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GASTROENTEROLOGY 2013;145:1215–1229
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REVIEWS IN BASIC AND CLINICAL
GASTROENTEROLOGY AND HEPATOLOGYRobert F. Schwabe and John W.
Wiley, Section Editors
Pathogenesis, Diagnosis, and Management of
CholangiocarcinomaSUMERA RIZVI and GREGORY J. GORES
Division of Gastroenterology and Hepatology, Mayo Clinic,
Rochester, Minnesota
Abbreviations used in this paper: a-SMA, a-smooth muscle
actin;CA19-9, carbohydrate antigen 19-9; CAF, cancer-associated
fibroblast;CCA, cholangiocarcinoma; CT, computed tomography; CXCR4,
chemo-kine (C-X-C motif) receptor 4; dCCA, distal
cholangiocarcinoma; ECM,extracellular matrix; EGFP, enhanced green
fluorescent protein; EGFR,epidermal growth factor–receptor; EMT,
epithelial–mesenchymal tran-sition; ERBB2, v-erb-b2 avian
erythroblastic leukemia viral oncogenehomolog 2; ERC, endoscopic
retrograde cholangiography; ERK, extra-cellular signal regulated
kinase; FGFR, fibroblast growth factor receptor;
Cholangiocarcinomas (CCAs) are hepatobiliary can-cers with
features of cholangiocyte differentiation;they can be classified
anatomically as intrahepaticCCA (iCCA), perihilar CCA (pCCA), or
distal CCA.These subtypes differ not only in their
anatomiclocation, but in epidemiology, origin, etiology,
path-ogenesis, and treatment. The incidence and mortalityof iCCA
has been increasing over the past 3 decades,and only a low
percentage of patients survive until 5years after diagnosis.
Geographic variations in the inci-dence of CCA are related to
variations in risk factors.Changes in oncogene and inflammatory
signaling path-ways, as well as genetic and epigenetic alterations
andchromosomeaberrations, havebeen shown to contributeto the
development of CCA. Furthermore, CCAs aresurrounded by a dense
stroma that contains manycancer-associated fibroblasts, which
promotes theirprogression. We have gained a better understanding
ofthe imaging characteristics of iCCAs and have developedadvanced
cytologic techniques to detect pCCAs. Patientswith iCCAs usually
are treated surgically, whereas livertransplantation after
neoadjuvant chemoradiation is anoption for a subset of patients
with pCCAs. We reviewrecent developments in our understanding of
the epide-miology and pathogenesis of CCA, along with advancesin
classification, diagnosis, and treatment.
Keywords: Cancer-Associated Fibroblasts; Distal
Chol-angiocarcinoma; Intrahepatic Cholangiocarcinoma;Molecular
Pathogenesis.
holangiocarcinoma (CCA) is the most common
FISH, fluorescence in situ hybridization; HGF, hepatocyte growth
factor;HBV, hepatitis B virus; HCC, hepatocellular carcinoma; HCV,
hepatitis Cvirus; iCCA, intrahepatic cholangiocarcinoma; IDH,
isocitrate dehydro-genase; IL 6, interleukin 6; KRAS, Kirsten rat
sarcoma viral oncogenehomolog; MAPK, mitogen-activated protein
kinase; miR, microRNA;MCL1, myeloid cell leukemia sequence 1; MET,
met proto-oncogene;MMP, matrix metalloproteinase; MRI, magnetic
resonance imaging; OR,odds ratio; pCCA, perihilar
cholangiocarcinoma; PDGF, platelet-derivedgrowth factor; PI,
phosphatidyl inositol; PI3K, phosphatidylinositol-4,5-bisphosphate
3-kinase; PSC, primary sclerosing cholangitis; STAT,
signaltransducer and activator of transcription; TP53, tumor
protein 53.
© 2013 by the AGA Institute0016-5085/$36.00
http://dx.doi.org/10.1053/j.gastro.2013.10.013
Cbiliary malignancy and the second most commonhepatic malignancy
after hepatocellular carcinoma (HCC).1
CCAs are epithelial tumors with features of
cholangiocytedifferentiation. Intrahepatic cholangiocarcinomas
(iCCAs)are located within the hepatic parenchyma. The second-order
bile ducts serve as the point of separation betweeniCCAs and
perihilar CCAs (pCCAs) or distal CCAs(dCCAs)—the cystic duct is the
anatomic boundary betweenthese latter 2 subtypes (Figure 1A).2 The
Bismuth–Corletteclassification stratifies perihilar tumors on the
basis ofbiliary involvement. This classification recently
wasextended to also take into account arterial and venous
encasement.3 pCCA is the most common type of CCA. In alarge
series of patients with bile duct cancer, 8% had iCCA,50% had pCCA,
and 42% had distal CCA.4 CCA has a poorprognosis; patients have a
median survival of 24 monthsafter diagnosis. The only curative
treatment option is sur-gery, for early stage disease.5
Epidemiology
Cholangiocarcinoma accounts for 3% of all gastro-
intestinal tumors. Over the past 3 decades, the overallincidence
of CCA appears to have increased.6 The percent-age of patients who
survive 5 years after diagnosis has notincreased during this time
period, remaining at 10%.7,8
In the United States, Hispanics and Asians have thehighest
incidence of CCA (2.8 per 100,000 and 3.3 per100,000,
respectively), whereas African Americans have thelowest incidence
of CCA (2.1 per 100,000). African Amer-icans also have lower
age-adjusted mortality ratescompared with whites (1.4 per 100,000
vs 1.7 per 100,000).Men have a slightly higher incidence of CCA and
mortalityfrom cancer than women.7 With the exception of
patientswith primary sclerosing cholangitis (PSC), a diagnosis
ofCCA is uncommon before age 40 years.
http://dx.doi.org/10.1053/j.gastro.2013.10.013
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Globally, hepatobiliary malignancies account for 13%
ofcancer-related deaths; 10%–20% of these are attributable toCCA.
The mean age at diagnosis of CCA is 50 years. Theglobal incidence
of iCCA varies widely, from rates of 113per 100,000 in Thailand to
0.1 per 100,000 in Australia.9,10
Differences in the prevalence of genetic and other riskfactors
presumably account for this extensive variation.
Epidemiologic studieshave indicated that the
age-adjustedmortality rate for iCCA is increasing, whereas the
mortalityrate from pCCA and dCCA could be decreasing.9–14 A studyof
a World Health Organization database reported a sub-stantial global
increase in iCCA mortality, with a decreasingtrend in mortality
from pCCA plus dCCA.15 Although thisobserved increase in the
incidence of CCA over the past 30years has been recorded as an
increase in iCCA, it could resultfrom misclassification of
perihilar tumors as iCCAs.16 Ac-cording to the US Surveillance,
Epidemiology, and End Re-sults database, the age-adjusted incidence
rate for iCCAincreased from 0.59 per 100,000 in 1990 to 0.91 per
100,000in 2001. It subsequently decreased to 0.6 per 100,000by
2007.Conversely, the incidence rate for pCCAplus dCCA
remainedaround 0.8 per 100,000 until 2001, and then
graduallyincreased to 0.97 per 100,000 by 2007. Perihilar tumors
werecoded as iCCAs before 2001 and subsequently were coded aspCCAs
after implementation of the third edition of the In-ternational
Classification of Disease for Oncology. This up-date likely
influenced the aforementioned changes inincidence rates of both CCA
subtypes. Similar trends in theincidence of CCA subtypes were noted
in the UnitedKingdom after the change to the third edition of the
Inter-national Classification of Disease for Oncology in
2008.6,16
Risk Factors
There are several established risk factors for CCA,
and most cases are sporadic.6,8,17 Geographic variations
inincidence rates of CCA are related in part to variations inrisk
factors. For example, in Southeast Asia, which has oneof the
highest incidence rates of CCA, infection with thehepatobiliary
flukes Opisthorchis viverrini and Clonorchissinensis has been
associated with the development of CCA.Both parasites cause chronic
inflammation and areconsidered carcinogens.8,18 Hepatolithiasis is
another riskfactor for CCA (mainly iCCA) in Asian countries.8
Chronicbiliary inflammation secondary to calculi has been pro-posed
to increase the risk of malignancy. Moreover,infestation with
hepatobiliary flukes has been shown to bemore common in patients
with hepatolithiasis.8,19 Theincidence and prevalence of CCA in
patients with bile duct(choledochal) cysts are also higher in Asian
than inWestern countries.20,21 Choledochal cystic
diseases,including Caroli’s disease, are rare congenital
abnormal-ities of the pancreatic and biliary ducts. Choledochal
cystscan be intrahepatic or extrahepatic, and are diagnosed
inpatients at an average age of 32 years old.8,17 Thorotrast,
apreviously used contrast agent that is now banned, wasfound to
increase risk for CCA by 300-fold in a Japanesestudy.22
In the West, PSC is the most common predisposingcondition for
CCA. Among patients with PSC, the annualrisk of development of CCA
is 0.5%–1.5%, with a lifetimeprevalence of 5%–10%17; CCA is
diagnosed within 2 yearsof PSC in most of these patients. A number
of potentialrisk factors for CCA in patients with PSC have
beenstudied, including smoking and alcohol, although defin-itive
data are lacking.8
Hepatitis B virus (HBV) or hepatitis C virus (HCV) infec-tion
and cirrhosis have been proposed as potential etiologiesof
iCCA.23–25 A recentmeta-analysis of 11 studies found thatcirrhosis,
HBV, and HCV were major risk factors for iCCA,with odds ratios
(ORs) of 22.92, 5.1, and 4.8, respectively.26 Acase-control study
from Korea found a significant associa-tion between HBV (OR, 2.3)
and CCA, but not HCV andCCA. Cirrhosis also was found to be a
significant risk factorfor CCA, with an OR of 13.6. HCV and
cirrhosis were asso-ciated with iCCA in aUS case-control study.
