Gallbladder cancer: current status

Arachidonic acid metabolism as a novel pathogenic factor in gastrointestinal cancers

Gastrointestinal (GI) cancers are a major global health burden, representing 20% of all cancer diagnoses and 22.5% of global cancer-related deaths. Their aggressive nature and resistance to treatment pose a significant challenge, with late-stage survival rates below 15% at five years. Therefore, there is an urgent need to delve deeper into the mechanisms of gastrointestinal cancer progression and optimize treatment strategies. Increasing evidence highlights the active involvement of abnormal arachidonic acid (AA) metabolism in various cancers. AA is a fatty acid mainly metabolized into diverse bioactive compounds by three enzymes: cyclooxygenase, lipoxygenase, and cytochrome P450 enzymes. Abnormal AA metabolism and altered levels of its metabolites may play a pivotal role in the development of GI cancers. However, the underlying mechanisms remain unclear. This review highlights a unique perspective by focusing on the abnormal metabolism of AA and its involvement in GI cancers. We summarize the latest advancements in understanding AA metabolism in GI cancers, outlining changes in AA levels and their potential role in liver, colorectal, pancreatic, esophageal, gastric, and gallbladder cancers. Moreover, we also explore the potential of targeting abnormal AA metabolism for future therapies, considering the current need to explore AA metabolism in GI cancers and outlining promising avenues for further research. Ultimately, such investigations aim to improve treatment options for patients with GI cancers and pave the way for better cancer management in this area.

Safety and efficacy of afatinib as add-on to standard therapy of gemcitabine/cisplatin in chemotherapy-naive patients with advanced biliary tract cancer: an open-label, phase I trial with an extensive biomarker program

BACKGROUND

To date, the cornerstone of treatment in patients with advanced or metastatic cholangiocarcinoma (CCA) is systemic chemotherapy based on a combination of gemcitabine and a platinum derivative. Other therapeutic approaches including targeted agents and tyrosine kinase inhibitors (TKI) have demonstrated disappointing results, highlighting the complexity of CCA. Recently, drugs aiming at the inhibition of HER-receptors have shown first therapeutic benefit in patients with late stage disease. The aim of this phase I study was to test the dose level toxicities (DLTs), safety and efficacy of afatinib, a highly specific panErbB family receptor TKI, in chemotherapy naive patients with advanced CCA in conjunction with an extensive biomarker program.

METHODS

Afatinib was administered continuously p. o. as add-on in patients with advanced CCA who received conventional chemotherapy with gemcitabine/cisplatin. A classical 3 + 3 phase I study was employed, while the maximum tolerated dose (MTD) of oral afatinib was determined in a 2 step dose escalation. Safety, overall survival (OS) and progression free survival (PFS) were evaluated for all patients. Finally, a translational biomarker analysis was conducted for the EGFR and VEGF signalling cascades.

RESULTS

Overall, 9 patients were enrolled. Further recruitment was discontinued due to lack of efficacy results of the tested drug in other indications. 30 mg afatinib could be safely administered as add-on to 80% of standard dose gemcitabine/cisplatin. The mOS and mPFS were 7.7 and 6.0 months, respectively. Diarrhoea and haematological disorders were the most common observed AEs. Almost all patients overexpressed EGFR on their tumour tissues, whereas none of them expressed mutations in Exons 18, 19 and 21. Non-responders showed a higher variation of VEGF-C, -D, leptin and sEGFR in their sera.

CONCLUSIONS

Afatinib failed to show survival benefits in combination with gemcitabine/cisplatin in patients with advanced CCA. Mutational analysis of EGFR and pathways associated with VEGF-C, -D and leptin might show promising results in future studies.

CLINICAL TRIALS REGISTRATION

NCT01679405 August, 2012.

Clinical significance of P-glycoprotein and glutathione S-transferase π expression in gallbladder carcinoma

P-glycoprotein (P-gp) and glutathione S-transferase π (GST-π) are not only drug-resistance markers, but also prognostic markers of various cancers. The aim of the present study was to investigate the clinical significance of P-gp and GST-π in gallbladder carcinoma (GBC). Tissue samples from 42 patients with GBC were immunostained. Demographic, clinical and follow-up data were collected and analyzed. The positive expression rates of P-gp and GST-π in the GBC tissues were significantly higher (76.2 and 64.3%, respectively) than that of chronic cholecystitis specimens (30 and 20%, respectively) (P=0.014 and 0.035, respectively), and correlated with the Nevin stage of GBC. Multivariate analysis demonstrated that patients with positive expression of P-gp and GST-π showed a significantly lower 2-year survival rate (11.1 and 12%, respectively) compared with patients with negative expression (55.6 and 45.5%, respectively) (P=0.013 and 0.036, respectively). P-gp was also found to be an independent prognostic marker of 2-year survival rate by logistic regression analysis (B=-2.76, P=0.061). Results of this study suggest that P-gp is a prognostic marker of GBC and the detection of P-gp and GST-π may contribute to the prognosis of GBC and the application of chemotherapy as a therapeutic treatment.

