical and surgical cases are retrieved from the medical literature and weaved into the table.

RESULTS

A total of 80 clinical cases which are relevant to the modified failure mode and effects analysis for the human biliary system have been reviewed and weaved into a designated table. The table is the backbone and framework for further expansion. Reviewing and updating the table is an iterative and continual process. The relevant clinical features in the modified failure mode and effects analysis are then extracted and included in the relevant Ishikawa diagram.

CONCLUSIONS

This article illustrates an application of engineering methodology in medicine, and it sows the seeds of potential cross-pollination between engineering and medicine. Establishing a modified failure mode and effects analysis can be a teamwork project or self-directed learning process, or a mix of both. Modified failure mode and effects analysis can be deployed to obtain inputs for an Ishikawa diagram which in turn can be used to enhance clinical experiences and clinical reasoning skills for clinicians, medical educators, and students.