Comparedwithcontrols, patients with iCCA had a higher prevalence
ofanti-HCV antibodies, with an OR of 7.9.24
CCA development has been associated with other riskfactors,
including inflammatory bowel disease indepen-dent of PSC, alcohol,
smoking, fatty liver disease, diabetes,cholelithiasis, and
choledocholithiasis.8,27–29 Additionalstudies have associated
variants of genes that regulateDNA repair, inflammation, and
carcinogen metabolismwith CCA development.8 Further studies are
necessary toverify these potential associations.
Cells of Origin
iCCA is a histologically diverse hepatobiliary ma-
lignancy considered to develop from biliary epithelial cellsor
hepatic progenitor cells (Figure 1B). A recently pro-posed
classification of iCCAs subdivided these tumorsinto the
conventional, bile ductular, or intraductalneoplasm type, or rare
variants (combined hepatocellularCCA, undifferentiated type,
squamous/adenosquamoustype). The conventional type includes
small-duct or pe-ripheral type and large-duct or perihilar type.30
Neural celladhesion molecule, a marker of hepatic progenitor
cells,has been detected in the bile ductular and combined
he-patocellular CCA types, so these might have originatedfrom
hepatic progenitor cells.30–32
Distal and pCCA have been proposed to arise from thebiliary
epithelium and peribiliary glands.33 Extrahepaticbile ducts and
large intrahepatic bile ducts are lined bymucin-producing cuboidal
cholangiocytes. A recent studyshowed that mucin-producing iCCAs and
hilar CCAs hadgene expression and immunohistochemical profiles
similarto those of the cylindric, mucin-producing
cholangiocytesthat line hilar and intrahepatic large bile
ducts.34
A model in which iCCAs arise from transdifferentiationand
subsequent neoplastic conversion of normal hepato-cytes into
malignant cholangiocytes has been proposed.Fan et al35 showed in
mice that overexpression of Notch1and AKT resulted in the
development of invasive cys-tadenocarcinomas via conversion of
hepatocytes into
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Figure 1. Anatomic localization of CCA and cells of origin in
CCA. (A)Anatomic localization of CCA. CCA is divided into 3
subtypes, basedon anatomic location. Modified with permission from
Elsevier andRazumilava et al.17 (B) Cells of origin in CCA.
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cholangiocyte precursors of iCCA.35 Sekiya and Suzuki36
also showed that in mice, Notch-mediated conversion
ofhepatocytes into biliary cells leads to macronodularcirrhosis and
iCCAs. Therefore, iCCAs may not have asingle lineage, but instead
derive from different cells oforigin. In support of this theory, a
recent study showedthat transformed hepatocytes, hepatoblasts, and
hepaticprogenitor cells can give rise to a broad spectrum of
livertumors, ranging from CCA to HCC.37 These studiesindicate that
multiple cell types, rather than only chol-angiocytes, transform
and develop into CCAs. Additionalanimal models of CCA and lineage
tracing studies arenecessary to help identify the cells of origin
for CCA.
Inflammation
CCAs frequently arises under conditions of
inflammation, which is believed to contribute to patho-genesis.
A variety of cytokines, growth factors, tyrosinekinases, and bile
acids can contribute to alterations inproliferation, apoptosis,
senescence, and cell-cycle regula-tion required for
cholangiocarcinogenesis.5 Inflammatory
cytokines activate inducible nitric oxide synthase, leadingto
excess nitric oxide with resultant single-stranded,
dou-ble-stranded, and oxidative DNA lesions, as well as inhi-bition
of DNA repair enzymes.38 Interleukin (IL)-6, aninflammatory
mediator secreted by CCA and stromal in-flammatory cells, can
function in an autocrine or para-crine manner to promote cell
survival and providemitogenic signals.39,40 Myeloid cell leukemia
sequence 1(MCL1) is an anti-apoptotic BCL2 family member
thatmediates tumor necrosis factor–related resistance
toapoptosis-inducing ligands in CCAs.41 IL-6 increases
theexpression of MCL1 via constitutive activation of
signaltransducer and activator of transcription (STAT) signalingand
protein kinase B (Akt).40,42 MCL1 transcription isactivated by IL-6
via a p38 mitogen-activated protein ki-nase (MAPK)-dependent
pathway.43 IL-6 binds to thegp130 receptor, leading to its
subsequent dimerizationand activation of the gp130-associated janus
kinases,including janus kinase 1 and janus kinase 2, which leadsto
STAT3 activation.44,45 Epigenetic silencing of suppressorof
cytokine signaling 3 results in sustained IL-6 signaling
viaSTAT3.46 Inflammatory signaling pathways thereforeappear to
promote the development of CCA by causingDNA damage and blocking
the apoptosis normallyinduced by the DNA damage response. These
cytokinesalso promote cell proliferation. The combination of
DNAdamage, evasion of apoptosis, and cell proliferation are
allcomponents of cell transformation.
Epidermal growth factor–receptor (EGFR) signalingalso
contributes to cholangiocarcinogenesis and CCAprogression.
Activation of EGFR leads to activation ofextracellular-signal
regulated kinases (ERKs) 1 and 2 (alsoknown as p44/42 MAPK). EGFR
inhibitors decreaseexpression of cyclooxygenase-2 by CCA cells.47
V-erb-b2avian erythroblastic leukemia viral oncogene homolog
2(ERBB2) is another member of the EGFR family thatcontributes to
CCA development. In mice, overexpressionof ERBB2 led to formation
of tumors along the biliaryepithelium.48 Hepatocyte growth factor
(hepapoietin A;scatter factor) (HGF) is a stromal paracrine
mediator thatregulates tumor invasiveness and metastasis.49–51
Activa-tion of MET, the receptor for HGF, up-regulates
severalsignaling pathways, including those involving
phosphati-dylinositol-4,5-bisphosphate 3-kinase (PI3K)–AKT,STAT3,
and MAPK.52 CCAs express higher levels of METand HGF than nontumor
tissues.53,54 MET overexpressionwas associated with activation of
members of the EGFRfamily, particularly of ERBB2.54,55
Cholestasis also contributes to the development ofCCA, and bile
acids have important roles in this process,activating growth
factors that mediate proliferation. Bileacids activate EGFR and
increase expression ofcyclooxygenase-2 via a MAPK cascade.56 In
addition to bileacids, cyclooxygenase-2 overexpression is induced
by oxy-sterols and inducible nitric oxide synthase.57 Oxysterolsare
overlooked in the pathogenesis of CCA.58 Theseoxidative degradation
products of cholesterol are abun-dant in bile. They are endogenous
ligands for the
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hedgehog signaling pathway59—a developmental pathwayimplicated
in CCA progression.60
Genetics
A few studies have assessed the roles of genetic factors,
such as chromosome aberrations or genetic and
epigeneticalterations in tumor suppressor genes and oncogenes, in
thepathogenesis of human CCA. However, these studies
haveproducednodefinitive results because they analyzed a
limitednumber of genes in combined CCA specimens, withoutseparate
analyses of different subtypes.61 A comparative ge-nomics
hybridization analysis of 32 CCA samples from pa-tients (7 iCCA, 13
pCCA, and 12 dCCA) showed that they allcontained gains at 16q, 17p,
17q, 19p, and 19q, whichincluded regions encoding ERBB2,
mitogen-activated pro-tein kinase kinase 2 (MEK2), and
platelet-derived growthfactor- beta (PDGFB).62 Ameta-analysis of 5
studies that usedcomparative genomics hybridization to analyze 98
iCCAsfound copynumber losses at 1p, 4q, 8p, 9p, 17p, and18q,
andgains at 1q, 5p, 7p, 8q, 17q, and 20q.61 In this
meta-analysis,there was considerable variation among the 4 studies
thatwere performed in Asia63–66 and the 1 study from Europe.67
This variation could have resulted from differences inethnicity
and etiologic associations among the studies.
Whole-exome sequencing analyses of 8 liver fluke-relatedCCAs
identified 206 somatic mutations in 187 genes.68 Thefrequency of
these mutations was validated in an addi-tional 46 liver
fluke-related CCAs. Mutations frequentlywere detected in oncogenes
and tumor suppressor genessuch as those encoding tumor protein 53
(TP53) (muta-tions in 44.4% of CCAs), Kirsten rat sarcoma viral
oncogenehomolog (KRAS) (16.7%), and SMAD family member 4(16.7%).
Mutations also were found in myeloid/lymphoidor mixed-lineage
leukemia 3 (MLL3) (14.8% of cases), ringfinger protein 43 (RNF43)
(9.3%), paternally expressed 3(PEG3) (5.6%), and roundabout, axon
guidance receptor,homolog 2 (ROBO2) (9.3%). These genes are
involved indeactivation of histone modifiers, activation of
G-proteins,and loss of genomic stability.68 This study, performed
inAsia, has been the only whole-exome sequence analysis ofCCAs.
Further whole-genome sequencing studies areneeded to evaluate CCAs
from Western patients.
A recent study comprising single-nucleotide poly-morphism array,
gene expression profile, and mutationanalyses of 149 iCCAs
identified inflammation and prolif-eration classes of this tumor.45
Several copy number alter-ations were identified, including losses
at 3p, 4q, 6q, 9p, 9q,13q, 14q, 8p, 17p, and 21q, and gains at 1q
and 7p.45 Fea-tures of the inflammation class included activation
of in-flammatory pathways, overexpression of cytokines,
andactivation of STAT3. The proliferation class was character-ized
by activation of oncogene signaling pathways involvingRAS, MAPK,
andMET. Activating mutations in KRAS havebeen detected frequently
in CCAs.69–71 At least 2 studieshave reported a higher incidence of
activating mutations inKRAS in pCCAs compared with iCCAs.71,72 In
one cohort,the incidence of these mutations was 53% in pCCAs
compared with 17% in iCCAs.71 In a transcriptome profileanalysis
of 104 CCAs and 59 matched nontumor samples(controls), patients
could be categorized based on overallsurvival time, early
recurrence, and presence or absence ofKRAS mutations; a detailed
class comparison identified 4subclasses of patients. Those with
CCAs with alteredexpression of genes that regulate proteasome
activity; withdysregulation of ERBB2; and with overexpression of
EGFR,MET, and Ki67 had the worst outcomes.71
Inactivation of TP53, which regulates the cell cycle, isone of
the most common genetic abnormalities in cancercells and also has
been detected during chol-angiocarcinogenesis. A review of 10
studies, comprising229 patients with CCA from Europe, Asia, and the
UnitedStates, reported TP53 mutations in 21% of CCAs.73 Mu-tations
in other genes, including EGFR, neuroblastomaRAS viral (v-ras)
oncogene homolog (NRAS), PI3K, andAPC, have been less frequently
described.44
There has been growing interest in the effects of
somaticmutations in genes encoding isocitrate dehydrogenases(IDH) 1
and 2. IDH1 and IDH2 mutations frequently havebeen detected in
gliomas, but rarely have been observed inother solid tumors.
