Inhibition of tumor vasculogenic mimicry and prolongation of host survival in highly aggressive gallbladder cancers by norcantharidin via blocking the ephrin type a receptor 2/focal adhesion kinase/paxillin signaling pathway

Vasculogenic mimicry (VM) is a newly-defined tumor microcirculation pattern in highly aggressive malignant tumors. We recently reported tumor growth and VM formation of gallbladder cancers through the contribution of the ephrin type a receptor 2 (EphA2)/focal adhesion kinase (FAK)/Paxillin signaling pathways. In this study, we further investigated the anti-VM activity of norcantharidin (NCTD) as a VM inhibitor for gallbladder cancers and the underlying mechanisms. In vivo and in vitro experiments to determine the effects of NCTD on tumor growth, host survival, VM formation of GBC-SD nude mouse xenografts, and vasculogenic-like networks, malignant phenotypes i.e., proliferation, apoptosis, invasion and migration of GBC-SD cells. Expression of VM signaling-related markers EphA2, FAK and Paxillin in vivo and in vitro were examined by immunofluorescence, western blotting and real-time polymerase chain reaction (RT-PCR), respectively. The results showed that after treatment with NCTD, GBC-SD cells were unable to form VM structures when injecting into nude mouse, growth of the xenograft was inhibited and these observations were confirmed by facts that VM formation by three-dimensional (3-D) matrix, proliferation, apoptosis, invasion, migration of GBC-SD cells were affected; and survival time of the xenograft mice was prolonged. Furthermore, expression of EphA2, FAK and Paxillin proteins/mRNAs of the xenografts was downregulated. Thus, we concluded that NCTD has potential anti-VM activity against human gallbladder cancers; one of the underlying mechanisms may be via blocking the EphA2/FAK/Paxillin signaling pathway.

Expression pattern of tumor endothelial marker 8 protein in gallbladder carcinomas

Tumor endothelial marker 8 protein (TEM8) is highly specific to tumor angiogenesis and is not required for normal adult angiogenesis and hence might prove to be a target for anti-angiogenic therapies in the future. We here evaluated protein and gene expression patterns in human endothelial cells of benign gallbladder - gallstone diseases (GSDs) and gallbladder carcinomas (GBCs) using immunostaining, immunofluorescence and western blotting techniques. Subjects comprised 175 GBC patients, 38 males and 137 females, aged 30-85 years (mean age 50.3 ± 13.4 years) and twenty with GSDs, aged 30-75 years, (51.4 ± 10.0 years) for comparison (male 4/20 and females 16/20). TEM8 protein expression increased significantly (p < 0.0001) with increasing stage of GBC and was mostly limited to endothelial cells, although there was no significant change with the grade. Interestingly, only 80-85 kDa and 60 kDa isoforms of TEM8 increased significantly whereas 45 kDa isoform was absent in GBCs. Conclusions- These results suggest that TEM8 plays an unknown important biological role to promote tumor angiogenesis in GBC.

[Expressions of VEGF-C and VEGF-D and their correlation with lymphangiogenesis and angiogenesis in gallbladder carcinoma]

OBJECTIVE

To investigate the expression of VEGF-C and VEGF-D and their correlations with lymphangiogenesis and angiogenesis in gallbladder carcinoma.

METHODS

Fifty cases of gallbladder carcinoma with complete clinical and pathological data were analyzed. The expression of VEGF-C and -D, D2-40, CD31 was assayed by immunohistochemical staining, with 10 samples of normal gallbladder tissues away from cancer and 19 samples of chronic cholecystitis as controls, and their correlation with clinicopathological findings were analyzed retrospectively.

RESULTS

Thirty-two (64.0%) of the 50 gallbladder cancers were positive for VEGF-C protein expression by immunohistochemistry and the positive rate of VEGF-D protein expression was 62.0% (31/50). The protein expression of VEGF-C and VEGF-D in tumor tissues was significantly higher than that in normal gallbladder tissues away from the tumor (P < 0.05), but no correlation with that in chronic cholecystitis (P < 0.05). The VEGF-C expression correlated with the patient age and lymph node metastasis (both P < 0.05). The VEGF-D expression only correlated with lymph node metastasis (P < 0.05). In the 50 gallbladder cancers, the MLVD was 6.9 + or - 3.6 and the MVD was 36.1 + or - 12.8. The MLVD in both VEGF-C and -D positive groups was significantly higher than that in the negative groups (P = 0.000), and the lymph node metastasis also increased. MVD in both VEGF-C and -D positive groups was higher than that in the negative groups (P < 0.05), and it was also correlated with tumor differentiation (P < 0.05). A significant positive correlation was also found between VEGF-C and VEGF-D expression (r = 0.498, P < 0.01).

CONCLUSION

VEGF-C and VEGF-D are involved in the lymphangiogenesis and angiogenesis in gallbladder carcinoma, promote lymph node metastasis of the tumor, and both are important in the regulation of lymphangiogenesis and angiogenesis in this cancer. VEGF-C and VEGF-D are of clinical significance in evaluating lymph node metastatic potency and estimation of prognosis in gallbladder carcinoma.

The prognostic value of angiogenesis by Chalkley counting in gallbladder carcinoma

BACKGROUND/AIMS

Tumor angiogenesis has been proposed as essential to tumor growth, proliferation and metastases however, for gallbladder neoplasia, these data remain obscure. Therefore, it was performed this study with the objective of evaluating the prognostic value of angiogenesis in gallbladder cancer.

METHODOLOGY

Thirty cases of gallbladder carcinoma were studied by immunohistochemical technique with antibody anti-CD105 for the identification of neoformed intratumoral vessels. The intratumoral micro vessel density was evaluated by Chalkley counting method, and researched the association of this index with the survival rate and the prognostic factors.

RESULTS

It was obtained, starting from the analysis of these data, a cut off in the index of the tumor vascular density at 8.5. It was observed an association between high intratumoral micro vessel density (index above or equal to 8.5) and survival rate lower to 6 months in 84.6% of cases.

CONCLUSION

The present study confirms the hypothesis that a high vascular density, appraised through the Chalkley counting method, is associated to a worse prognosis in patients of gallbladder carcinoma.

[A case of unresectable advanced gallbladder cancer successfully treated by oral S-1 and hepatic arterial infusion (HAI) of low-dose CDDP therapy]

The patient was a 64-year-old woman. Oral S-1 and hepatic arterial infusion (HAI) of low-dose CDDP therapy were started for unresectable advanced gallbladder cancer associated with liver metastasis and numerous lymph node metastases. Marked regression of the liver metastasis and lymph node metastases was observed by this treatment, and upon completion of the second course they had almost completely resolved. The tumor marker values also converted to negative. We report a case in which oral S-1 and HAI of low-dose CDDP therapy was effective against advanced gallbladder cancer associated with liver metastasis and multiple lymph node metastases.

