Surgical strategy for bile duct cancer: Advances and current limitations

Practice guidelines for managing extrahepatic biliary tract cancers

Backgrounds/Aims

Reported incidence of extrahepatic bile duct cancer is higher in Asians than in Western populations. Korea, in particular, is one of the countries with the highest incidence rates of extrahepatic bile duct cancer in the world. Although research and innovative therapeutic modalities for extrahepatic bile duct cancer are emerging, clinical guidelines are currently unavailable in Korea. The Korean Society of Hepato-Biliary-Pancreatic Surgery in collaboration with related societies (Korean Pancreatic and Biliary Surgery Society, Korean Society of Abdominal Radiology, Korean Society of Medical Oncology, Korean Society of Radiation Oncology, Korean Society of Pathologists, and Korean Society of Nuclear Medicine) decided to establish clinical guideline for extrahepatic bile duct cancer in June 2021.

Methods

Contents of the guidelines were developed through subgroup meetings for each key question and a preliminary draft was finalized through a Clinical Guidelines Committee workshop.

Results

In November 2021, the finalized draft was presented for public scrutiny during a formal hearing.

Conclusions

The extrahepatic guideline committee believed that this guideline could be helpful in the treatment of patients.

The role of subspecialized radiologist reviews in preoperative conference for hepato-pancreato-biliary disease

PURPOSE

To identify the role of subspecialized radiologists in preoperative conferences of radiologists and surgeons in the management of hepato-pancreato-biliary (HPB) diseases.

METHODS

We retrospectively evaluated the prospective data of 247 patients (mean age, 63.8 years; 173 men) who were referred for preoperative conferences (n = 258; 11 were discussed twice) for HPB disease between September 2021 and April 2022. Before each preoperative conference, subspecialized radiologists reviewed all available imaging studies and treatment plan information. After each conference, any change to the treatment plan was documented (major, minor, or none). Additional information provided by the radiologists was collected (significant, supplementary, or none). Uni- and multivariable analyses were performed to determine factors that resulted in a major change to the treatment plan.

RESULTS

Of the 258 reviewed cases, a major change was made to the treatment plan in 26 cases (10.1 %) and a minor change in 41 (15.9 %). Significant information was provided in 27 cases (10.5 %) and supplementary information in 72 (27.9 %). In the multivariable analysis, additional information about local tumor extent (odds ratio [OR], 6.3; 95 % confidence interval [CI], 2.1-19.5; p = 0.001) and distant metastasis detection (OR, 33.2; 95 % CI, 5.1-216.6; p < 0.001) was significantly associated with a major change.

CONCLUSION

The involvement of subspecialized radiologists in preoperative conferences resulted in major treatment plan changes in 10.1 % of the cases, primarily associated with the added information about local tumor extent and distant metastasis.

Real-Time Fluorescence Imaging to Identify Cholangiocarcinoma in the Extrahepatic Biliary Tree Using an Enzyme-Activatable Probe

Introduction

Complete resection is the only possible treatment for cholangiocarcinoma in the extrahepatic biliary tree (eCCA), although current imaging modalities are limited in their ability to accurately diagnose longitudinal spread. We aimed to develop fluorescence imaging techniques for real-time identification of eCCA using an enzyme-activatable probe, which emits fluorescence immediately after activation by a cancer-specific enzyme.

Methods

Using lysates and small tissue fragments collected from surgically resected specimens, we selected the most specific probe for eCCA from among 800 enzyme-activatable probes. The selected probe was directly sprayed onto resected specimens and fluorescence images were acquired; these images were evaluated for diagnostic accuracy. We also comprehensively searched for enzymes that could activate the probe, then compared their expression levels in cancer and non-cancer tissues.

Results

Analyses of 19 samples (four cancer lysates, seven non-cancer lysates, and eight bile samples) and 54 tissue fragments (13 cancer tissues and 41 non-cancer tissues) revealed that PM-2MeSiR was the most specific fluorophore for eCCA. Fluorescence images of 7 patients were obtained; these images enabled rapid identification of cancerous regions, which closely matched histopathology findings in 4 patients. Puromycin-sensitive aminopeptidase was identified as the enzyme that might activate the probe, and its expression was upregulated in eCCA.

Conclusion

Fluorescence imaging with PM-2MeSiR, which may be activated by puromycin-sensitive aminopeptidase, yielded generally high accuracy. This technique may be useful for real-time identification of the spread of eCCA during surgery and endoscopic examinations.

Surgical outcomes and prognostic factors of distal common bile duct adenocarcinoma: chronological analysis in a single high-volume institutional experience

Background

Distal common bile duct (dCBD) cancer is typical indication for pancreaticoduodenectomy (PD). We aimed to retrospectively evaluate surgical outcomes and investigate prognostic factors of dCBD adenocarcinoma for which PD was performed at a single institution.

Methods

We searched consecutive cases of dCBD adenocarcinoma undergone PD at Samsung Medical Center from 1995 to 2018. Cases with distant metastasis or palliative intent were excluded. The year in which the survival rate was dramatically improved was identified and entire years were divided into two periods for comparison. To balance between the two periods, we conducted propensity score matching (PSM) analysis using age, sex, body mass index (BMI), and American Society of Anesthesiologist score.

Results

Total of 804 cases were enrolled in this study. The entire period was divided into early period of 18 years and recent period of 6 years. The early and late period included 466 and 338 patients, respectively. As a result of PSM, balanced 316 patients were selected from each of the two periods. Significant improvements in surgical outcomes were identified, including shorter operation time, fewer blood loss, shorter hospitalization, and favorable overall survival. As results of multivariable analysis of independent risk factors for overall survival, older age and advanced N stage were identified, as expected. It was distinct that aggressive surgery and advanced tumor state in the early period and a lower BMI in the late period negatively affected the survival, respectively.

Conclusions

Surgical outcomes of dCBD cancer underwent PD was improved. There were few modifiable factors to improve survival and continuous further study is needed to detect dCBD cancer in the early stages.

