A case of an alpha-fetoprotein-producing intrahepatic cholangiocarcinoma suggests probable cancer stem cell origin

Clinical diagnosis and treatment strategies for sarcomatoid intrahepatic cholangiocarcinoma

Sarcomatoid intrahepatic cholangiocarcinoma (SiCCA) is a malignant tumor composed of mixed epithelial cells and mesenchymal cells derived from malignant bile duct cells. SiCCA has a low incidence and has no specific clinical manifestations and serological and imaging examinations. The diagnosis of SiCCA relies on histopathology and immunohistochemistry. The very high malignancy of SiCCA makes it prone to liver and other organ metastases. SiCCA has a poor prognosis because it has a low surgical resection rate, is easy to relapse shortly after surgery, and has no effective prevention and treatment measures. Comprehensive analysis integrating imaging, serum tumor markers, and histopathological examination technology is an important measure to improve the diagnosis of SiCCA and reduce the misdiagnosis rate. Early diagnosis, surgical treatment, and comprehensive postoperative treatment based on chemotherapy are the keys to improving the survival and prognosis of patients with SiCCA.

Cancer Stem Cells in Intrahepatic Cholangiocarcinoma; Their Molecular Basis, and Therapeutic Implications

Cancer tissue consists of heterogenous cell types, and cancer stem cells (CSCs) are a subpopulation of the tissue which possess therapy resistance, tumor reconstruction capability, and are responsible for metastasis. Intrahepatic cholangiocarcinoma (iCCA) is one of the most common type of liver cancer that is highly aggressive with poor prognosis. Since no target therapy is efficient in improving patient outcomes, new therapeutic approaches need to be developed. CSC is thought to be a promising therapeutic target because of its resistance to therapy. Accumulating evidences suggests that there are many factors (surface marker, stemness-related genes, etc.) and mechanisms (epithelial-mesenchymal transition, mitochondria activity, etc.) which are linked to CSC-like phenotypes. Nevertheless, limited studies are reported about the application of therapy using these mechanisms, suggesting that more precise understandings are still needed. In this review, we overview the molecular mechanisms which modulate CSC-like phenotypes, and discuss the future perspective for targeting CSC in iCCA.

Diagnosis and treatment of hepatocellular carcinoma. Update of the consensus document of the AEEH, AEC, SEOM, SERAM, SERVEI, and SETH

Hepatocellular carcinoma (HCC) is the most common primary liver neoplasm and one of the most common causes of death in patients with cirrhosis of the liver. In parallel, with recognition of the clinical relevance of this cancer, major new developments have recently appeared in its diagnosis, prognostic assessment and in particular, in its treatment. Therefore, the Spanish Association for the Study of the Liver (AEEH) has driven the need to update the clinical practice guidelines, once again inviting all the societies involved in the diagnosis and treatment of this disease to participate in the drafting and approval of the document: Spanish Society for Liver Transplantation (SETH), Spanish Society of Diagnostic Radiology (SERAM), Spanish Society of Vascular and Interventional Radiology (SERVEI), Spanish Association of Surgeons (AEC) and Spanish Society of Medical Oncology (SEOM). The clinical practice guidelines published in 2016 and accepted as National Health System Clinical Practice Guidelines were taken as the reference documents, incorporating the most important recent advances. The scientific evidence and the strength of the recommendation is based on the GRADE system.

Developing a Selection-aided Model to Screen Cirrhotic Intrahepatic Cholangiocarcinoma for Hepatectomy

Background: This study aimed to establish a model predicting the prognosis of intrahepatic cholangiocarcinoma (ICC) patients with cirrhosis before liver resection (LR). Methods: An Eastern Hepatobiliary Surgery Hospital (EHBH) model using the preoperative factors was established in a training cohort (305 patients from 2006 to 2011) and validated in an internal validation cohort (113 patients from 2012 to 2014). Predictive performance and discrimination were evaluated and compared with other staging systems. Results: The EHBH model containing preoperative factors of carbohydrate antigen 19-9 (CA19-9), radiological tumor diameter, tumor number, and satellite nodules outperformed other staging systems in predicting the prognosis of ICC. A contour plot of 3-year survival probability and a nomogram to form two differentiated groups of patients (high-risk group and low-risk group) were constructed based on the EHBH model to help surgeons predicting the overall survival (OS) before LR. Patients from the high-risk group (>86.56 points) in the training cohort had worse OS rates compared with those from the low-risk group (≤86.56 points). The one-, three-, and five-year OS rates were 50.4%, 29.0%, and 21.0% for the high-risk group and 68.2%, 45.5%, and 39.7% for the low-risk group, respectively (P<0.001). The same results were obtained in the internal validation patients. Conclusion: The contour plot is an easy-to-use tool to individually show the 3-year prognosis of ICC patients with different preoperative CA19-9 values and radiological characteristics before surgery. The EHBH model was suitable for selecting cirrhotic patients for LR to acquire a better survival.

Radiomics predict postoperative survival of patients with primary liver cancer with different pathological types

Background

Radiomics can be used to determine the prognosis of liver cancer, but it might vary among cancer types. This study aimed to explore the clinicopathological features, radiomics, and survival of patients with hepatocellular carcinoma (HCC), mass-type cholangiocarcinoma (MCC), and combined hepatocellular-cholangiocarcinoma (CHCC).

Methods

This was a retrospective cohort study of patients with primary liver cancer operated at the department of hepatobiliary surgery of the First Affiliated Hospital of Zhejiang University from 07/2013 to 11/2015. All patients underwent preoperative liver enhanced MRI scans and diffusion-weighted imaging (DWI). The radiomics characteristics of DWI and the enhanced equilibrium phase (EP) images were extracted. The mRMR (minimum redundancy maximum relevance) was applied to filter the parameters.

