Preclinical evidence for preventive and curative effects of resveratrol on xenograft cholangiocarcinogenesis

Cholangiocarcinoma (CCA), the malignant tumor of bile duct epithelial cells, is a relatively rare yet highly lethal cancer. In this work, we tested the ability of Resveratrol (RV) to prevent and cure CCA xenograft in nude mice and investigated molecular mechanisms underpinning such anticancer effect. Human CCA cells were xenografted in mice that were or not treated prior to or after to transplantation with RV. Tumor growth was monitored and analyzed for the markers of cell proliferation, apoptosis, and autophagy. TCGA was interrogated for the molecules possibly targeted by RV. RV could inhibit the growth of human CCA xenograft when administered after implantation and could reduce the growth or even impair the implantation of the tumors when administered prior the transplantation. RV inhibited CCA cell proliferation, induced apoptosis with autophagy, and strongly reduced the presence of CAFs and production of IL-6. Interrogation of CCA dataset in TCGA database revealed that the expression of IL-6 Receptor (IL-6R) inversely correlated with that of MAP-LC3 and BECLIN-1, and that low expression of IL-6R and of MIK67, two pathways downregulated by RV, associated with better survival of CCA patients. Our data demonstrate that RV elicits a strong preventive and curative anticancer effect in CCA by limiting the formation of CAFs and their release of IL-6, and this results in up-regulation of autophagy and apoptosis in the cancer cells. These findings support the clinical use of RV as a primary line of prevention in patients exposed at risk and as an adjuvant therapeutics in CCA patients.

Development of Fruit and Vegetable Consumption Promotion Model in a High-Risk Population for Cholangiocarcinoma in Thailand: An Action Research

OBJECTIVE

This study aimed to develop a model for promoting fruit and vegetable consumption  in Thailand's high-risk population for cholangiocarcinoma (CCA).

METHODS

Action research was used as a guiding framework for model development. Participants were divided into groups for process development and evaluation. Group discussions and practice notes were utilized as tools for process development. Data were collected through questionnaires. Qualitative data were categorized and analyzed using content analysis. Descriptive and inferential statistics were applied to analyze quantitative data.

RESULTS

The model development process, following the PAOR framework (Planning, Action, Observation, Reflection), involved fruit and vegetable consumption promotion.  The model, named the "NONGBO NO-CCA Model" included various components: active involvement of villagers in planning, objective sharing of experiences and brainstorming to identify CCA prevention strategies, establishment of networks to support community healthcare, enhancement of community self-reliance through utilization of local resources, and encouragement of chemical-free and environmentally friendly fruit and vegetable cultivation. Following model development, at-risk individuals demonstrated a statistically significant improvement in knowledge, attitude, and practice (p<0.001).

CONCLUSION

The findings indicate that at-risk individuals exhibited improvements in knowledge, attitude, and practice. Knowledge gains may be attributed to educational training activities, improved attitudes may result from networking processes, and modifications in practice behaviors may be influenced by community participation. Therefore, active involvement in community development can serve as a guiding principle for effective proactive CCA prevention.

p53 protects against formation of extrahepatic biliary precancerous lesions in the context of oncogenic Kras

KRAS and TP53 mutations are frequently observed in extrahepatic biliary cancer. Mutations of KRAS and TP53 are independent risk factors for poor prognosis in biliary cancer. However, the exact role of p53 in the development of extrahepatic biliary cancer remains elusive. In this study, we found that simultaneous activation of Kras and inactivation of p53 induces biliary neoplasms that resemble human biliary intraepithelial neoplasia in the extrahepatic bile duct and intracholecystic papillary-tubular neoplasm in the gall bladder in mice. However, inactivation of p53 was not sufficient for the progression of biliary precancerous lesions into invasive cancer in the context of oncogenic Kras within the observation period. This was also the case in the context of additional activation of the Wnt signaling pathway. Thus, p53 protects against formation of extrahepatic biliary precancerous lesions in the context of oncogenic Kras.

Epidemiology and Control of Opisthorchis viverrini Infection: Implications for Cholangiocarcinoma Prevention

It is known that Opisthorchis viverrini (OV) is the most significant risk factor for the development of cholangiocarcinoma (CCA); hence, it is also known as carcinogenic parasite. Effective control and elimination of OV infection should significantly reduce O. viverrini-related CCA. This chapter includes details of the three recently developed innovative tools, namely the Isan cohort database software, an OV-RDT for screening of O. viverrini, and an ultrasound telecommunication system. Past and current control programs, i.e., education, medication, and sanitation were discussed and stressed the need for a comprehensive control program which encompasses primary, secondary, and tertiary patient care programs for confirmation and management of suspected CCA cases. The approach of mathematical modeling for control of OV and CCA was also briefly described. Additionally, we highlighted the current progress toward control of OV and CCA in Thailand and potential for expansion into nearby countries in Southeast Asia.

Chimeric immune checkpoint protein vaccines inhibit the tumorigenesis and growth of rat cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most common primary liver malignancy and carries a dismal prognosis due to difficulties in achieving an optimal resection, and poor response to current standard-of-care systemic therapies. We previously devised a CTLA4-PD-L1 DNA cancer vaccine (DNA vaccine) and demonstrated its therapeutic effects on reducing tumor growth in a thioacetamide (TAA)-induced rat intrahepatic CCA (iCCA) model. Here, we developed a CTLA4-PD-L1 chimeric protein vaccine (Protein vaccine), and examined its effects in the rat iCCA model. In a therapeutic setting, iCCA-bearing rats received either DNA plus Protein vaccines or Protein vaccine alone, resulting in increased PD-L1 and CTLA-4 antibody titers, and reduced iCCA tumor burden as verified by animal positron emission tomography (PET) scans. Treating iCCA-bearing rats with Protein vaccine alone led to the increase of CTAL4 antibody titers that correlated with the decrease of tumor SUV ratio, indicating regressed tumor burden, along with increased CD8 and granzyme A (GZMA) expression, and decreased PD-L1 expression on tumor cells. In a preventive setting, DNA or Protein vaccines were injected in rats before the induction of iCCA by TAA. Protein vaccines induced a more sustained PD-L1 and CTLA-4 antibody titers compared with DNA vaccines, and was more potent in preventing iCCA tumorigenesis. Correspondingly, Protein vaccines, but not DNA vaccines, downregulated PD-L1 gene expression and hindered the carcinogenesis of iCCA. Taken together, the CTLA4-PD-L1 chimeric protein vaccine may function both as a therapeutic cancer vaccine and as a preventive cancer vaccine in the TAA-induced iCCA rat model.

