Update on Biliary Neoplasms - Pathology · Biliary Neoplasms Arief Suriawinata, M.D. Professor of...
Transcript of Update on Biliary Neoplasms - Pathology · Biliary Neoplasms Arief Suriawinata, M.D. Professor of...
Update on Biliary Neoplasms
Arief Suriawinata, M.D.
Professor of Pathology and Laboratory Medicine
Geisel School of Medicine at Dartmouth
Department of Pathology and Laboratory Medicine
Dartmouth-Hitchcock Medical Center
Outline
• Update on epidemiology and clinical features
• Update on classification of biliary neoplasms
– Intrahepatic, perihilar and distal cholangiocarcinoma
– Cholangiolocarcinoma
– Intraductal papillary neoplasm of bile duct
– Intraductal tubulopapillary
• Update on pathogenesis, staging and treatment
– Histopathogenesis
– TNM
– Molecular pathogenesis and treatment
CholangiocarcinomaDefinition
Cholangiocarcinoma (CC) = adenocarcinoma arising from the
malignant transformation of bile duct epithelium anywhere along
the biliary tree from :
Small bile ducts and ductules
(intrahepatic CC)
Segmental to large bile ducts at hilum of
liver or outside of liver (extrahepatic CC)
Cholangioca in common bile ductBile duct & ductules
Cholangiocarcinoma
• Aggressive tumor
• “Silent” & advanced stage at presentation
• Anatomically difficult to access
• Highly desmoplastic & paucicellular
Epidemiology of CC
• 15-20% of primary liver malignancy in the U.S.
• Incidence rate*:
0.95 cases per 100,000 adults in U.S.0.2 cases per 100,000 adults in Australia96 cases per 100,000 men in Thailand*Incidence rate varies depending on local risk factors, genetics and classification
• U.S. SEER data – 3X increase of CC between 1975-99****Confirmed by data from Western Europe & Japan
• Inconsistent trends due to inconsistent classification
• Increase incidence of intrahepatic CC
Decrease incidence of carcinoma of unknown primary
Improvement on accuracy and availability of diagnostic tools
Cholangiocarcinoma
• Majority are de novo malignancy
• Definite risk factors– Primary sclerosing cholangitis
– Liver fluke infection (Opistorchis viverrini)
– Hepatolithiasis
– Biliary malformation (choledochal cysts, Caroli's diease)
– Thorotrast
• Probable risk factors– Liver fluke infection (Clonorchis sinensis)
– Hepatitis C
– Cirrhosis
– Toxins (dioxin, polyvinyl chloride)
– Biliary-enteric drainage procedures
Cholangiocarcinoma (CC)
Intrahepatic CC Extrahepatic CC
Peripheral CC = Peripheral ICC= Mass forming ICCSmall intrahepatic bile ducts, ductulesand canals of Hering
Perihilar CCSecond order bile duct
Hilar CC“Klatskin tumor”At or near junction of R and L hepatic ducts
Distal CCCommon bile duct
Classification of CholangiocarcinomaWHO vs UICC/AJCC
• Majority - no clear association with liver disease• Advanced liver disease/cirrhosis and chronic viral
hepatitis infection• Benign biliary lesions and malformations
• Primary sclerosing cholangilitis• Hepatolithiasis• Parasitic biliary infestation• Biliary malformations
Perihilar CCLobar extrahepaticbile duct
Intrahepatic CC (20%)Small intrahepatic bile ducts, ductules and canals of Hering, to second order bile ducts
Perihilar CC (50%)Second order bile ducts to cystic duct, incl. “Klatskintumor”
Distal CC (30%)Common bile duct
Blechaz, et al. Nat Rev Gastroenterol Hepatol. 2012
Classification of Cholangiocarcinoma
Extrahepatic CC
Classification of Intrahepatic Cholangiocarcinoma Based on Growth Pattern
Yamasaki S. Hepatobiliary Pancreat Surg. 2003
Mass forming type60%
Periductal infiltrating type20%
Mixed type20%
Blechaz, et al. Nat Rev Gastroenterol Hepatol. 2012
Histological Subtypes of Intrahepatic Cholangiocarcinoma
Large duct type
• Columnar cells with abundant mucin S100P+