Results

There were 44 patients with MCC, 59 with HCC, and 33 with CHCC. Macrovascular invasion, tumor diameter, positive ferritin preoperatively, positive AFP preoperatively, positive CEA preoperatively, Correlation, Inverse Difference Moment, and Cluster Prominence in model A (DWI and clinicopathological parameters) were independently associated with overall survival (OS) (P<0.05). Lymphadenopathy, gender, positive ferritin preoperatively, positive AFP preoperatively, positive CEA preoperatively, Uniformity, and Cluster Prominence in model B (EP and clinicopathological parameters) were independently associated with OS (P<0.05). Macrovascular invasion, lymphadenopathy, gender, positive ferritin preoperatively, positive CEA preoperatively, Uniformity_EP, GLCMEnergy_DWI, and Cluster Prominence_EP in model C (image texture and clinicopathological parameters) were independently associated with OS (P<0.05). Those factors were used to construct three nomograms to predict OS.

Conclusions

Clinicopathological and radiomics features are independently associated with the OS of patients with primary liver cancer.

Intrahepatic sarcomatoid cholangiocarcinoma

Sarcomatoid carcinoma is a rare tumour composed of intermingled malignant epithelial and mesenchymal cells, and it has been reported in various organs including the liver. Sarcomatoid cholangiocarcinoma (CCC) is an extremely rare liver primary tumour. Here, we report a case of an elderly man who was admitted to our hospital after head trauma. He performed a head CT that diagnosed cerebral metastasis. On abdominal CT, he presented a 10×8×9 cm-sized hypodense liver mass in the VII and VIII segments, with peripheral enhancement. Histological and immunohistochemical examination of the tumour showed a malignant neoplasm with both carcinomatous and sarcomatous components and positive expression of cytokeratin and vimentin antibodies. The patient was diagnosed with intrahepatic sarcomatoid CCC at an advanced stage and died 45 days after the diagnosis. We emphasise the importance of immunohistochemistry which may provide a clue to proper diagnosis.

Simply and sensitively simultaneous detection hepatocellular carcinoma markers AFP and miRNA-122 by a label-free resonance light scattering sensor

In this study, an intelligent and label-free sensor is utilized for the first time to one-spot simultaneous detection hepatocellular carcinoma markers AFP and miRNA-122 by a resonance light scattering (RLS) sensor. cDNA1 hybridizes with cDNA2 to form double-stranded DNA (dsDNA). The construction of dsDNA and methyl violet is used to form the RLS sensor via the electronic interaction. When AFP or miRNA-122 is present, the cDNA (cDNA1 or cDNA2) can bindings of target, thereby RLS intensity changed proportionally with the concentration of AFP or that of miRNA-122. The detection limits of AFP and miRNA-122 are 0.94 μg/L and 98 pM respectively, and their good linear which ranges from 5 to 100 μg/L and 200 pM to 10 nM are achieved using the assay. In the presence of miRNA-122 and AFP mixtures, AFP bound to the AFP aptamer to increase the RLS signal, and miRNA-122 bound to the miRNA-122 complementary strand to decrease the RLS signal. The RLS signal changed in response to changing AFP and miRNA-122 concentrations, so that one-spot simultaneous detection of alpha fetal protein and miRNA-122 is achieved. This method has potential practical applications in the research of hepatocellular carcinoma.

Incorporation of alpha-fetoprotein(AFP) into subclassification of BCLC C stage hepatocellular carcinoma according to a 5-year survival analysis based on the SEER database

PURPOSE

To evaluate the effect of serum alpha-fetoprotein(AFP) on prognosis of patients with hepatocellular carcinoma (HCC) and put forward a proposal to modify BCLC staging system and the recommended treatment of patients with stage C.

RESULTS

AFP positive was an independent poor prognostic factor of HCC. Race, pathological grade, T stage, M stage were also regarded to be significant predicted factors for poorer prognosis. When combining AFP status with AJCC stage, patients with A1 disease had a worse prognosis compared with those with A0 disease within each stage. Patients with A1 disease of each T/N stage had a worse prognosis than patients with A0 disease of the respective stage, and the prognosis of patients with A1 disease with lower T stages was worse or similar to that of patients with A0 disease of higher T stages.

MATERIALS AND METHODS

We performed a retrospective study of all patients histologically diagnosed HCC from January 1, 2004, through December 31, 2008, from the SEER database.

CONCLUSIONS

AFP can be used as a subclassification index to modify the AJCC staging system of HCC. Since BCLC stage is the most widely used staging system, we recommend routine pre-treatment AFP testing as standard of care in HCC and incorporate AFP status into the BCLC staging system to modify the recommended treatment of patients with stage C.

Dynamics of liver enzymes in rabbits experimentally infected with Fasciola sp. (Intermediate form from Japan)

Dynamics of serum liver enzymes in rabbits experimentally infected with metacercariae of Fasciola sp. (intermediate form between Fasciola hepatica and F. gigantica) were monitored. Gradual increase of serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were observed from 3 weeks post-inoculation (WPI) and peaked at 6 WPI, which corresponded well to the period of migration and development of juvenile fluke in the liver parenchyma and the time when the young adult flukes migrated to the bile duct. However, no significant increase in serum gamma-glutamyl transferase (GGT) and alkaline phosphatase (ALP) were observed. This could reflect reduced or minimal injury of bile ducts and biliary epithelia as the flukes had reached the adult stage. Alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA) were not detected in the infected rabbit during the course of the experiment. Serum liver enzymes monitoring might be useful for understanding the host-parasite relationship in fascioliasis.