Inflammatory pathways and cholangiocarcinoma risk mechanisms and prevention

Cholangiocarcinoma (CCA), a neoplasm burdened by a poor prognosis and currently lacking adequate therapeutic treatments, can originate at different levels of the biliary tree, in the intrahepatic, hilar, or extrahepatic area. The main risk factors for the development of CCA are the presence of chronic cholangiopathies of various etiology. To date, the most studied prodromal diseases of CCA are primary sclerosing cholangitis, Caroli's disease and fluke infestations, but other conditions, such as metabolic syndrome, nonalcoholic fatty liver disease and obesity, are emerging as associated with an increased risk of CCA development. In this review, we focused on the analysis of the pro-inflammatory mechanisms that induce the development of CCA and on the role of cells of the immune response in cholangiocarcinogenesis. In very recent times, these cellular mechanisms have been the subject of emerging studies aimed at verifying how the modulation of the inflammatory and immunological responses can have a therapeutic significance and how these can be used as therapeutic targets.

Cholangiocarcinoma protective factors in Greater Mekong Subregion: Critical issues for joint planning to sustainably solve regional public health problems

Although Opisthorchis viverrini (OV), lifestyle, and diet co-factors have a relatively high prevalence in the Greater Mekong Subregion (GMS) population, cumulative (0–74) incidence rates of cholangiocarcinoma (CCA) do not reach 5% in this region. Other co-factors must influence, but in this study, we only highlighted positive factors for guiding joint planning to address public health problems at the regional level. Therefore, we aimed to study prevalence and factors associated with CCA incidence focusing only on protective factors. A cross-sectional analytic study was carried out from June to October 2017. Participants with informed consent completed the questionnaires. Descriptive statistics were used to analyze general information. Primary variables were classified into high and low levels by mean. Logistic regression was employed to investigate the correlation between interesting variables and the overall risk level of CCA. The overall prevalence of CCA protective factors of the whole region was knowledge (61.39%), health beliefs (42.32%), prevention behavior (31.93%), and community participation (14.53%). When considering the proportions at a high level, they were 49.53%, 53.72%, 35.37%, and 49.67%, respectively. Significant factors associated with CCA prevention were females with secondary or vocational education, a high level of perceived seriousness and benefits, and community participation. These findings are likely to be helpful for both the public and administrators. First, it can be information for people to be aware of CCA risk. Second, policy-driven authorities at the local or regional level should apply the critical issues from this study for joint planning to sustainably solve regional public health problems.

Effectiveness of Leader Village Health Volunteers Training Program on Preventing Cholangiocarcinoma in Thailand: Advantages for High-Risk Area with Limited Public Health Personnel

Cholangiocarcinoma (CCA) still affects the health of rural people in northeast Thailand. Most people had a high level of overall risk according to CCA risk assessment in 2014. The question is how to make prevention of CCA as cost-effective as possible. The most appropriate answer is that someone should become a health leader to transfer knowledge to the public. This is the reason for developing the training program for village health volunteers (VHVs)-who play the role of change agents-to transfer knowledge to villagers. As for the evaluation of success, it is not evaluated if VHVs have increased knowledge or not, but it is assessed if people have better knowledge/attitudes, which lead to the correct behavior modification or not. After the program had been implemented for 2 years, people were evaluated on knowledge, attitudes, perception, and satisfaction with the operation of VHVs in providing people with the knowledge and ability to prevent CCA. It was found that people had a higher level of knowledge and attitudes in preventing CCA than before implementing the program. Also, they perceived that VHVs transferred knowledge to villagers so that they had the ability to prevent CCA. Nowadays, VHVs in the digital era (VHVs 4.0) is very useful in solving CCA problems in Thailand because they are the main drivers of success. Potential development of VHVs together with use of digital technology is an advantage for high-risk area with limited public health personnel.

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.

Effects of aspirin and non-steroidal anti-inflammatory drugs on the risk of cholangiocarcinoma: a meta-analysis

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) can suppress the proliferation of cholangiocarcinoma (CCA) cells in vitro through inhibition of cyclooxygenase-2. However, the effects of aspirin and NSAIDs on the risk of CCA remain unclear. We performed this meta-analysis to assess the risk of biliary tract cancers in patients who take aspirin and/or NSAIDs.

METHODS

A systematic review was conducted utilizing MEDLINE, EMBASE, Cochrane databases from inception through October 2017 to identify studies that assessed the association of aspirin and/or NSAIDs use with risk of biliary tract cancers including CCA, gallbladder cancer and ampulla of Vater cancer. Effect estimates from the studies were extracted and combined using the random-effect, generic inverse variance method of DerSimonian and Laird.

RESULTS

Five observational studies with a total of 9 200 653 patients were enrolled. The pooled OR of CCA in patients with aspirin use was 0.56 (95% CI, 0.32-0.96). Egger's regression asymmetry test was performed and showed no publication bias for the association between aspirin use and CCA with P = 0.42. There was no significant association between NSAIDs use and CCA, with a pooled OR of 0.79 (95% CI, 0.28-2.21). One study showed a significant association between aspirin use and reduced risk of gallbladder cancer with OR of 0.37 (0.17-0.80). However, there was no significant association between aspirin and ampulla of Vater cancer with OR of 0.22 (0.03-1.65).

CONCLUSIONS

Our study demonstrates a significant association between aspirin use and a 0.56-fold decreased risk of CCA. However, there is no association between the use of NSAIDs and CCA.

Association between physical activity and risk of hepatobiliary cancers: A multinational cohort study

BACKGROUND & AIMS

To date, evidence on the association between physical activity and risk of hepatobiliary cancers has been inconclusive. We examined this association in the European Prospective Investigation into Cancer and Nutrition cohort (EPIC).