Multidetector CT of Extrahepatic Bile Duct Cancer: Diagnostic Performance of Tumor Resectability and Interreader Agreement

Background In extrahepatic bile duct (EHD) cancer, accurate assessment of resectability is essential for curative surgery, but pertinent guidelines from the perspectives of radiologists are yet to be developed. Purpose To investigate the performance of multiphasic CT in the assessment of longitudinal tumor extent, vascular invasion, and resectability of EHD cancer according to the Korean Society of Abdominal Radiology consensus recommendation and to evaluate the interreader agreement. Materials and Methods This retrospective study included patients with EHD cancer who underwent multiphasic CT examinations with section thickness of 3 mm or less before surgery from January 2016 to December 2018. Four abdominal radiologists independently evaluated the overall and biliary segment-wise longitudinal tumor extent, the presence of hepatic artery and/or portal vein invasion, and the resectability according to the Korean Society of Abdominal Radiology recommendations. The diagnostic performance was assessed with sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve. Interreader agreement was determined using κ statistics. Results A total of 112 patients (mean age ± SD, 61 years ± 11; 73 men) were evaluated. The accuracy of the overall longitudinal tumor extent assessment ranged from 56.3% (63 of 112 patients) to 74.1% (83 of 112 patients). The sensitivity for detecting secondary confluence involvement (n = 62) was lower than that for the primary confluence or intrapancreatic duct (n = 115; 38.5%-75% vs 72.1%-96.3%, respectively). Vascular invasion (n = 17) had moderate sensitivity (28.6%-71.4%) and high specificity (77.5%-99.0%). For predicting negative-margin (R0) resection (n = 85), the sensitivity and specificity ranged from 71.8% to 96.5% and from 11.1% to 66.7%, respectively, and the areas under the receiver operating characteristic curve ranged from 0.69 to 0.80. Interreader agreements for tumor extent, vascular invasion, and resectability had κ values of 0.65-0.89, 0.21-0.64, and 0.35-0.56, respectively. Conclusion For the preoperative evaluation of extrahepatic bile duct cancer, the Korean Society of Abdominal Radiology consensus recommendation enabled systematic assessment of longitudinal tumor extent and vascular invasion with acceptable performance in predicting negative-margin resection with use of multiphasic CT and with fair to good interreader agreement. © RSNA, 2022 Online supplemental material is available for this article.

Comparison of oncologic outcomes of extrahepatic cholangiocarcinoma according to tumor location: perihilar cholangiocarcinoma versus distal bile duct cancer

Purpose

Extrahepatic cholangiocarcinoma is distinguished into perihilar cholangiocarcinoma (PHC) and distal bile duct cancer (DBC). The studies for each subtype have been conducted separately. This study compared oncological outcomes between PHC and DBC.

Methods

From 2001 to 2017, patients who underwent surgery at Seoul National University Hospital for PHC or DBC were enrolled. T stage was reclassified for tumor extent as ‘confined to’ or ‘beyond’ the bile duct (BD). In survival analysis, stage matching was performed based on tumor extent and lymph node (LN) metastasis.

Results

There were 680 patients enrolled: 295 with PHC and 385 with DBC. The R0 resection rate was higher in DBC (77.3% vs. 89.9%, P = 0.001). Tumors confined to BD were more common in PHC (61.7% vs. 37.7%, P = 0.001). The 5-year survival rate (5YSR) was higher in DBC patients (30.8% vs. 47.8%, P = 0.001). After stage matching, DBC patients showed better 5YSR for tumors confined to BD/LN(–) (47.1% vs. 64.3%), confined to BD/LN(+) (22.0% vs. 35.0%), beyond BD/LN(–) (21.9% vs. 49.8%), and beyond BD/LN(+) (9.6% vs. 26.9%). The overall recurrence rate was higher in PHC (59.7% vs. 51.9%, P = 0.045), with no difference in the recurrence types between two groups. Radiation therapy was effective for patients with advanced stage disease (5YSR: 35.8% vs. 29.5%, P = 0.022); adjuvant chemotherapy was effective for patients receiving R1 resection (5YSR: 37.3% vs. 13.2%, P = 0.040).

Conclusion

Differences were identified in oncological outcomes between PHC and DBC, including pathologic findings and survival outcomes.

Horizons on the Therapy of Biliary Tract Cancers: A State-of-the-art Review

Biliary tract cancers (BTCs) comprise a group of heterogeneous poor prognosis cancers with increasing incidence recent years. The combination chemotherapy with cisplatin and gemcitabine is the first-line therapy for advanced BTC. There remains no accepted standard treatment in the second-line setting. Nowadays, more and more novel treatment strategies have entered development, with some encouraging results being seen. Here, we review the current treatment status and clinical characteristics of BTC, the role of immunotherapy in BTC as well as the design of clinical trials for oncology drugs for BTC which aim to focus on the future profiles of clinical care and resolution of BTC.

Ruxolitinib Combined with Gemcitabine against Cholangiocarcinoma Growth via the JAK2/STAT1/3/ALDH1A3 Pathway

Cholangiocarcinoma is the most common primary malignant tumor of the bile duct. The current standard first-line treatment for advanced or metastatic cholangiocarcinoma is gemcitabine and cisplatin. However, few effective treatment choices exist for refractory cholangiocarcinoma, and additional therapeutic drugs are urgently required. Our previous work demonstrated that the ALDH isoform 1A3 plays a vital role in the malignant behavior of cholangiocarcinoma and may serve as a new therapeutic target. In this study, we found a positive correlation between ALDH1A3 protein expression levels and the cell migration abilities of three cholangiocarcinoma cell lines, which was verified using ALDH1A3-overexpressing and ALDH1A3-knockdown clones. We also used ALDH1A3-high and ALDH1A3-low populations of cholangiocarcinoma cell lines from the library of integrated network-based cellular signatures (LINCS) program and assessed the effects of ruxolitinib, a commercially available JAK2 inhibitor. Ruxolitinib had a higher cytotoxic effect when combined with gemcitabine. Furthermore, the nuclear translocation STAT1 and STAT3 heterodimers were markedly diminished by ruxolitinib treatment, possibly resulting in decreased ALDH1A3 activation. Notably, ruxolitinib alone or combined with gemcitabine led to significantly reduced tumor size and weight. Collectively, our studies suggest that ruxolitinib might suppress the ALDH1A3 activation through the JAK2/STAT1/3 pathway in cholangiocarcinoma, and trials should be undertaken to evaluate its efficacy in clinical therapy.

Imaging of Intrahepatic Cholangiocarcinoma

Cholangiocarcinoma is the second most common primary hepatic malignancy and is a heterogeneous tumor of biliary epithelium. We discuss the risk factors, anatomic classification of cholangiocarcinoma (CC) as well as the different morphologic subtypes of CC. Imaging findings of CC on different modalities are described, focusing on intrahepatic CC. Recently recognized imaging features that carry prognostic significance, such as a worse prognosis in tumors that have more desmoplastic stroma, are detailed. Other benign and malignant entities that should be considered in the differential diagnosis of CC will also be discussed.

The Clinical Management of Cholangiocarcinoma in the United States and Europe: A Comprehensive and Evidence-Based Comparison of Guidelines

BACKGROUND

The incidence of cholangiocarcinoma has doubled over the last 15 years with a similar rise in mortality, which provides the impetus for standardization of evidence-based care through the establishment of guidelines.