Autotaxin Expression in Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors. Despite the important progress observed in liver surgery, the survival rates are discouraging. The aim of this study was to investigate the expression of autotaxin in hepatocellular carcinoma.

MATERIALS AND METHODS

Liver tissues from 28 human hepatocellular carcinomas were evaluated for the expression of autotaxin by immunohistochemistry. The gender, age, histological grade, lymphovascular invasion, number of tumors, levels of serum alpha-fetoprotein (aFP), presence of liver cirrhosis, hepatitis, surgery and survival rates were recorded.

RESULTS

Immunohistochemistry confirmed the expression of autotaxin in hepatocellular carcinoma. The histological grade seems to be the only independent predictor of stronger autotaxin expression, as significantly higher levels of autotaxin were detected in histological grades II and III. In addition, levels of autotaxin seem to be the most important independent prognostic factor related to poor survival. There was an eight-fold higher risk of death in patients with high levels of autotaxin compared to patients with low levels.

CONCLUSIONS

Autotaxin expression in hepatocellular carcinoma could be of great importance. High autotaxin expression in HCC is detected in patients with histological grade II and III. Further, patients with elevated expression levels were found to possess an eight-fold higher risk of death. Autotaxin role in HCC should be further elucidated.

PIVKA-II is a useful tool for diagnostic characterization of ultrasound-detected liver nodules in cirrhotic patients

Protein induced by vitamin K absence-II (PIVKA-II) is a potential screening marker for hepatocellular carcinoma (HCC). Limited data are available about its utility in discriminating neoplastic from regenerative nodules at ultrasonography (US) evaluation in cirrhotic patients. Aim of this study was to investigate the diagnostic utility of PIVKA-II in cases showing liver nodules of uncertain diagnosis at US.Ninety cirrhotics with US evidence of liver nodule(s) were enrolled. All patients underwent blood sampling within 1 week of US and were thereafter followed up. HCC was confirmed in 40/90 cases, and in all cases it was in a very early/early stage. All sera were tested for PIVKA-II and alpha-fetoprotein (AFP) at the end of follow-up. PIVKA-II at a cut off of 60 mAU/mL was significantly associated with HCC at both univariate and multivariate analysis (P = .016 and P = .032, respectively). AFP at a cut off of 6.5 ng/mL was not associated with HCC at univariate analysis (P = .246). ROC curves showed that PIVKA-II had 60% sensitivity, 88% specificity, 80% positive predictive value (PPV), and 73% negative predictive value (NPV), whereas AFP had 67% sensitivity, 68% specificity, 63% PPV, and 72% NPV. AUROC curves showed that the combination of both biomarkers increased the diagnostic accuracy for HCC (AUC 0.76; sensitivity 70%, specificity 94%, PPV 91%, and NPV 79%).In conclusion, PIVKA-II is a useful tool for the diagnostic definition of US-detected liver nodules in cirrhotic patients, and it provides high diagnostic accuracy for HCC when combined with AFP.

Biliary tract cancer stem cells - translational options and challenges

Management of biliary tract cancer remains challenging. Tumors show high recurrence rates and therapeutic resistance, leading to dismal prognosis and short survival. The cancer stem cell model states that a tumor is a heterogeneous conglomerate of cells, in which a certain subpopulation of cells - the cancer stem cells - possesses stem cell properties. Cancer stem cells have high clinical relevance due to their potential contributions to development, progression and aggressiveness as well as recurrence and metastasis of malignant tumors. Consequently, reliable identification of as well as pharmacological intervention with cancer stem cells is an intensively investigated and promising research field. The involvement of cancer stem cells in biliary tract cancer is likely as a number of studies demonstrated their existence and the obvious clinical relevance of several established cancer stem cell markers in biliary tract cancer models and tissues. In the present article, we review and discuss the currently available literature addressing the role of putative cancer stem cells in biliary tract cancer as well as the connection between known contributors of biliary tract tumorigenesis such as oncogenic signaling pathways, micro-RNAs and the tumor microenvironment with cancer stem cells.

Hepatitis B virus is associated with the clinical features and survival rate of patients with intrahepatic cholangiocarcinoma

BACKGROUND AND OBJECTIVE

The pathogenesis and development of intrahepatic cholangiocarcinoma (ICC) may be triggered by hepatitis B virus (HBV). We conducted this retrospective study to explore the potential association between HBV infection and the clinical features and survival rate of patients with ICC.

METHODS

Patients with ICC who had undergone a curative resection were enrolled and divided into three groups according to the seropositivity of the hepatitis B surface antigen (HBsAg) and the hepatitis B core antibody (anti-HBc). The groups were as follows: group I, HBsAg (+)/anti-HBc (+); group II, HBsAg (-)/anti-HBc (+); group III HBsAg (-)/anti-HBc (-). The symptoms, pathologic findings, and outcome information of all patients were retrospectively reviewed. The patient sera were isolated to detect anti-HCV, HBsAg, and anti-HBc. Surgical specimens were assessed by hematoxylin and eosin (HE) staining. The expression of cytokeratin 7 was evaluated by immunohistochemistry. Finally, the 1-, 3-, and 5-year cumulative survival rates were analyzed.

RESULTS

Ninety-seven patients with ICC were enrolled in group I (n=26); group II, (n=50), and group III (n=21). A total of 26.8% (26/97) patients with ICC were positive for HBsAg. Patients with HBV-associated ICC tended to be younger (P=0.018), have lower CA19-9 levels (P=0.000), a higher alpha fetal protein (AFP) level (P=0.012) and prothrombin time (P=0.030), a higher risk of hepatic cirrhosis (P=0.001), and poor differentiation (P=0.028). The 1-, 3-, and 5-year cumulative survival rates for patients within the three groups were as follows: 27.3%, 0%, and 0% for group I, respectively; 62.5%, 30.0%, and 0% for group II, respectively; and 87.5%, 66.7%, and 50.0% for group III, respectively. The results were significantly different in an overall comparison (P=0.000).