METHODS

We identified 275 hepatocellular carcinoma (HCC) cases, 93 intrahepatic bile duct cancers (IHBCs), and 164 non-gallbladder extrahepatic bile duct cancers (NGBCs) among 467,336 EPIC participants (median follow-up 14.9 years). We estimated cause-specific hazard ratios (HRs) for total physical activity and vigorous physical activity and performed mediation analysis and secondary analyses to assess robustness to confounding (e.g. due to hepatitis virus infection).

RESULTS

In the EPIC cohort, the multivariable-adjusted HR of HCC was 0.55 (95% CI 0.38-0.80) comparing active and inactive individuals. Regarding vigorous physical activity, for those reporting >2 hours/week compared to those with no vigorous activity, the HR for HCC was 0.50 (95% CI 0.33-0.76). Estimates were similar in sensitivity analyses for confounding. Total and vigorous physical activity were unrelated to IHBC and NGBC. In mediation analysis, waist circumference explained about 40% and body mass index 30% of the overall association of total physical activity and HCC.

CONCLUSIONS

These findings suggest an inverse association between physical activity and risk of HCC, which is potentially mediated by obesity.

LAY SUMMARY

In a pan-European study of 467,336 men and women, we found that physical activity is associated with a reduced risk of developing liver cancers over the next decade. This risk was independent of other liver cancer risk factors, and did not vary by age, gender, smoking status, body weight, and alcohol consumption.

Fish sharing as a risk factor for Opisthorchis viverrini infection: evidence from two villages in north-eastern Thailand

BACKGROUND

Foodborne trematodiasis (FBT) is a significant global health problem, with the liver flukes Opisthorchis viverrini, O. felineus, and Clonorchis sinensis contributing to half of the global burden of FBT. North-eastern Thailand where O. viverrini is endemic and un-cooked fish dishes remain an integral part of the food culture has the highest reported incidence of opisthorchiasis, including associated cholangiocarcinoma. Both food sharing and eating practices are potentially important factors in FTB, suggesting an important role for the social ecology of disease transmission in these rural communities.

METHODS

Two rural Thai-Lao villages that were part of a 12-village project in Northeastern Thailand were selected for detailed investigation of O. viverrini infection risk associated with sharing of raw fish dishes among households. The project included screening individuals for infection and cholangiocarcinoma, a household questionnaire, and offering treatment options for positive individuals. Social network mapping was used to construct raw fish dish-sharing networks and create a proxy variable capturing variability in the degree of food sharing (DFS), measured as the number of different households with which each household shared fish dishes. Measures of associations between DFS, O. viverrini infection, the frequency of raw fish consumption, and the number of raw fish dishes consumed were generated using binary logistic regression, proportional odds ordinal logistic regression, and Poisson regression.

RESULTS

The results showed that the probability that a household has members infected with O. viverrini increased by ~7% (P < 0.01) for each additional household included in its network. Moreover, the frequency and number of types of raw fish dishes consumed increased significantly as the DFS increased. Of the two villages, that with the highest infection prevalence (48% versus 34.6%) had significantly higher social connectivity overall (P < 0.001).

CONCLUSIONS

Our findings suggest that the social ecology of human settlements may be key to understanding the transmission dynamics of some FBT. In the case of O. viverrini in Thai-Lao communities, for which food sharing is a traditional practice supporting social cohesion, food sharing network mapping should be incorporated into community-based interventions. These should encourage fish dish preparation methods that minimize infection risk by targeting households with high DFS values.

Primary Care Intervention to Prevent and Control Cholangiocarcinoma: Lesson from Nakhon Ratchasima, Thailand

BACKGROUND

Cholangiocarcinoma (CCA) is a bile duct cancer. It includes intra-and extra-hepatic bile duct. It is most commonly found in Thailand particularly in the northeast and north region. Those regions have been reported as the highest of incident of the world.

OBJECTIVE

Primary car interven in the risk areas of CCA among population in Nakhon Ratchasima province,Thailand.

MATERIAL AND METHOD

A community-based study was conducted among three districts of Nakhon Ratchasima province, Thailand including Bua Yai, Chum Phuang, and Mueang Yang district between July and December 2015. Mix method was used in this study that included cross-sectional survey, action research, and application of Geographic Information System. The study was composed of five steps, develop Korat CCA network, CCA screening by using Korat CCA verbal screening test, detection of liver fluke and CCA in the population at risk by using Kato Katz thick smear technique and ultrasonography, health behavior modification, and development of Geographic Information System for CCA database.

RESULTS

Three hundred fifty five participants were tested for liver fluke infection and the infection rate was found to be 2.25%. Eight cases from 88 participants at risk had a dilated bile duct. Populations at risk in each district were selected for health modification briefing that used the social engagement model. Seven community rules were agreed, cooked fish consumption, stop under-cooked fish, hygienic defecation, CCA campaign, food safety club, annual health check, an ongoing monitoring by village health volunteer and local public health officer.

CONCLUSION

Infection in Nakhon Ratchasima is high. A community briefing and rules were agreed. A geovisual display of the population at risk for CCA is now available.

Double Common Bile Duct with Ectopic Drainage into the Stomach Found in Asymptomatic

The case of a patient with asymptomatic double common bile duct that was identified by chance is presented. A 41-year-old man underwent esophagogastroduodenoscopy(EGD) as part of a regular health checkup, during which he was found to have an elevated lesion in the lesser curvature of the upper gastric corpus with bile draining from its tip. Further examination led to a diagnosis of double common bile duct from the left intrahepatic bile duct to the opening into the stomach. Morphological abnormalities of the biliary tree are commonly encountered in everyday gastroenterological practice, but a double common bile duct with an ectopic opening into the stomach is comparatively rare. It is also associated with an increased risk of developing cancer of the stomach or bile duct, and as such is a biliary abnormality that must be treated with caution. This case is reported together with a discussion of the literature.

Epithelial Transforming Growth Factor-β Signaling Does Not Contribute to Liver Fibrosis but Protects Mice From Cholangiocarcinoma

BACKGROUND & AIMS

Transforming growth factor-β (TGFβ) exerts key functions in fibrogenic cells, promoting fibrosis development in the liver and other organs. In contrast, the functions of TGFβ in liver epithelial cells are not well understood, despite their high level of responsiveness to TGFβ. We sought to determine the contribution of epithelial TGFβ signaling to hepatic fibrogenesis and carcinogenesis.