METHODS

We compared available guidelines on the clinical management of cholangiocarcinoma in the United States and Europe, which included the National Comprehensive Cancer Network (NCCN), European Society for Medical Oncology (ESMO), British Society of Gastroenterology (BSG) and the International Liver Cancer Association (ILCA) guidelines.

RESULTS

There is discordance in the recommendation for biopsy in patients with potentially resectable cholangiocarcinoma and in the recommendation for use of fluorodeoxyglucose positron emission tomography scans. Similarly, the recommendation for preoperative biliary drainage for extrahepatic and perihilar cholangiocarcinoma in the setting of jaundice is inconsistent across all four guidelines. The BILCAP (capecitabine) and ABC-02 trials (gemcitabine with cisplatin) have provided the strongest evidence for systemic therapy in the adjuvant and palliative settings, respectively, but all guidelines have refrained from setting them as standard of care, given heterogeneity in the study cohorts and ABC-02's negative intention-to-treat results.

CONCLUSIONS

Future progress in enhancing survivorship of patients with cholangiocarcinoma would likely entail improvements in diagnostic biomarkers and novel systemic therapies. Based on recent results from studies of targeted therapy, future iterations of the guidelines will likely incorporate molecular profiling.

Current Status and Recent Update of Imaging Evaluation for Peri-Hilar Cholangiocarcinoma

간문주변부의 해부학적 복잡성으로 인해 간문주변부 담관암은 그 진단과 치료가 어려운 질환으로 알려져 있다. 간문주변부 담관암이 의심되는 환자에 있어서, 영상 검사는 이상 소견의 발견 및 감별 진단, 종양의 종축 침범 부위의 파악, 인접 혈관 침범과 원격 전이 유무의 파악, 그리고 최종적으로 수술적 절제 가능 유무의 평가에 있어 핵심적인 역할을 하고 있다. 이 종설에서는 간문주변부 담관암의 분류 및 종양의 평가를 위해 권고되는 표준 영상 검사의 기법과 간문주변부 담관암의 전형적인 영상 소견에 대해 기술할 예정이다. 종축 방향의 종양 침범 파악, 인접 혈관 침범 및 원격 전이 유무의 평가에 있어서 각 영상 검사 소견과 그 진단능에 대해 논의할 예정이다. 이후 전통적인 절제 가능성 평가의 개념에 대해 고찰하고, 최근의 경향을 소개한다.

Radiologic Evaluation and Structured Reporting Form for Extrahepatic Bile Duct Cancer: 2019 Consensus Recommendations from the Korean Society of Abdominal Radiology

Radiologic imaging is important for evaluating extrahepatic bile duct (EHD) cancers; it is used for staging tumors and evaluating the suitability of surgical resection, as surgery may be contraindicated in some cases regardless of tumor stage. However, the published general recommendations for EHD cancer and recommendations guided by the perspectives of radiologists are limited. The Korean Society of Abdominal Radiology (KSAR) study group for EHD cancer developed key questions and corresponding recommendations for the radiologic evaluation of EHD cancer and organized them into 4 sections: nomenclature and definition, imaging technique, cancer evaluation, and tumor response. A structured reporting form was also developed to allow the progressive accumulation of standardized data, which will facilitate multicenter studies and contribute more evidence for the development of recommendations.

Robotic radical surgery for hilar cholangiocarcinoma: A single-centre case series

BACKGROUND

Radical resection for hilar cholangiocarcinoma is considered one of the most complicated abdominal operations. We report our initial experience with robotic radical resection for hilar cholangiocarcinoma.

METHODS

Between March 2017 and February 2019, the perioperative outcomes of 48 patients were analysed. In addition, there were two techniques for hepaticojejunostomy in the robotic approach. Comparison of the conventional and novel methods for hepaticojejunostomy was also performed to assess the efficacy of the technique.

RESULTS

The operative duration and intraoperative blood loss volume was 276 minutes and 150 mL, respectively. The overall morbidity was 58.3% and the major morbidity was 10.4%. The overall mortality was 0%. No significant differences in the perioperative outcomes of hepaticojejunostomy were found between the 2 groups.

CONCLUSION

Robotic resection is a potential alternative to open surgery for appropriately selected patients with hilar cholangiocarcinoma. Further studies are required to detect the long-term outcomes of this procedure.

The Significance of Adjuvant Therapy for Extrahepatic Cholangiocarcinoma After Surgery

Extrahepatic cholangiocarcinoma (EHCC) is a rare malignant tumor, and current treatment methods are also relatively limited. Radical surgery is the only potentially curative method for the long survival time. However, despite undergoing radical resection, prognosis remained poor due to the high recurrence rate and distant metastasis. Therefore, adjuvant chemotherapy and radiotherapy should be offered to patients who have undergone surgery. Unfortunately, the low incidence of this disease has resulted in a lack of high-level evidence to confirm the importance of adjuvant chemotherapy or radiotherapy. At present, it is still controversial whether adjuvant therapy can prolong the survival of patients after operation, especially patients with negative margins or lymph nodes. Furthermore, standard regimens of adjuvant have not been identified. This review summarizes the currently available evidence of the effect of adjuvant therapy in the management of EHCC. Ultimately, we concluded that adjuvant therapy may improve survival in high-risk (positive margin or lymph node or advanced stage) patients and adjuvant concurrent chemoradiotherapy followed by chemotherapy may be the optimum selection for them. This needs to be verified by randomized prospective clinical trials.

Effect of Educational Intervention Based on the Health Belief Model and Self-Efficacy in Promoting Preventive Behaviors in a Cholangiocarcinoma Screening Group

Cholangiocarcinoma (CCA) is a neoplasm known as one of the most common causes of cancer-related deaths in Southeast Asia, particularly in Thailand, Laos, and Cambodia. Prevention and health education are required. Therefore, this study aimed to determine the effectiveness of an educational intervention to prevent CCA among a rural population in Thailand based on the health belief model (HBM) and self-efficacy frameworks. In this quasi-experimental study, 60 participants (30 participants in the experimental group and 30 participants in the control group) were selected in 2017. The educational intervention for the experimental group consisted of seven training sessions (introduction to CCA, risk factors, complications, benefits and barriers to proper consumption of cooked fish, carcinogenic agents, behavioral protection, and self-efficacy in applying preventive behaviors). A questionnaire that consisted of demographic information, knowledge, and HBM constructs (perceived susceptibility, severity, benefits, barriers, cues to action, and self-efficacy) was used to measure CCA preventive behaviors before and 3 months after the intervention. Data were analyzed using SPSS-22 via chi-squared, paired t-tests, and independent samples t tests at a significance level of 0.5. Three months after the intervention, the experimental group showed a significant increase in the knowledge, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, self-efficacy, and CCA preventive behaviors compared to the control group. This study showed the effectiveness of the intervention based on the HBM constructs and self-efficacy in the adoption of CCA preventive behaviors 3 months post intervention in the risk group. Thus, these models may serve as a framework for designing and implementing educational interventions for the prevention of CCA.

