Ta-Sen Yeh

Malignant perihilar biliary obstruction: magnetic resonance cholangiopancreatographic findings

OBJECTIVE:We studied the efficacy of magnetic resonance cholangiopancreatography (MRCP) in the evaluation of malignant perihilar biliary obstructions, with reference to endoscopic retrograde cholangiopancreatography (ERCP).METHODS:A total of 40 patients with malignant perihilar biliary obstructions, who underwent both MRCP (Magnetom Vision; Siemens, Erlangen, Germany; projection technique and multislice plus maximum intensity projection) and ERCP examinations, were studied. The study group included hilar cholangiocarcinoma (Klatskin tumor) in 26 patients, icteric hepatocellular carcinoma in four patients, gallbladder carcinoma in five patients, and metastasis from other than hepatobiliary origin in five patients. Axial and coronal magnetic resonance (MR) images were added simultaneously to the MRCP. The mean serum bilirubin level on admission was 11.5 mg/ml (range, 2.8–28.5 mg/ml). The presence and extent of malignant biliary obstruction were determined with both MRCP and ERCP following the known criteria: an abrupt and irregular character of a distal narrow segment, a proportionally dilated biliary tree proximally, and an irregularly shaped intraluminal filling defect. The efficacy of the MRCP examination in detecting the presence of biliary obstruction, its anatomical extent, and the underlying cause, respectively, was compared to that of ERCP.RESULTS:MRCP examination was successfully performed on all patients, whereas ERCP examination was unsuccessful in two patients. Both MRCP and ERCP were very effective in detecting the presence of biliary obstructions (40 of 40 vs 38 of 38, p = 1.0). MRCP was superior in its investigation of anatomical extent (34 of 40 vs 24 of 38, p = 0.015) and the cause of the jaundice (31 of 40 vs 22 of 38, p = 0.023) compared to ERCP. Specifically, the performance of MRCP is promising for the interpretation of cholangiocarcinoma (22 of 26) and gallbladder carcinoma (five of five), but is relatively ineffective for the interpretation of icteric HCC (two of four) and metastasis (two of five).CONCLUSION:MRCP represented an ideal noninvasive diagnostic tool for the evaluation of malignant perihilar biliary obstructions with reference to ERCP.

MicroRNA-214 downregulation contributes to tumor angiogenesis by inducing secretion of the hepatoma-derived growth factor in human hepatoma

BACKGROUND & AIMS Unusual hypervascularity is a hallmark of human hepatocellular carcinoma (HCC). Although microRNA-214 (miR-214) is upregulated in other human cancers, it is downregulated in HCC. We elucidated the biological and clinical significance of miR-214 downregulation in HCC. METHODS MicroRNAs deregulated in HCC were identified using array-based microRNA profiling. A luciferase reporter assay confirmed target association between miR-214 and the hepatoma-derived growth factor (HDGF). Tube formation and in vivo angiogenesis assays validated the roles of miR-214/HDGF in angiogenesis. RESULTS miR-214 downregulation was associated with higher tumor recurrence and worse clinical outcomes. Ectopic expression of miR-214 suppressed xenograft tumor growth and microvascularity of the tumors and their surrounding tissues. The genes downregulated by ectopic expression of miR-214 were involved in the regulation of apoptosis, cell cycle, and angiogenesis. Integrated analysis disclosed HDGF as a downstream target of miR-214. Conditioned medium of HCC cells contained bioactivity to stimulate tube formation of human umbilical vein endothelial cells, which was abolished by pretreatment of the conditioned media with HDGF antibodies, suppression of HDGF expression or ectopic expression of miR-214 in the donor HCC cells. The angiogenic activity of the conditioned media, lost by ectopic expression of miR-214 in the donor cells, was restored by supplementation with recombinant HDGF. In vivo tumor angiogenesis assays showed significant suppression of tumor vascularity by ectopic expression of miR-214. CONCLUSIONS A novel role of microRNA in tumorigenesis is identified. Downregulation of miR-214 contributes to the unusual hypervascularity of HCC via activation of the HDGF paracrine pathway for tumor angiogenesis.