METHODS

TGFβ signaling in liver epithelial cells was inhibited by albumin-Cre-, K19-CreERT-, Prom1-CreERT2-, or AAV8-TBG-Cre-mediated deletion of the floxed TGFβ receptor II gene (Tgfbr2). Liver fibrosis was induced by carbon tetrachloride, bile duct ligation, or disruption of the multidrug-resistance transporter 2 gene (Mdr2). Hepatocarcinogenesis was induced by diethylnitrosamine or hepatic deletion of PTEN.

RESULTS

Deletion of Tgfbr2 from liver epithelial cells did not alter liver injury, toxin-induced or biliary fibrosis, or diethylnitrosamine-induced hepatocarcinogenesis. In contrast, epithelial deletion of Tgfbr2 promoted tumorigenesis and reduced survival of mice with concomitant hepatic deletion of Pten, accompanied by an increase in tumor number and a shift from hepatocellular carcinoma to cholangiocarcinoma. Surprisingly, both hepatocyte- and cholangiocyte-specific deletion of Pten and Tgfbr2 promoted the development of cholangiocarcinoma, but with different latencies. The prolonged latency and the presence of hepatocyte-derived cholangiocytes after AAV8-TBG-Cre-mediated deletion of Tgfbr2 and Pten indicated that cholangiocarcinoma might arise from hepatocyte-derived cholangiocytes in this model. Pten deletion resulted in up-regulation of Tgfbr2, and deletion of Tgfbr2 increased cholangiocyte but not hepatocyte proliferation, indicating that the main function of epithelial TGFBR2 is to restrict cholangiocyte proliferation.

CONCLUSIONS

Epithelial TGFβ signaling does not contribute to the development of liver fibrosis or formation of hepatocellular carcinomas in mice, but restricts cholangiocyte proliferation to prevent cholangiocarcinoma development, regardless of its cellular origin.

Development of a Health Education Modification Program Regarding Liver Flukes and Cholangiocarcinoma in High Risk Areas of Nakhon Ratchasima Province Using Self-Efficacy and Motivation Theory

A quasi-experimental study was conducted to develop a health education modification program based on self-efficacy and motivation regarding liver flukes and cholangiocarcinoma development in Keang Sanam Nang district, Nakhon Ratchasima province, Thailand. A total of 36 individuals were invited to participate in the program and were screened for population at risk of liver fluke infection and cholangiocarcinoma using SUT-OV-001 and SUT-CCA-001. Development of health education modification program regarding liver fluke and cholangiocarcinoma prevention included 3 steps: (1) preparation, (2) health education program, and (3) follow-up and evaluation. The study was implemented for 10 weeks. Pre-and-post-test knowledge was measured with questionnaires, Kuder-Richardson-20: KR-20 = 0.718,and Cronbach's Alpha Coefficient = 0.724 and 0.716 for perception and outcome expectation questionnaires. Paired and independent t-tests were applied for data analysis. The majority of the participants were female (55.6%), aged between ≤50 and 60 years old (36.1%), married (86.1%), education level of primary school (63.9%), agricultural occupation (80.6%), and income <4,000 Baht (44.4%). The results revealed that after the health education program, the experimental group had a mean score of knowledge, perception, and outcome expectation regarding liver fluke and cholangiocarcinoma prevention significantly higher than before participation and in the control group. In conclusion, this successful health education modification program for liver fluke and cholangiocarcinoma, therefore may useful for further work behavior modification in other epidemic areas.

Behavioral Modification Regarding Liver Fluke and Cholangiocarcinoma with a Health Belief Model Using Integrated Learning

This study aimed to modify behavior regarding liver fluke and cholangiocarcinoma prevention in Chumphuang district, Nakhon Ratchasima province, Thailand through integrated learning. A total of 180 participants were included through purposive selection of high-risk scores on verbal screening. Participants attended the health education program which applied the health belief model included family based, knowledge station based, academic merit based and community based learning. Data were collected using a questionnaire composed of 4 parts: 1) personal information, 2) knowledge, 3) perceived susceptibility, severity, benefits, and barriers, 4) practice regarding liver fluke and cholangiocarcinoma prevention. The result revealed that the majority were female (79.9%), age ≥60 years old (33.2%), primary school educational level (76.1%), and agricultural occupation (70.1%). The mean scores of knowledge, perception, and practice to liver fluke and cholangiocarcinoma prevention, before participated the integrative learning were low, moderate, and low, respectively. Meanwhile, the mean score of knowledge, perceived susceptibility, severity, benefits, and barriers, and practice regarding liver fluke and cholangiocarcinoma prevention, were higher with statistical significance after participation in the integrated learning. This finding indicates that health education programs may successfully modify health behavior in the rural communities. Therefore they may useful for further work behavior modification in other epidemic areas.

Hepatolithiasis and intrahepatic cholangiocarcinoma: A review

Although the incidence of hepatolithiasis is decreasing as the pattern of gallstone disease changes in Asia, the prevalence of hepatolithiasis is persistently high, especially in Far Eastern countries. Hepatolithiasis is an established risk factor for cholangiocarcinoma (CCA), and chronic proliferative inflammation may be involved in biliary carcinogenesis and in inducing the upregulation of cell-proliferating factors. With the use of advanced imaging modalities, there has been much improvement in the management of hepatolithiasis and the diagnosis of hepatolithiasis-associated CCA (HL-CCA). However, there are many problems in managing the strictures in hepatolithiasis and differentiating them from infiltrating types of CCA. Surgical resection is recommended in cases of single lobe hepatolithiasis with atrophy, uncontrolled stricture, symptom duration of more than 10 years, and long history of biliary-enteric anastomosis. Even after resection, patients should be followed with caution for development of HL-CCA, because HL-CCA is an independent prognostic factor for survival. It is not yet clear whether hepatic resection can reduce the occurrence of subsequent HL-CCA. Furthermore, there are no consistent findings regarding prediction of subsequent HL-CCA in patients with hepatolithiasis. In the management of hepatolithiasis, important factors are the reduction of recurrence of cholangitis and suspicion of unrecognized HL-CCA.