Diagnosis of gallbladder diseases by contrast-enhanced phase-inversion harmonic ultrasonography

We evaluated the usefulness of contrast-enhanced ultrasonography(US) for detecting and differentiating gallbladder lesions. Contrast-enhanced coded phase-inversion harmonic US was performed on 90 patients with gallbladder abnormalities. After administering Levovist, we observed the gallbladders in real time. Contrast-enhanced coded phase-inversion harmonic ultrasonography was compared with B-mode US and contrast-enhanced computer tomography (CT) with regard to the sensitivity and specificity in depicting the elevated gallbladder lesions. Furthermore, we assessed how the vascular patterns of the elevated gallbladder lesions depicted by contrast-enhanced US correlated with the diagnosis. Contrast-enhanced US efficiently discriminated true lesions from biliary sludge, unlike B-mode US. Consequently, contrast-enhanced US was more specific (100%) than B-mode US (81%), although their sensitivities were similar (98% and 96%, respectively). Contrast-enhanced US was also more sensitive that contrast-enhanced CT (98% versus 79%), although the two methods were equally sensitive (100% versus 95%). We classified the vascular patterns of the abnormalities depicted by contrast-enhanced US in the 90 cases into types 1 to 4, which represent branch-like, heterogeneous, homogeneous, and avascular patterns, respectively. All type 1 and 2 lesions were over 10 mm in size while most (88%) type 3 lesions were 10 mm or less in size. While the majority of carcinomas (86%) were type 1 or 2, three benign lesions also showed these patterns. Thus, the vascular pattern may simply reflect the size of the lesion and therefore its usefulness in diagnosing gallbladder lesions may be limited. Nevertheless, contrast-enhanced US is clearly superior to the other techniques in discriminating biliary sludge from other lesions.

Antitumor Effect of Gemcitabine on Orthotopically Inoculated Human Gallbladder Cancer Cells in Nude Mice

BACKGROUND

The prognosis of gallbladder carcinoma is poor; therefore, investigating the efficacy of new chemotherapy agents is essential for the treatments for this tumor. Recently, several studies have reported clinical trials using gemcitabine as treatment for advanced gallbladder cancers. However, the antitumor effects of gemcitabine on gallbladder carcinoma have not been examined in in vitro and in vivo model systems.

METHODS

We examined the cytotoxicity of gemcitabine in four biliary tract cancer cell lines using the WST-1 assay. In addition, we examined the effect of gemcitabine on gallbladder cancers resulting from orthotopic inoculation of NOZ gallbladder tumor cells into nude mice. One week after transplantation, the mice were randomized into two groups: In Group A, the mice were treated by an intra-peritoneal injection of 0.9% sodium chloride for three weeks after inoculation (control). In Group B, the mice were treated by an intra-peritoneal injection of gemcitabine (125 mg / kg) for three weeks. All mice were sacrificed one week after the end of treatment, and macroscopic and histological findings were evaluated. The expression levels of proliferating-cell nuclear antigen (PCNA) were examined to investigate cellular proliferation activity, and Tunnel assays were performed to determine apoptotic status. Survival duration of the mice after gemcitabine treatment was compared to that of untreated mice.

RESULTS

The gemcitabine sensitivity of the four biliary tract cancer cell lines was similar in a dose dependent manner. In the in vivo models, the Group A mice showed huge tumors of the gallbladder, with liver invasion and lymph node metastases. However, there were no abdominal tumors in the Group B mice, and microscopic gallbladder cancer could only be detected from histological findings. The mean percent of PCNA-positive tumor cells was significantly higher in tumors from mice in Group A (71.9%) compared to those of Group B (34.7%). The mean percent of Tunnel-positive tumor cells was significantly lower in mice from Group A (2.0%) than those from Group B (5.7%). Survival duration was prolonged significantly in the gemcitabine-treated mice relative to untreated mice.

CONCLUSIONS

Gemcitabine treatment may inhibit tumor progression and prolong survival in gallbladder cancer by inhibiting cell proliferation and inducing apoptosis.

[Vasculogenic mimicry in human primary gallbladder carcinoma and clinical significance thereof]

OBJECTIVE

To investigate if there is vasculogenic mimicry (VM) in human primary gallbladder carcinoma and clinical significance thereof.

METHODS

Seventy-four specimens of primary gallbladder carcinoma obtained from operation underwent HE staining and double staining of CD(31) and PAS to observe the existence of VM. The correlation of pathological examination and clinical outcomes was analyzed.

RESULTS

VM was seen in 10 of the 74 (13.5%) specimens. VM was not correlated with age, sex, location, diameter, differentiation degree, Nevin stage, and invasion depth of tumor, and existence of lymph node metastasis; but was associated with histological type (chi(2) = 10.241, P = 0.017), hepatic metastasis (chi(2) = 11.904, P = 0.01), and poor overall survival (chi(2) = 5.771, P = 0.016). Cox analysis showed that existence of VM, invasion depth, lymph node metastasis, hepatic metastasis, and operational method were independent risk factors of the prognosis of primary gallbladder carcinoma.

CONCLUSION

VM exists in human primary gallbladder carcinoma. Those cases of human primary gallbladder carcinoma with VM have a poorer prognosis.

Immunohistochemical demonstration of c-Kit protooncogene product in gallbladder cancer

BACKGROUND/PURPOSE

Although some gallbladder carcinomas are immunoreactive for c-Kit, the reasons for the c-Kit expression and its clinicopathologic implications are unknown.

METHODS

We investigated the prevalence of c-Kit immunoreactivity, its clinicopathologic correlates (including microvessel density and postoperative outcome), and the possible mechanisms of c-Kit expression. We reviewed retrospectively, the clinicopathologic records of 47 patients who had undergone macroscopically complete gallbladder carcinoma resection. The numbers of patients at pathologic stages I to IV, according to current TNM-based staging, were 10, 5, 18, and 14, respectively. For immunohistochemical examination, we used monoclonal antibodies against c-Kit and CD 34 (progenitor cell markers), cytokeratin 7 and cytokeratin 19 (cholangiocyte markers), and OCH1E5 (a hepatocyte marker). Control tissue samples were from five gallbladder specimens each with chronic cholecystitis, polyp, and adenoma.

RESULTS

Cytoplasmic immunostaining for c-Kit was detected in 21 of the 47 gallbladder carcinomas (45%), and in 1 of the 15 control specimens (diagnosis, chronic cholecystitis). Young age was significantly associated with c-Kit positivity; however, there were no significant differences in the incidence of c-Kit positivity among other variables, including tumor stage and outcome. However, microvessel density was significantly higher in c-Kit-positive gallbladder carcinoma compared with c-Kit-negative gallbladder carcinoma. None of the 47 cancer specimens or the 15 control specimens were stained for CD34 and OCH1E5, but all 47 cancer specimens were stained for cytokeratins 7 and 19.

CONCLUSIONS

Gallbladder carcinomas positive for c-Kit are unlikely to arise from immature cells, but may be associated with neovascularization. Angiogenesis inhibitors, such as tyrosine kinase inhibitors, therefore, may suppress the growth of some gallbladder cancers.