IDHmutations were detected in 22% ofCCA specimens—more frequently
in iCCAs (28%) thanpCCAs and dCCAs (7%).74 Recurrent mutations in
IDH1were observed in a subset of biliary tract tumor samples in
arecent broad-based mutation profile analysis of gastroin-testinal
tumors.75 A subsequent analysis of 62 CCAsdetected IDH1mutations in
only iCCAs.75 IDH1 and IDH2mutations were associated significantly
with increasedlevels of p53 and DNA hypermethylation.76
Epigeneticchanges associated with IDHmutations likely mediate
theironcogenic effects. The product of the enzymatic activity
ofmutant IDH1 and IDH2 is 2-hydroxyglutarate (Figure 2A).This
metabolite therefore might serve as a biomarker forIDH1 and
IDH2mutations, and for a subset of patientswhomight be treated with
IDH inhibitors77–79 (Figure 2B).
A number of epigenetic alterations, such as
promoterhypermethylation and microRNA dysregulation, havebeen
associated with the development of CCA. However,whole-epigenome
analysis has not been conducted andmicroRNA (miR) profiling is
possible with only smallnumbers of tumor samples.80,81 Promoter
hyper-methylation has been reported to silence tumor suppres-sor
genes including CDKN2 (observed in 17%–83% ofCCAs), suppressor of
cytokine signaling 3 (in 62%46), Ras as-sociation (RalGDS/AF-6)
domain family member 1(RASSF1A) (in 31%–69%), and APC (in
27%–47%).45,61
Gene fusions, such as the BCR-ABL gene in chronicmyeloid
leukemia, are drivermutations in cancer,whichplaya role in certain
cancers.82 Fibroblast growth factor receptor(FGFR) fusions are
active kinases. A recent study identifiednovel FGFR2 gene fusions
in CCA.82 Cells with these FGFRfusions were susceptible to FGFR
inhibitors, signifying thatFGFR kinase inhibition may be a valid
therapeutic strategyin CCA patients harboring these gene
fusions.82
miRs are noncoding RNAs that function in post-transcriptional
regulation of gene expression. A cluster
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Figure 2. IDH mutations. (A)Function of wild-type andmutant IDH
(mIDH). Wild-typeenzymes catalyze a reactionthat converts
isocitrate toa-ketoglutarate and reducesNADP to NADPH. The
mutantenzymes acquire a neomorphicactivity that converts the
normalmetabolite a-KG to 2-HG, andconsumption rather than
pro-ductionofNADPH.2-HG leads toinhibitionof
certaindioxygenases,which has been postulated toresult in
cancer-promotingevents. (B) Potential of personal-ized medicine for
CCA, usingmIDH inhibitors, as an example.a-KG, a-ketoglutarate;
2-HG,2-hydroxyglutarate; NADPH,nicotinamide adenine dinucleo-tide
phosphate.
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of 38 miRs was expressed differentially in 27 iCCA sam-ples,
compared with nontumor tissues. miR21 is overex-pressed in CCAs and
could have oncogenic effects, partlyby inhibiting programmed cell
death 4 and tissue inhibi-tor of matrix metalloproteinase (MMP)3.83
miR21 alsowas found to regulate phosphatase and tensin
homologdeleted on chromosome ten–dependent activation of
PI3Ksignaling in CCAs, to affect chemosensitivity.84
miR200Cprevents the epithelial–mesenchymal transition (EMT);changes
in its level might be used as a prognostic factor.80
Further studies are needed to determine how alterations inmiRs
contribute to the development of CCA, and howthese changes might be
used to determine patients’prognoses.
Developmental Pathways
The Notch signaling pathway regulates embryonic
development and proliferation of the biliary tree.85
Notsurprisingly, therefore, Notch dysregulation also hasbeen
implicated in cholangiocarcinogenesis. Two recentstudies in mice
have shown that Notch activation isrequired for conversion of
normal adult hepatocytes tobiliary cells that are precursors of
iCCA.35,36 Over-expression of intracellular domain of the Notch 1
re-ceptor in liver cells of mice resulted in formation ofiCCAs.86
In this model, an inhibitor of g-secretase, anenzyme necessary for
Notch signaling, suppressed tumorformation.
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Another evolutionary conserved, developmentalpathway is the
Hedgehog signaling pathway. Hedgehogsignaling is deregulated in
many types of tumors,including CCAs. Inhibition of hedgehog
signaling withcyclopamine impedes CCA cell migration,
proliferation,and invasion.87,88 Hedgehog signaling also has
beenimplicated in survival signaling by myofibroblast-derivedCCAs.
PDGF-b protects CCA cells and promotes tumorsurvival in mice with
CCAs, but cyclopamine reverses theseeffects.60
Wnt signaling also is required for intrahepatic bile
ductdevelopment and proliferation.89 Wnt-inducible signalingpathway
protein 1v is overexpressed in stroma nestsaround CCAs, and levels
of Wnt-inducible signalingpathway protein 1v are associated with
reduced survivaltimes of patients. Wnt-inducible signaling pathway
pro-tein 1v stimulated the invasive activity of CCA cell lines
byactivating MAPK1 and MAPK3.90
Tumor Microenvironment
Carcinogenesis in CCA includes alterations in the
stroma, recruitment of fibroblasts, remodeling of
theextracellular matrix (ECM), changing patterns of immunecell
migration, and promotion of angiogenesis(Figure 3A).91 iCCAs and
pCCAs are characterized by adense and reactive desmoplastic stroma
(Figure 3B) thatcontains many a-smooth muscle actin
(a-SMA)–positivemyofibroblasts, also known as cancer-associated
fibro-blasts (CAFs). The tumor stroma surrounds the malignantducts
and glands and comprises most of the tumormass.92,93 The stroma
promotes tumor progression viareciprocal communication between the
stromal cells andcancer cells.92
The precise origin of CAFs is unclear, although severalcell
types, including hepatic stellate cells, portal fibro-blasts, and
bone marrow–derived precursor cells, havebeen proposed as
candidates.92,94–96 The EMT also hasbeen proposed to produce
CAFs.93 During tumorigen-esis, the EMT is characterized by the
presence of tumorcells that express mesenchymal markers such as
vimen-tin, tenascin, fibronectin, and the zinc finger
proteinSnail.92 Immunohistochemical studies have shown
theexpression of these markers by human CCA celllines.97–99 In
mice, xenograft tumors grown fromenhanced green fluorescent protein
(EGFP)-expressinghuman CCA cells were found to be surrounded
andinfiltrated by a-SMA–expressing CAFs. Interestingly,EGFP was not
co-expressed with a-SMA, indicating thatthe EMT does not produce
CAFs in CCAs.100 Based oncombined evidence, a-SMA–expressing CAFs
appear tobe a heterogeneous population of cells that originatefrom
several cell lineages, but not from epithelial cancercells.
CAFs produce factors that stimulate ECM production,leading to a
fibrogenic response (Figure 3C).92 Factorsproduced by CAFs include
transforming growth factor-b,PDGF isomers, connective tissue growth
factor, and
insulin-like growth factor binding proteins.92 PDGF-mediated
interactions between CAFs and tumor cellshave been observed, such
as recruitment of CAFs byPDGF-D secreted by CCA cells.60,100,101
PDGF-D stimu-lates CAF migration via its receptor
platelet-derivedgrowth factor receptor (PDGFR), which is
highlyexpressed on CAFs, and activation of small Rho
guanosinetriphosphatases and the JNK signaling pathway.100
Activated CAFs also secrete paracrine factors that pro-mote
initiation and progression of cancer. These includematricellular
proteins, growth factors, chemokines, andECM proteases. Periostin
is a matricellular protein that isoverexpressed by CAFs compared
with normal fibroblasts;its presence correlates with shorter
survival times of pa-tients. Knockdown of the periostin receptor,
the a5 sub-unit of integrin, with small interfering RNA,
reducedstimulation of tumor proliferation and invasion by
peri-ostin.102 The ECM that surrounds pancreatic tumors alsohas
been shown to overexpress periostin, which promotestumor
invasiveness.103 Tenascin-C, another ECM proteinproduced by CAFs,
also promotes tumor migration andinvasiveness.92 In CCA cell lines,
HGF promoted inva-siveness and motility by inducing phosphorylation
of Aktand ERK 1/2.104 Similarly, stromal cell–derived
factor-1,through activation of its receptor chemokine (C-X-Cmotif)
receptor 4 (CXCR4), induced CCA cell invasion viaERK 1/2 and
Akt.105,106 This process was disrupted by theCXCR4 inhibitor
AMD3100.106
ECM degradation and remodeling is required for tumorprogression.
MMPs degrade and remodel the ECM duringfibrogenesis and
carcinogenesis. MMP1, MMP2, MMP3,and MMP9 are strongly expressed in
CCAs and are asso-ciated with invasive tumors.107,108 Fibroblast
activationprotein is a stromal protein; its high expression by
CAFshas been associated with tumors with an
aggressivephenotype.109
The exact mechanisms by which tumor and stromacommunicate are
not clear. However, the importance ofthe desmoplastic stroma in CCA
progression indicatesthat it could be a new therapeutic target,
perhaps via se-lective targeting of CAFs.110
Animal Models
Animal models are essential for the development of
new therapeutic strategies and diagnostic tools.111 Animalmodels
of CCA (Table 1) include mice with xenografttumors,43,112–119 mice
with genetic changes that lead toCCA formation,86,120–124 rats with
orthotopic tu-mors,125,126 and animals that develop CCAs after
exposureto carcinogens.55,127–129 Although these models offer
anopportunity to bridge the chasm between in vitro findingsand
clinical applicability, they have limitations. The
tumormicroenvironment is an important feature in CCA devel-opment.