Suppression of Ov-grn-1 encoding granulin of Opisthorchis viverrini inhibits proliferation of biliary epithelial cells

Multistep processes likely underlie cholangiocarcinogenesis induced by chronic infection with the fish-borne liver fluke, Opisthorchis viverrini. One process appears to be cellular proliferation of the host bile duct epithelia driven by excretory-secretory (ES) products of this pathogen. Specifically, the secreted growth factor Ov-GRN-1, a liver fluke granulin, is a prominent component of ES and a known driver of hyper-proliferation of cultured human and mouse cells in vitro. We show potent hyper-proliferation of human cholangiocytes induced by low nanomolar levels of recombinant Ov-GRN-1 and similar growth produced by low microgram concentrations of ES products and soluble lysates of the adult worm. To further explore the influence of Ov-GRN-1 on the flukes and the host cells, expression of Ov-grn-1 was repressed using RNA interference. Expression of Ov-grn-1 was suppressed by 95% by day 3 and by ~100% by day 7. Co-culture of Ov-grn-1 suppressed flukes with human cholangiocyte (H-69) or human cholangiocarcinoma (KKU-M214) cell lines retarded cell hyper-proliferation by 25% and 92%, respectively. Intriguingly, flukes in which expression of Ov-grn-1 was repressed were less viable in culture, suggesting that Ov-GRN-1 is an essential growth factor for survival of the adult stage of O. viverrini, at least in vitro. To summarize, specific knock down of Ov-grn-1 reduced in vitro survival and capacity of ES products to drive host cell proliferation. These findings may help to contribute to a deeper understanding of liver fluke induced cholangiocarcinogenesis.

[Cytology is in pivotal role at screening and surveillance of PSC]

Primary sclerosing cholangitis (PSC) is an autoimmune disease leading to biliary strictures and inflammation. The lifetime risk for cholangiocarcinoma (CCA) among PSC patients is 7-13%, and biliary dysplasia is thought to be a precursor lesion for CCA. The diagnosis of PSC is based on endoscopic retrogradic cholangiography (ERC). During ERC brush cytology samples are routinely taken in our unit to detect possible biliary dysplasia. With repeated cytological dysplasia, liver transplantation is considered. Aneuploidy in DNA flow cytometry may support the suspicion of dysplasia. PSC is the most common indication for liver transplantation in Finland, and half of transplantations are prophylactic.

[Treatment of cholestatic hepatic diseases: more than the substitution of fat soluble vitamins?]

The clinical-biochemical syndrome of cholestasis is characterized by an alteration in bile constituents. As a consequence, the concentrations of bilirubin, bile acids, phospholipids and cholesterol are elevated. The main clinical symptoms of cholestasis are icterus and pruritus, and in severe cases xanthelasma and xanthoma. Primary intrahepatic cholestasis, caused by impaired bile secretion in the liver, should be separated from the extrahepatic secondary cholestasis which is a consequence of a biliary obstruction. This paper evaluates the therapy of liver diseases which developed as consequence of a primary disturbance in bile secretion.

iNOS-dependent DNA damage via NF-kappaB expression in hamsters infected with Opisthorchis viverrini and its suppression by the antihelminthic drug praziquantel

Inflammation-mediated DNA damage triggered by Opisthorchis viverrini (OV) infection is a major risk factor of cholangiocarcinoma (CCA). We have recently reported that nitrative and oxidative DNA damage participates in CCA development caused by repeated infection with OV [Pinlaor et al., Carcinogenesis 2004; 25:1535-42]. Therefore, to clarify the preventive effect of the antihelminthic drug praziquantel against cholangiocarcinogenesis, we assessed the effect of this drug on nitrative and oxidative DNA damage, including the formation of 8-nitroguanine and 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodG), and the expression of inducible nitric oxide synthase (iNOS) by immunohistochemistry in OV-infected hamsters. We also examined the expression of nuclear factor-kappaB (NF-kappaB), which functions as a tumor promoter in inflammation-associated cancer. Our results showed that although 1-week treatment with praziquantel did not kill parasites completely in hamsters on days 14 and 30, this drug dramatically reduced inflammatory cell infiltration. Double immunofluorescence staining showed that drug treatment almost completely diminished OV-induced 8-nitroguanine and 8-oxodG formation in bile duct epithelial cells. Quantitative analysis using an electrochemical detector coupled to HPLC revealed that 8-oxodG level in the liver of OV-infected hamsters was significantly decreased by drug treatment (p<0.05). Western blotting and immunohistochemistry revealed that the expression of NF-kappaB and iNOS in bile duct epithelium was reduced by drug treatment. The amount of nitrate plus nitrite in the liver and plasma was significantly decreased after drug treatment. It is concluded that praziquantel can exhibit a preventive effect against OV-induced cholangiocarcinoma by inhibiting iNOS-dependent DNA damage through not only elimination of parasites but also a potential antiinflammatory effect.

Impact of dominant stenoses on the serum level of the tumor marker CA19-9 in patients with primary sclerosing cholangitis

BACKGROUND/AIMS

Patients with primary sclerosing cholangitis (PSC) have an increased risk of developing hepatobiliary tumors. The tumor marker CA19-9 was claimed to indicate the occurrence of bile duct carcinoma. This study aimed to assess whether increased serum levels of CA19-9 in PSC patients with dominant stenoses indicate bile duct carcinoma.

METHODS

The study cohort comprised 106 patients treated over a median time of 5.0 years (range 0.5 - 13 years). All patients were treated with ursodeoxycholic acid (UDCA) and whenever they developed dominant stenoses by endoscopic dilatation of these stenoses. In endoscopically treated patients, CA19-9 levels were measured before and 3, 6, 12 and 24 months after endoscopic dilatation.

RESULTS

Of the 106 patients, 22 carcinoma-free patients and 3 patients with bile duct carcinoma had elevated CA 19 - 9 levels. In 14 out of 25 patients with elevated CA19-9 levels, dominant stenoses were diagnosed and treated by endoscopic dilatation. In 71.4 % of the endoscopically treated patients, CA19-9 levels decreased following the endoscopic intervention.