Cyclooxygenase-2 expression determines neo-angiogenesis in gallbladder carcinomas

Neo-angiogenesis may have an important role in the poor prognosis of gallbladder carcinoma. An enhanced expression of COX-2 was found in precancerous lesions and in gallbladder carcinoma, likely to be involved in carcinogenesis as well as in angiogenesis. To study the relationships between the COX-2 expression and degree of vascularization, as well as to evaluate their role in the prognosis of patients with gallbladder carcinoma. 27 cases of gallbladder adenocarcinoma were included, classified grading I-III according the WHO classification. The COX-2 and endothelial antigen CD105 expressions were assessed immunohistochemically. COX-2 expression was evaluated according to the percentage and staining intensity of positive cells into "COX-2 positive" and "COX-2 negative" groups. In order to assess tumor microvessel density (MVD), CD105 positively stained microvessels were counted for each specimen in predominantly vascular areas (hot spots) at 200 x magnification. The MVD ranged from 9 to 46 microvessels/field. 15 tumors belonged to the hypervascular group (MVD > or = 25) and 12 to the hypovascular group. There were 16 (59.2%) COX-2 positive cases. There was difference in the degree of angiogenesis between COX-2 positive vs. COX-2 negative group: 11 (68.8%) out of 16 "COX-2 positive" tumors were hypervascular, in comparison with just 4 (36.4%) of "COX-2 negative" tumors. Our data show that the MVD corresponds to the COX-2 overexpression in gallbladder carcinomas. Augmented tumor neovascularization induced by COX-2 might be responsible for the poor prognosis in gallbladder carcinoma patients.

Hypoxia inducible factors 1alpha and 2alpha are associated with VEGF expression and angiogenesis in gallbladder carcinomas

AIMS

To investigate the significance of the hypoxia inducible factors HIF-1alpha and HIF-2alpha in gallbladder adenocarcinomas and their relation to angiogenesis and to the expression of VEGF, an angiogenic factor transcriptionally regulated by HIFalphas.

METHODS

HIF-1alpha and 2alpha expression was assessed immunohistochemically in 60 patients with early gallbladder adenocarcinomas, treated with surgery alone. In addition, the vascular density (VD) and the expression of the angiogenic factors VEGF and thymidine phosphorylase (TP) were examined. The results were correlated with clinico-pathological features and prognosis.

RESULTS

Overexpression of HIF-1alpha and 2alpha was significantly associated with increased tumor angiogenesis and VEGF expression, while HIF-2alpha was linked with upregulation of TP. None of these factors were associated with T-stage and tumor grade. Although HIFs did not relate significantly with prognosis, patients with HIF-1/2 expression who failed to switch-on VEGF or intratumoral angiogenesis had a favorable outcome.

CONCLUSION

Hypoxia inducible factors are upregulated in a large proportion of gallbladder adenocarcinomas, a feature strongly related to increased expression of VEGF and intensified angiogenesis.

Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up

OBJECTIVE

To assess clinical benefit of portal vein embolization (PVE) before extended, complex hepatectomy for biliary cancer.

SUMMARY BACKGROUND DATA

Many investigators have addressed clinical utility of PVE before simple hepatectomy for metastatic liver cancer or hepatocellular carcinoma, but few have reported PVE before hepatectomy for biliary cancer due to the limited number of surgical cases.

METHODS

This study involved 240 consecutive patients with biliary cancer (150 cholangiocarcinomas and 90 gallbladder cancers) who underwent PVE before an extended hepatectomy (right or left trisectionectomy or right hepatectomy). All PVEs were performed by the "ipsilateral approach" 2 to 3 weeks before surgery. Hepatic volume and function changes after PVE were analyzed, and the outcome also was reviewed.

RESULTS

There were no procedure-related complications requiring blood transfusion or interventions. Of the 240 patients, 47 (19.6%) did not undergo subsequent hepatectomy. The incidence of unresectability was higher in gallbladder cancer than in cholangiocarcinoma (32.2% versus 12.0%, P < 0.005). The remaining 193 patients (132 cholangiocarcinomas and 61 gallbladder cancers) underwent hepatectomy with resection of the caudate lobe and extrahepatic bile duct (n = 187), pancreatoduodenectomy (n = 42), and/or portal vein resection (n = 63). Seventeen (8.8%) patients died of postoperative complications: mortality was higher in gallbladder cancer than in cholangiocarcinoma (18.0% versus 4.5%, P < 0.05); and it was also higher in patients whose indocyanine green clearance (KICG) of the future liver remnant after PVE was <0.05 than those whose index was >or=0.05 (28.6% versus 5.5%, P < 0.001). The 3- and 5-year survival after hepatectomy was 41.7% and 26.8% in cholangiocarcinoma and 25.3% and 17.1% in gallbladder cancer, respectively (P = 0.011). In 136 other patients with cholangiocarcinoma who underwent a less than 50% resection of the liver without PVE, a mortality of 3.7% and a 5-year survival of 27.6% were observed, which was similar to the 132 patients with cholangiocarcinoma who underwent extended hepatectomy after PVE.

CONCLUSIONS

PVE has the potential benefit for patients with advanced biliary cancer who are to undergo extended, complex hepatectomy. Along with the use of PVE, further improvements in surgical techniques and refinements in perioperative management are necessary to make difficult hepatobiliary resections safer.

[Effects of norcantharidin on angiogenesis of human gallbladder carcinoma and its anti-angiogenic mechanisms]

OBJECTIVE

To investigate the effects of norcantharidin (NCTD) on angiogenesis of human gallbladder carcinoma and its anti-angiogenic mechanisms.

METHODS

Human gallbladder carcinoma cells of the line GBC-SD were cultured. BALB/c nude mice were inoculated subcutaneously with the GBC-SD cells and then randomly divided into 6 groups: NCTD group, injected intraperitoneally with 1/5 of the LD(50) of NCTD twice a week for 6 weeks; 5-fluorouracil (5-FU) group, injected intraperitoneally with 1/5 of the LD(50) of 5-FU twice a week for 6 weeks; endostatin (ES) group, intraperitoneally with ES; NCTD + 5-FU group, injected intraperitoneally with 1/5 of the LD(50) of NCTD and 1/5 of the LD(50) of 5-FU twice a week for 6 weeks; NCTD + ES group, injected intraperitoneally with 1/5 of the LD(50) of NCTD and ES twice a week for 6 weeks; and normal saline (NS) group (control group), injected with NS. The mice were killed in the 7th week. The tumors were taken out to measure their volumes and undergo microscopy. SABC method of immunohistochemistry was used to measure the microvessel density (MVD) and the protein expression of the angiogenesis-related factors: proliferating cell nuclear antigen (PCNA), vascular endothelial growth factor (VEGF), angiopoietin (Ang)-2, thrombospondin (TSP), and tissue inhibitor of metalloprotease (TIMP)(2). Suspension of single tumor cell was prepared to examine the cell apoptosis by flow cytometry. RT-PCR was used to examine the mRNA expression of PCNA, VEGF, Ang-2, TSP, and TIMP2.