CONCLUSION

Patients with HBV-associated ICC showed different clinicopathological features and lower survival rates compared to patients with ICC without HBV infection.

HBV-associated intrahepatic cholangiocarcinoma with high serum alpha-fetoprotein: a case report with review of literature

Background

Intrahepatic cholangiocarcinoma (ICC) is a rare malignant tumor. The etiology of ICC remains poorly understood. Recently, hepatitis B virus (HBV) infection has been implicated as a potential risk factor for ICC, particularly in HBV-endemic areas. Elevation of serum alpha-fetoprotein (AFP) is seen in approximately 20 % of ICC patients. However, serum AFP levels higher than 10,000 ng/mL have only been reported in a few ICC patients. We report an unusual case of HBV-associated ICC occurring in a male with a markedly elevated serum AFP.

Case presentation

A 60-year-old East Asian male presented with complaints of epigastric distention and right shoulder pain. Laboratory tests showed HBV infection, HBV deoxyribonucleic acid (DNA) slightly elevated (21 IU/mL) and serum AFP markedly elevated (12,310 ng/mL). Computed tomography (CT) scan found a large and irregular mass in the left lobe of the liver. The patient underwent the left hepatic lobe resection. Histopathological examination showed chronic hepatitis B in the background liver and the immunohistochemical (IHC) findings strongly supported the diagnosis of ICC with aberrant expression of AFP. Serum AFP and HBV DNA declined to normal level postoperatively. The patient received four cycles of gemcitabine plus oxaliplatin and took entecavir to prevent HBV reactivation. The patient kept disease free for 18 months in the latest follow-up.

Conclusion

ICC patients with HBV infection should be distinguished from other ICC cases, based on distinct clinicopathological features and favorable outcome. Screening for HBV infection should be carried out before initiation of chemotherapy. Antiviral therapy is indicated for prevention of HBV reactivation.

[Diagnosis and treatment of hepatocellular carcinoma. Update consensus document from the AEEH, SEOM, SERAM, SERVEI and SETH]

Hepatocellular carcinoma is the most common primary malignancy of the liver and one of the most frequent causes of death in patients with liver cirrhosis. Simultaneously with the recognition of the clinical relevance of this neoplasm, in recent years there have been important developments in the diagnosis, staging and treatment of HCC. Consequently, the Asociación Española para el Estudio del Hígado has driven the need to update clinical practice guidelines, continuing to invite all the societies involved in the diagnosis and treatment of this disease to participate in the drafting and approval of the document (Sociedad Española de Trasplante Hepático, Sociedad Española de Radiología Médica, Sociedad Española de Radiología Vascular e Intervencionista y Sociedad Española de Oncología Médica). The clinical practice guidelines published in 2009 accepted as Clinical Practice Guidelines of the National Health System has been taken as reference document, incorporating the most important advances that have been made in recent years. The scientific evidence for the treatment of HCC has been evaluated according to the recommendations of the National Cancer Institute (www.cancer.gov) and the strength of recommendation is based on the GRADE system.

A need for cautious interpretation of elevated serum germ cell tumor markers in children. Review and own experiences

Protocols for pediatric germ cell tumors (GCT) allow for chemotherapy (CHT) initiation without histological diagnosis, based on typical clinical and radiological picture and increased alphafetoprotein (AFP) or beta-human chorionic gonadotropin serum levels. Such strategy may result in misdiagnoses in rare cases. We present two patients with abdominal tumors and high serum AFP levels, diagnosed as GCT. In both, no tumor shrinkage and increasing AFP was observed after first cycles of multidrug CHT for pediatric GCT. Histological examination of biopsied tumor tissues revealed metastatic cholangiocarcinoma in patient 1 and pancreatoblastoma in patient 2, which implicated immediate change of therapy. Presented cases support the necessity to consider the tumor biopsy when patients diagnosed with GCT based on typical clinical presentation and elevated AFP do not respond to CHT with AFP decrease and tumor size reduction.

Alpha-Fetoprotein Measurement Benefits Hepatocellular Carcinoma Surveillance in Patients with Cirrhosis

OBJECTIVES

Liver cirrhosis is a major risk factor for hepatocellular carcinoma (HCC), and all liver study societies recommend HCC surveillance in patients with cirrhosis. However, no ideal modality for HCC surveillance has been determined. The aim of this study is to assess the effectiveness of α-fetoprotein (AFP) measurement in HCC surveillance.

METHODS

In this retrospective analysis, all patients with cirrhosis, who received HCC surveillance through ultrasound (US) and AFP measurement between January 2002 and July 2010, were followed up until June 2013. The performance effectiveness of surveillance using AFP, US, or both in HCC detection was compared.

RESULTS

Overall, 1,597 patients were followed for a median duration of 4.75 (range 1.42-12) years. Over the 8563.25-person-year follow-up period, 363 patients (22.7%) developed HCCs. For HCC detection, the area under the receiver operator characteristic curve of surveillance AFP was 0.844 (95% confidence interval: 0.820-0.868, P<0.001). When the traditional cutoff value of 20 ng/ml was used, the sensitivity and specificity of AFP were 52.9% and 93.3%, respectively. US exhibited a sensitivity and specificity of 92.0% and 74.2%, respectively. A combination of US and AFP exhibited a sensitivity and specificity of 99.2% and 68.3%, respectively. By using cut-off at 20 ng/ml and AFP level increase ≥2 × from its nadir during the previous 1 year, the combination of US and AFP yielded a sensitivity of 99.2% and an improved specificity of 71.5%.