CONCLUSIONS

In PSC patients, increased serum levels of CA19-9 are rarely due to the development of bile duct carcinoma. In patients with dominant stenoses, the relief of biliary obstruction by endoscopic dilatation may lead to a decrease of the serum levels of CA19-9.

Cholangiocarcinoma: molecular targeting strategies for chemoprevention and therapy

Cholangiocarcinomas are devastating cancers that are increasing in both their worldwide incidence and mortality rates. The challenges posed by these often lethal biliary tract cancers are daunting, with conventional treatment options being limited and the only hope for long-term survival being that of complete surgical resection of the tumor. Unfortunately, the vast majority of patients with cholangiocarcinoma typically seek treatment with advanced disease, and often these patients are deemed poor candidates for curative surgery. Moreover, conventional chemotherapy and radiation therapy have not been shown to be effective in prolonging long-term survival, and although photodynamic therapy combined with stenting has been reported to be effective as a palliative treatment, it is not curative. Thus, there is a real need to develop novel chemopreventive and adjuvant therapeutic strategies for cholangiocarcinoma based on exploiting select molecular targets that would impact in a significant way on clinical outcome. This review focuses on potential preventive targets in cholangiocarcinogenesis, such as inducible nitric oxide synthase, cyclooxygenase-2, and altered bile acid signaling pathways. In addition, molecular alterations related to dysregulation of cholangiocarcinoma cell growth and survival, aberrant gene expression, invasion and metastasis, and tumor microenvironment are described in the context of various clinical and pathological presentations. Moreover, an emphasis is placed on the importance of critical signaling pathways and postulated interactions, including those of ErbB-2, hepatocyte growth factor/Met, interleukin-6/glycoprotein130, cyclooxygenase-2, vascular endothelial growth factor, transforming growth factor-beta, MUC1 and MUC4, beta-catenin, telomerase, and Fas pathways as potential molecular therapeutic targets in cholangiocarcinoma.

Experimental investigation of opisthorchiasis-associated cholangiocarcinoma induction in the Syrian hamster - pointers for control of the human disease

Appropriate animal models for specific diseases in man can facilitate elucidation of mechanisms underlying tumour development and allow potential interventions and therapeutic regimens to be tested in vivo before consideration for use in the human situation. In the North-east of Thailand exceptionally high levels of cholangiocellular carcinomas (CCCs) are encountered, related to infestation with Opisthorchis viverrini liver flukes. The Syrian hamster can also be infected with metacercariae of the fluke and heavy loads of parasites cause the development of cirrhotic livers. While the presence of flukes alone does not give rise to neoplasms, large yields of cholangiofibrotic lesions and CCCs can be readily induced with additional carcinogenic insult. While removal of the parasite with the antihelminthic drug Praziquantel can protect against carcinogenesis, this is dependent on the timing of the drug administration and the efficacy of application to the human situation remains to be confirmed. The available information would suggest that interest needs to be concentrated on potential chemopreventive agents which could be administered to individuals at high risk. Furthermore, understanding of the genesis of CCCs and the characteristics of preneoplastic lesions, again as assessed in the animal model, might allow novel approaches to identification of early stage cases and effective surgical intervention.

Long-term results after cholecystectomy alone for patients with pancreaticobiliary maljunction without bile duct dilatation

A pancreaticobiliary maljunction (PB-MJ) without bile duct dilatation is relatively rare. The standard treatment for these patients remains controversial. In this study, we followed up the patients with PB-MJ without bile duct dilatation who mainly underwent a cholecystectomy alone. Eighteen adult patients with PB-MJ without bile duct dilatation (8 males and 10 females with a mean age of 54.8 years) were treated surgically. When the diameter of the common bile duct was less than 10 mm, such bile ducts were diagnosed to have no dilatation. The main clinical indications for surgery were cholecystolithiasis in 12 patients, choledocholithiasis in 3, cholecystocholedocholithiasis in 1, and carcinoma of the gallbladder in 2. The amylase levels of gallbladder bile in 14 patients ranged from 115 to 454,000 IU/ml. A simple cholecystectomy was performed in 12 patients, a cholecystectomy with bile duct drainage was performed in 3, a cholecystectomy with a choledochojejunostomy without bile duct resection was performed in 1, and a cholecystectomy with a lymph node dissection was performed in 2. Three patients died of other diseases. The remaining 15 patients have all been doing well for 20-209 months after surgery. In conclusion, a prophylactic resection of the extrahepatic bile duct and biliary diversion could be unnecessary for patients with PB-MJ without bile duct dilatation, when no bile stasis, such as choledocholithiasis, is observed.

Prophylactic excision of the gallbladder and bile duct for patients with pancreaticobiliary maljunction

HYPOTHESIS

Pancreaticobiliary maljunction (PBM) is a high-risk factor for biliary tract carcinogenesis because of a continuous reflux of pancreatic juice into the biliary tract. It remains to be disclosed whether we should perform prophylactic excision of gallbladders and bile ducts.

DESIGN

A person-year method.

SETTING

A university hospital.

PATIENTS

We studied 68 patients with PBM treated between August 1, 1974, and December 31, 1999.

MAIN OUTCOME MEASURES

Relative risks (observed number-expected number ratios) of gallbladder and bile duct carcinomas according to type of bile duct dilation (ie, cystic dilation, diffuse dilation, and nondilation).

RESULTS

Observed number-expected number ratios of gallbladder carcinomas were high: 291.3 in 43 patients with cystic dilation, 167.2 in 16 patients with diffuse dilation, and 419.6 in 7 patients with nondilation. Observed number-expected number ratios of bile duct carcinomas were 194.2 in 43 patients with cystic dilation before surgery and 142.8 in 39 patients with cystic dilation after long postsurgical follow-up. All these values were statistically significant (P<.01).

CONCLUSIONS

The gallbladder carries a high risk for carcinogenesis in all types of dilation in patients with PBM. The bile duct carcinomas of PBM were exclusively identified by the type of cystic dilation. Prophylactic cholecystectomy should be recommended for all dilation types, and prophylactic excision of bile ducts including cholecystectomy should be performed in patients with PBM and cystic dilation. Complete excision of extrahepatic dilated bile ducts and careful follow-up for carcinogenesis in residual dilated bile ducts should be recommended for patients with PBM and cystic dilation.