RESULTS

(1) The MVD of the NCTD group was 4.12 +/- 1.4, significantly lower than those of the 5-FU group (15.8 +/- 5.9) and control group (17.6 +/- 3.2) (both P < 0.01), but not significantly different from those of the NCTD + 5-FU group (3.8 +/- 1.7), ES group (4.5 +/- 2.1), and NCTD + ES group (2.9 +/- 1.5) (all P > 0.05). The mice treated with NCTD showed significantly smaller tumor volume, lower PCNA protein expression, higher apoptotic rate, and higher PCNA/apoptosis ratio (P < 0.05 or P < 0.01), and significant correlation between MVD and tumor volume and between MVD and PCNA/apoptosis ratio (both P < 0.05). (2) The protein expression of VEGF and of Ang-2 of the NCTD group were both significantly lower than those of the control and 5-FU groups (all P < 0.01), however, not significantly different from those of the ES, NCTD + 5-FU, and NCTD + ES groups; and the protein expression of TSP and of TIMP2 of the NCTD group were both significantly higher than those of the control and 5-FU groups (all P < 0.01), however, not significantly different from those of the ES, NCTD + 5-FU, and NCTD + ES groups. MVD was positively correlated with VEGF and Ang-2 expression and negatively correlated with the expression of TSP and TIMP2 (all P < 0.05). (3) In comparison with the control group, the mRNA expression of VEGF and of Ang-2 of the tumor cells of the NCTD group were both significantly lower and the mRNA expression of TIMP2 was significantly higher.

CONCLUSION

NCTD down-regulates the expression of the angiogenic factors, such as VEF|GF and Ang-2, and up-regulates the expression of the anti-angiogenic factors, such as TDP and TIMP2, thus inhibiting the angiogenesis in tumor, such as human gallbladder carcinoma, and further inhibiting the growth of tumor.

Analysis of p53 and vascular endothelial growth factor expression in human gallbladder carcinoma for the determination of tumor vascularity

AIM: To examine the expression of p53 and vascular endothelial growth factor (VEGF) as well as microvessel count (MVC) and to investigate the role of VEGF as an angiogenic marker and the possible role of p53 in the regulation of angiogenesis in human gallbladder carcinoma.

METHODS: Surgically resected specimens of 49 gallbladder carcinomas were studied by immunohistochemical staining for p53 protein, VEGF, and factor VIII-related antigen. VEGF expression and mutant p53 expression were then correlated with Nevin stage, differentiation grade, MVC, and lymph node metastasis.

RESULTS: Positive p53 protein and VEGF expressions were found in 61.2% and 63.3% of tumors, respectively. p53 and VEGF staining status was identical in 55.1% of tumors. The Nevin staging of p53- or VEGF-positive tumors was significantly later than that of negative tumors. The MVC in p53- or VEGF-positive tumors was significantly higher than that in negative tumors, and MVC in both p53- and VEGF-negative tumors was significantly lower than that in the other subgroups.

CONCLUSION: Our findings suggest that p53-VEGF pathway can regulate tumor angiogenesis in human gallbladder carcinoma. Combined analysis of p53 and VEGF expression might be useful for predicting the tumor vascularity of gallbladder cancer.

Cyclooxygenase-2 promotes angiogenesis by increasing vascular endothelial growth factor and predicts prognosis in gallbladder carcinoma

AIM: To investigate the relationships between the expression of cyclooxygenase-2 (COX-2), vascular endothelial growth factor (VEGF) and the degree of vascularization, clinicopathologic feature, survival time of patients with gallbladder carcinomas.

METHODS: Sixty-four gallbladder carcinoma specimens were evaluated for COX-2, VEGF expression by immunohi-stochemical methods. Microvessel counts (MVC) were determined using CD₃₄. The relationships between COX-2, VEGF expression, CD₃₄-stained MVC, clinicopathologic features and survival time were analyzed. The correlations between COX-2 and VEGF expression, CD₃₄-stained MVC were also investigated.

RESULTS: COX-2, VEGF immunoreactivity were observed in 71.9% (46/64) and 54.7% (35/64) specimens, respectively. The average MVC in 64 cases of gallbladder carcinoma was 57±14 per high power vision field. The status of MVC was closely correlated with Nevin staging, tumor differentiation and lymph node metastasis (P<0.01, 0.002, and 0.003, 0.000, respectively). Increased VEGF expression was significantly correlated with tumor differentiation (poorly and moderately>well differentiated, P<0.05, P = 0.016). Clinical stages had no relation with the expression of VEGF (P>0.05, P = 0.612). There was a positive correlation between COX-2 expression and clinical stages. The positive rate of COX-2 was higher in cases of Nevin stages S₄-S₅ (81.8%) than in those of Nevin stages S₁-S₃ (50.0%) with a statistical significance (P<0.01, P = 0.009). The expression of COX-2 did not vary with differentiation (P>0.05, P = 0.067). Statistically significant differences were also observed according to lymph node metastasis, COX-2 expression and VEGF expression (P<0.01, 0.000, and 0.001, respectively). There was no relation between VEGF, COX-2 expression, MVC and the age and sex of patients. MVC and VEGF positive rate in the COX-2 positive gallbladder carcinoma tissue was higher than that in the COX-2 negative tissue (P<0.05, 0.000, and 0.032, respectively). Patients with VEGF, COX-2 positive tumors had a significantly shorter survival time than those with negative tumors (P<0.05, 0.004, 0.01, respectively).

CONCLUSION: Augmented tumor neovascularization induced by VEGF may be one of the several effects of COX-2 responsible for poor prognosis of human gallbladder carcinoma. COX-2 inhibitor, either in combination therapy with other agents, or for chemoprevention, may be effective via suppression of angiogenesis in this fatal disease.

[Expression of P62 in gallbladder carcinoma tissues and its correlation with angiogenesis]

AIM

To detect the expressions of P62 and bFGF in human gallbladder carcinoma tissues and microvessel density(MVD) inside tumor, explore their correlation with each other, and their relationship with tumor's clinical pathological properties.

METHODS

The expressions of P62 and bFGF in 41 cases of human gallbladder carcinoma tissues and 22 cases of chronic cholecystitis tissues were detected by SP immunohistochemical staining. The MVD was examined by SP immunohistochemical staining with anti CD34 mAb.

RESULTS

The positive rates of P62 and bFGF in 41 cases of gallbladder carcinoma tissues (63.4% and 75.6%, respectively) were significantly higher than those in 22 cases of chronic cholecystitis tissues(P<0.01). The expression of P62 was associated with lymph node metastasis(P<0.05), but had no relation to tumor's histological grading and clinical stage. The expression of bFGF was correlated with tumor's histological grading and clinical stage, but not with lymph node metastasis. There was a positive correlation between P62 and bFGF expression rates(r = 0.512, P<0.01). Both proteins had no relation with patient's age, sex, tumor's type or cholelithiasis. MVD in the gallbladder carcinoma tissues was significant higher than that in the chronic cholecystitis tissues(P<0.01). The expression rates of P62 and bFGF were all correlated with MVD in gallbladder carcinoma tissues(P<0.05 and P<0.01), respectively. MVD in the gallbladder carcinoma tissues was associated with clinical stages and lymph node metastasis status (P<0.05, and P<0.01), respectively. but had no relation with patient's age, sex, tumor's type, histological grading and cholelithiasis.

CONCLUSION

Expressions of P62 and bFGF were closely associated with angiogenesis in gallbladder carcinoma tissues, which may play a pivotal role in genesis and progression in gallbladder carcinoma. Expressions of P62 and bFGF may be helpful for diagnosis and therapy of gallbladder carcinoma.

Immunohistochemical study of microvessel density, CD44 (standard form), p53 protein and c-erbB2 in gallbladder carcinoma

BACKGROUND

The purpose of the present study was to investigate microvessel density (MVD), and the expression of CD44 adhesion molecule, p53 protein and c-erbB2 in gallbladder carcinoma, and their relation to histological grade and tumor invasiveness.