CONCLUSIONS

The complementary use of AFP and US improved the effectiveness of HCC surveillance in patients with cirrhosis.

Role of liver stem cells in hepatocarcinogenesis

Liver cancer is an aggressive disease with a high mortality rate. Management of liver cancer is strongly dependent on the tumor stage and underlying liver disease. Unfortunately, most cases are discovered when the cancer is already advanced, missing the opportunity for surgical resection. Thus, an improved understanding of the mechanisms responsible for liver cancer initiation and progression will facilitate the detection of more reliable tumor markers and the development of new small molecules for targeted therapy of liver cancer. Recently, there is increasing evidence for the “cancer stem cell hypothesis”, which postulates that liver cancer originates from the malignant transformation of liver stem/progenitor cells (liver cancer stem cells). This cancer stem cell model has important significance for understanding the basic biology of liver cancer and has profound importance for the development of new strategies for cancer prevention and treatment. In this review, we highlight recent advances in the role of liver stem cells in hepatocarcinogenesis. Our review of the literature shows that identification of the cellular origin and the signaling pathways involved is challenging issues in liver cancer with pivotal implications in therapeutic perspectives. Although the dedifferentiation of mature hepatocytes/cholangiocytes in hepatocarcinogenesis cannot be excluded, neoplastic transformation of a stem cell subpopulation more easily explains hepatocarcinogenesis. Elimination of liver cancer stem cells in liver cancer could result in the degeneration of downstream cells, which makes them potential targets for liver cancer therapies. Therefore, liver stem cells could represent a new target for therapeutic approaches to liver cancer in the near future.

Intrahepatic cholangiocarcinoma and cholangiolocellular carcinoma in cirrhosis and chronic viral hepatitis

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver cancer. Cirrhosis and chronic viral hepatitis are known to be important risk factors for ICC, especially the mass-forming (MF) type of ICC at the periphery of the liver. Cholangiolocellular carcinoma (CoCC) is a rare type of primary liver cancer, which is thought to originate from hepatic progenitor or stem cells. CoCC often exhibits the similar MF type at the periphery of the liver, as ICC, and CoCC is also associated with cirrhosis or chronic viral hepatitis. Better survival rates after surgery have been reported for ICC patients with chronic viral hepatitis than for those without chronic viral hepatitis, although survival rates did not differ significantly in relation to cirrhosis. On the other hand, patients with CoCC had better surgical results than those with MF-type ICC. This review summarizes the clinical characteristics and surgical outcomes of ICC and CoCC associated with cirrhosis or chronic viral hepatitis.

Treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a highly prevalent and lethal neoplasia. Several studies have shown that HCC is the main cause of death in patients with cirrhosis. A better knowledge of the natural history of the tumor and the development of staging systems has allowed to refine the prognosis of the patients. The Barcelona Clinic Liver Cancer system (BCLC) has become the preferred staging system since it takes into account the tumor characteristics, the degree of liver impairment and the physical performance. It has been endorsed by several scientific associations and research consortia as it does not just define prognosis, but, more interestingly, it links staging with prognosis assessment and treatment recommendation. Curative therapies such as resection, transplantation and ablation can improve survival in patients diagnosed at an early HCC stage and may offer a long-term cure with overall survival that may exceed 70% at 5 years. Patients with intermediate stage HCC benefit from chemoembolization and proper selection of candidates permits a 50% survival at 3-4 years. Finally, patients diagnosed at an advanced stage benefit from sorafenib, an oral available, multikinase inhibitor with antiangiogenic and antiproliferative effects. Current research efforts are aimed at further refining prognosis prediction through molecular profiling and enhanced clinical characterization. At the same time, better knowledge of the molecular mechanisms of cancer should result in a further improvement of the current life expectancy of patients.

Oleanolic acid and ursolic acid inhibit proliferation in transformed rat hepatic oval cells

AIM

To investigate H2O2-induced promotion proliferation and malignant transformation in WB-F344 cells and anti-tumor effects of ursolic acid (UA) and oleanolic acid (OA).

METHODS

WB-F344 cells were continuously exposed to 7 x 10(-7) mol/L H2O2 for 21 d. Observations of cell morphology, colony formation rates, flow cytometric analysis of cell cycle changes and aneuploidy formation indicated that H2O2 was able to induce malignant transformation of WB-F344 cells. We treated malignantly transformed WB-F344 cells with 4 μmol/L OA or 8 μmol/L UA for 72 h and analyzed the cell cycle distribution by flow cytometry.

RESULTS

MTT assay showed that 7 x 10(-7) mol/L H2O2 decreased G1 phase subpopulation from 73.8% to 49.6% compared with the control group, and increased S phase subpopulation from 14.5% to 31.8% (P < 0.05 vs control group). Cell morphology showed that nucleus to cytoplasm ratio increased, many mitotic cells, prokaryotes and even tumor giant cells were shown in H2O2-induced WB-F344 cells. Fluorescence activated cell sorting analysis showed that WB-F344 cell aneuploidy increased to 12% following H2O2 treatment. Flow cytometric analysis of the transformed WB-F344 cells following treatment with OA (4 μmol/L) and UA (8 μmol/L) showed that OA increased G1 subpopulation to 68.6%, compared to 49.7% in unexposed cells. UA increased G1 subpopulation to 67.4% compared to 49.7% in unexposed cells (P < 0.05 vs H2O2 model group).

CONCLUSION

H2O2 causes the malignant transformation of WB-F344 cells. OA and UA exert anti-tumor effects by inhibiting the proliferation in malignantly transformed WB-F344 cells.