Chemotherapy for inoperable advanced or metastatic cholangiocarcinoma: retrospective analysis of 78 cases in a single center over four years

BACKGROUND

Systemic chemotherapy is the treatment of choice for inoperable (advanced or metastatic) cholangiocarcinoma. According to phase II and III trials, regimens combining 5-fluorouracil (5FU) or gemcitabine with a platinum salt have provided an overall response rate of 12-50% with a median overall survival of 5-16 months.

METHODS

This was a retrospective analysis of 78 consecutive cases of inoperable cholangiocarcinoma treated by palliative chemotherapy from July 2005 to November 2009 in one center. We firstly aimed to evaluate the impact of palliative chemotherapy in terms of survival and secondly to analyze possible related prognostic factors.

RESULTS

This cohort included 25 female and 53 male patients, with a mean age of 60.8 ± 11.4 years. Intrahepatic and extrahepatic cholangiocarcinoma were observed in 57 and 21 patients, respectively. First-line chemotherapy regimens were as follows: gemcitabine (n = 7), gemcitabine plus oxaliplatin (with or without cetuximab; n = 62) and 5FU plus cisplatin (n = 9). None of the patients achieved a complete response. The partial response rate was 35.9% (27/78), and the stable disease rate was 26.9% (21/78), giving a disease control rate of 62.8%. At the time of this analysis, with a median follow-up of 18 months, 13 patients were survivors. Median overall survival was 10 months [95% confidence interval (CI) 7-12], and median progression-free survival was 7 months (95% CI 6-8). Upon univariate analysis, only the distribution of the disease was significantly linked with prognosis, with a median overall survival of 10 months (95% CI 10-24) for solitary tumors versus 7 months (95% CI 6-11) in the case of infiltrative or multifocal tumors (p = 0.039).

CONCLUSION

The disease control rate, overall survival and progression free-survival in this single-center retrospective study were in agreement with earlier reports. Specific features of this cohort were a large proportion of cholangiocarcinoma with associated cirrhosis (n = 30/78, 38.5%), mostly intrahepatic (n = 25/30, 83.5%). This confirms the increasing incidence of intrahepatic localization and the epidemiological link recently reported between intrahepatic biliary tract carcinoma and cirrhosis.

Identification of CD146 expression, angiogenesis, and lymphangiogenesis as progression, metastasis, and poor-prognosis related markers for gallbladder adenocarcinoma

Gallbladder cancers (GBC) are associated with high disease-specific mortality rates because of no means of early detection and effective therapies. In this study, we investigated CD146 expression, microvessel densities, and lymph vessel densities in 108 adenocarcinomas, 15 gallbladder polyps, 35 chronic cholecystitis tissues, and 46 peritumoral tissues using immunohistochemistry. We demonstrated that positive CD146 expression, and average microvessel and lymph vessel counts in gallbladder adenocarcinomas were significantly higher than those in peritumoral tissues, polyps, and chronic cholecystitis (ps < 0.01). Positive CD146 expression, and average microvessel and lymph vessel counts were also significantly lower in cases with well-differentiated adenocarcinoma, maximal tumor diameter <2 cm, no metastasis of lymph node, and no invasion of regional tissues than in cases with poorly differentiated adenocarcinoma, maximal tumor diameter ≥ 2 cm, metastasis in lymph nodes, and invasion of regional tissues (p < 0.05 or p < 0.01). Univariate Kaplan-Meier analysis showed that increased expression of CD146 (p = 0.056), higher average microvessel counts (p < 0.05), and lymph vessel counts (p < 0.05) were associated with decreased overall survival. Multivariate Cox regression analysis showed that average microvessel and lymph vessel counts (ps < 0.05) were independent prognostic predictors in gallbladder adenocarcinoma. Our study suggested that the elevated expression of CD146, angiogenesis, and lymphangiogenesis might be closely related to progression, invasion, metastasis, and prognosis of gallbladder adenocarcinoma.