Second primary malignancy in patients with cholangiocarcinoma: a population-based study

Background

A population-based estimate of risk of second primary malignancy (SPM) in patients with cholangiocarcinoma (CCA) is still lacking.

Objectives

To investigate the overall and site-specific risk of SPM in patients with CCA. To identify risk factors of SPM and further evaluate the impact of SPM on overall survival (OS) and disease specific survival (DSS) in patients with CCA.

Methods

Patients with histologically diagnosed CCA between 1973 and 2015 were identified from the Surveillance, Epidemiology and End Results database. Standardized incidence ratio (SIR) was calculated. Risk factors for SPM and CCA survival were evaluated by logistic, Cox, and nomogram methods.

Results

We found that the overall risk of SPM in patients with CCA was significantly higher than that in the general population (SIR =1.27, 95% CI =1.03–1.55, P<0.05). The risk of SPM was significantly increased at specific sites, including transverse colon, intrahepatic bile duct, other biliary, and thyroid. A significant increase in overall risk was characterized in the subgroups of patients aged ≤29, patients aged 30–59 years, females, whites, and patients with latency ≤11 months (63.41, 2.45, 1.4, 1.3, and 2.6-fold, respectively). In patients with CCA, not having undergone surgery for the first primary malignancy (vs having undergone surgery for the first primary malignancy; HR =0.269; 95% CI =0.211–0.342; P<0.001) was associated with significantly decreased risk of SPM. Patients with SPM had better OS and DSS than those without SPM (Log rank P<0.001). Absence of SPM was an independent risk factor for poorer OS and DSS.

Conclusion

Although the risk of SPM in patients with CCA was significantly increased, the presence of SPM did not shorten OS and DSS of patients with CCA, possibly due to the relatively poorer survival of patients with CCA.

Comparison of long-term efficacy between endoscopic and percutaneous biliary drainage for resectable extrahepatic cholangiocarcinoma with biliary obstruction: A systematic review and meta-analysis

BACKGROUND/AIM

For resectable extrahepatic cholangiocarcinoma with biliary obstruction, it remains a controversy whether to choose percutaneous transhepatic biliary drainage (PTBD) or endoscopic biliary drainage (EBD). A systematic review was conducted to compare the long-term efficacy between the two techniques.

MATERIALS AND METHODS

Eligible studies were searched from January 1990 to May 2018, comparing the long-term efficacy between EBD and PTBD for extrahepatic cholangiocarcinoma. Primary end point was overall survival (OS) rate, and secondary end points included postoperative severe complications and seeding metastasis. Effect size on outcomes was calculated using a fixed- or random-effect model, accompanied with hazard ratio (HR) and 95% confidence interval (CI).

RESULT

Six studies were included in this meta-analysis. Meta-analysis showed that EBD was superior to PTBD in OS (HR = 0.70, 95% CI 0.59-0.84,P= 0.0002). But subgroup results showed that the superiority disappeared in distal cholangiocarcinoma (HR = 0.76, 95% CI 0.56-1.01,P= 0.06). Other prognostic factors such as intraoperative blood transfusion, lymphatic metastasis and seeding metastasis, were inconsistent between groups. In addition, regional disparity was obviously apparent between Japanese and non-Japanese studies.

CONCLUSION

The conclusion that EBD was superior to PTBD in OS for resectable extrahepatic cholangiocarcinoma with biliary obstruction is less convincing, and more trials need to be conducted in future.

Diagnostic and Prognostic Role of 18-FDG PET/CT in the Management of Resectable Biliary Tract Cancer

OBJECTIVES

Role of 18-FDG PET/CT had been well established in other more prevalent malignancies such as colorectal and lung cancer; however, this is not as well defined in cholangiocarcinoma. Literature focusing on the prognostic values of preoperative PET/CT for resectable cholangiocarcinoma is scarce.

METHOD

This is a retrospective cohort of 66 consecutive patients who had received curative resection for cholangiocarcinoma from 2010 to 2015. All patients had preoperative 18-FDG PET/CT performed. Accuracy of metastatic lymph node detection of PET/CT and the prognostic value of maximum standard uptake value (SUV-max) was explored.

RESULTS

There were 38 male and 28 female recruited, and the median age was 66. Intrahepatic cholangiocarcinoma (ICC) constituted the majority (59.1%) of the cases, followed by hilar cholangiocarcinoma (22.8%), gallbladder cancer (13.6%) and common bile duct cancer (4.5%). The 3-year disease-free survival (DFS) and overall survival (OS) of the whole population were 27.1 and 39.2%, respectively. The median follow-up duration was 27 months. The accuracy of PET/CT in metastatic lymph node detection was 72.7% (P = 0.005, 95% CI 0.583-0.871) and 81.8% (P = 0.011, 95% CI 0.635-0.990) in whole population and ICC subgroup analysis, respectively. SUV-max was shown by multivariate analysis to be an independent factor for DFS (P = 0.007 OR 1.16, 95% CI 1.04-1.29) and OS (P = 0.012 OR 1.145, 95% CI 1.030-1.273) after resection. SUV-max of 8 was shown to be a discriminant cut-off for poor oncological outcomes in patients with early cholangiocarcinoma (TNM stage I or II) after curative resection (3-year DFS: 21.2 vs. 63.2%, P = 0.004, and 3-year OS: 29 vs. 74% P = 0.048, respectively).

CONCLUSION

PET/CT is a reliable imaging modality for metastatic lymph node detection in cholangiocarcinoma. Tumour SUV-max is an independent factor for oncological outcomes in patients with resectable disease. For patients who have TNM stage I or II cholangiocarcinoma, tumour SUV-max over 8 is associated with significantly inferior disease-free and overall survival even after curative resection.

Exploring the role of oncolytic viruses in hepatobiliary cancers

The standard of care for early hepatobiliary cancers (HBC) includes surgical resection. Liver transplantations or locoregional therapies are beneficial in early hepatocellular carcinoma (HCC) under certain circumstances. Systemic treatments have some benefit in advanced HBC, though long-term prognosis remains poor. We evaluated the role of oncolytic viruses in the treatment of HBCs through a systematic literature review. The recombinant vaccinia virus JX-594 improved median survival in patients with local/metastatic HCC more strongly at high dose than at low dose (14.1 vs 6.7 months; p = 0.08) in a Phase II study. A Phase III study with JX-594 and sorafenib in advanced HCC is ongoing. No survival benefit in HCC was seen with two other recombinant adenoviruses (Ad-TK and DL1520). Several preclinical trials using oncolytic viruses in HBC showed promising results, warranting clinical studies.