Characteristics of intrahepatic cholangiocarcinoma in patients with hepatitis B virus infection: clinicopathologic study of resected tumours

Recent efforts suggest an aetiological role of hepatitis B virus (HBV) infection in intrahepatic cholangiocarcinoma (ICC). The purpose of this study was to clarify the clinicopathologic characteristics and surgical outcomes of patients with HBV-associated ICC. All patients with chronic HBV infection were identified from a database of patients with ICC that underwent surgical resection between 1 January 2005 and 31 December 2006. Their clinicopathologic and survival characteristics were compared with ICC patients without chronic HBV infection. The age of the HBV-associated ICC patients tend to be younger than that of ICC patients without chronic HBV infection. HBV-associated ICC patients tend to have higher abnormal α-fetoprotein levels and lower abnormal serum carbohydrate antigen19-9 (CA19-9), r-glutamyltransferase (r-GT) and alkaline phosphatase levels. The pathologic features of the resected specimens revealed that HBV-associated ICC patients tended to be of the mass-forming type have a lower prevalence of lymphatic involvement and poorer tumour differentiation, and a higher prevalence of capsule formation and liver cirrhosis. Patients with HBV-associated ICC had a significantly better survival than patients without chronic HBV infection. The clinicopathological features of HBV-associated ICC patients showed significant differences from ICC patients without HBV infection. These tumours are characterized by the mass-forming growth pattern and appeared to have a more favourable prognosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hepatitis viruses infection and risk of intrahepatic cholangiocarcinoma: evidence from a meta-analysis

Background

Studies investigating the association between Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections and intrahepatic cholangiocarcinoma (ICC) have reported inconsistent findings. We conducted a meta-analysis of epidemiological studies to explore this relationship.

Methods

A comprehensive search was conducted to identify the eligible studies of hepatitis infections and ICC risk up to September 2011. Summary odds ratios (OR) with their 95% confidence intervals (95% CI) were calculated with random-effects models using Review Manager version 5.0.

Results

Thirteen case–control studies and 3 cohort studies were included in the final analysis. The combined risk estimate of all studies showed statistically significant increased risk of ICC incidence with HBV and HCV infection (OR = 3.17, 95% CI, 1.88-5.34, and OR = 3.42, 95% CI, 1.96-5.99, respectively). For case–control studies alone, the combined OR of infection with HBV and HCV were 2.86 (95% CI, 1.60-5.11) and 3.63 (95% CI, 1.86-7.05), respectively, and for cohort studies alone, the OR of HBV and HCV infection were 5.39 (95% CI, 2.34-12.44) and 2.60 (95% CI, 1.36-4.97), respectively.

Conclusions

This study suggests that both HBV and HCV infection are associated with an increased risk of ICC.

Cancer stem cells in breast cancer

The cancer stem cell (CSC) theory is generally acknowledged as an important field of cancer research, not only as an academic matter but also as a crucial aspect of clinical practice. CSCs share a variety of biological properties with normal somatic stem cells in self-renewal, the propagation of differentiated progeny, the expression of specific cell markers and stem cell genes, and the utilization of common signaling pathways and the stem cell niche. However, CSCs differ from normal stem cells in their chemoresistance and their tumorigenic and metastatic activities. In this review, we focus on recent reports regarding the identification of CSC markers and the molecular mechanism of CSC phenotypes to understand the basic properties and molecular target of CSCs. In addition, we especially focus on the CSCs of breast cancer since the use of neoadjuvant chemotherapy can lead to the enrichment of CSCs in patients with that disease. The identification of CSC markers and an improved understanding of the molecular mechanism of CSC phenotypes should lead to progress in cancer therapy and improved prognoses for patients with cancer.

Comparison of serum tumor markers for intrahepatic cholangiocarcinoma and hepatocellular carcinoma

Serum tumor markers such as alpha-fetoprotein (AFP), carcinoembryonic antigen, carbohydrate antigen (CA) 19-9, CA242, and CA50 were analyzed to evaluate their diagnostic values in single and combined tests for distinguishing intrahepatic cholangiocarcinoma (ICC) from hepatocellular carcinoma (HCC). Preoperative serum levels of AFP, carcinoembryonic antigen, CA19-9, CA242, and CA50 were measured in 45 ICC and 76 HCC patients. The serum levels and the positive rate of AFP, CA19-9, and CA242 were significantly different between the ICC patients and HCC patients. Although AFP (-) was the most sensitive assay for distinguishing ICC from HCC (91.1%), its specificity was significantly lower than that of CA242 (+) and CA19-9 (+). The combination of AFP (-) and CA242 (+) afforded a high specificity of 94.3 per cent and showed highest accuracy (78.5%). Evaluation of patients without liver cirrhosis also showed similar results. The diagnostic value of CA242 (+) is better than that of CA19-9 (+) and AFP (-) in distinguishing ICC from HCC. Combined detection of AFP (-) and CA242 (+) can improve the specificity and accuracy of diagnosing ICC.

Evaluation of risk factors and clinicopathologic features for intrahepatic cholangiocarcinoma in Southern China: a possible role of hepatitis B virus

BACKGROUND

Recent efforts suggest an etiologic role of hepatitis B virus (HBV) infection in intrahepatic cholangiocarcinoma (ICC) and the involvement of hepatic progenitor cell in ICC development, without definitive conclusions. This case-control study was undertaken to investigate risk factors for ICC, and clinicopathological features of HBV-associated ICC were analyzed.

METHODS

The report comprised 98 patients with pathologically confirmed ICC and 196 healthy control subjects. Logistic regression was used to determine odds ratios and 95% confidence intervals. The sex and age distributions of HBV-related and unrelated ICC patients were compared respectively with those of 882 HBV-associated hepatocellular carcinoma patients from a random selection, and the clinicopathological data of 62 ICC patients with or without HBV infection undergoing surgical resection were compared.