Is preventive resection of the extrahepatic bile duct necessary in cases of pancreaticobiliary maljunction without dilatation of the bile duct?

BACKGROUND

No consensus has been reached on whether preventive resection of the extrahepatic bile duct is necessary in cases of pancreaticobiliary maljunction (PBM) without dilatation of the extrahepatic bile duct (undilated type).

METHODS

Sixty-eight patients with PBM underwent corrective surgery and several clinical characteristics and pathological findings including K-ras point mutation were evaluated.

RESULTS

Unlike dilated bile duct, none of the patients with undilated type duct had clinical symptoms in early childhood. In patients with either cystic or spindle type duct, amylase levels in the bile duct were >10(4) U/l, whereas those in patients with undilated type duct were <10(4) U/l. Postoperative scintigraphy of the biliary system of undilated type revealed no evidence of cholestasis. After surgery, eight patients with undilated type duct, in whom the bile duct had been preserved, had no further clinical symptoms and no evidence of malignancy. Bile duct tissue specimens revealed no hyperplasia, dysplasia or cancerous lesions and they had no K-ras mutation in undilated type.

CONCLUSION

The results showed that there was little bile stasis, injury to the mucosa was mild and less genetic changes could be seen in patients with undilated type duct. Therefore, in patients without dilatation of bile duct and advanced cancer, cholecystectomy alone is sufficient.

[Risk groups for pancreatic and bile duct carcinomas]

Biliopancreatic carcinoma has a poor prognosis since the diagnosis of the tumor occurs late when advanced disease is present. The identification of potential causes and earlier diagnosis are needed to prevent the disease or identify it early enough to improve survival. The main risk factors for pancreatic cancer include advanced age, cigarette smoking, high-fat diet, diabetes mellitus, chronic pancreatitis (especially hereditary pancreatitis) and a positive family history of pancreatic cancer. The most important etiologic factor for the development of gallbladder cancer is gallstone disease. Patients with anatomic abnormalities and chronic inflammatory conditions (primary sclerosing cholangitis, infections with parasites) have an increased incidence of bile duct cancers. Several new and promising imaging techniques have recently become available and our understanding of the mechanisms of carcinogenesis are growing rapidly. However, there is currently no effective screening strategy applicable and it is unknown when to begin screening. For pancreatic cancer, reduction of risk is likely to occur with avoidance of smoking and promotion of healthful diets. Cholecystectomy rates have increased since the introduction of new laparoscopic techniques and will eventually reduce the incidence of gallbladder cancer. Improved imaging techniques, the identification of new genes and a better definition of genetic alterations that characterize preinvasive lesions will hopefully allow to develop sensitive and specific technologies to screen and to detect early biliopancreatic cancer for even premalignant lesions to improve the mostly fatal prognosis if this tumor.

Prevention of implantation metastases after resection of proximal bile duct tumours with pre-operative low dose radiation therapy

AIMS

Pre-operative endoscopic retrograde cholangiopancreatography (ERCP) with biliary drainage is associated with a greater risk of implantation metastases after resection of proximal bile duct tumours. In a previous study among patients who had undergone biliary drainage before resection, eight patients (20%) developed implantation metastases, within 1 year following resection. The aim of this analysis was to evaluate the results of pre-operative irradiation with regard to a possible reduction of implantation metastases.

METHODS

Twenty-one patients with proximal bile duct tumours who had undergone resection following pre-operative irradiation were retrospectively analysed. Pre-operative radiation therapy consisted of three fractions of 3.5 Gy external beam irradiation of the hilar area.

RESULTS

Pre-operative biliary drainage was performed in 19 patients (90%). All patients received pre-operative radiotherapy during which no complications were noted. None of the patients developed implantation metastases within a follow-up time of 2 to 79 months.

CONCLUSION

The results of this study suggest that pre-operative radiotherapy in patients with a resectable proximal bile duct tumour who have undergone pre-operative drainage, decreases the risk of implantation metastases. To be certain about the role of pre-operative radiotherapy, a randomized study is required. Until then, we advocate standard low dose radiotherapy preceding resection in all patients with lesions suggestive of a proximal bile duct tumour who have undergone biliary drainage.

Inhibitory effects of 1'-acetoxychavicol acetate on N-Nitrosobis(2-oxopropyl)-amine-induced initiation of cholangiocarcinogenesis in Syrian hamsters

The influence of 1'-acetoxychavicol acetate (ACA) during the initiation stage was investigated in the N-nitrosobis(2-oxopropyl)amine (BOP)-initiated hamster tumorigenesis model. Ninety male 5-week-old hamsters were divided into three groups, each consisting of 30 animals, and s.c. injected with 20 mg / kg of BOP twice with a one-week interval. Groups 1 through 3 were fed diet supplemented with ACA at concentrations of 500, 100 and 0 ppm, respectively, for 3 weeks starting one week before the first carcinogen application. At the termination of experimental week 54, the total incidence and multiplicity of cholangiocellular adenomas and carcinomas in group 1 (17.9% and 0.3 < 0.9) were significantly (P < 0.05 and P < 0.01) decreased as compared to the group 3 values (50.0% and 0.7 < 0.8). The ACA treatments also showed a tendency to reduce the development of preneoplastic lesions in the pancreas, a main target organ of BOP, although this was not statistically significant. Our results thus indicate that ACA exerts an inhibitory effect on BOP-induced cholangiocarcinogenesis in hamsters. Taken together with previous findings of inhibited colon, oral and skin carcinogenesis in rats and mice, they suggest that ACA is a candidate chemopreventive agent with a wide spectrum of activity.

The significance of hepatectomy for primary intrahepatic stones

The objective of this study was to evaluate the significance of performing hepatectomy for primary intrahepatic stones. Observations on the morphology of the bile ducts, histopathological findings of the excised liver, and treatment results were reviewed in 29 of 35 patients with primary intrahepatic stones. The remaining 6 patients (17.1%) were excluded because they had intrahepatic cholangiocarcinoma. The subjects were classified into two groups according to the morphological characteristics of the bile ducts; one group comprised 25 patients having strictures in the central bile duct, and another group comprised 4 patients having no biliary stricture, but a localized dilatation in the distal bile duct. Calcium bilirubinate stones were found in all the patients with a biliary stricture, whereas cholesterol stones were found in those without a biliary stricture. Hepatectomy was performed in 25 of the 29 patients (86.2%), the results of which were excellent. In fact, during the past 10 years, no postoperative complications have occurred, nor have there been any retained or recurrent stones. Moreover, the postoperative hospitalization period was as short as 15.3 days. The findings of this study indicate that hepatectomy allows treatment for primary intrahepatic stones to be completed within a short period of time without incurring serious postoperative complications, and serves as a useful prophylactic technique for recurrent stones.