METHODS

Immunohistochemical staining with antibodies against factor VIIIRAg, CD44 standard form (CD44s), p53 protein and c-erbB2 was performed on paraffin sections from 33 cases of gallbladder carcinoma.

RESULTS

Significant increase of MVD with increasing depth of invasion (P < 0.02) was observed. No association of MVD with histological differentiation, CD44s, p53 and c-erbB2 protein expression was found. The expression of p53 protein was significantly higher in deeply invasive tumors (P = 0.028) and in moderately and poorly differentiated carcinomas (P < 0.05). The CD44s expression was higher in well-differentiated carcinomas (P < 0.05). c-erbB2 expression was found in 30.4% of tumors studied, but did not relate to any other parameters.

CONCLUSION

Microvessel density and p53 protein expression increase progressively with increasing tumor invasiveness in gallbladder carcinomas. Microvessel density, p53 protein, CD44s, and perhaps c-erbB2 expression may be implicated in gallbladder carcinoma evolution.

Microscopic liver metastasis: prognostic factor for patients with pT2 gallbladder carcinoma

Hepatic metastasis is the most frequent mode of recurrence of advanced gallbladder cancer after radical resection. The aims of this study were to clarify the clinical significance of microscopic liver metastasis from pT2 gallbladder cancer and to clarify whether partial hepatectomy can prevent hepatic recurrence in patients with microscopic liver metastasis. The subjects included 20 patients with pT2 tumors who underwent radical surgery and partial hepatectomy with lymph node dissection. Microscopic liver metastasis was defined as a distant metastatic nodule including cancer cell nests in the lumen of the portal vein and discrete nodular lesions in the liver, all less than 5 mm in diameter. Cox's proportional hazard regression was used to analyze factors that contributed to outcomes. Microscopic metastases were detected in the resected livers from 5 of 20 patients. There were more metastatic lesions within 1 cm of the gallbladder bed than were located 1 to 2 cm away from it. Microscopic liver metastases showed a strong correlation with the extent of blood vessel invasion around the primary tumor and were frequently detected in patients with a primary tumor localized on the hepatic side and with more than 3 cm of subserosal invasion. In four of five patients with microscopic liver metastases, recurrence was found in the remnant liver, which led to death within 15 months after the initial operation. Microscopic liver metastasis, operative curability, and lymph node metastasis were assessed as independent prognostic factors. A large proportion of patients with microscopic liver metastasis suffered from hepatic recurrence. Our results suggest that partial hepatectomy alone cannot prevent hepatic recurrence in patients with microscopic liver metastasis.

Influence of the site of human gallbladder xenograft (Mz-ChA-1) on angiogenesis at the distant site

We reported that orthotopic xenograft of human gallbladder cancer (Mz-ChA-2) produced a greater amount of endogenous angiogenic inhibitory factors, however, only TGFbeta1 suppressed angiogenesis and tumor growth at the distant site (intracranium). The aim of this study was to confirm the validity of our previous findings that the site of the primary tumor would influence the angiogenesis in the distant site in a different xenograft of human gallbladder cancer (Mz-ChA-1). The growth rates, histology of the ectopic (flank) and orthotopic (gallbladder) xenografts, the plasma level of TGFbeta1, micro-circulation and angiogenesis in the distant site (intracranium) were estimated by size-measurement, hematoxylin and eosin staining, ELISA, intravital fluorescence microscopic observation and cranial window gel assay for angiogenesis. All experiments were performed in severe combined immunodeficient (SCID) mice. Orthotopic tumors grew faster and were less necrotic than ectopic tumors. Angiogenesis, vessel diameters, vessel density and leukocyte-rolling count in the distant site were significantly decreased in orthotopic tumor-bearing mice compared to those in either ectopic or no tumor-bearing mice. The plasma level of TGFbeta1 was significantly elevated in mice bearing orthotopic tumor as compared with ectopic and no tumor-bearing mice. Angiogenesis at the distant site was inhibited by the orthotopic xenograft of Mz-ChA-1 by the greatest amount of TGFbeta1 production. The results of the present study together with our previous study imply that the primary tumor microenvironment is conducive to the angiogenesis at a distant site by the production of the endogenous angiogenesis inhibitor TGFbeta1.

Relationship between inducible nitric oxide synthase expression and angiogenesis in primary gallbladder carcinoma tissue

AIM: To explore the relationship between angiogenesis and biological behaviors of primary gallbladder carcinoma (PGBC), the relationship between the expression of inducible nitric oxide synthase (iNOS) and biological behaviors of PGBC and its relationship with the expression of iNOS and angiogenesis of PGBC.

METHODS: The expression of iNOS and micro-vessel density (MVD) were assessed by immunohistochemical method and image analysis system in 40 specimens of PGBC and in 8 specimens of normal gallbladder. The immunostaining results and related clinicopathologic materials were analyzed by statistical methods.

RESULTS: MVD in PGBC was significantly higher than that in normal gallbladder tissue (46 ± 14 vs 14 ± 6, P < 0.05), and was not related with age, gender, tumor size and histological type. MVD of poorly and undifferentiated tumor tissues was higher than that of moderately-differentiated and well-differentiated tumor tissues (52 ± 9 vs 43 ± 9 vs 33 ± 6, P < 0.01). MVD of Nevin IV and V stages was higher than that of Nevin I, II and III stages (52 ± 8 vs 37 ± 13, P < 0.01). MVD of cases with lymphatic or liver metastasis was significantly higher than that without liver metastasis (55 ± 6 vs 42 ± 10, P < 0.05) or lymphatic metastasis (53 ± 8 vs 38 ± 8, P < 0.01). The positive level index (PLI) of iNOS in PGBC was 0.435 ± 0.134, and was not related with age, gender, tumor size, histological type, differentiation and clinical stage of PGBC. The PLI of iNOS in cases with lymphatic metastasis was higher than that without lymphatic metastasis (0.573 ± 0.078 vs 0.367 ± 0.064, P < 0.01). The PLI of iNOS in cases with liver metastasis was higher than that without liver metastasis (0.533 ± 0.067 vs 0.424 ± 0.084, P < 0.05). There was a significant correlation between PLI of iNOS and MVD in PGBC (P < 0.05).

CONCLUSION: Angiogenesis of PGBC is significantly related to the biological behaviors of PGBC. The expression of iNOS is related to the biological behaviors of PGBC. The detection of MVD and the expression of iNOS in PGBC can be used as parameters to determine the degree of malignancy and prognosis.

Vascular endothelial growth factor (VEGF) expression in operable gallbladder carcinomas

AIM

To investigate the angiogenic and prognostic role of vascular endothelial growth factor (VEGF) in operable gallbladder carcinomas.

METHODS

Sixty patients with early gallbladder carcinomas, treated with surgery alone, were investigated immunohistochemically for the expression of VEGF, thymidine phosphorylase (TP) and new blood vessel formation. The results were correlated with clinico-pathological features and prognosis.

RESULTS

An increased VEGF secretion in gallbladder carcinomas was significantly associated with increased angiogenesis but not with patients survival, although high angiogenesis did relate with poor prognosis. TP was also associated with angiogenesis, but only the combined VEGF/TP expression was associated with unfavourable survival. Histological grade was another independent factor of prognosis.