Percutaneous intraductal radiofrequency ablation in the management of unresectable Bismuth types III and IV hilar cholangiocarcinoma

Purpose

To assess the feasibility and safety of percutaneous intraductal radiofrequency ablation (RFA) for unresectable Bismuth types III and IV hilar cholangiocarcinoma.

Results

Percutaneous intraductal RFA combined with metal stent placement was successful in all patients without any technical problems; the technical success rate was 100%. Chemotherapy was administered to two patients. After treatment, serum direct bilirubin levels were notably decreased. Six patients died during the follow-up period. Median stent patency from the time of the first RFA and survival from the time of diagnosis were 100 days (95% confidence interval (CI), 85–115 days) and 5.3 months (95% CI, 2.5–8.1 months), respectively. No acute pancreatitis, bile duct bleeding and perforation, bile leakage, or other severe complications occurred. Four cases of procedure-related cholangitis, three cases of postoperative abdominal pain, and five cases of asymptomatic transient increase in serum amylase were observed. One patient who presented with stent blockage 252 days' post-procedure underwent repeat ablation.

Materials and Methods

Between September 2013 and May 2015, nine patients with unresectable Bismuth types III and IV hilar cholangiocarcinoma who were treated with percutaneous intraductal RFA combined with metal stent placement after the percutaneous transhepatic cholangial drainage were included in the retrospective analysis. Procedure-related complications, stent patency, and survival after treatment were investigated.

Conclusion

Percutaneous intraductal RFA combined with metal stent placement is a technically safe and feasible therapeutic option for the palliative treatment of unresectable Bismuth types III and IV hilar cholangiocarcinoma. Its long-term efficacy and safety is promising, but needs further study via randomized and prospective trials that include a greater number of patients.

Defining the Chance of Statistical Cure Among Patients with Extrahepatic Biliary Tract Cancer

BACKGROUND

While surgery offers the best curative-intent treatment, many patients with biliary tract malignancies have poor long-term outcomes. We sought to apply a non-mixture cure model to calculate the cure fraction and the time to cure after surgery of patients with peri-hilar cholangiocarcinoma (PHCC) or gallbladder cancer (GBC).

METHODS

Using the Extrahepatic Biliary Malignancy Consortium, 576 patients who underwent curative-intent surgery for gallbladder carcinoma or peri-hilar cholangiocarcinoma between 1998 and 2014 at 10 major hepatobiliary institutions were identified and included in the analysis. A non-mixture cure model was adopted to compare mortality after surgery to the mortality expected for the general population matched by sex and age.

RESULTS

The median and 5-year overall survival (OS) were 1.9 years (IQR, 0.9-4.9) and 23.9 % (95 % CI, 19.6-28.6). Among all patients with PHCC or GBC, the probability of being cured after surgery was 14.5 % (95 % CI, 8.7-23.2); the time to cure was 9.7 years and the median survival of uncured patients was 1.8 years. Determinants of cure probabilities included lymph node metastasis and CA 19.9 level (p ≤ 0.05). The cure fraction for patients with a CA 19.9 < 50 U/ml and no lymph nodes metastases were 39.0 % versus only 5.1 % among patients with a CA 19.9 ≥ 50 who also had lymph node metastasis.

CONCLUSIONS

Examining an "all comer" cohort, <15 % of patients with PHCC or GBC could be considered cured after surgery. Factors such CA 19.9 level and lymph node metastasis independently predicted long-term outcome. Estimating the odds of statistical cure following surgery for biliary tract cancer can assist in decision-making as well as inform discussions around survivorship.

Adjuvant therapy in biliary tract and gall bladder carcinomas: a review

Biliary tract carcinomas are relatively rare, but are increasingly diagnosed. They comprise several anatomically contiguous sites, so are often grouped together, but they do appear to represent distinct diseases, in part because of anatomical and surgical considerations. Complete upfront surgical resection is generally difficult because these cancers are often diagnosed at relatively advanced stages of disease. Thus, adjuvant therapy is often considered. This paper will review the evidence underpinning current recommendations for adjuvant therapy in biliary carcinomas.

Patterns and prognostic value of lymph node dissection for resected perihilar cholangiocarcinoma

BACKGROUND AND AIM

Lymph node metastasis is a major prognostic factor for perihilar cholangiocarcinoma (PHC). However, prognostic significance of extent of node dissection, lymph node ratio (LNR), and number and location of positive nodes remain unclear. We aimed to evaluate whether node status, LNR, or number or location of positive nodes are independent factors for staging in PHC and to determine the minimum requirements for node examination.

METHODS

The Surveillance, Epidemiology, and End Results database was used to identify 1116 resected PHCs from 1998 to 2008. The correlation between nodal status and survival was analyzed retrospectively.

RESULTS

Lymph node metastasis occurred in 43.4% patients and was an independent predictor for overall survival and cancer-specific survival. No survival benefit was observed for an increasing number of node retrieval in node-positive patients. However, in node-negative patients, ≥13 node dissection was of more survival benefit than 3 ≤ total lymph node count (TLNC) ≤ 12 and TLNC < 3 (5-year overall survival: 52.8% vs 39.7% vs 26.3%, P = 0.001; 5-year cancer-specific survival: 60.6% vs 46.3% vs 30.0%, P = 0.001). No difference in survival between patients with regional and distant node involvement was found. Survival for patients with greater than three positive nodes was significantly worse than that for those with three or less (relative ratio: 1.466, P = 0.001). And patients with LNR > 0.27 also had unfavorable prognosis (relative ratio: 1.376, P = 0.001).

CONCLUSIONS

We determined that to adequately assess nodal status of this life-threatening disease, 13 or more nodes retrieval should be considered. Number of positive nodes and LNR rather than location of metastatic nodes may be defined as parameters for staging of PHC.

Neoadjuvant treatment of biliary tract cancer: state-of-the-art and new perspectives

Gall bladder cancer (GBC), and intrahepatic and extrahepatic (perihilar or distal bile duct's) cholangiocarcinomas (CCA) are usually diagnosed in locally advanced or node-positive stage, with a short survival rate. Thus, it appears essential to explore novel strategies for improving disease downstage and radical surgery. Chemoradiotherapy followed by liver transplantation seems to be one of the most promising approaches for intrahepatic or perihilar disease while chemotherapy with novel radiotherapy techniques (such stereotactic body radiation) emerged as an attractive preoperative treatment in distal diseases. In this paper, we will review currently available knowledge about neoadjuvant treatment of biliary tract cancers (BTC) paying attention to challenges that make this type of management in clinical practice difficult.