It sometimes can be a challenge to study in-teractions between
cancer cells and the stroma in micewith xenograft tumors because
the tumor is not growingin the same microenvironment as it does in
human beings.
-
Figure 3. Microenvironment of cholangiocarc-inoma. (A)
Components of the tumor microenvi-ronment in CCA. (B) Micrograph of
a stromalCCA. (C) Factors secreted by cancer-associatedfibroblasts.
CTGF, connective tissue growth fac-tor; SDF-1, stromal cell–derived
factor 1; TGF-b,transforming growth factor-b.
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Table 1. Animal Models of Cholangiocarcinoma
Experimental approach Key features Study
Mice with xenograft tumorsInjection of 3 � 106 Mz-ChA-1 cells
Tumor development in 3 weeks Fava et al112Injection of 5 � 106
Sk-ChA-1 cells � intratumoral tamoxifen injections Significantly
decreased CCA development with intratumoral
tamoxifen injectionsPawar et al113
Injection of 2 � 106 QBC939 cells � magnetic nanoparticle
injections via tail vein CCA tumor growth inhibition with magnetic
nanoparticles Tang et al114Injection of IL-6 overexpressed Mz-ChA-1
stable cell line (Mz-ChA-IL6) vs
control vector Mz-ChA-1 cell lineOverexpression of IL-6
increased growth of xenograft tumors Meng et al43
Injection of miR26a overexpressed CCLP1 cell line vs scramble
controlCCLP1 cell line
Overexpression of miR26a increased growth of xenograft tumors
Zhang et al115
Injection of miR494 overexpressed stable HuCCT1 cell line vs
control vectorHuCCT1 cell line
Overexpression of miR494 increased growth of xenograft tumors
Olaru et al116
Injection of stable QBC939 cell line transfected with Slug siRNA
vs controlvector QBC939 cell line
Slug silencing suppressed growth of xenograft tumors Zhang et
al117
Injection of CypA silenced stable M139 cell line vs control
vector M139 cell line CypA silencing decreased growth of xenograft
tumors Obchoei et al118
Injection of stable QBC939 cell line transfected with Beclin-1
siRNA vscontrol vector QBC939 cell line
Beclin-1 silencing decreased growth of xenograft tumors Hou et
al119
Genetically engineered mouse modelsLiver-specific inactivation
of SMAD4 and PTEN Tumor formation in all animals at 4–7 months of
age Xu et al120
Chronic carbon tetrachloride exposure in TP53-deficient mice
Development of tumors with dense peritumoral fibrosis and other
histologicand genetic features of human iCCA
Farazi et al121
Liver-specific inactivation of macrophage stimulating factor 1
and 2 Tumor development (HCC or CCA) in all mice by 6 months of age
Song et al122
Liver-specific ablation of WW45, a homolog of Drosophila
Salvador andadaptor for the Hippo kinase
Development of tumors with mixed histologic features of HCC and
CCA Lee et al123
Liver-specific activation of KRAS and deletion of TP53
Development of stroma-rich tumors; shortened time to tumor
developmentand increased metastasis with the combination of KRAS
activation and TP53 deletion
O’Dell et al124
Overexpression of intracellular domain of Notch1 in livers of
transgenic mice Formation of tumors with features characteristic of
iCCA Zender et al86
Orthotopic rat modelsInoculation of BDEneu cells into bile duct
of isogenic rats Rapid (21–26 days) development of
cholangiocarcinoma characterized by biliary
obstruction and gross peritoneal metastasis; origin of tumor
stroma andtumor tissue from same species (rat)
Sirica et al125
Three-dimensional organotypic culture model of CCA in rats
Stromal microenvironment, gene expression profile, and
pathophysiologiccharacteristics that mimic desmoplastic iCCA in
vivo
Campbell et al126
Carcinogen-induced modelsFuran-induced cholangiocarcinogenesis
in rat liver Formation of mucin-producing CCA tumors;
overexpression of C-NEU and MET Radaeva et al55
Chronic administration of thioacetamide in lean rats and rats
withfaulty leptin receptors
Increased development and growth of CCA tumors inlean rats
treated with thioacetamide
Fava et al127
Administration of DEN � LMBDL to induce chronic cholestasisand
CCA development
Increased CCA progression in mice with LMBDL given DEN compared
withmice without LMBDL given DEN
Yang et al128
Inoculation with O viverrini and administration
ofdimethylnitrosamine in hamsters
Development of pus and tumor in liver starting at 20 weeks after
O viverriniinfection/DEN administration; all hamsters in
experimental groupwere dead by 28 weeks
Plengsuriyakarnet al129
BDEneu, highly malignant cholangiocarcinoma cell line; CCLP1,
cholangiocarcinoma cell line; C-NEU, rat homologue of human ERBB2;
CypA, cyclophilin A; DEN, diethylnitrosamine; HuCCT1,
cholangiocarcinomacell line; KRAS, Kirsten rat sarcoma viral
oncogene homolog; LMBDL, left and median bile duct ligation; M139,
cholangiocarcinoma cell line; Mz-ChA-1, cholangiocarcinoma cell
line; PTEN, phosphatase andtensin homolog deleted on chromosome
ten; QBC939, human hilar bile duct carcinoma cell line; Sk-ChA-1,
cholangiocarcinoma cell line; siRNA, small interfering RNA; SMAD4,
SMAD family member 4.
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A model described by Sirica et al,125 in which rat CCAcells were
injected into rat biliary trees, is unique inthat the stroma and
epithelial cells were derived from thesame species. These animals
allow for investigations oftumor–stroma interactions that more
closely resemblethose of patients. Although transgenic models do
allowfor study of the tumor microenvironment, they tend to
betechnically challenging and expensive. Animals with ge-netic
alterations that lead to production of CCAs thatresemble human
tumors are needed.
Diagnosis and Management
It can be a challenge to diagnose CCA because of
its paucicellular nature, anatomic location, and silentclinical
character. Diagnosis requires a high index of sus-picion and a
multidisciplinary approach that involvesclinical, laboratory,
endoscopic, and radiographic analyses.
iCCA
iCCA is divided into mass-forming, periductal
infiltrating, and intraductal growth types.130 The
clinicalmanifestations of iCCA include nonspecific symptomssuch as
abdominal pain, cachexia, malaise, fatigue, andnight sweats.2 iCCA
frequently presents as an intrahepaticmass lesion; imaging
modalities including computed to-mography (CT) and magnetic
resonance imaging (MRI)aid in the diagnosis. The use of contrast
enhancementimproves the sensitivity of MRI for detection of
iCCAbecause these tumors typically have progressive uptake
ofcontrast during the venous phase. HCCs, on the otherhand, are
characterized by rapid contrast uptake duringthe arterial phase,
followed by a delayed venous washoutphase.131 CT and MRI have
similar utility in the evalua-tion of tumor size and detection of
satellite lesions.However, CT may be better for assessment of
vascularencasement, identification of extrahepatic metastasis,
anddetermination of resectability.17,132
Serum levels of carbohydrate antigen 19-9 (CA19-9), atumor
biomarker, can aid in diagnosis, but this assaydetects iCCA with
only 62% sensitivity and 63% speci-ficity.133 Moreover, increased
levels of CA19-9 also havebeen observed in patients with benign
diseases such asbacterial cholangitis or choledocholithiasis.5
Nonetheless,very high levels of CA19-9 (�1000 U/mL) have
beenassociated with metastatic iCCA, so this assay might beused in
disease staging rather than diagnosis.134 Mixedtumors are
characterized by histologic and imaging fea-tures of HCC and iCCA.
In these cases, immunohisto-chemical analysis for cytokeratins 7
and 19 can beuseful—tumors positive for cytokeratins can be
consideredto be mixed hepatocellular CCA.17,135 A definitive
diag-nosis of iCCA requires liver biopsy analysis. According tothe
World Health Organization classification criteria,iCCAs can be
adenocarcinomas or mucinous carcinomas.2
The treatment of choice for iCCA is surgical resection.Patients
should undergo surgery only if they havepotentially resectable
tumors and are appropriate surgical
candidates. After surgical resection, the median time
ofdisease-free survival is 26 months; reported rates of recur-rence
are 60%–65%.136,137 Approximately 60% of patientssurvive for 5
years after resection. Factors associated withrecurrence and
reduced survival time after resection includevascular invasion,
lymph node metastasis, multiple tumors,and cirrhosis.4,138 Nuclear
expression of S100A4, a memberof the S100 family of calcium-binding
proteins, inneoplastic ducts was associated with metastasis
andreduced time of survival after surgical resection in a subsetof
patients with CCA.139
Liver transplantation as a curative option for iCCA ishighly
controversial. iCCA was reported to recur in 70% ofpatients within
5 years of liver transplantation, and themedian disease-free
survival time was 8 months in a seriesof 14 patients with iCCA or
mixed HCC-iCCA.135 Patientswith very small iCCAs (
-
Figure 4. Diagnostic modalitiesused for cholangiocarcinoma.(A)
MRI of a pCCA mass (out-lined in circle). (B) CT image of apCCA
mass with right portalvein encasement (black arrow).(C) Magnetic
resonance chol-angiopancreatography image ofcommon hepatic duct
involve-ment by tumor (white arrow). (D)ERC image showing
excludedsegmental ducts (white arrows)in a patient with a hilar
biliarystricture extending into the rightmain hepatic duct.
Figure 5. Time to diagnosis of a cholangiocarcinoma based on
FISHanalysis and CA19-9 levels. Reprinted with permission from
WileyInterScience and Barr et al.146
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be performed on the primary tumor because it candisseminate the
tumor.143 ERC serves a diagnostic andtherapeutic purpose—it is used
to assess and sample thebiliary tree via brush cytology and
endoscopic biopsy, aswell as dilatation and stent placement in
cases of biliaryobstruction.