CONCLUSION

Both VEGF and TP expression are associated with high rate of angiogenesis, a factor directly associated with prognosis. The combined expression of these angiogenic factors confer a particularly poor post-operative outcome, speculature.

Correlation of P-glycoprotein expression with poor vascularization in human gallbladder carcinomas

AIM: To investigate the relationship between the expression of P-glycoprotein (P-gp) and the degree of vascularization in gallbladder carcinomas.

METHODS: P-gp was stained with streptavidin-peroxidase complex immunohistochemical method in routine paraffin-embedded sections of gallbladder carcinomas. Microvessel counts (MVC) were determined using factor-VIII-related antigens.

RESULTS: The average MVC in 32 cases of gallbladder carcinomas was (34 ± 10)/HP. The value of MVC was closely correlated with Nevin staging and tumor differentiation (P < 0.01 and P < 0.05). The total expression rate of P-gp was 62.5%. The P-gp expression rate in cases of Nevin staging S1-S3 (78.6%) was higher than that of S4-S5 (50.0%) with no statistical significance. The P-gp expression rate was not correlated with tumor differentiation or pathologic types. The value of MVC in P-gp (+) cases was markedly lower than that in P-gp (-) cases (P < 0.01). The positive rate of P-gp was significantly higher in cases of smaller MVC than those of bigger MVC (P < 0.05).

CONCLUSION: MVC may be used as one of the important parameters to reflect the biological behaviors of gallbladder carcinomas. As a major cause of drug resistance, the overexpression of P-gp is closely correlated with the poor vascularization in gallbladder carcinomas.

Immunohistochemical analysis of transforming growth factor beta in gallbladder cancer

TGF-beta is highly expressed in various cancer cells, yet its mechanism suppressing the cell cycle fails and cell proliferation accelerates, resulting in carcinogenesis. However, there are only a very few reports on animal experiments or clinical specimens with regard to the TGF-beta in gallbladder cancer. We performed immunohistochemical analysis of TGF-beta expression with regard to cell proliferation, angiogenesis, and tumor cell infiltration in clinical specimens of gallbladder cancer. TGF-beta immunoreactivity was significantly higher in advanced cancer than in early cancer. With regard to Ki-67 labeling index, there was no significant difference between early cancer and advanced one. There was no statistically significant difference of the density of pre-existing blood vessels (CD34) between TGF-beta-positive group and negative one. The density of angiogenic vessels (CD105) was significantly greater in the TGF-beta-positive group than in the negative one. Tumor-associated macrophage infiltration was significantly higher in the TGF-beta-positive group than in the negative one. No statistically significant differences in cumulative survival rate were noted between patients in the TGF-beta-positive and TGF-beta-negative groups. In conclusion, our study revealed that in patients with gallbladder cancer, expression of TGF-beta increases according to cancer progression and strongly influences angiogenesis and macrophage infiltration, which contributes to tumor proliferation, but acts weakly on cancer cells by itself.

Prognostic role of angiogenesis in operable carcinoma of the gallbladder

The prognostic significance of intratumoral angiogenesis was investigated in 62 patients with stage I-III carcinomas of the gallbladder treated with simple cholecystectomy. Microvessel density (MVD) was assessed immunohistochemically, using the alkaline phosphatase/anti-alkaline phosphatase method and the monoclonal antibody CD31. The mean MVD was 30.5 vessels per x 200 optical field. Using the thirty-third and the sixty-sixth percentile, the patients were grouped into three MVD categories: low (MVD 9-18; 20 patients), medium (MVD 19-31; 20 patients), and high (MVD 32-86; 22 patients). A high MVD was more frequent in well-differentiated adenocarcinomas compared with moderately and poorly differentiated tumors (p = 0.04), but there was no statistically significant association between MVD and T stage, or patients' age or sex. Multivariate analysis, including MVD, T stage, and histologic grade, showed that MVD was a significant independent prognostic factor in carcinomas of the gallbladder (p = 0.001, t ratio 3.3). It is believed that the assessment of intratumoral angiogenesis in patients with operable gallbladder carcinomas may be useful in predicting prognosis and, perhaps, in decision making for postoperative adjuvant treatment.

Liver metastasis from gallbladder carcinoma: anatomic correlation with cholecystic venous drainage demonstrated by helical computed tomography during injection of contrast medium in the cholecystic artery

BACKGROUND

The current study evaluated whether the sites of liver metastasis from gallbladder carcinoma are correlated with areas of cholecystic venous drainage (CVD) utilizing helical computed tomography (CT) during the injection of contrast medium into the cholecystic artery (cholecystic artery CT).

METHODS

Cholecystic artery CT scans were performed in 26 patients with gallbladder carcinoma. Liver metastases were examined retrospectively in these patients on CT, and the sites of liver metastasis and CVD were compared closely. The patients were divided into concurrent (those who had metastasis at the time of cholecystic artery CT), early postoperative metastasis (those who developed metastasis within 6 months after surgery), and late postoperative metastasis (those who developed metastasis more than 6 months after surgery) groups. The frequency of metastasis related to CVD was compared between the three groups.

RESULTS

A total of 32 metastases were identified in 11 patients, 21 of which were related to CVD. Six patients were included in the concurrent metastasis group; 18 of 20 tumors were found to be related closely to CVD. There were two patients in the early postoperative metastasis group; all three of the tumors detected were found to be closely related to CVD. Three patients were subclassified as being in the late postoperative metastasis group; none of the nine tumors detected appeared to be in areas associated with CVD.

CONCLUSIONS

The sites of liver metastases were found to be well correlated with the areas with CVD, particularly in the concurrent and early postoperative metastasis groups. CVD may be a useful marker of potential areas of liver metastasis from gallbladder carcinoma, particularly in patients with early stage metastasis.

Stromal sialyl Le(a) expression is correlated with vascular invasion of human gallbladder adenocarcinoma

Sialyl Le(a) antigen (CA19-9), a member of a family of high molecular weight glycoproteins, was originally described as a gastrointestinal- and pancreatic-specific tumor marker. Recent studies have demonstrated that sialyl Lea is a ligand for E-selectin and may play an important role in tumor metastasis. However, expression patterns of sialyl Le(a) have not yet been established in human gallbladder carcinomas. In this study, we examined sialyl Le(a) expression in human gallbladder adenocarcinoma and its clinicopathological significance. Sialyl Le(a) immunoreactivity was detected not only in cancer cells (cytoplasmic type; 68.5%, 37/54) but also in cancer stroma (stromal type; 46.3%, 24/54). According to TNM classification, stromal sialyl Le(a) expression was detected in 60. 0% (24/40) and 7.1% (1/14) of the T2-4 and T1 cancers, respectively (p<0.01). Stromal sialyl Le(a)-positive gallbladder cancers frequently showed lymphatic invasion, venous invasion and lymph node metastasis (62.9%, 62.5% and 70.0%, respectively) (p<0.01). These observations suggested that sialyl Le(a) expression plays important roles in vascular invasion and metastasis of human gallbladder adenocarcinomas.

Tumor angiogenesis in gallbladder carcinoma

BACKGROUND/AIMS

Neovascularization of tumor tissue has been proposed to be essential for tumor growth, proliferation and, eventually, metastasis. Although the microvessel count in some kinds of solid tumor was shown to correlate with clinical outcome, little is known about its significance in gallbladder carcinoma.