Utility of intraoperative cytology of resection margins in biliary tract and pancreas tumors

BACKGROUND

Intraoperative diagnosis of resection margins in the biliary tract and pancreas tumors is important in deciding extent of resection; however, diagnosis based solely on frozen sections is sometimes difficult. Therefore, we investigated the usefulness of intraoperative cytology (IC) combined with frozen section (FS) histology. We present the results with a discussion of the value of this combination and its associated problems.

METHODS

We examined 80 bile duct resection margin specimens from 42 patients, and 34 pancreatic resection margin specimens from 29 patients, who underwent intraoperative diagnosis of resection margins during surgery for biliary tract or pancreatic tumors between October 2012 and January 2014. IC was performed on imprint specimens prepared from surfaces of margins being examined. The results were compared with FS and final histology of operative materials.

RESULTS

In IC, excluding cases with insufficient material, the results for bile duct margins; sensitivity was 96.7%, specificity 100% and accuracy 98.7%. The results for pancreatic margins; sensitivity was 100%, specificity 92.9%, and accuracy 93.3%. In FS, the results for bile duct margins; sensitivity was 96.8%, specificity 100%, and accuracy 98.8%. The results for pancreatic margins; sensitivity was 66.7%, specificity 100%, and accuracy 97.1%.

CONCLUSION

IC is quick, highly accurate and very easy to perform. This study even included a specimen for which only IC led to an accurate diagnosis. IC used in combination with FS can achieve intraoperative diagnosis with high overall accuracy.

The significance of genetics for cholangiocarcinoma development

Cholangiocarcinoma (CCA) is a rare malignancy of the liver, arising from bile ducts. The incidence is increasing worldwide, but the prognosis has remained dismal and virtually unchanged in the past 30 years. Although several risk factors have been associated with the development of this cancer, none of them are normally identified in most patients. Diagnosis in advanced stages of the disease and limited therapeutic options contribute to poor survival rates. The recent analysis of genetic and epigenetic alterations occurring in CCA has shed new light in the understanding of the molecular mechanisms leading to the malignant transformation of biliary cells. Further studies in this direction may foster new diagnostic, prognostic and therapeutic approaches. This review provides a global overview of recent advances in CCA and describes the most important genetic mutations and epigenetic alterations so far reported in CCA.

Volume change and liver parenchymal signal intensity in Gd-EOB-DTPA-enhanced magnetic resonance imaging after portal vein embolization prior to hepatectomy

Purpose. To investigate the liver volume change and the potential of early evaluation by contrast-enhanced magnetic resonance imaging (MRI) using gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) after portal vein embolization (PVE). Materials and Methods. Retrospective evaluations of computed tomography (CT) volumetry of total liver and nonembolized areas were performed before and 3 weeks after PVE in 37 cases. The percentage of future liver remnant (%FLR) and the change ratio of %FLR (%FLR ratio) were calculated. Prospective evaluation of signal intensities (SIs) was performed to estimate the role of Gd-EOB-DTPA-enhanced MRI as a predictor of hypertrophy in 16 cases. The SI contrast between embolized and nonembolized areas was calculated 1 week after PVE. The change in SI contrast before and after PVE (SI ratio) was also calculated in 11 cases. Results. %FLR ratio significantly increased, and SI ratio significantly decreased (both P < 0.01). There were significant negative correlations between %FLR and SI contrast and between %FLR and SI ratio (both P < 0.01). Conclusion. Hypertrophy in the nonembolized area after PVE was indicated by CT volumetry, and measurement of SI contrast and SI ratio in Gd-EOB-DTPA-enhanced MRI early after PVE may be useful to predict the potential for hepatic hypertrophy.

Imaging bile duct tumors: pathologic concepts, classification, and early tumor detection

Cholangiocarcinoma is the most common primary malignancy of the bile ducts which has several predisposing factors such as hepatolithiasis and primary sclerosing cholangitis, and can develop from precancerous conditions such as biliary intraepithelial neoplasia and intraductal papillary neoplasm of the bile duct. As surgical resection of early stage cholangiocarcinoma or precancerous lesions may provide better prognosis, early detection of those lesions is very important. Imaging studies play important roles in the diagnosis of bile duct tumors followed by appropriate management. Indeed, not only diagnosis of cholangiocarcinoma but also appropriate categorization of bile duct tumors based on their morphologic features and location on cross-sectional imaging studies, including computed tomography and magnetic resonance imaging, is important to predict their biologic behaviors, and choose relevant treatment strategies. We herein review the classification system of the bile duct tumors with their radiologic and pathologic findings as well as role of imaging in the early detection of bile duct tumors.

Intraoperative placement of external biliary drains for prevention and treatment of bile leaks after extended liver resection without bilioenteric anastomosis

BACKGROUND

Improved surgical techniques, substantial preoperative diagnostics, and advanced perioperative management permit extensive and complex liver resection. Thus, hepatic malignancies that would have been considered inoperable some years ago may be curatively resected today. Despite all this progress, biliary leakage remains a clinically relevant issue, especially after extended liver resection. Intraoperative decompression of bile ducts by means of distinct biliary drains is controversial. Although drainage is rarely used as a routine procedure, it might be useful in selected patients at high risk for biliary leakage.

METHODS

We describe surgical management of long-segment exposed or injured bile ducts after extended parenchymal resection with concomitant lymphadenectomy. Because blood supply to the bile duct may be impaired, the risk of biliary necrosis and/or leakage is significant. Internal splinting of the bile duct to ensure optimum decompression plus guidance might be helpful. Thus, in selected cases after trisectionectomy we inserted an external-internal or internal-external drain into long-segment exposed bile ducts. For internal-external drains the tube was diverted via the major duodenal papilla into the duodenum and then transfixed after the duodenojejunal flexure through the jejunal wall by means of a Witzel's channel.

RESULTS

Because the entire bile duct is splinted, this technique is superior to bile duct decompression with a T-tube. This is supported by the course of a patient suffering biliary leakage after extended right-sided hepatectomy for colorectal metastasis. Initially, a T-tube was inserted for decompression, but biliary leakage persisted. After inserting transhepatic external-internal drainage, bile leakage stopped immediately. The patient's course was then uneventful. Five other patients (mostly with locally advanced hepatocellular or cholangiocellular carcinoma) treated similarly were discharged without complications. Drain removal 6 weeks postoperatively was uncomplicated in five of the 6 patients. In the sixth patient, external-internal drainage was replaced by a Yamakawa-type prosthesis for a biliary stricture. None of the patients suffered severe complications during long-term follow-up.