Fluorescence in situ hybridization (FISH) analysis in-creases
the sensitivity of cytology in diagnosing pCCA.144
FISH can detect polysomy or amplification of at least
2chromosomes: tetrasomy and trisomy 7. Of these, polys-omy in the
presence of a dominant stricture is consideredsufficient for the
diagnosis of pCCA, especially if thepolysomy can be confirmed over
time.145 Tetrasomy canbe seen during the M phase of mitosis and
should beinterpreted with caution.5 Trisomy 7 often is observedwith
inflammation of the biliary tree. Detection of polys-omy by FISH
also has been shown to predict the devel-opment of malignancies in
patients with PSC with nomass and equivocal cytology. In a recent
study, patientswith PSC who had polysomy and levels of CA19-9
greaterthan 129 U/mL all went on to develop cancer, mainlywithin 2
years (Figure 5).146
The only curative options for pCCA are surgical resec-tion and
neoadjuvant chemoradiation followed by livertransplantation. The
Bismuth–Corlette staging classifica-tion is based on the anatomic
location of the CCA withinthe biliary tree and is meant to help
guide decision mak-ing. Recently, this classification was expanded
to take into
account vascular encasement and parenchymal value ofthe
potential remnant lobe.3 Surgical resection entailslobar hepatic
and bile duct resection, regional lymphade-nectomy, and Roux-en-Y
hepaticojejunostomy. Potentialcontraindications to curative
surgical resection includecontralateral or bilateral vascular
encasement and pCCAextension bilaterally to the level of the
secondary biliarybranches. The presence of regional lymphadenopathy
does
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Table 2. Criteria for Liver Transplantation in pCCA
Diagnosis of cholangiocarcinoma
Positive transluminal biopsyPositive biliary brush
cytologyMalignant-appearing stricture on ERC with a CA 19-9
level> 100 U/mL
and/or FISH polysomyMass lesion on cross-sectional imaging and
malignant-appearing
stricture on ERC/MRCPTumor size
Radial tumor diameter of �3 cmTumor confined to biliary tree
Absence of intrahepatic or extrahepatic
metastasisUnresectability
Unresectable hilar tumor (above the cystic duct)CCA in a PSC
patient (owing to skip lesions, the field defect, and
parenchymal liver disease)
MRCP, magnetic resonance cholangiopancreatography.
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not necessarily preclude surgery.147 Occasionally, a tumormay be
resectable but the remnant lobe has limited vol-ume. In such cases,
resectability can be achieved by pre-operative relief of biliary
obstruction and portal veinembolization of the affected lobe with
resultant compen-satory hyperplasia of the contralateral unaffected
liverlobe.147 Rates of 5-year survival after surgical resectionwith
negative margins range from 11% to 41%.147
With the advent of new liver transplantation
protocols,neoadjuvant chemoradiation followed by transplantationhas
become an appealing option for patients selected care-fully using
stringent criteria (Table 2). Sixty-five percent ofpatientswhowere
treatedwithneoadjuvant therapy followedby liver transplantation
at12 large-volume transplant centerssurvived for 5 years.148
Rigorous selection is imperative forsuccessful outcomes.
Eligibility criteria include radial diam-eter of tumor of less than
3 cm, absence of intrahepatic orextrahepatic metastasis, and, in
the case of patients withoutPSC, unresectability.149 Because of the
presence of paren-chymal liver disease, patients with PSC typically
require livertransplantation rather than surgical resection.
For patients who are not candidates for surgical resectionor
liver transplantation, systemic chemotherapy with gem-citabine and
cisplatin is recommended. For patients withbiliary obstruction,
adequate drainage is essential to relievecholestasis and increase
tolerance to chemotherapy.17
dCCA
Intraductal papillary neoplasm and biliary intra-
epithelial neoplasia are the precursor lesions of dCCA.30
dCCA arises from the point of insertion of the cysticduct to the
ampulla of Vater and therefore can be difficultto distinguish from
early pancreatic cancer.17 Analogousto pCCA, patients typically
present with painless jaundice,and laboratory analysis is
consistent with biliary obstruc-tion. Although pCCA and dCCA are
distinct with respectto their pathogenesis and treatment, most
studies evalu-ating diagnostic modalities have grouped these as
extra-hepatic CCAs. Cross-sectional imaging, endoscopicultrasound,
and ERC therefore are used in the samemanner in the diagnosis of
dCCA as with pCCA.
Diagnosis is made on the basis of the presence of adominant
stricture and positive cytology and/or detectionof polysomy by
FISH.2 Surgical treatment of dCCA typi-cally entails a Whipple
procedure. Only 27% of patientssurvive for 5 years after surgical
resection that attainsnegative margins.4 The role of neoadjuvant
chemo-radiation is limited. For patients who are not candidatesfor
surgical resection, chemotherapy may be considered.17
Future Directions
Treatment options for CCA are limited and overall
survival rates are low. Earlier detection of CCA increasesthe
chance of having curative treatment options. However,despite recent
advances in diagnosis, such as improvedimaging and cytology
techniques, including FISH, furtherwork is necessary to overcome
the challenge of diagnosingCCA at an earlier stage. CCA often still
is diagnosed basedon clinical criteria, such as a
malignant-appearing bileduct stricture, increased serum levels of
CA19-9, appear-ance of a mass during MRI, normal serum levels of
IgG4level, and so forth.
There are significant geographic and ethnic variationsin the
incidence of CCA, so genetic factors are likely tocontribute to its
pathogenesis. Inflammatory and onco-genic signaling pathways also
are involved in chol-angiocarcinogenesis, and are potential
therapeutic targets.Further studies are necessary to elucidate the
role of ge-netic aberrations, particularly in regions encoding
keycomponents of signaling pathways. In addition, the role ofmiRs
as biomarkers remains to be fully elucidated. CCAsare
heterogeneous; treatments are likely to be designedbased on
features of each individual tumor.150 Potentialtherapeutic targets
could include the MET tyrosine re-ceptor kinase, FGFR2, the
PI3K–Akt–mTOR pathway, andIDH mutations. Molecular profiling of
tumors, to identifytheir specific mutations, could make it possible
to offertargeted therapies in personalized treatments (Figure
2B).
Although cancer cells containmanygenetic and
functionalaberrations, the tumor stroma appears to be more
uniformand has strong potential as a target for new
combinationtherapies. Further work is needed to highlight the
dynamicreciprocal communication between tumor and stroma.
References
1. Welzel TM, McGlynn KA, Hsing AW, et al. Impact of
classification ofhilar cholangiocarcinomas (Klatskin tumors) on the
incidence ofintra- and extrahepatic cholangiocarcinoma in the
United States.J Natl Cancer Inst 2006;98:873–875.
2. Blechacz B, Komuta M, Roskams T, et al. Clinical diagnosis
andstaging of cholangiocarcinoma. Nat Rev Gastroenterol
Hepatol2011;8:512–522.
3. Deoliveira ML, Schulick RD, Nimura Y, et al. New staging
systemand a registry for perihilar cholangiocarcinoma. Hepatology
2011;53:1363–1371.
4. DeOliveira ML, Cunningham SC, Cameron JL, et al.
Chol-angiocarcinoma: thirty-one-year experience with 564 patients
at asingle institution. Ann Surg 2007;245:755–762.
5. Blechacz BG, Gores, GJ. Tumors of the bile ducts,
gallbladder, andampulla. In: Feldman, ed. Sleisenger and
Fordtran’s
-
1226 RIZVI AND GORES GASTROENTEROLOGY Vol. 145, No. 6
REV
IEWS
AND
PER
SPEC
TIVES
gastrointestinal and liver disease. Volume 1. 9th ed.
Philadelphia:Saunders, 2010:1171–1176.
6. Khan SA, Davidson BR, Goldin RD, et al. Guidelines for the
diag-nosis and treatment of cholangiocarcinoma: an update. Gut
2012;61:1657–1669.
7. Everhart JE, Ruhl CE. Burden of digestive diseases in the
UnitedStates part III: liver, biliary tract, and pancreas.
Gastroenterology2009;136:1134–1144.
8. Tyson GL, El-Serag HB. Risk factors for cholangiocarcinoma.
Hep-atology 2011;54:173–184.
9. Shaib Y, El-Serag HB. The epidemiology of
cholangiocarcinoma.Semin Liver Dis 2004;24:115–125.
10. Sripa B, Pairojkul C. Cholangiocarcinoma: lessons from
Thailand.Curr Opin Gastroenterol 2008;24:349–356.
11. Khan SA, Taylor-Robinson SD, Toledano MB, Beck A, Elliott
P,Thomas HC. Changing international trends in mortality rates
forliver, biliary and pancreatic tumours. J Hepatol
2002;37:806–813.
12. Khan SA, Toledano MB, Taylor-Robinson SD. Epidemiology,
riskfactors, and pathogenesis of cholangiocarcinoma. HPB
(Oxford)2008;10:77–82.
13. McGlynn KA, Tarone RE, El-Serag HB. A comparison of trends
in theincidence of hepatocellular carcinoma and intrahepatic
chol-angiocarcinoma in the United States. Cancer Epidemiol
BiomarkersPrev 2006;15:1198–1203.
14. Patel T. Increasing incidence and mortality of primary
intrahepaticcholangiocarcinoma in the United States. Hepatology
2001;33:1353–1357.
15. Patel T. Worldwide trends in mortality from biliary tract
malig-nancies. BMC Cancer 2002;2:10.
16. Khan SA, Emadossadaty S, Ladep NG, et al. Rising trends
incholangiocarcinoma: is the ICD classification system
misleadingus? J Hepatol 2012;56:848–854.
17. Razumilava N, Gores GJ. Classification, diagnosis, and
manage-ment of cholangiocarcinoma. Clin Gastroenterol Hepatol
2013;11:13–21 e1; quiz e3–e4.