RESULTS

There was an association between ICC and each of HBV infection, liver cirrhosis, hepatolithiasis, and liver fluke infestation with the odds ratios (95% confidence intervals) of 2.75 (1.27-5.95), 8.42 (2.50-28.37), 22.81 (7.16-72.68), and 3.55 (1.60-7.89), respectively, with a marked synergism of cirrhosis and HBV infection (20.67; 5.40-79.06). Compared with HBV-unrelated ICC patients, HBV-related ICC patients were more common in male and younger subjects, had a higher incidence of abnormal serum alfa-fetoprotein level, cirrhosis, and neutrophilic infiltration, and had a lower proportion of elevated carbohydrate antigen 19-9 (CA19-9) values.

CONCLUSIONS

The independent association of HBV infection with ICC, synergy between cirrhosis and HBV infection, and some clinicopathological similarities between HBV-related ICC and hepatocellular carcinoma suggests that both may share similar or common tumorigenic process and may possibly originate from malignant transformation of hepatic progenitor cell.

Cancer stem cells and telomerase as potential biomarkers in veterinary oncology

Despite advances in chemotherapy and radiotherapy, cancer remains a disease of high morbidity and mortality in domestic animals. In parallel to the development of novel therapeutic interventions, appropriate biomarkers are required to detect early-stage disease and disease remission and relapse at both gross and molecular levels, and the effectiveness of therapy. The field of cancer pathogenesis has grown exponentially over the last decade, both in terms of our understanding of the underlying molecular events, and the technologies available to interrogate the cancer cell. This paper reviews the role of the telomerase enzyme and of telomere length as potential biomarkers in cancer. Furthermore, the potential role of cancer stem cells as biomarkers of malignancy and disease progression is assessed.

Hepatitis B virus-associated intrahepatic cholangiocarcinoma and hepatocellular carcinoma may hold common disease process for carcinogenesis

AIMS

To evaluate potential risk factors for intrahepatic cholangiocarcinoma (ICC) and analyse clinicopathologic characteristics of ICC patients with seropositive hepatitis B surface antigen (HBsAg).

METHODS

A retrospective case-control study was conducted. Cases were 317 ICC patients referred to the Eastern Hepatobiliary Surgery Hospital in China between 2003 and 2006. Controls were 634 healthy individuals. Adjusted odds ratios (ORs) were calculated in logistic regression analysis. Among 317 consecutively enrolled ICC patients, 154 patients were seropositive HBsAg (48.6%). We compared clinicopathologic characteristics of these patients (group I) with ICC patients seronegative for HBsAg (group II; n=163) and compared the age and sex distributions of patients in group I with randomly selected hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC) (group III; n=1,140).

RESULTS

Compared with the controls, ICC patients had a high prevalence of seropositive HBsAg, cirrhosis, hepatolithiasis and hepatic schistosomiasis. Compared with seronegative-HBsAg ICC patients, seropositive-HBsAg ICC patients were younger, more frequently male and had a higher proportion of abnormal aminotransferase and serum alpha-fetoprotein (AFP) level, histological inflammation and cirrhosis, right-lobe focus, poor tumour differentiation, tumour encapsulation and microvascular invasion; had a lower proportion of abnormal serum carbohydrate antigen 19-9 (CA19-9) level and lymphatic metastasis. The age and sex distribution profiles were nearly identical between seropositive-HBsAg ICC patients and HBV-associated HCC patients.

CONCLUSIONS

The HBV infection, cirrhosis, hepatolithiasis and hepatic schistosomiasis may be potential risk factors for ICC. HBV-associated ICC shares many clinicopathological similarities with HBV-associated HCC. The result indicated HBV-associated ICC and HBV-associated HCC may hold common disease process for carcinogenesis.

Primary liver tumors: origin and target therapy

BACKGROUND

The liver is the largest gland and chief metabolic organ of the human body possessing a unique ability to regenerate. The general interest of primary liver tumors is noteworthy because of their increasing worldwide incidence and mortality. Recent studies have focused on the ancestors of mature hepatocytes, which are capable of proliferating, differentiating and self-renewing.

OBJECTIVE

To provide a brief and up-to-date review on the cellular origin of primary liver tumors and to examine the use of stem cells in potential future therapeutic attempts.

METHODS

A review of relevant literature.

RESULTS

It is clear that hepatic progenitor cells (HPCs) could be the basis of some hepatocellular carcinomas (HCC), cholangiocarcinomas (CHC), hepatocellular adenomas and hepatoblastomas. Cancer stem cell (CSC) theory emphasizes the role of hepatic stem cells in the development and progression of liver tumors.

CONCLUSION

The expression of HPCs markers may be used as new independent prognostic factors in HCC. Conventional treatments for HCC do not seem to be beneficial for the majority of patients and new therapeutic approaches such as gene therapy and targeted drug therapy are of great clinical interest.

Etiological and clinicopathologic characteristics of intrahepatic cholangiocarcinoma in young patients

AIM: To investigate the prevalence, risk factors, and clinicopathologic characteristics of intrahepatic cholangiocarcinoma (ICC) in young patients.

METHODS: A retrospective analysis was performed in ICC patients referred to the Eastern Hepatobiliary Surgery Hospital in Shanghai, China. Among 317 consecutively enrolled patients, 40 patients were aged ≤ 40 years (12.61%). We compared the risk factors and clinicopathologic characteristics of these patients (group I: n = 40) with those aged > 40 years (group II: n = 277).