Cancer surveillance in patients with primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a chronic fibroinflammatory syndrome involving the biliary tract, often accompanied by inflammatory bowel disease (IBD). This syndrome is a prototype disease linking chronic inflammation to carcinogenesis. Indeed, PSC is associated with an increased risk of cholangiocarcinoma (CCA), gallbladder cancer, hepatocellular carcinoma (HCC), and colorectal cancer. Herein, we review the risk for these malignancies in PSC and discuss rational cancer surveillance strategies for these patients. Where evidence is limited, we suggest a pragmatic approach. In this regard, we recommend interval screening for CCA with noninvasive imaging modalities and serum carbohydrate antigen 19-9 determinations annually. These imaging studies also serve to screen for gallbladder cancer and HCC. Screening for colorectal cancer is more firmly established in PSC patients with IBD and includes colonoscopy at the time of PSC diagnosis and, thereafter, at 1-2-year intervals. We also highlight areas where more information is required, such as management of biliary tract dysplasia and cancer chemoprevention in PSC.

Identification of PEG10 and TSG101 as carcinogenesis, progression, and poor-prognosis related biomarkers for gallbladder adenocarcinoma

PEG10 is a transcriptional factor while TSG101 is involved in numerous cellular processes, including apoptotic resistance. Overexpression of PEG10 and TSG101 were observed in a variety of human cancers. However, their expression and clinical significance in gallbladder cancer (GBC) have not yet been identified. To understand the tumor biology of GBC at the molecular level, we examined PEG10 and TSG101 expression in 108 adenocarcinomas, 15 gallbladder polyps, 35 chronic cholecystitis tissues, and 46 peritumoral tissues by using immunohistochemistry. Overexpression of PEG10 and TSG101 was detected in gallbladder adenocarcinoma (48.1% and 47.2%, respectively). Conversely, there was less expression detected in the peritumoral tissues (19.6%), adenomatous polyps (13.3%), and gallbladder epithelium with chronic cholecystitis (5.1%) (p < 0.01, p < 0.05, and p < 0.01, respectively). Notably, the benign lesions with positive PEG10 and/or TSG101 expression showed moderately or severely atypical hyperplasia in gallbladder epithelium. The overexpression of PEG10 and TSG101 was significantly associated with differentiation, tumor mass, lymph node metastasis and invasion of adenocarcinoma. Univariate Kaplan-Meier analysis showed that overexpression of PEG10 (p = 0.041) and TSG101 (p = 0.025) was closely associated with decreased overall survival. Multivariate Cox regression analysis revealed that positive expression of PEG10 (p = 0.036) or TSG101 (p = 0.022) is a predictor of poor prognosis in gallbladder adenocarcinoma. Our study suggested that overexpression of PEG10 and TSG101 might be closely related to the carcinogenesis, progression, clinical biological behaviors, and prognosis of gallbladder adenocarcinoma.

Gender-Specific Prognostic Markers of Patients with Gallbladder Cancer after Surgical Resection

The aim of this study was to elucidate gender-specific markers for postresectional long-term survival of gallbladder cancer (GBC) based on a cohort of Chinese patients. Clinicopathological records of 81 patients (27 males and 54 females) after surgical resection for GBC were reviewed retrospectively. The influence of each variable on survival was determined using the Kaplan-Meier method and log-rank test. For females, Cox regression analysis was also adopted. Univariate analysis showed that the absence of lymph node and distant metastases, differentiation grade, and curative resection were associated with prolonged survival for all males, whereas tumor size, differentiation grade, and the presence of lymph node metastases influenced the overall or disease-free survival of patients after curative resection (all P < 0.05). On the other hand, Nevin stage was an independent marker for both overall survival for all females and overall and disease-free survival for female patients who underwent curative resection. Additionally, resection type and differentiation grade were of independent prognostic significance for different subgroups of females (all P < 0.05). Our data suggested that tumor-related factors affect prognosis of both male and female patients with GBC after resection. Of these factors, tumor differentiation status might be more significant for males, but Nevin stage had a stronger predictive potential for females.