18. Shin HR, Oh JK, Lim MK, et al. Descriptive epidemiology of
chol-angiocarcinoma and clonorchiasis in Korea. J Korean Med
Sci2010;25:1011–1016.
19. Huang MH, Chen CH, Yen CM, et al. Relation of
hepatolithiasis tohelminthic infestation. J Gastroenterol Hepatol
2005;20:141–146.
20. Edil BH, Cameron JL, Reddy S, et al. Choledochal cyst
disease inchildren and adults: a 30-year single-institution
experience. J AmColl Surg 2008;206:1000–1005; discussion
1005–1008.
21. Mabrut JY, Bozio G, Hubert C, et al. Management of
congenital bileduct cysts. Dig Surg 2010;27:12–18.
22. Kato I, Kido C. Increased risk of death in
thorotrast-exposed patientsduring the late follow-upperiod. Jpn
JCancerRes1987;78:1187–1192.
23. Lee TY, Lee SS, Jung SW, et al. Hepatitis B virus infection
andintrahepatic cholangiocarcinoma in Korea: a case-control study.
AmJ Gastroenterol 2008;103:1716–1720.
24. Shaib YH, El-Serag HB, Nooka AK, et al. Risk factors for
intrahepaticand extrahepatic cholangiocarcinoma: a hospital-based
case-controlstudy. Am J Gastroenterol 2007;102:1016–1021.
25. Sorensen HT, Friis S, Olsen JH, et al. Risk of liver and
other types ofcancer in patients with cirrhosis: a nationwide
cohort study inDenmark. Hepatology 1998;28:921–925.
26. Palmer WC, Patel T. Are common factors involved in the
patho-genesis of primary liver cancers? A meta-analysis of risk
factors forintrahepatic cholangiocarcinoma. J Hepatol
2012;57:69–76.
27. Shaib YH, El-Serag HB, Davila JA, et al. Risk factors of
intrahepaticcholangiocarcinoma in the United States: a case-control
study.Gastroenterology 2005;128:620–626.
28. Welzel TM, Graubard BI, El-Serag HB, et al. Risk factors for
intra-hepatic and extrahepatic cholangiocarcinoma in the United
States:a population-based case-control study. Clin Gastroenterol
Hepatol2007;5:1221–1228.
29. Welzel TM, Mellemkjaer L, Gloria G, et al. Risk factors for
intra-hepatic cholangiocarcinoma in a low-risk population: a
nationwidecase-control study. Int J Cancer 2007;120:638–641.
30. Nakanuma Y, Sato Y, Harada K, et al. Pathological
classification ofintrahepatic cholangiocarcinoma based on a new
concept. World JHepatol 2010;2:419–427.
31. Komuta M, Spee B, Vander Borght S, et al.
Clinicopathologicalstudy on cholangiolocellular carcinoma
suggesting hepatic pro-genitor cell origin. Hepatology
2008;47:1544–1556.
32. Tsuchiya A, Kamimura H, Tamura Y, et al. Hepatocellular
carcinomawith progenitor cell features distinguishable by the
hepatic stem/progenitor cell marker NCAM. Cancer Lett
2011;309:95–103.
33. Cardinale V, Carpino G, Reid L, et al. Multiple cells of
origin incholangiocarcinoma underlie biological, epidemiological
and clin-ical heterogeneity. World J Gastrointest Oncol
2012;4:94–102.
34. Komuta M, Govaere O, Vandecaveye V, et al. Histological
diversity incholangiocellular carcinoma reflects the different
cholangiocytephenotypes. Hepatology 2012;55:1876–1888.
35. Fan B, Malato Y, Calvisi DF, et al. Cholangiocarcinomas can
originatefrom hepatocytes in mice. J Clin Invest
2012;122:2911–2915.
36. Sekiya S, Suzuki A. Intrahepatic cholangiocarcinoma can
arise fromNotch-mediated conversion of hepatocytes. J Clin Invest
2012;122:3914–3918.
37. Holczbauer A, Factor VM, Andersen JB, et al. Modeling
pathogen-esis of primary liver cancer in lineage-specific mouse
cell types.Gastroenterology 2013;145:221–231.
38. Jaiswal M, LaRusso NF, Burgart LJ, et al. Inflammatory
cytokinesinduce DNA damage and inhibit DNA repair in
cholangiocarcinomacells by a nitric oxide-dependent mechanism.
Cancer Res 2000;60:184–190.
39. Park J, Tadlock L, Gores GJ, et al. Inhibition of
interleukin6-mediated mitogen-activated protein kinase activation
attenuatesgrowth of a cholangiocarcinoma cell line. Hepatology
1999;30:1128–1133.
40. Kobayashi S, Werneburg NW, Bronk SF, et al. Interleukin-6
con-tributes to Mcl-1 up-regulation and TRAIL resistance via an
Akt-signaling pathway in cholangiocarcinoma cells.
Gastroenterology2005;128:2054–2065.
41. Taniai M, Grambihler A, Higuchi H, et al. Mcl-1 mediates
tumor ne-crosis factor-related apoptosis-inducing ligand resistance
in humancholangiocarcinoma cells. Cancer Res 2004;64:3517–3524.
42. Isomoto H, Kobayashi S, Werneburg NW, et al. Interleukin 6
upre-gulates myeloid cell leukemia-1 expression through a
STAT3pathway in cholangiocarcinoma cells. Hepatology
2005;42:1329–1338.
43. Meng F, Yamagiwa Y, Ueno Y, et al. Over-expression of
interleukin-6enhances cell survival and transformed cell growth in
human ma-lignant cholangiocytes. J Hepatol 2006;44:1055–1065.
44. Sia D, Tovar V, Moeini A, et al. Intrahepatic
cholangiocarcinoma:pathogenesis and rationale for molecular
therapies. Oncogene2013;32:4861–4870.
45. Sia D, Hoshida Y, Villanueva A, et al. Integrative molecular
analysisof intrahepatic cholangiocarcinoma reveals 2 classes that
havedifferent outcomes. Gastroenterology 2013;144:829–840.
46. Isomoto H, Mott JL, Kobayashi S, et al. Sustained
IL-6/STAT-3signaling in cholangiocarcinoma cells due to SOCS-3
epigeneticsilencing. Gastroenterology 2007;132:384–396.
47. Yoon JH, Gwak GY, Lee HS, et al. Enhanced epidermal growth
factorreceptor activation in human cholangiocarcinoma cells. J
Hepatol2004;41:808–814.
48. Kiguchi K, Carbajal S, Chan K, et al. Constitutive
expression ofErbB-2 in gallbladder epithelium results in
development ofadenocarcinoma. Cancer Res 2001;61:6971–6976.
49. Matsumoto K, Nakamura T. Hepatocyte growth factor and the
Metsystem as a mediator of tumor-stromal interactions. Int J
Cancer2006;119:477–483.
50. Nishimura K, Kitamura M, Miura H, et al. Prostate stromal
cell-derived hepatocyte growth factor induces invasion of
prostatecancer cell line DU145 through tumor-stromal interaction.
Prostate1999;41:145–153.
51. Nakamura T, Matsumoto K, Kiritoshi A, et al. Induction of
hepato-cyte growth factor in fibroblasts by tumor-derived factors
affects
-
December 2013 CHOLANGIOCARCINOMA 1227
REV
IEW
SAND
PER
SPEC
TIVES
invasive growth of tumor cells: in vitro analysis of
tumor-stromalinteractions. Cancer Res 1997;57:3305–3313.
52. Comoglio PM, Giordano S, Trusolino L. Drug development of
METinhibitors: targeting oncogene addiction and expedience. Nat
RevDrug Discov 2008;7:504–516.
53. Lai GH, Radaeva S, Nakamura T, et al. Unique epithelial cell
pro-duction of hepatocyte growth factor/scatter factor by
putativeprecancerous intestinal metaplasias and associated
“intestinal-type” biliary cancer chemically induced in rat liver.
Hepatology2000;31:1257–1265.
54. Miyamoto M, Ojima H, Iwasaki M, et al. Prognostic
significance ofoverexpression of c-Met oncoprotein in
cholangiocarcinoma. Br JCancer 2011;105:131–138.
55. Radaeva S, Ferreira-Gonzalez A, Sirica AE. Overexpression of
C-NEUand C-MET during rat liver cholangiocarcinogenesis: a link
betweenbiliary intestinalmetaplasiaandmucin-producing
cholangiocarcinoma.Hepatology 1999;29:1453–1462.
56. Yoon JH, Higuchi H, Werneburg NW, et al. Bile acids
inducecyclooxygenase-2 expression via the epidermal growth
factorreceptor in a human cholangiocarcinoma cell line.
Gastroenter-ology 2002;122:985–993.
57. Yoon JH, Canbay AE, Werneburg NW, et al. Oxysterols
inducecyclooxygenase-2 expression in cholangiocytes: implications
forbiliary tract carcinogenesis. Hepatology 2004;39:732–738.
58. Kuver R. Mechanisms of oxysterol-induced disease: insights
fromthe biliary system. Clin Lipidol 2012;7:537–548.
59. Nachtergaele S, Mydock LK, Krishnan K, et al. Oxysterols
areallosteric activators of the oncoprotein Smoothened. Nat Chem
Biol2012;8:211–220.
60. Fingas CD, Bronk SF, Werneburg NW, et al.
Myofibroblast-derivedPDGF-BB promotes Hedgehog survival signaling
in chol-angiocarcinoma cells. Hepatology 2011;54:2076–2088.
61. Andersen JB, Thorgeirsson SS. Genetic profiling of
intrahepaticcholangiocarcinoma. Curr Opin Gastroenterol
2012;28:266–272.
62. McKay SC, Unger K, Pericleous S, et al. Array comparative
genomichybridization identifies novel potential therapeutic targets
in chol-angiocarcinoma. HPB (Oxford) 2011;13:309–319.
63. Koo SH, Ihm CH, Kwon KC, et al. Genetic alterations in
hepato-cellular carcinoma and intrahepatic cholangiocarcinoma.