CONCLUSIONS

The bile duct drainage technique presented in this study was useful for preventing and treating bile leakage after long-segment exposure of extrahepatic bile ducts during major hepatectomy. Transhepatic or internal-external drains are often used for bilioenteric anastomoses, but similar drainage techniques have not been reported for the native bile duct. T-tubes are generally used in this situation. In particular cases, however, inner splinting of the bile duct and appropriate movement of the bile via a tube can be helpful.

ERCC1 mRNA expression as a postoperative prognostic marker in extrahepatic bile duct cancer

BACKGROUND

No reliable biomarker for biliary tract cancer has yet been identified because of the varying composition of the cancer type, differences in tumor location, a mixture of curative and non-curative operations, and differences in operative methods.

METHODS

Fifty extrahepatic bile duct cancer patients, pathologically diagnosed with papillary or tubular adenocarcinoma who underwent a pancreatoduodenectomy with R0 resection, were included in the study. Messenger RNA (mRNA) expression levels were measured from formalin-fixed, paraffin-embedded samples by real-time reverse-transcription polymerase chain reaction.

RESULTS

The preliminary analysis selected ten patients who have survived more than 5 years (LS group) and ten who had a relapse within 2 years (SS group). mRNA expression of seven target genes was examined, but only excision repair cross-complementing 1 (ERCC1) mRNA levels showed a significant difference between the LS and SS groups (median ERCC1: LS 26.5 vs. SS 9.7; p = 0.0073). The median survival time of patients with high ERCC1 levels was significantly longer than in patients with low ERCC1 levels (p = 0.0105). Thirty more patients with identical backgrounds were added to the study, and ERCC1 mRNA levels were measured in all 50 patients. Those with high ERCC1 mRNA levels had a significantly greater overall survival (OS) time compared with those with low ERCC1 levels (MST: 174 vs. 86 M; p = 0.048). Multivariate analysis found that an absence of lymph node metastases and high ERCC1 expression were significantly associated with improved OS.

CONCLUSION

ERCC1 mRNA expression appears to be a useful prognostic biomarker for extrahepatic bile duct cancer with R0 resection.

A novel armed oncolytic measles vaccine virus for the treatment of cholangiocarcinoma

Cholangiocarcinoma (CC) is curable only in early stages by complete surgical resection. Thus, in advanced disease stages in which a complete removal of the tumor mass is no longer possible and palliative chemotherapy achieves only modest success, therapeutics employing new methods of action are desperately needed. Oncolytic viruses employed in clinical studies have been shown to spread preferentially in cancer cells. Beyond that, virotherapeutic cell killing can be enhanced by virus-based expression of suicide genes. We engineered a measles vaccine virus (MeV) vector expressing super cytosine deaminase (SCD), a fusion protein of yeast cytosine deaminase and uracil phosphoribosyltransferase, which converts the prodrug 5-fluorocytosine (5-FC) to 5-fluorouracil (5-FU) and subsequently to 5-fluorouridine-monophosphate. This novel vector was evaluated using three different human-derived CC cell lines. In vitro, all CC cell lines were found to be permissive to MeV infection. Partial blocking of MeV-mediated oncolysis could be overcome by employment of the SCD transgene together with administration of 5-FC. In vivo, intratumoral application of SCD-armed MeV together with a systemic 5-FC treatment showed a significant reduction in tumor size in a TFK-1 xenograft mouse model when compared with virus-only treatment. In a second animal experiment employing a HuCCT1 xenograft tumor model, an enhanced SCD-armed MeV vector, in which the SCD transgene was expressed from a different genomic position, led not only to reduced tumor volumes, but also to a significant survival benefit. On the basis of these encouraging preclinical data on employment of SCD-armed MeV for the virotherapeutic treatment of chemotherapy-resistant CC, a clinical virotherapy trial is set up currently.

Prognostic factors following surgical resection of distal bile duct cancer

Purpose

Prognostic factors for distal bile duct cancer are contentious. This study was conducted to analyze the prognostic factors of distal bile duct cancer after surgery with the aim of identifying those associated with diminished survival.

Methods

Two hundred forty-one patients who underwent pylorus-preserving pancreaticoduodenectomy (PPPD) or Whipple procedure in our tertiary hospital from February 1995 to June 2011 were retrospectively analyzed. All patients were pathologically proven to have distal bile duct adenocarcinoma. Postoperative complications, survival, and well-known prognostic factors after resection for distal bile duct cancer were investigated.

Results

Preoperative elevated carbohydrate antigen 19-9 (CA 19-9) level (P = 0.006), positive resection margin (P < 0.001), advanced T stage (P = 0.043), and lymph node metastasis (P = 0.002) were significantly independent worse prognostic indicators by multivariate analysis of resectable distal bile duct cancer.

Conclusion

R0 resection is the most important so that frozen sections should be utilized aggressively during each operation. For the distal bile duct cancer with elevated preoperative CA 19-9 level or advanced stage, further study on postoperative adjuvant treatment may be warranted.

Principles of surgical resection in hilar cholangiocarcinoma

The aim of this article is to describe the surgical techniques for the treatment of hilar cholangiocarcinoma (HC). Resection with microscopically negative margin (R0) is the only way to cure patients with HC. Today, resection of the caudate lobe and part of segment IV, combined with a right or left hepatectomy, bile duct resection, lymphadenectomy of the hepatic hilum and sometimes vascular resection, is the standard surgical procedure for HC. Intraoperative frozen-section examination of proximal and distal biliary margins is necessary to confirm the suitability of resection. Although lymphadenectomy probably has little direct effect on survival, inaccurate staging information may influence post resection treatment recommendations. Aggressive venous and arterial resections should be undertaken in selected cases to achieve a R0 resection. The concept of “no-touch proposed” in 1999 by Neuhaus et al combine an extended right hepatectomy with systematic portal vein resection and caudate lobectomy avoiding hilar dissection and possible intraoperative microscopic dissemination of cancer cells. More recently minor liver resections have been proposed for treatment of HC. As the hilar bifurcation of the bile ducts is near to liver segments IV, V and I, adequate liver resection of these segments together with the bile ducts can result in cure.

Surgical management trends for cholangiocarcinoma in the USA 1998-2009

BACKGROUND

Surgical advancements have improved outcomes for cholangiocarcinoma (CCA) patients, but this expertise is not uniformly available. This research examines CCA surgical treatment patterns.