Aberrant expression of CDX2 is closely related to the intestinal metaplasia and MUC2 expression in intraductal papillary neoplasm of the liver in hepatolithiasis

Intraductal papillary neoplasia of the liver (IPNL) frequently presents gastrointestinal metaplasia with aberrant expression of MUC2 and MUC5AC and oversecretion of mucin into the ductal lumen. In this study, the involvement of CDX2, a homeodomain protein involved in the regulation of intestinal development and differentiation, in the expression of MUC2 was examined in mucinous intrahepatic cholangiocarcinoma (ICC) (n=7) and IPNL with hepatolithiasis (n=19) with comparison to conventional ICC (n=11), and intraductal papillary mucinous tumor and invasive ductal carcinoma of the pancreas (n=9 and 11, respectively). A total of 33 cases of hepatolithiasis, extrahepatic biliary obstruction and normal livers were used as the control. Immunohistochemically, both MUC2 and MUC5AC were frequently expressed in mucinous ICC and IPNL, while expression of MUC2 was not seen in conventional ICC. The nuclear expression of CDX2 was closely associated with the expression of MUC2 in mucinous ICC and IPNL. This intimate association of MUC2 and CDX2 was confirmed by double immunostaining. The cytoplasmic CDX2 expression was frequent in the mucinous and the conventional ICC and pancreatic carcinoma, irrespective of MUC2 and MUC5AC expression. CDX2 mRNA was detected in neoplastic cells showing cytoplasmic as well as nuclear expression of CDX2 by reverse transcriptase-polymerase chain reaction. One IPMT expressed MUC2 associated with nuclear CDX2 expression, while the other IPMT and conventional pancreatic carcinoma expressed MUC5AC only. Aberrant expression of CDX2 is closely related to the overexpression of MUC2 in mucinous ICC and IPNL associated with hepatolithiasia, suggesting its role in intestinal differentiation and its association with carcinogenesis in these tumors.

Stathmin1 overexpression associated with polyploidy, tumor‐cell invasion, early recurrence, and poor prognosis in human hepatoma

Frequent intrahepatic metastasis causes early tumor recurrence and dismaying prognosis of human hepatocellular carcinoma (HCC). We recently identified overexpression of stathmin1 (STMN1) in human HCC. This study was designed to elucidate the clinical and biological significance of overexpression of STMN1 in HCC. Expression of STMN1 was conducted by quantitative reverse transcription‐polymerase chain reaction and immunoblotting assays on 58 pairs of HCC and para‐tumor liver tissues from patients with HCC along with normal liver tissues as the controls. Association of STMN1 overexpression with tumor recurrence and prognosis was investigated by Kaplan–Meier cumulative survival and Cox Regression analyses. Roles of STMN1 in cell cycle, cell motility, and invasion were determined by in vitro assays. STMN1 overexpression in hepatoma was strongly associated with local invasion (P = 0.031), early recurrence (P = 0.002), and poor prognosis (P = 0.005), and was an independent indicator for tumor recurrence (P = 0.0045). STMN1 overexpression further identified subgroups of HCC patients with higher tumor recurrence and worse prognosis among HCC patients with early tumor stage (T1) or intermediate histological grades (G2 and G3), both of whom represent the majority of HCC patients receiving primary curative hepatectomy. Silencing STMN1 expression via RNA interference suppressed invasion activity, while ectopic expression of STMN1 enhanced cell invasion and caused polyploidy of cells. In conclusion, STMN1 overexpression could predict early tumor recurrence and poor prognosis, particularly at early stage of hepatoma. Overexpression of STMN1 promoted polyploidy formation, tumor‐cell invasion, and intrahepatic metastasis, suggesting that STMN1 can be a target for anti‐cancer therapy of human hepatoma.