• High CEA & CA19-9
• Perineural invasion, lymph node metastasis
• KRAS mutation
• Worse survival
Small duct type
• Cuboidal or low columnar cells with no or rare mucin
• N-cadherin +, NCAM +
• IDH 1&2 mutation, FGFR2 translocation
• Better survival
Hayashi, et al. Am J Surg Pathol 2016
ICC Small Duct Type
Hayashi, et al. Am J Surg Pathol 2016
Risk Factors of Intrahepatic CC
• Majority of patients had no associated liver
disease or cirrhosis – de novo
• Risk factors: primary sclerosing cholangitis,
inflammatory bowel diseases, nonspecific
cirrhosis, alcoholic liver disease, HCV infection
• Chronic hepatitis C virus is a risk factor for ICC
– HCV cirrhosis -> ~1000-fold increase of risk to develop HCC
Advanced chronic liver disease (including HBV) -> increase risk
Peripheral/Intrahepatic CC and Hepatitis C Infection
• Association between peripheral CC and HCV infection – 30-60%
• Gerber, et al (1997) – epithelial damage of small intrahepatic duct is a characteristic of HCV infection
• Torbenson, et al (2007) - 53% cases of bile duct dysplasia were in the setting of chronic HCV infection
• Other possibilities:
– infection of the ductular epithelium
– interface hepatitis – chronic inflammation of ductules and canals of Hering
HCV – interface hepatitis CK19 – bile ductules & canals of Hering
Intrahepatic CC and Hepatitis C Infection
Role of Hepatic Stem/Progenitor Cells
Recent studies have reported:
• HPC’s residing in canals of Hering can differentiate into
hepatocytes and cholangiocytes
• HPC’s are activated in most advanced chronic liver diseases
• Neural cell adhesion molecule (NCAM) is expressed in early
ductal development and disappears with maturation of bile
duct
– Ductular reaction often express NCAM
– Canals of Hering and ductular reaction are positive for c-kit (HPC
marker)
Canals of Hering and reactive bile ductules in advanced chronic liver disease are candidate for hepatic progenitor cells
Komuta M, et al: Hepatology 2008;47:1544-56
Cholangiolocellular carcinoma (CLC)
• Associated with HCC, cholangiocarcinoma or pure• “Mixed/combined HCC-CC, stem cell type”
Cholangiolocellular carcinoma (CLC)
CK7, CK19, N-CAM and p53 (+)
N-CAM p53
Cholangiolocellular Carcinoma vs. Mixed HCC-CC
• Mixed HCC-CCAs are heterogeneous– Classical & stem cell types
• Cholangiolocellular carcinoma is a distinct entity– Chromosomal instability, active TGF beta signaling
Moeni, et al. Journal of Hepatology 2017
Spectrum of Liver Tumors
HepatocyteStem cell
compartmentDuctule & small duct
Bile Duct
Other Etiology of Intrahepatic CC
• Malignant transformation of benign or
premalignant cholangiocellular lesions
– Biliary hamartoma/von Meyenburg complexes
– Bile duct adenoma
– Biliary adenofibroma
Perihilar Cholangiocarcinoma
• UICC/AJCC - Second order branch of bile ducts to cystic duct
– Includes “Klatskin tumor” (= hilar CC – WHO)
• Different biology and management
• Periductal-infiltrating form is the most common
– Perineural invasion and lymph node metastasis
• Painless jaundice and cholangitis, hypertrophy–atrophy complex
• Increased CA19-9, r/o IgG4 cholangiopathy
• Challenging tissue diagnosis
Intrahepatic CC • Small intrahepatic bile ducts,
ductules and canals of Hering• Mass forming
Perihilar CC • Large bile ducts• Associated with BilIN• Infiltrate along large bile ducts
Intrahepatic CC • Small intrahepatic bile ducts,
ductules and canals of Hering• Mass forming
Perihilar CC Large bile ducts• Associated with BilIN• Infiltrate along large bile ducts
Distal (Extrahepatic) Cholangiocarcinoma
• Tumor growing along the common bile duct between the cystic duct and the ampulla of Vater
– “cholangiocarcinoma” vs “bile duct carcinoma”