METHODS

A retrospective analysis of the U.S. Nationwide Inpatient Sample from 1998-2009 identified CCA patients at high-volume (HV) versus low-volume (LV) hospitals, and teaching versus nonteaching hospitals. We performed multinomial and multivariate logistic regressions to compare differences of surgical treatment between HV vs. LV hospitals, and teaching vs. nonteaching hospitals. Liver resection (LR), pancreaticoduodenectomy, bile duct (BD) resection, and combined liver/BD resection were considered more aggressive therapy than BD stent or bypass.

RESULTS

A total of 32,561 patients with CCA were identified. The proportion receiving surgery declined from 36 to 30 %. There was no increase in the proportion of LRs or combined liver/BD resection. Patients at HV or teaching hospitals were more likely to receive surgical treatment [odds ratio (OR), 1.3, p < 0.001; OR, 1.4, p < 0.001].

DISCUSSION

Despite increasing evidence that surgical resection increases survival, the number of patients receiving surgery has decreased. Although combined liver/BD resection has been advocated as standard management for proximal CCA, the practice has not increased. All patients with CCA should be considered for assessment at a HV teaching hospital.

Laparoscopic resection of hilar cholangiocarcinoma

BACKGROUND

Surgical resection is the only curative treatment for hilar cholangiocarcinoma. Laparoscopic hepatectomy has been used to treat several types of liver neoplasms. However, technical issues have limited the adoption of laparoscopy for the treatment of hilar cholangiocarcinoma. To date there is only one report of minimally invasive procedure for hilar cholangiocarcinoma in the literature. The present video-assisted procedure shows a laparoscopic resection of hilar cholangiocarcinoma.

PATIENT AND METHODS

A 43-year-old woman with progressive jaundice due to left-sided hilar cholangiocarcinoma was referred for treatment. The decision was to perform a laparoscopic left hepatectomy with lymphadenectomy and resection of extrahepatic bile ducts. Biliary reconstruction was performed using the hybrid method.

RESULTS

Operative time was 300 minutes with minimum blood loss and no need for blood transfusion. Recovery was uneventful, and the patient was discharged on postoperative Day 7. Pathology revealed a well-differentiated cholangiocarcinoma with negative lymph nodes and clear surgical margins. The patient is well with no signs of the disease 18 months after the procedure.

CONCLUSIONS

Laparoscopic left hepatectomy with lymphadenectomy is safe and feasible in selected patients and when performed by surgeons with expertise in liver surgery and minimally invasive techniques. The use of a hybrid method may be needed for biliary reconstruction, especially in cases where position and size of remnant bile ducts may jeopardize the anastomosis. Further studies are still needed to confirm the benefit of this approach over conventional surgery for hilar cholangiocarcinoma.

Liver transplantation for hilar cholangiocarcinoma--a single-centre experience

BACKGROUND

Cholangiocarcinoma is an infrequent malignancy, often unresectable at the time of diagnosis. Liver transplantation may offer a chance for cure, but results in the past have been disappointing, prompting transplant centres to adopt multimodal treatment protocols and extreme patient selection.

PURPOSE

This study was designed to evaluate the outcome of patients with irresectable hilar cholangiocarcinoma undergoing liver transplantation in order to determine criteria for patient selection.

METHODS

We reviewed our prospective cancer registry for patients with hilar cholangiocarcinoma treated by transplantation since 1997. Data were evaluated regarding tumour location, stage, overall survival, recurrence rates and prognostic factors.

RESULTS

Liver transplantation with lymphadenectomy was realised in 16 patients with hilar cholangiocarcinoma. Seven patients received a living donor graft. Lymph node metastases were found in eight patients with a median of 13 harvested nodes and had a statistically significant negative impact on overall survival irrespective of tumour size. Only one patient underwent neoadjuvant brachytherapy and developed fatal septic complications; 3- and 5-year survival rates were 63 and 50 % in lymph node-negative patients without neoadjuvant treatment.

CONCLUSIONS

Acceptable survival rates can be achieved by transplantation for hilar cholangiocarcinoma with lymph node metastases as the only exclusion criterion. We recommend staging laparotomy with lymphadenectomy along the common hepatic artery prior to liver transplantation.

ANN as a prognostic tool after treatment of non-seminoma testicular cancer

Testicular cancer is rare but is the most common cancer in males between 15 and 34 years of age. Two principal types of testicular cancer are distinguished: seminomas and non-seminomas. If detected early, the overall cure rate for testicular cancer exceeds 90%. In this study, artificial neural network (ANN) analysis as a prognostic tool was demonstrated regard to five year recurrence after the non-seminoma treatment. Data from 202 patients treated for non-seminoma were available for evaluation and comparison. A total of 32 variables were analysed using the ANN. The ANN approach, as an advanced multivariate data processing method, was demon-strated to provide objective prognostic data. Some of these prognostic factors are consistent or even imperceptible with previously evaluated by other statistical methods.

Isocitrate dehydrogenase 1 and 2 mutations in cholangiocarcinoma

Somatic mutations in isocitrate dehydrogenase 1 and 2 genes are common in gliomas and help stratify patients with brain cancer into histologic and molecular subtypes. However, these mutations are considered rare in other solid tumors. The aims of this study were to determine the frequency of isocitrate dehydrogenase 1 and 2 mutations in cholangiocarcinoma and to assess histopathologic differences between specimens with and without an isocitrate dehydrogenase mutation. We sequenced 94 formalin-fixed, paraffin-embedded cholangiocarcinoma (67 intrahepatic and 27 extrahepatic) assessing for isocitrate dehydrogenase 1 (codon 132) and isocitrate dehydrogenase 2 (codons 140 and 172) mutations. Multiple histopathologic characteristics were also evaluated and compared with isocitrate dehydrogenase 1/2 mutation status. Of the 94 evaluated specimens, 21 (22%) had a mutation including 14 isocitrate dehydrogenase 1 and 7 isocitrate dehydrogenase 2 mutations. Isocitrate dehydrogenase mutations were more frequently observed in intrahepatic cholangiocarcinoma than in extrahepatic cholangiocarcinoma (28% versus 7%, respectively; P = .030). The 14 isocitrate dehydrogenase 1 mutations were R132C (n = 9), R132S (n = 2), R132G (n = 2), and R132L (n = 1). The 7 isocitrate dehydrogenase 2 mutations were R172K (n = 5), R172M (n = 1), and R172G (n = 1). Isocitrate dehydrogenase mutations were more frequently observed in tumors with clear cell change (P < .001) and poorly differentiated histology (P = .012). The results of this study show for the first time that isocitrate dehydrogenase 1 and 2 genes are mutated in cholangiocarcinoma. The results of this study are encouraging because it identifies a new potential target for genotype-directed therapeutic trials and may represent a potential biomarker for earlier detection of cholangiocarcinoma in a subset of cases.

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.