[Precancerous lesions of the gallbladder]

This Mini-review summarizes the epidemiology, predisposing and pre-cancerous conditions related to carcinoma of the gallbladder. In 75% of cases, gallbladder cancer is a cholangiocarcinoma, usually presenting in a late and advanced stage, and it carries one of the worst prognoses of all GI malignancies. Early stage disease is usually discovered incidentally by the pathologist in a gallbladder specimen removed for calculous cholecystitis. It occurs three times more frequently in women than in men and invasive forms usually occur after the age of 60. Incidence varies with geographic location. Besides genetic and geographic factors, the presence of one or more large gallstones is a major risk factor. Gallbladder polyps larger than 1.5 cm. (especially solitary sessile hypoechogenic polyps) are associated with a 50% risk of malignancy. Choledochal cysts and other variations of the biliopancreatic junction are also associated with high risk; cancer may occur at a much younger age in these patients and in the absence of gallstones. Porcelain gallbladder is a risk factor, particularly when there is calcification of the gallbladder mucosa. Chronic gallbladder infection has been implicated as a risk factor for malignant degeneration. Finally, cancer of both the gallbladder and the bile ducts is more frequent in patients suffering from primary biliary cirrhosis.

Biological characteristics of cancers in the gallbladder and biliary tract and targeted therapy

Adenocarcinomas of the gallbladder (GBC) and bile ducts (cholangiocarcinoma) (combined as biliary tract cancers, BTC) are uncommon tumors in the United States, but are endemic in parts of South America and Asia. BTC are aggressive tumors with poor survival. Published response rates to chemotherapy are less than 30% and no survival benefit has been demonstrated from palliative systemic therapy. Improved understanding of the biological characteristics and molecular carcinogenic mechanisms of these malignancies may lead to improved therapeutic regimens for patients.

Overexpression of LAPTM4B-35 closely correlated with clinicopathological features and post-resectional survival of gallbladder carcinoma

Gallbladder carcinoma (GBC) is a malignancy with dismal prognosis and unclear gene expression profile. We aimed to first present the expression of LAPTM4B-35, one product of a cancer associated gene recently cloned in hepatocellular carcinoma (HCC), and its correlation with clinicopathological features and prognosis of GBC. Immunohistochemical detection of LAPTM4B-35 was performed on samples from 75 patients with GBC. LAPTM4B-35 protein was overexpressed in 57 patients (76%) with GBC. The staining scores were significantly related to histology type, lymph node involvement, distant metastasis, Nevin staging and differentiation of GBC (P<0.05). Univariate analysis revealed that overall or disease-free survival of patients was inversely associated with its staining scores (P<0.001). Multivariate analysis showed that LAPTM4B-35 staining score was an independent prognostic marker for both overall and disease-free post-resectional survival of GBC (P=0.004 and 0.027, respectively). LAPTM4B-35 overexpressed in a majority of GBCs and correlated with clinicopathological features and post-resectional survival.

Expression of IGF-I, IGF-II, and IGF-IR in gallbladder carcinoma. A systematic analysis including primary and corresponding metastatic tumours

AIMS

The insulin-like growth factor (IGF) system has been implicated in tumour development and progression. This study was designed to analyse the expression of the IGF-I receptor (IGF-IR) and its ligands (IGF-I, IGF-II) in gallbladder cancer.

METHODS

IGF-I, IGF-II, and IGF-IR immunoreactivity was investigated in 57 gallbladder carcinomas and corresponding lymph node (n = 11) and hepatic (n = 7) metastases using a tissue microarray technique and correlated with tumour stage, grade, and patient outcome.

RESULTS

Cancer tissue allowing a reliable evaluation of IGF-I, IGF-II, and IGF-IR was present in 55 of 57 primary tumours and 17 of 18 metastases. IGF-I and IGF-II immunoreactivity was seen in 25 and 14 of the 55 primary tumours, in addition to six and three of the 17 metastases, respectively. No associations with tumour stage, grade, or prognosis were detected. IGF-IR was expressed in 52 of 55 primary tumours and all 17 metastases. IGF-IR staining intensity decreased with tumour cell dedifferentiation. Moreover, IGF-IR expression in less than 50% of cancer cells was an independent marker of poor prognosis in multivariate analysis (risk ratio, 4.0; 95% confidence interval, 1.4 to 11.2; p = 0.01).

CONCLUSIONS

The expression of IGF-IR and its ligands provides evidence for the existence of an auto/paracrine loop of tumour cell stimulation in gallbladder cancer and makes this type of cancer a candidate for therapeutic strategies aimed at interfering with the IGF pathway. The recognition of IGF-IR as a new independent prognostic biomarker may help to identify patients who might benefit from adjuvant treatment.