• Clinical presentation similar to perihilar CC
– Cholestasis, cholangitis
• Lymph node metastasis is less common than perihilar CC
Biliary Tract and Pancreas
• Close anatomical location and related embryology
– Ventral pancreas derives from biliary tract
• Share many features
– Peribiliary glands contains pancreatic acini and enzymes
– Similar lining epithelium
– Similar metaplastic changes (intestinal, gastric and oncocytic)
• Similar nonneoplastic and neoplastic diseases
Nakanuma Y, et al., 2013
Biliary Intraepithelial Neoplasia (BilIN)
• Analogous to other intraepithelial neoplasia– pancreas – PanIN, prostate – PIN
• Microscopic flat or low-papillary dysplastic epithelium, – Aka biliary dysplasia, atypical biliary epithelium, or carcinoma in situ
• Occurs more often in chronic biliary diseases - hepatolithiasis, choledochal cysts, and primary sclerosing cholangitis
• p21, p53, cyclin D1 and SMAD4 are involved in the carcinogenesis of BilIN, similar to PanIN
Biliary Intraepithelial Neoplasia (BilIN)
New two tier system Previous three tier system Dysplasia
BilIN low gradeBilIN-1 Mild
BilIN-2 Moderate dysplasia
BilIN high grade BilIN-3 Severe dysplasia = CIS
Benign BilIN
Invasive CaInvasive Ca
Intraductal Papillary Neoplasm of Bile Duct (IPNB)
• Analogous to IPMN of pancreas
• Dilated and cystic biliary system
• Multifocal papillary epithelial lesions
+/- mucin production
• Extrahepatic > intrahepatic bile duct
• May give rise to invasive carcinoma
(up to 74%)
• IPNB Type 1– Histologically similar to IPMN of the pancreas– Mucin production– Intrahepatic and hilar bile duct– Gastric > oncocytic>intestinal types– Less aggressive
• IPNB Type 2– Histologically different from IPMN of pancreas– Less mucin production– Extrahepatic bile duct– High grade, complex histological architecture with
irregular papillary branching or with foci of solid-tubular components
– More aggressive
Intraductal Tubulopapillary Neoplasm
• Analogous to ITPN of the pancreas
• Mass forming, exophytic, within biliary tree
• Intrahepatic (70%), perihilar (20%), extrahepatic (10%)
• Typical tubular pattern, solid, with abortive papillae & often necrosis
Katabi, et al. Am J Surg Pathol 2012 Schlitter, et al. Modern Pathology 2015
MUC1 +MUC2 –MUC6 +MUC5AC -
• Commonly associated with invasive tubular carcinoma (80%), but favorable prognosis
• Invasive carcinoma – small duct type > large duct type
• Mutations in KRAS, PIK3CA, and loss of SMAD4 are rare
• Overall combined survival rates showed favorable prognosis
Schlitter, et al. Modern Pathology 2015
Intraductal Tubulopapillary Neoplasm
Molecular Pathogenesis of Biliary Intraductal Lesions
Lining Epithelium
Peribiliary glands
Intraductal Papillary Neoplasm
KRAS, GNAS
Intraductal TubulopapillaryNeoplasm
PIK3CA, CDKN2A, p16
Invasive Carcinoma
KRAS-TP53Dependent
KRAS-TP53Independent
Biliary IntraepithelialNeoplasia
KRAS, p21, cyclin D1, SMAD4
Modified from Schlitter, et al. Modern Pathology 2015
2017 AJCC TNM Staging 8th EditionIntrahepatic Bile Ducts
T 2010 AJCC 7th Ed 2017 AJCC 8th Ed
T0 No evidence of primary tumor No evidence of primary tumor
Tis Carcinoma in situ (intraductal tumor) Carcinoma in situ (intraductal tumor)
T1 Solitary tumor without vascular invasion Solitary tumor without vascular invasion, ≤5cm or >5cm
T1a Solitary tumor ≤5cm without vascular invasion
Solitary tumor >5cm without vascular invasion
T2 Solitary tumor with intrahepatic vascular invasion or multiple tumors, with or without vascular invasion
T2a Solitary tumor with vascular invasion
T2b Multiple tumors, with or without vascularinvasion
T3 Tumor perforating visceral peritoneum Tumor perforating visceral peritoneum