METHODOLOGY

In order to determine whether tumor angiogenesis is a prognostic factor in gallbladder carcinoma patients, microvessels in selected areas (a 200x field, 0.74 mm2) in specimens resected from 40 patients with gallbladder carcinomas were identified by immunostaining endothelial cells for the endothelial antigen CD34 and counted.

RESULTS

Univariate analysis showed a relationship between the microvessel count and survival (p=0.04), but multivariate analysis revealed that the microvessel count was not an independent prognostic factor (p=0.256). Although it correlated with the lymph node status (p=0.044), it bore no relation to tumor status or clinical stage.

CONCLUSIONS

These results indicate that participation of neovascularization in gallbladder cancer spread is minor, especially during the early course.

Expression of vascular endothelial growth factor in human gallbladder lesions

The purpose of this study was to examine whether vascular endothelial growth factor (VEGF) regulates angiogenesis in human gallbladder carcinomas. We examined the expression of VEGF in 131 gallbladder lesions by immunohistochemistry and in situ mRNA hybridization technique. VEGF immunoreactivity was detected in 100% (9/9) of hyperplasias, 75% (3/4) of adenomas and 91% (107/118) of carcinomas. In gallbladder carcinoma tissues, VEGF mRNA level directly correlated with its protein level. VEGF expression in the neoplasms significantly correlated with vascularization, but not prognostic parameters. These findings suggest that VEGF is commonly expressed in human gallbladder carcinomas and may contribute to neovascularization during carcinogenesis.

[Clinical assessment of contrast-enhanced ultrasonography for the diagnosis of gall bladder diseases]

We evaluated the efficacy of contrast-enhanced ultrasonography (CEUS) with intra-arterial injection of CO2 microbubbles in 37 cases of gall bladder diseases. CEUS clearly visualized arterial flow and vascularity in every lesions without debris and gave us the precise information of vascular structure for the differential diagnosis of gall bladder tumors. For example, highly bifurcated tumor vessels and strong enhancement was observed in gall bladder cancer and we could detect relatively strong enhancement along the lumen with lack of enhancement of Rokitansky-Aschoff sinus in localized-type adenomyomatosis. Though CEUS is now an invasive modality, it will enable us to understand the non-invasive modality such as color doppler imaging with intra-venous administration of microbubbles in the future.

Colour Doppler-guided spectral analysis of gall-bladder wall flow

For the purpose of the present study to diagnose gall-bladder cancers, which cannot be detected or are only partly visible by conventional ultrasonography (US), we attempted differential diagnoses of 69 patients with gall-bladder diseases (12 with gall-bladder cancer, five with acute cholecystitis, 11 with chronic cholecystitis, 27 with cholesterol polyp and 14 with adenomyomatosis) using the evaluation of gall-bladder wall blood flow (GWBF). GWBF was evaluated by colour Doppler-guided spectral analysis (CDSA). Thirty-three healthy volunteers were selected as controls at random. Two parameters of GWBF, namely flow velocity and resistive index (RI), were compared between patients with gall-bladder diseases and healthy volunteers. GWBF could be ultrasonically evaluated in 92 (90%) of 102 subjects. All 12 patients with gall-bladder cancer had a significantly rapid blood flow value compared with other patients and healthy volunteers. There was no significant difference in RI among patients and healthy volunteers. When cut-off level of the flow velocity was set at 30 cm/s, gall-bladder cancer could be diagnosed by flow velocity with 100% sensitivity (12/12) and 96% specificity (50/52). Using the same cut-off level of the flow velocity, 17 patients were analysed prospectively. In four asymptomatic gall-bladder cancers and two acute cholecystitis cases with some symptoms, the flow velocity was over 30 cm/s. In two of four patients with gall-bladder cancer, only a part of the tumour was visualized on conventional abdominal US. In conclusion, CDSA was more useful for diagnosing gall-bladder lesions than the conventional abdominal US due to estimation of arterial flow velocity in the gall-bladder wall.

Anatomy and clinical importance of cholecystic venous drainage: helical CT observations during injection of contrast medium into the cholecystic artery

OBJECTIVE

The purpose of this study was to use helical CT to elucidate the anatomy and clinical importance of cholecystic venous drainage.

SUBJECTS AND METHODS

We performed helical CT of the upper abdomen during injection of contrast medium through a superselectively catheterized cholecystic artery (cholecystic artery CT) in 28 patients, all of whom were surgical candidates for suspected hepatobiliary abnormality. In nine of these patients, CT during arterial portography (CTAP) was also performed.

RESULTS

Cholecystic venous blood most frequently entered peripheral portal branches of hepatic segment V (27 of 28 patients, 96%) and segment IV (26 of 28, 93%). In order of decreasing frequency, cholecystic venous blood also drained to segments I, VI, VIII, III, and VII. Cholecystic venous blood subsequently drained into the middle hepatic vein (21 of 28, 75%) or right hepatic vein (20 of 28, 71%). In two patients with adenocarcinoma involving the gallbladder associated with multiple liver metastases, cholecystic venous drainage was seen around each metastatic focus. In the nine patients in whom both cholecystic artery CT and CTAP were performed, nontumorous portal perfusion defects were attributable to cholecystic venous drainage.

CONCLUSION

Recognition of cholecystic venous drainage as a possible pathway for spread of disease from the gallbladder to the liver and also as one of the causes of non-tumorous portal perfusion defects seen on CTAP is important.

[Splanchnic portal circulation (enhancement of radiologic image intensity and of visibility of collateral branches with prostaglandin E1)]

The authors present the results of a comparative study of mesenterico-portographies with and without the use of Prostaglandin E1 (PGE1) injected intrarterially into the superior mesenteric artery as an adjunct to the radiographic procedure. Twenty eight patients, with varied hepatic and biliopancreatic ailments, referred to the Radiologic Department for angiographic appraisal of the splanchnic circulation were studied. Two series of radiographies were realized after catheterization of the superior mesenteric artery: a first after the injection of the contrast only and a second after the injection of 50 micrograms of PGE1 as a bolus prior the contrast means. The difference in opacification of the various segments of the portal system and the lapse of time necessary to attain the maximum radiographic density were appraised. They observed that, with the use of PGE1 was attained a regular, intense and swift opacification of the superior mesenteric vein, portal vein and intrahepatic branches in all patients that had those segments previous and/or hepatotropic circulation. There was a significative reduction in the lapse of time necessary to attain the maximum opacification. Also they observed, with the use of the PGE1, the opacification of collateral branches of the portal system in more patients and intensification in those that were previously opacified. Because of the good results attained with the use of the PGE1, its transitory pharmacologic action and absence of collateral reactions with the dose used, they recommend its regular use when this investigation is performed.

Carcinoma of the gallbladder: color Doppler ultrasound and CT findings

A case of a large polypoidal gallbladder carcinoma presenting with empyema is described. Heterogeneous echoes filled the gallbladder lumen on gray-scale sonography. Color Doppler ultrasound detected vascularity within the gallbladder lumen, thereby differentiating the intraluminal tumor from isoechoic sludge and pus. Correlative computed tomography showed an enhancing intraluminal mass, with small enhancing vessels that corresponded to those seen with color Doppler sonography.