RESULTS: Group I had distinct features compared with group II, including a low frequency of hepatolithiasis (P = 0.000); a high positive rate of serum hepatitis B surface antigen (P = 0.000) and hepatitis B virus (HBV)-associated cirrhosis (P = 0.038); a high frequency of α-fetoprotein (> 400 μg/L) (P = 0.011); a low frequency of carbohydrate antigen 19-9 (> 37 U/mL) (P = 0.017); and a high frequency of liver histological inflammation (P = 0.002). Although there was no significant difference between the two groups in regards to hepatic schistosomiasis, alcohol-associated cirrhosis and cirrhosis due to other causes (P > 0.05), they only occurred in the elderly group.

CONCLUSION: The risk factors are significantly different between young and elderly ICC patients. HBV and HBV-associated cirrhosis are the most important risk factors for young ICC patients.

Advances in research on liver cancer stem cells

Cancer stem cells have been identified in various human tumors. However, it remains controversial as to whether or not liver cancer stem cells (LCSCs) exist until now. There are two hypotheses to explain the origin of liver cancer stem cells: the dedifferentiation of mature hepatocytes and the maturation arrest of liver stem cells. Now, the latter is generally acknowledged to be the better one. To obtain direct evidence for the existence of LCSCs, many researchers focus their studies on the surface markers on LCSCs to identify ideal markers for isolation of LCSCs. Besides, the relationship between side population (SP) cells and LCSCs also attracts much attention. Therefore, the study of LCSCs is probably of great significance for the diagnosis and treatment of liver cancer.

Expression of stem cell factor and its receptor c-Kit during the development of intrahepatic cholangiocarcinoma

Stem cell factor (SCF) and its receptor, c-Kit, constitute an important signal transduction system with proliferative and anti-apoptotic functions. Besides regulating hemopoietic stem cell proliferation and liver regeneration, it has been implicated in the regulation of human malignancies. However, the cellular expression of the SCF-c-Kit gene system in the liver during cholangiocarcinogenesis has not been studied to date. The protein- and mRNA-expression levels of SCF and c-Kit genes were examined in normal rat liver, in isolated normal rat liver cells and in a thioacetamide-induced rat model of intrahepatic cholangiocarcinoma (CC). Immunohistochemical analysis of the normal liver showed that SCF is expressed in the wall of the hepatic artery and in some cells, which were located along the sinusoids, although it was absent from hepatocytes and biliary epithelial cells. The mRNA analysis of isolated normal liver cell populations revealed a co-expression of SCF- and c-Kit-mRNA in sinusoidal endothelial cells and in Kupffer cells, whereas passaged and cultured liver myofibroblasts (MFs) expressed only SCF. Low levels of the SCF- and c-Kit-mRNA expression could be detected in isolated hepatocytes of the normal liver. Immunohistochemical analysis of the CC tissue showed SCF positivity in proliferating biliary cells (CK-19(+)), in macrophages (ED-1(+)) and in MFs (alpha-smooth-muscle-actin, alpha-SMA(+)) of the tumoral microenvironment. c-Kit-positivity could be detected on hepatocytes of the regenerating nodules and on the proliferating bile ducts of CC. Compared with the normal liver tissue, SCF-mRNA from the CC tissue was upregulated up to 20-fold, whereas c-Kit-mRNA was upregulated up to fivefold. These data indicate that several cell populations may become able to express SCF and/or c-Kit during cholangiocarcinogenesis. Therefore, the SCF-c-Kit system may contribute to tumor development, for instance, by inducing proliferation of hepatocytes and of biliary cells and by acting as a surviving factor for CC cells.

Using naturally occurring tumours in dogs and cats to study telomerase and cancer stem cell biology

The recently described cancer stem cell theory opens up many new challenges and opportunities to identify targets for therapeutic intervention. However, the majority of cancer related therapeutic studies rely upon rodent models of human cancer that rarely translate into clinical success in human patients. Naturally occurring cancers in dogs, cats and humans share biological features, including molecular targets, telomerase biology and tumour genetics. Studying cancer stem cell biology and telomere/telomerase dynamics in the cancer bearing pet population may offer the opportunity to develop a greater understanding of cancer biology in the natural setting and evaluate the development of novel therapies targeted at these systems.

Clinicopathologic characteristics of intrahepatic cholangiocarcinoma in patients with positive serum a-fetoprotein

AIM: To explore clinicopathologic characteristics of intrahepatic cholangiocarcinoma (ICC) in patients with positive serum a-fetoprotein (AFP).

METHODS: One hundred and thirty one patients who underwent surgical dissection for pathologically confirmed ICC were divided into a positive AFP (> 20 ng/mL) group (n = 32) and a negative AFP group (n = 99), whose clinicopathologic features were analyzed and compared.

RESULTS: The positive rate of HBsAg and liver cirrhosis of the positive AFP group was higher than that of the negative AFP group, while the positive rate of CA19-9 (> 37 U/mL) and the lymph node metastasis rate was lower.

CONCLUSION: ICC patients with positive AFP share many clinicopathologic similarities with hepatocellular carcinoma.

Road for understanding cancer stem cells: model cell lines

There is increasing evidence suggesting that stem cells are susceptive to carcinogenesis and, consequently, can be the origin of many cancers. Recently, the neoplastic potential of stem cells has been supported by many groups showing the existence of subpopulations with stem cell characteristics in tumor biopsies such as brain and breast. Evidence supporting the cancer stem cell hypothesis has gained impact due to progress in stem cell biology and development of new models to validate the self-renewal potential of stem cells. Recent evidence on the possible identification of cancer stem cells may offer an opportunity to use these cells as future therapeutic targets. Therefore, model systems in this field have become very important and useful. This review will focus on the state of knowledge on cancer stem cell research, including cell line models for cancer stem cells. The latter will, as models, help us both in the identification and characterization of cancer stem cells and in the further development of therapeutic strategies including tissue engineering.