CancerGenet Cytogenet 2001;130:22–28.
64. Uhm KO, Park YN, Lee JY, et al. Chromosomal imbalances
inKorean intrahepatic cholangiocarcinoma by comparative
genomichybridization. Cancer Genet Cytogenet 2005;157:37–41.
65. Lee JY, Park YN, Uhm KO, et al. Genetic alterations in
intrahepaticcholangiocarcinoma as revealed by degenerate
oligonucleotideprimed PCR-comparative genomic hybridization. J
Korean Med Sci2004;19:682–687.
66. Wong N, Li L, Tsang K, et al. Frequent loss of chromosome 3p
andhypermethylation of RASSF1A in cholangiocarcinoma. J
Hepatol2002;37:633–639.
67. Homayounfar K, Gunawan B, Cameron S, et al. Pattern of
chro-mosomal aberrations in primary liver cancers identified
bycomparative genomic hybridization. Hum Pathol
2009;40:834–842.
68. OngCK, SubimerbC,Pairojkul C, et al. Exomesequencing of
liver fluke-associated cholangiocarcinoma. Nat Genet
2012;44:690–693.
69. Xu RF, Sun JP, Zhang SR, et al. KRAS and PIK3CA but not
BRAFgenes are frequently mutated in Chinese cholangiocarcinoma
pa-tients. Biomed Pharmacother 2011;65:22–26.
70. Ohashi K, Nakajima Y, Kanehiro H, et al. Ki-ras mutations
and p53protein expressions in intrahepatic cholangiocarcinomas:
relation togross tumor morphology. Gastroenterology
1995;109:1612–1617.
71. Andersen JB, Spee B, Blechacz BR, et al. Genomic and
geneticcharacterization of cholangiocarcinoma identifies
therapeutic tar-gets for tyrosine kinase inhibitors.
Gastroenterology 2012;142:1021–1031 e15.
72. Tada M, Omata M, Ohto M. High incidence of ras gene mutation
inintrahepatic cholangiocarcinoma. Cancer 1992;69:1115–1118.
73. Khan SA, Thomas HC, Toledano MB, et al. p53 Mutations in
humancholangiocarcinoma: a review. Liver Int 2005;25:704–716.
74. Kipp BR, Voss JS, Kerr SE, et al. Isocitrate dehydrogenase 1
and 2mutations in cholangiocarcinoma. HumPathol
2012;43:1552–1558.
75. Borger DR, Tanabe KK, Fan KC, et al. Frequent mutation of
iso-citrate dehydrogenase (IDH)1 and IDH2 in
cholangiocarcinomaidentified through broad-based tumor genotyping.
Oncologist 2012;17:72–79.
76. Wang P, Dong Q, Zhang C, et al. Mutations in isocitrate
dehydroge-nase 1 and 2 occur frequently in intrahepatic
cholangiocarcinomasand share hypermethylation targets with
glioblastomas. Oncogene2013;32:3091–3100.
77. Reitman ZJ, Parsons DW, Yan H. IDH1 and IDH2: not your
typicaloncogenes. Cancer Cell 2010;17:215–216.
78. Rohle D, Popovici-Muller J, Palaskas N, et al. An inhibitor
of mutantIDH1 delays growth and promotes differentiation of glioma
cells.Science 2013;340:626–630.
79. Wang F, Travins J, DeLaBarre B, et al. Targeted inhibition
of mutantIDH2 in leukemia cells induces cellular differentiation.
Science2013;340:622–626.
80. Oishi N, Kumar MR, Roessler S, et al. Transcriptomic
profiling re-veals hepatic stem-like gene signatures and interplay
of miR-200cand epithelial-mesenchymal transition in intrahepatic
chol-angiocarcinoma. Hepatology 2012;56:1792–1803.
81. Chen L, Yan HX, Yang W, et al. The role of microRNA
expressionpattern in human intrahepatic cholangiocarcinoma. J
Hepatol2009;50:358–369.
82. Wu YM, Su F, Kalyana-Sundaram S, et al. Identification of
targetableFGFRgene fusions in diverse cancers.
CancerDiscov2013;3:636–647.
83. Yamanaka S, Olaru AV, An F, et al. MicroRNA-21 inhibits
Serpini1, agene with novel tumour suppressive effects in gastric
cancer. DigLiver Dis 2012;44:589–596.
84. Meng F, Henson R, Lang M, et al. Involvement of human
micro-RNAin growth and response to chemotherapy in human
chol-angiocarcinoma cell lines. Gastroenterology
2006;130:2113–2129.
85. Hofmann JJ, Zovein AC, Koh H, et al. Jagged1 in the portal
veinmesenchyme regulates intrahepatic bile duct development:
in-sights into Alagille syndrome. Development
2010;137:4061–4072.
86. Zender S, Nickeleit I, Wuestefeld T, et al. A critical role
for notchsignaling in the formation of cholangiocellular
carcinomas. CancerCell 2013;23:784–795.
87. Jinawath A, Akiyama Y, Sripa B, et al. Dual blockade of
theHedgehog and ERK1/2 pathways coordinately decreases
prolifer-ation and survival of cholangiocarcinoma cells. J Cancer
Res ClinOncol 2007;133:271–278.
88. El Khatib M, Kalnytska A, Palagani V, et al. Inhibition of
hedgehogsignaling attenuates carcinogenesis in vitro and increases
ne-crosis of cholangiocellular carcinoma. Hepatology
2013;57:1035–1045.
89. Sirica AE, Nathanson MH, Gores GJ, et al. Pathobiology of
biliaryepithelia and cholangiocarcinoma: proceedings of the Henry
M.and Lillian Stratton Basic Research Single-Topic Conference.
Hep-atology 2008;48:2040–2046.
90. Tanaka S, Sugimachi K, Kameyama T, et al. Human WISP1v,
amember of the CCN family, is associated with invasive
chol-angiocarcinoma. Hepatology 2003;37:1122–1129.
91. Junttila MR, de Sauvage FJ. Influence of tumour
micro-environmentheterogeneity on therapeutic response. Nature
2013;501:346–354.
92. Sirica AE. The role of cancer-associated myofibroblasts in
intra-hepatic cholangiocarcinoma. Nat Rev Gastroenterol Hepatol
2012;9:44–54.
93. Kalluri R, Zeisberg M. Fibroblasts in cancer. Nat Rev Cancer
2006;6:392–401.
94. Dranoff JA, Wells RG. Portal fibroblasts: underappreciated
media-tors of biliary fibrosis. Hepatology 2010;51:1438–1444.
95. Okabe H, Beppu T, Hayashi H, et al. Hepatic stellate cells
may relateto progression of intrahepatic cholangiocarcinoma. Ann
Surg Oncol2009;16:2555–2564.
-
1228 RIZVI AND GORES GASTROENTEROLOGY Vol. 145, No. 6
REV
IEWS
AND
PER
SPEC
TIVES
96. Quante M, Tu SP, Tomita H, et al. Bone marrow-derived
myofibro-blasts contribute to the mesenchymal stem cell niche and
promotetumor growth. Cancer Cell 2011;19:257–272.
97. Li T, Li D, Cheng L, et al. Epithelial-mesenchymal
transition inducedby hepatitis C virus core protein in
cholangiocarcinoma. Ann SurgOncol 2010;17:1937–1944.
98. Sato Y, Harada K, Itatsu K, et al. Epithelial-mesenchymal
transitioninduced by transforming growth factor-{beta}1/Snail
activation ag-gravates invasive growth of cholangiocarcinoma. Am J
Pathol 2010;177:141–152.
99. Korita PV, Wakai T, Ajioka Y, et al. Aberrant expression of
vimentincorrelates with dedifferentiation and poor prognosis in
patientswith intrahepatic cholangiocarcinoma. Anticancer Res
2010;30:2279–2285.
100. Cadamuro M, Nardo G, Indraccolo S, et al. Platelet-derived
growthfactor-D and Rho GTPases regulate recruitment of
cancer-associated fibroblasts in cholangiocarcinoma. Hepatology
2013;58:1042–1053.
101. Fingas CD, Mertens JC, Razumilava N, et al. Targeting
PDGFR-betain cholangiocarcinoma. Liver Int 2012;32:400–409.
102. Utispan K, Thuwajit P, Abiko Y, et al. Gene expression
profiling ofcholangiocarcinoma-derived fibroblast reveals
alterations related totumor progression and indicates periostin as
a poor prognosticmarker. Mol Cancer 2010;9:13.
103. Baril P, Gangeswaran R, Mahon PC, et al. Periostin
promotesinvasiveness and resistance of pancreatic cancer cells to
hypoxia-induced cell death: role of the beta4 integrin and the PI3k
pathway.Oncogene 2007;26:2082–2094.
104. Menakongka A, Suthiphongchai T. Involvement of PI3K and
ERK1/2pathways in hepatocyte growth factor-induced
cholangiocarcinomacell invasion. World J Gastroenterol
2010;16:713–722.
105. Ohira S, SasakiM, HaradaK, et al. Possible regulation
ofmigration ofintrahepatic cholangiocarcinoma cells by interaction
of CXCR4expressed in carcinoma cells with tumor necrosis
factor-alpha andstromal-derived factor-1 released in stroma. Am J
Pathol 2006;168:1155–1168.
106. Leelawat K, Leelawat S, Narong S, et al. Roles of the
MEK1/2 andAKT pathways in CXCL12/CXCR4 induced cholangiocarcinoma
cellinvasion. World J Gastroenterol 2007;13:1561–1568.
107. Terada T, Okada Y, Nakanuma Y. Expression of
immunoreactivematrix metalloproteinases and tissue inhibitors of
matrix metal-loproteinases in human normal livers and primary liver
tumors.Hepatology 1996;23:1341–1344.
108. Prakobwong S, Yongvanit P, Hiraku Y, et al. Involvement of
MMP-9 inperibiliary fibrosis and cholangiocarcinogenesis via
Rac1-dependentDNA damage in a hamstermodel. Int J Cancer
2010;127:2576–2587.