Cholangiographic spectrum of intraductal papillary mucinous neoplasm of the bile ducts

Objective:To propose a cholangiographic classification for intraductal growth type intrahepatic cholangiocarcinoma (IG-ICC) and its precursor, collectively termed intraductal papillary mucinous neoplasm of the bile ducts (IPMN-B). Summary Background Data:For the extensive clinicopathologic variations of IPMN-B, a detailed characterization of cholangiography for IPMN-B is beneficial for determining the optimal therapeutic strategy. Methods:A total of 124 patients with cholangiography-available and pathologically proven IPMN-B were retrospectively studied. Numbers of IPMN-B type 1, type 2, type 3, and type 4 were 33, 17, 15, and 59, respectively. A cholangiographic classification was proposed based on the presence of hepatolithiasis, mucobilia, neoplasia localization, and concomitant malignancies. The demographics, histologic grading, management, and survival were also analyzed. Results:All 33 IPMN-B type 1 and 12 of 17 IPMN-B type 2 displayed cholangiographic pattern IA demonstrating hepatolithiasis-related biliary stricture. The remaining 5 IPMN-B type 2 displayed cholangiographic pattern IB or IC, which demonstrated mucobilia without discernible neoplasia. Seven of 15 IPMN-B type 3 and 52 of the 59 IPMN-B type 4 displayed cholangiographic pattern IIA or IIB, which demonstrated overt intraductal neoplasia. Seven IPMN-B type 3 or 4 displayed cholangiographic pattern IIIA or IIIB, which demonstrated IPMN-B and concomitant malignancies. For those presenting with cholangiographic pattern IA, IC, IIA, IIB, and IIIA, straightforward hepatectomies for the diseased lobes were performed. For those with pattern IB, surgical resections were performed only when there was emergence of mucin-producing neoplasia. For those with IIIB, the concomitant malignancies were considered inoperable. No disease-related death occurred in IPMN-B type 1and 2. The mean survival rates of IPMN-B type 3 and type 4 were 55.5 ± 17.1 months and 36.9 ± 6.3 months, respectively. Conclusion:The presented cholangiographic classification facilitates the management for IPMN-B. Significant survival discrepancy at the various stages warrants a more aggressive surgical strategy.

Video-assisted endoscopic thyroidectomy.

BACKGROUND Several experimental and clinical reports concerning endoscopic parathyroid surgery have appeared. However, reports concerning minimally invasive surgery for thyroid remains rare. Herein we present a new method, called video-assisted endoscopic thyroidectomy (VAET), for the management of various benign thyroid diseases. METHODS In all, 16 consecutive patients who underwent VAET for benign thyroid diseases were retrospectively studied. The study group included nodular hyperplasia in 8 patients, follicular adenoma in 6, and Hurthles tumor and simple cyst in 1 each. A 2 to 3 cm transverse incision was made on the suprasternal notch. The wound was deepened to expose the underlying trachea from which the plane of the thyroid fascia was accessed directly, and the working space was established with lifting method using conventional instrument. All surgical procedures could be manipulated and monitored under laparoscopy without gas insufflation. The ultrasonically activated scalpel was the principal instrument used for VAET. RESULTS All 16 patients underwent VAET successfully without conversion to open thyroidectomy. The surgical procedures included lobectomy in 13 and extirpation in 3. The operation time ranged from 28 minutes to 5 hours (mean 1 hour, 42 minutes). For the 5 most recent cases, lobectomy took an average of 2 hours, whereas extirpation less than 40 minutes. The tumor size ranged from 3.5 cm to 8.0 cm (mean 5.8 cm). There were no surgical complications. All patients but 1 were discharged on postoperative day 2. During follow-up, all patients demonstrated euthyroid function and satisfactory cosmetic results. CONCLUSIONS VAET emerges as a promising minimally invasive surgical technique replacing conventional thyroidectomy for benign thyroid diseases in selected cases, with the advantage of satisfactory cosmetic results.