T4 Tumor with periductal invasion Tumor involving localextrahepatic structures by direct invasion
2017 AJCC TNM Staging 8th EditionPerihilar Bile Ducts
T 2010 AJCC 7th Ed 2017 AJCC 8th Ed
T0 No evidence of primary tumor No evidence of primary tumor
Tis Carcinoma in situ Carcinoma in situ / high grade dysplasia
T1 Tumor confined to bile duct, with extension up to the muscle layer or fibrous tissue
Tumor confined to bile duct, with extension up to the muscle layer or fibrous tissue
T2a Tumor invades beyond the wall of bile duct to surrounding adipose tissue
Tumor invades beyond the wall of bile duct to surrounding adipose tissue
T2b Tumor invades adjacent hepatic parenchyma Tumor invades adjacent hepatic parenchyma
T3 Tumor invades unilateral branches of the portal vein or hepatic artery
Tumor invades unilateral branches of the portal vein or hepatic artery
T4 Tumor invades main portal vein or its branchesbilaterally; or the common hepatic artery; or the second-order biliary radicals bilaterally; or unilateral second order biliary radicals with contralateral portal vein or hepatic artery involvement
Tumor invades main portal vein or its branchesbilaterally; or the common hepatic artery; or unilateral second order biliary radicals with contralateral portal vein or hepatic artery involvement
2017 AJCC TNM Staging 8th EditionDistal Bile Ducts
T 2010 AJCC 7th Ed 2017 AJCC 8th Ed
T0 No evidence of primary tumor No evidence of primary tumor
Tis Carcinoma in situ Carcinoma in situ / high grade dysplasia
T1 Tumor confined to bile duct histologically Tumor invades the bile duct wall with a depth <5mm
T2 Tumor invades beyond the wall of bile duct Tumor invades the bile duct wall with a depth greater than 5-12mm
T3 Tumor invades the gallbladder, pancreas,duodenum or other adjacent organs without involvement of the celiac axis, or the superior mesenteric artery
Tumor invades the bile duct wall with a depth >12mm
T4 Tumor involves the celiac axis, or the superior mesenteric artery
Tumor involves the celiac axis, or the superior mesenteric artery, and/or common hepatic artery
Clinical Staging
• Tumor location
• Tumor growth pattern
• Size and number of intrahepatic masses
• Presence of vascular invasion
• Presence of cirrhosis
• Evaluation of biliary tree
• Metastasis
Clinical Staging
• Multiphasic contrast-enhanced CT
• MRI with MR cholangiopancreatography
• Cholangiography (PTC, ERCP, MRCP)
• PET/CT
HCC vs CCTumors > 2cm, vascular involvement
Evaluation of biliary treeBiliary brushing
Occult metastasis
Ancillary Diagnostic Tests• FISH polysomy on cytology brush specimen
– 1q21, 7p12, 8q24, and 9p21
– sensitivity 93%, specificity 100%
• Next generation sequencing
– KRAS, TP53, and CDKN2A
– sensitivity 85%
• miRNA on bile
– sensitivity 67%, specificity 96%
• Circulating tumor DNA (ctDNA)
– Differentially methylated regions on HOXA1, PRKCB, CYP26C1, and PTGDR
– sensitivity 83%, specificity 93%Barr Fritcher, et al. Gastroenterology 2015Dudley, et al. J Mol Diagn 2016Li, et al. Hepatology 2014Yang, et al. Gastroenterology 2017
Treatment for Intrahepatic CC
• Surgical resection remains the mainstay of potentially curative treatment
– Median disease free survival = 12-36mos
– Cirrhosis is an unfavorable independent factor
• Liver transplantation after neoadjuvant chemoradiationfor early stage peripheral CC
– 5 year survival for tumor <2cm = 65-73%
– 5 year survival for tumor >2cm or multiple = 45%
• Transarterial chemoembolization
• Radioembolization
• EB & IM radiotherapy
AdvancedUnresectable
Treatment for Perihilar CC
Rizvi, et al. Clinical Oncology 2018
Treatment of Distal CC
Rizvi, et al. Clinical Oncology 2018
Emerging Molecularly-directed Therapies
Rizvi, et al. Nature 2018