Risk of bile duct carcinogenesis after excision of extrahepatic bile ducts in pancreaticobiliary maljunction

BACKGROUND

A reflux of pancreatic juice into the biliary tract caused by pancreaticobiliary maljunction (PBM) has been considered important in the development of biliary tract carcinogenesis in choledochal cysts. We excised extrahepatic bile ducts in patients with choledochal cysts to terminate the reflux of pancreatic juice. We investigated whether this surgery could stop the development of the residual bile duct carcinoma.

METHODS

Fifty-six patients with a diagnosis of PBM with choledochal dilatation underwent surgical excision of extrahepatic bile ducts. We applied a person-year method to compare the relative risks (observed number/expected number) of biliary tract carcinoma before and after surgery.

RESULTS

In 3 patients, bile duct carcinoma developed in residual dilated segments 19 years 6 months, 8 years 8 months, and 2 years 5 months, respectively, after surgery. Although the relative risk in the post-surgery group was slightly decreased by surgery, it was still high compared with that of the general population.

CONCLUSIONS

The incidence of bile duct carcinoma is still high, even after excision of extrahepatic bile ducts in PBM patients with choledochal dilatation. For these patients, careful long-term follow-up is necessary, especially after operations that leave the dilated bile ducts, such as cases of Todani's type IV-A.

[Treatment of congenital dilatation of the bile ducts. Apropos of 3 cases]

Congenital dilatation of the bile duct is an uncommon lesion requiring surgical treatment. Complete excision of the diseased bile duct prevents development of carcinoma of the bile duct. We report three cases of congenital dilatation of the biliary three, each illustrating a particular aspect of the therapeutic strategy. One patient had an unusual anomaly of the pancreaticobiliary junction that required pancreaticoduodenectomy. Another patient developed carcinoma of the bile duct 15 years after an internal derivation of a choledochal cyst. The last patient had dilatations of the common and intrahepatic bile ducts associated with congenital hepatic fibrosis.

The herbal medicine sho-saiko-to inhibits proliferation of cancer cell lines by inducing apoptosis and arrest at the G0/G1 phase

Water-soluble ingredients of the herbal medicine sho-saiko-to dose-dependently inhibited the proliferation of a human hepatocellular carcinoma cell line (KIM-1) and a cholangiocarcinoma cell line (KMC-1). Fifty % effective doses on day 3 of exposure to sho-saiko-to were 353.5 +/- 32.4 micrograms/ml for KIM-1 and 236.3 +/- 26.5 micrograms/ml for KMC-1. However, almost no suppressive effects were detected in normal human peripheral blood lymphocytes or normal rat hepatocytes. Sho-saiko-to suppressed the proliferation of the carcinoma cell lines significantly more strongly than did each of its major ingredients, i.e., saikosaponin a, c, and d, ginsenoside Rb1 and Rg1, glycyrrhizin, baicalin, baicalein, and wogonin, or another herbal medicine, juzen-taiho-to (P < 0.05 or 0.005). Because such ingredients are barely soluble in water, there could be synergistic or additive effects of the ingredients in sho-saiko-to. Morphological, DNA, and cell cycle analyses revealed two possible modes of action of sho-saiko-to to suppress the proliferation of carcinoma cells; (a) it induces apoptosis in the early period of exposure and (b) it induces arrest at the G0/G1 phase in the late period of exposure.

Cholangiocarcinoma: epidemiology, mechanisms of carcinogenesis and prevention

Cholangiocarcinoma is a relatively rare cancer; worldwide it accounts for an estimated 15% of liver cancers. In most areas, the etiology is rather obscure, and identified risk factors such as hepatolithiasis, inflammatory bowel disease, and exposure to Thorotrast can account for only a small proportion of cases. In certain areas of southeast and eastern Asia, however, incidence rates are very high, and here there is a strong association with infection with the liver flukes Clonorchis sinensis and Opisthorchis viverrini. The mechanisms of carcinogenesis in O. viverrini infection have been the subject of considerable research; it seems that the presence of parasites induces DNA damage and mutations as a consequence of the formation of carcinogens/free radicals and of cellular proliferation of the intrahepatic bile duct epithelium. Preventive strategies in areas endemic for liver flukes appear straightforward, but breaking the cycle of infection has proved difficult in practice.

Electrolytic stents to inhibit tumor growth. An experimental study in vitro and in rats

Obstruction of metallic stents used in the management of malignant biliary strictures is common and in several cases due to tumor growth through the stent wall. In an experimental animal model in rats, a tumor was implanted subcutaneously adjacent to different metallic stents. Ingrowth of tumor through the wall of these stents was frequent. A stent generating direct electric current on the basis of electrolysis was developed and tested in vitro and in the experimental model. The study confirms that an "electrolytic" stent can inhibit ingrowth of tumor.

Cholangiocarcinoma associated with liver fluke infection: a preventable source of morbidity in Asian immigrants

In the Far East infection with the liver flukes Clonorchis sinensis and Opisthorchis viverrini is the most frequently documented cause of cholangiocarcinoma. Liver fluke infection in the United States remains a health problem for more than 500,000 Southeast Asian refugees who have immigrated to this country since 1975. Recent surveys have revealed that up to 26% of Asian immigrants have an active liver fluke infection. However, the common clinical manifestations of this condition, as well as the possibility of developing such long-term sequelae as cholangiocarcinoma, remain unknown to many physicians providing care for this population. This report describes a clinically unsuspected C. sinensis infection associated with cholangiocarcinoma in an elderly Chinese immigrant, and emphasizes the importance of early diagnosis and treatment of all liver fluke infections in the prevention of bile duct neoplasms in high risk populations.