Hepatic Resection of the Intraductal Papillary Type of Peripheral Cholangiocarcinoma

BackgroundPeripheral cholangiocarcinoma (PCC) can be grossly classified into mass-forming, periductal-infiltrating, and intraductal papillary (IP) types. Information on IP-PCC patients undergoing hepatectomy is sparse because of the small number of cases.MethodsThe clinical features of 40 IP-PCC patients undergoing hepatectomy between 1977 and 2000 were reviewed. The clinical features of 94 PCC patients without IP growth undergoing hepatectomy were used for comparison.ResultsIP-PCC and non–IP-PCC groups had similar age distributions (P = .674), sex ratios (P = .079), and positive rates for serum carcinoembryonic antigen and CA 19–9 (P = .121 and .795, respectively). The two groups also exhibited similar rates of association between hepatolithiasis and PCC (P = .230). However, more IP-PCC patients exhibited signs during admission, and more had ALT values >36 IU/L; they also had smaller tumors, more mucobilia association, and tumors in earlier stages and had undergone more postoperative chemotherapy. Multivariate logistic regression analysis showed that only ALT >36 IU/L differentiated IP-PCC from non–IP-PCC patients. The two groups exhibited similar operative mortality (P = 1.0). Follow-up ranged from 1.6 to 125.2 months (mean and median, 44.6 and 5.7 months, respectively). The 1-, 3-, and 5-year overall survival rates were 72.9%, 41.2%, and 24.7%, respectively, in the IP-PCC group and 43.3, 6.03%, and 2.01% in the non–IP-PCC group. The prognosis was favorable for the IP-PCC patients (P < .00001), particularly for IP-PCC patients who received curative hepatectomy (P = .013).ConclusionsIP-PCC patients had significantly better survival than non–IP-PCC patients, and aggressive curative hepatic resection is associated with a longer survival.

Characterization of intrahepatic cholangiocarcinoma of the intraductal growth‐type and its precursor lesions

A cohort of patients with intraductal growth‐type intrahepatic cholangiocarcinoma (IG‐ICC) and its precursor lesions, collectively termed intraductal papillary neoplasm of the liver (IPNL), was characterized with respect to demographics, clinical manifestations, perioperative management, long‐term survival, and molecular features associated with carcinogenesis. A total of 122 patients with IPNL types 1 through 4, 108 patients with non–IG‐ICC and 210 patients with hepatolithiasis alone were studied. Expression of CDX2, TFF1, MUC1, MUC2, MUC5AC, EGFR, and p53 was determined by using immunohistochemistry. Females predominated in those with hepatolithiasis alone and IPNL. The mean age of patients with hepatolithiasis alone was 6 to 8 years younger than that of those with IPNL. The association with hepatolithiasis in patients with IPNL types 1 and 2, IPNL types 3 and 4, and non–IG‐ICC was 100%, 79%, and 64%, respectively. Mucobilia, anemia, and elevated serum carcinoembryonic antigen levels were helpful in distinguishing IG‐ICC and its precursor lesions. The mean survival of patients with IPNL type 3, IPNL type 4, and non–IG‐ICC was 55.5 months, 36.9 months, and 15.8 months, respectively. The incidence of expression of CDX2 and TFF1 was maximal in IPNL type 3. Expression and cellular distribution of MUC2 and CDX2 were similar. MUC5AC was strongly expressed in all patients with IPNL; EGFR and p53 were rarely expressed in patients with IPNL. In conclusion, hepatolithiasis appears to be a precipitating factor in the development of IPNL. Signs of mucobilia were specific for the diagnosis of IPNL. Expression of CDX2 and MUC2 are helpful in differentiating IPNL and non–IG‐ICC. Significant differences in survival associated with the various lesions studied warrants a more aggressive surgical strategy in their management. (HEPATOLOGY 2005;42:657–664.)