109. Cohen SJ, Alpaugh RK, Palazzo I, et al. Fibroblast
activation proteinand its relationship to clinical outcome in
pancreatic adenocarci-noma. Pancreas 2008;37:154–158.
110. Mertens JC, Fingas CD, Christensen JD, et al. Therapeutic
effects ofdeleting cancer-associated fibroblasts in
cholangiocarcinoma.Cancer Res 2013;73:897–907.
111. Ko KS, Peng J, Yang H. Animal models of cholangiocarcinoma.
CurrOpin Gastroenterol 2013;29:312–318.
112. Fava G, Marucci L, Glaser S, et al. gamma-Aminobutyric acid
in-hibits cholangiocarcinoma growth by cyclic AMP-dependent
regu-lation of the protein kinase A/extracellular signal-regulated
kinase1/2 pathway. Cancer Res 2005;65:11437–11446.
113. Pawar P, Ma L, Byon CH, et al. Molecular mechanisms of
tamoxifentherapy for cholangiocarcinoma: role of calmodulin. Clin
CancerRes 2009;15:1288–1296.
114. Tang T, Zheng JW, Chen B, et al. Effects of targeting
magnetic drugnanoparticles on human cholangiocarcinoma xenografts
in nudemice. Hepatobiliary Pancreat Dis Int 2007;6:303–307.
115. Zhang J, Han C, Wu T. MicroRNA-26a promotes
chol-angiocarcinoma growth by activating beta-catenin.
Gastroenter-ology 2012;143:246–256 e8.
116. Olaru AV, Ghiaur G, Yamanaka S, et al. MicroRNA
down-regulated inhuman cholangiocarcinoma control cell cycle
through multiple
targets involved in the G1/S checkpoint. Hepatology
2011;54:2089–2098.
117. Zhang K, Chen D, Wang X, et al. RNA interference targeting
slugincreases cholangiocarcinoma cell sensitivity to cisplatin via
upre-gulating PUMA. Int J Mol Sci 2011;12:385–400.
118. Obchoei S, Weakley SM, Wongkham S, et al. Cyclophilin A
en-hances cell proliferation and tumor growth of liver
fluke-associatedcholangiocarcinoma. Mol Cancer 2011;10:102.
119. Hou YJ, Dong LW, Tan YX, et al. Inhibition of active
autophagy in-duces apoptosis and increases chemosensitivity in
chol-angiocarcinoma. Lab Invest 2011;91:1146–1157.
120. Xu X, Kobayashi S, Qiao W, et al. Induction of intrahepatic
chol-angiocellular carcinoma by liver-specific disruption of Smad4
andPten in mice. J Clin Invest 2006;116:1843–1852.
121. Farazi PA, Zeisberg M, Glickman J, et al. Chronic bile duct
injuryassociated with fibrotic matrix microenvironment provokes
chol-angiocarcinoma in p53-deficient mice. Cancer Res
2006;66:6622–6627.
122. Song H, Mak KK, Topol L, et al. Mammalian Mst1 and Mst2
ki-nases play essential roles in organ size control and tumor
sup-pression. Proc Natl Acad Sci U S A 2010;107:1431–1436.
123. Lee KP, Lee JH, Kim TS, et al. The Hippo-Salvador pathway
restrainshepatic oval cell proliferation, liver size, and liver
tumorigenesis.Proc Natl Acad Sci U S A 2010;107:8248–8253.
124. O’Dell MR, Huang JL, Whitney-Miller CL, et al. Kras(G12D)
and p53mutation cause primary intrahepatic cholangiocarcinoma.
CancerRes 2012;72:1557–1567.
125. Sirica AE, Zhang Z, Lai GH, et al. A novel “patient-like”
model ofcholangiocarcinoma progression based on bile duct
inoculation oftumorigenic rat cholangiocyte cell lines. Hepatology
2008;47:1178–1190.
126. Campbell DJ, Dumur CI, Lamour NF, et al. Novel organotypic
culturemodel of cholangiocarcinoma progression. Hepatol Res
2012;42:1119–1130.
127. Fava G, Alpini G, Rychlicki C, et al. Leptin enhances
chol-angiocarcinoma cell growth. Cancer Res 2008;68:6752–6761.
128. Yang H, Li TW, Peng J, et al. A mouse model of
cholestasis-associated cholangiocarcinoma and transcription factors
involvedin progression. Gastroenterology 2011;141:378–388, 388
e1–e4.
129. Plengsuriyakarn T, Eursitthichai V, Labbunruang N, et
al.Ultrasonography as a tool for monitoring the development
andprogression of cholangiocarcinoma in Opisthorchis
viverrini/dimethylnitrosamine-induced hamsters. Asian Pac J Cancer
Prev2012;13:87–90.
130. Yamasaki S. Intrahepatic cholangiocarcinoma: macroscopic
typeand stage classification. J Hepatobiliary Pancreat Surg
2003;10:288–291.
131. Rimola J, Forner A, Reig M, et al. Cholangiocarcinoma in
cirrhosis:absence of contrast washout in delayed phases by
magneticresonance imaging avoids misdiagnosis of hepatocellular
carci-noma. Hepatology 2009;50:791–798.
132. Vilgrain V. Staging cholangiocarcinoma by imaging studies.
HPB(Oxford) 2008;10:106–109.
133. Blechacz B, Gores GJ. Cholangiocarcinoma: advances in
patho-genesis, diagnosis, and treatment. Hepatology
2008;48:308–321.
134. Patel AH, Harnois DM, Klee GG, et al. The utility of CA
19-9 in thediagnoses of cholangiocarcinoma in patients without
primarysclerosing cholangitis. Am J Gastroenterol
2000;95:204–207.
135. Sapisochin G, Fidelman N, Roberts JP, et al. Mixed
hepatocellularcholangiocarcinoma and intrahepatic
cholangiocarcinoma in pa-tients undergoing transplantation for
hepatocellular carcinoma.Liver Transpl 2011;17:934–942.
136. Endo I, Gonen M, Yopp AC, et al. Intrahepatic
cholangiocarcinoma:rising frequency, improved survival, and
determinants of outcomeafter resection. Ann Surg
2008;248:84–96.
137. Choi SB, Kim KS, Choi JY, et al. The prognosis and survival
outcomeof intrahepatic cholangiocarcinoma following surgical
resection:
-
December 2013 CHOLANGIOCARCINOMA 1229
REV
IEW
SAND
PER
SPEC
TIVES
association of lymph node metastasis and lymph node
dissectionwith survival. Ann Surg Oncol 2009;16:3048–3056.
138. Li YY, Li H, Lv P, et al. Prognostic value of cirrhosis for
intrahepaticcholangiocarcinoma after surgical treatment. J
Gastrointest Surg2011;15:608–613.
139. Fabris L, Cadamuro M, Moserle L, et al. Nuclear expression
ofS100A4 calcium-binding protein increases
cholangiocarcinomainvasiveness and metastasization. Hepatology
2011;54:890–899.
140. Kuhlmann JB, Blum HE. Locoregional therapy for
chol-angiocarcinoma. Curr Opin Gastroenterol 2013;29:324–328.
141. Valle J, Wasan H, Palmer DH, et al. Cisplatin plus
gemcitabineversus gemcitabine for biliary tract cancer. N Engl J
Med 2010;362:1273–1281.
142. Yamashita Y, Takahashi M, Kanazawa S, et al. Hilar
chol-angiocarcinoma. An evaluation of subtypes with CT and
angiog-raphy. Acta Radiol 1992;33:351–355.
143. Heimbach JK, Sanchez W, Rosen CB, et al. Trans-peritoneal
fineneedle aspiration biopsy of hilar cholangiocarcinoma is
associatedwith disease dissemination. HPB (Oxford)
2011;13:356–360.
144. Moreno Luna LE, Kipp B, et al. Advanced cytologic
techniques forthe detection of malignant pancreatobiliary
strictures. Gastroen-terology 2006;131:1064–1072.
145. Barr Fritcher EG, Kipp BR, Voss JS, et al. Primary
sclerosing chol-angitis patients with serial polysomy fluorescence
in situ hybridi-zation results are at increased risk of
cholangiocarcinoma. Am JGastroenterol 2011;106:2023–2028.
146. Barr Fritcher EG, Voss JS, Jenkins SM, et al. Primary
sclerosingcholangitis with equivocal cytology: fluorescence in situ
hybridiza-tion and serum CA 19–9 predict risk of malignancy. Cancer
Cyto-pathol 2013. Epub ahead of print.
147. Nagorney DM, Kendrick ML. Hepatic resection in the
treatment ofhilar cholangiocarcinoma. Adv Surg 2006;40:159–171.
148. Darwish Murad S, Kim WR, Harnois DM, et al. Efficacy of
neo-adjuvant chemoradiation, followed by liver transplantation,
forperihilar cholangiocarcinoma at 12 US centers.
Gastroenterology2012;143:88–98 e3; quiz e14.
149. Hong JC, Jones CM, Duffy JP, et al. Comparative analysis
ofresection and liver transplantation for intrahepatic and hilar
chol-angiocarcinoma: a 24-year experience in a single center. Arch
Surg2011;146:683–689.
150. Geynisman DM, Catenacci DV. Toward personalized treatmentof
advanced biliary tract cancers. Discov Med 2012;14:41–57.
Received August 8, 2013. Accepted October 10, 2013.
Reprint requestsAddress requests for reprints to: Gregory J.
Gores, MD, Professor of
Medicine and Physiology, Mayo Clinic, 200 First Street
SW,Rochester, Minnesota 55905. e-mail: [email protected];fax:
(507) 284-0762.
AcknowledgmentsThe authors would like to thank Dr Thomas Smyrk
for kindly
providing the stromal cholangiocarcinoma photomicrograph and
MsCourtney Hoover for outstanding secretarial support.
Conflicts of interestThe authors disclose no conflicts.
FundingThis work was supported by National Institutes of Health
grants
DK59427 (G.J.G.) and T32 DK007198 (S.R.), and the Mayo
Foundation.
mailto:[email protected]
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