Hepatic metastases from carcinoma of the gallbladder

BACKGROUND

The optimal hepatic resection margin for gallbladder cancer (GBC) is still debated. To explore this issue, the authors analyzed the mode of hepatic spread of GBC.

METHODS

Of 85 patients undergoing radical cholecystectomy, 20 had hepatic metastases. The pattern of hepatic metastasis was examined grossly and histologically in specimens.

RESULTS

Twelve patients had evidence of microscopic angiolymphatic portal tract invasion, with or without direct liver invasion. Four had direct invasion alone, and three had distant hepatic metastatic nodules. The distance (y axis) between the farthest angiolymphatic lesion and primary tumor (mm) correlated significantly with the gross depth (x axis) of direct invasion (mm): y = 1.3 + 0.33x (r = 0.88, P < 0.01). Three patients with metastatic nodules died of blood-borne disease within a year. Eight of the others obtained either long-term palliation or cure after potentially curative resection. Lymph node metastases were detected in 90% of patients.

CONCLUSIONS

The extent of microscopic angiolymphatic portal tract invasion correlates well with the gross depth of direct invasion of the liver. This correlation may be useful for estimating adequate hepatectomy margins. A hepatectomy with an adequate margin combined with a radical lymphadenectomy provides benefit for selected patients with hepatic metastases.

Image-directed and color Doppler studies of gallbladder tumors

Thirteen cases of primary adenocarcinoma of the gallbladder (GB), 1 of malignant fibrous histocytoma, 3 of metastatic adenocarcinoma, 5 of adenoma, 5 of polypus, 2 of xanthogranuloma, 6 of chronic cholecystitis, 4 of acute cholecystitis, and 8 of subacute cholecystitis were studied by image-directed and color Doppler ultrasonography (CDUS). All of the 14 cases of primary GB cancer (10 masses, 4 thickening wall) were found to have a high velocity arterial blood flow signal in the wall of the GB. In contrast, the 3 cases of metastatic cancer of the GB had no blood flow signal in the wall of the GB. For the 30 cases of benign lesions of the GB, only in 12 cases was a low velocity blood flow signal found. Nine of 10 cases of primary GB malignancy were found to have high velocity arterial blood flow signals in the tumor masses. No blood flow signal was observed in the masses of 13 cases (3 of metastatic adenocarcinoma, 5 of adenoma, 5 of polypus). An abnormal high velocity arterial blood flow signal observed within masses in the GB or in the GB wall is a significant feature of primary GB cancer and thus helps to differentiate primary GB cancer from metastatic and benign lesions of the GB.

[CO2US via an implantable port--drug distribution in intraarterial chemotherapy for hepatic tumors and evaluation of effect]

The distribution of blood flow was determined from the distribution of CO2 by US performed during the infusion of CO2 microbubbles via an implantable port (IP-CO2US) in intraarterial chemotherapy for hepatic tumor, and the usefulness of this method in determining tumor vascularity and evaluating the effects of therapy was investigated. A total of 16 patients, 12 of whom had metastatic liver tumor, two hepatocellular carcinoma, one gall bladder carcinoma, and one cholangiocellular carcinoma were studied. The enhanced areas in the liver in 16 patients in whom IP-CO2US was performed a total of 24 times were consistent in all cases with the enhanced areas demonstrated by IP-RI angiography performed a total of 10 times within 10 days, and were also consistent with one exception with the enhanced areas demonstrated by IP-CTA performed 14 times. The tumor detection rate was markedly higher with IP-CO2US than with plain US or IP-DSA, and was similar to that of IP-CTA. Evaluation of the vascularity of individual nodules by IP-CO2US surpassed that by IP-DSA, and was similar to that of IP-CTA. It was demonstrated that blood flow distribution (intrahepatic drug distribution) can be equally well grasped with IP-CO2US, which is a simple and convenient method, as with IP-RI angiography. It was also suggested that IP-CO2US is useful in the evaluation of tumor vascularity and the effect of therapy.

[Lymphatic and vascular systems of the gallbladder--with special reference to carcinoma of the gallbladder]

To understand the spreading modes of cancer of the gallbladder concerning its surgical treatment, relation between the infiltration depth of the cancer and the lymph and blood vessel systems in the gallbladder was investigated. Clinico-pathological studies of 23 cases of the gallbladder carcinoma showed that the infiltration depth related to the degree of differentiation, invasiveness to lymph and blood vessel, and the metastasis of lymph nodes. Lymphatic and vascular systems of the gallbladder and bile duct were examined in 22 dogs. The vasculature in the wall of the gallbladder was divided into three layers. The veins at the liver bed were communicated with the intrahepatic portal veins. The lymphatic system in the wall was more clearly shown after obstruction of lymph vessels by ligation of soft tissues in the hepatoduodenal ligament and revealed four layers. The lymph vessels draining from the gallbladder descended along the cystic duct and the bile duct. They passed the portal and pancreatoduodenal lymph nodes and entered the cisterna chyli. In addition, lymph obstruction revealed other lymph tracts to the hepatic parenchyma of the hepatic hilum, retroperitoneum, celiac axis and the splenic vessel regions. The findings suggest that (1) simple cholecystectomy is suitable for the intramucosal carcinoma. (2) for the carcinoma infiltrating to the lamina muscularis, vascular invasion and spreading to the liver through the liver bed of gallbladder is suspected, and (3) for the carcinoma with subserosal infiltration, hepatic segmentectomy with complete resection of the extrahepatic bile duct and removal of the regional lymph nodes of the hepatoduodenal ligament and the vicinity of the gastropancreatic region are required because vascular and lymphatic spreads are suspected. Adjuvant therapy should be required and strict follow up survey should be maintained.

Angiographic findings in two carcinoid tumors of the gallbladder

Angiography was performed in 2 patients with carcinoid tumors of the gallbladder. In the first case, proper hepatic angiography revealed an obstruction and irregular neovascularization of the cystic artery and an encasement of the right hepatic artery. In the second case, celiac angiography revealed a dilatation and fine neovascularization of the cystic artery. In both cases, moderate hypervascular metastatic lesions were demonstrated in the liver. Although hypervascular metastases might suggest the diagnosis of metastasis from carcinoid tumor, the specific diagnosis of carcinoid tumor of the gallbladder must rely on the pathologic evidence.

Angiography in malignant and chronic inflammatory lesions of the gallbladder

Angiography findings in 18 patients with carcinoma of the gallbladder and 17 with cholecystitis indicate that similar abnormalities may appear in both lesions. Irregularities and obstruction of arteries were more common in malignant disease and somewhat more severe. Accumulation of contrast medium and prominent veins occurred in both groups. Displacement of adjacent vessels was more common in malignant disease. As chronic inflammatory lesions cannot with certainty be differentiated angiographically from malignant disease, cholecystectomy is recommended when the abnormalities described are demonstrated.

[Angiography in biliary neoplasia (author's transl)]

The angiographic appearances of biliary neoplasms and their differential diagnosis is discussed in relation to 15 patients with annular carcinomas of the gall bladder or bile ducts. The outstanding angiographic features of biliary carcinomas are irregularities of the arterial contours and vascular occlusion, followed in importance by neo-vascularity of the malignant tumour.