Hepatitis B virus–DNA level and basal core promoter A1762T/G1764A mutation in liver tissue independently predict postoperative survival in hepatocellular carcinoma

Hepatitis B virus (HBV) is a major etiological factor of hepatocellular carcinoma (HCC). However, the postoperative prognostic value of the virological factors assayed directly from liver tissue has never been investigated. To address this issue, 185 liver samples obtained from the noncancerous part of surgically removed HBV‐associated HCC tissues were subjected to virological analysis. Assayed factors included the amount of HBV‐DNA in the liver tissues; genotype; and the presence of the HBV precore stop codon G1896A mutation, basal core promoter A1762T/G1764A mutation, and pre‐S deletions/stop codon mutation. All virological factors and clinicopathological factors were subjected to Cox proportional hazard model analysis to estimate postoperative survival. It was found that an HBV‐DNA level >3.0 × 107 copies/g of liver tissue and the presence of the basal core promoter mutation independently predicted disease‐free (adjusted hazard ratio 1.641 [95% confidence interval (CI) 1.010‐2.667] and 2.075 [95% CI 1.203‐3.579], respectively) and overall (adjusted hazard ratio 2.807 [95% CI 1.000‐7.880] and 5.697 [95% CI 1.678‐19.342], respectively) survival. Kaplan‐Meier survival analysis indicated that in‐frame, short stretch (<100 bp) pre‐S deletions, but not large fragment (>100 bp) pre‐S deletions, were significantly associated with poorer disease‐free (P = 0.005) and overall (P = 0.020) survival. A hot deletion region located between codons 107 and 141 of the pre‐S sequence was identified for the short stretch pre‐S deletion mutants. Conclusion: The amount of HBV‐DNA in liver tissue and the presence of the basal core promoter mutation were two independent predictors for postoperative survival in HCC. A short stretch pre‐S deletion located between codons 107 and 141 was strongly associated with a poorer postoperative prognosis. (Hepatology 2010)

Expression of Epidermal Growth Factor Receptor, Apomucins, Matrix Metalloproteinases, and p53 in Rat and Human Cholangiocarcinoma: Appraisal of an Animal Model of Cholangiocarcinoma

Objective:We sought to determine the expression of molecular markers in an animal model of cholangiocarcinoma compared with those in human cholangiocarcinoma. Summary Background Data:Cholangiocarcinoma is a rare disease characterized by early intrahepatic and extrahepatic spread, which seriously limits the efficacy of surgery. Establishing an experimental model to study the cholangiocarcinogenesis is desirable. Methods:Sprague-Dawley rats weighing 300 ± 50 g were used for the study group. The animals were given 0.3% thioacetamide in tap water continuously. Thirty mass-forming peripheral cholangiocarcinoma patients also were studied. Expression of epidermal growth factor receptor (EGFR), MUC1, MUC2, MUC5AC, MMP-2, MMP-9, and p53 in both human and experimental rat cholangiocarcinoma was examined using immunohistochemistry. Results:Using thioacetamide 0.3% as a hepatoxin to induce cholangiocarcinoma in rats, microfoci of cancerous cells were detected from 12 weeks, and all experimental rats displayed diffuse mass-forming cholangiocarcinoma after 24 weeks. EGFR was strongly expressed in 14 (47%) of 30 human cholangiocarcinoms and 24 (100%) of 24 rat cholangiocarcinomas, respectively. MUC1 was strongly expressed in all human and rat cholangiocarcinomas, whereas MUC2 and MUC5AC were focally and weakly expressed. MMP-2 and MMP-9 were strongly expressed in 22 (73%) of 30 human cholangiocarcinomas and 24 (100%) of 24 rat cholangiocarcinomas, respectively. p53 overexpression was detected in 9 (30%) of 30 human cholangiocarcinoma and none of the rat cholangiocarcinoma, respectively. Conclusions:The expression of EGFR, apomucins, MMPs, and p53 in rat cholangiocarcinoma was strongly homologous to human cholangiocarcinoma. Thioacetamide-induced cholangiocarcinoma in rats provides an excellent model for investigating cholangiocarcinogenesis in vivo.