In contrast to extrahepatic cholangiocarcinoma (CC), the incidence of intrahepatic cholangiocarcinoma (ICC) has been steadily increased in Western countries not merely through improvement in diagnosis 1,2. In the UK, since the mid-1990s, ICC has overtaken hepatocellular carcinoma (HCC) as the leading cause of death because of a primary liver tumor 3. In addition to the two main associated conditions (cirrhosis and chronic bile duct disease), Shaib et al. 4 reported, in a recent large case–control study, that chronic liver disease because of alcohol or hepatitis C virus (HCV) infection, diabetes, and smoking were also risk factors of ICC. Both peripheral and hilar CC are considered to be ICC; however, they differ significantly in terms of clinicopathologic characteristics 5,6. In contrast to hilar ICC, similar to extrahepatic CCs, peripheral ICC is a tumor that originates within the small bile ducts with phenotypical characteristics similar to those of hepato-CCs or cytokeratin (CK) 19-positive HCC 7. Studies have reported different alterations in some tumor-suppressor genes and oncogenes 8,9 or have suggested a progenitor cell origin of this tumor 10. However, the characterization of the changes observed in the distant nontumoral liver specifically in this form has not been well described. These data could help to identify patients at risk and could provide insights into the potential process involved in this carcinogenesis. In the present study, we have investigated the clinical characteristic and histopathologic changes in the distant nontumoral liver in patients with peripheral ICC occurring in the absence of cirrhosis or chronic bile duct disease.
Patients and methods
This retrospective study included 382 patients living in France with ICC diagnosed between 1992 and March 2007 at Jean Verdier and Henri Mondor hospital. Of these, 91 patients had peripheral form. Thirty-four patients were excluded because of associated cirrhosis (n=21), chronic bile duct disease (n=4), mixed HCC–CC form (n=4), and distant nontumoral liver not available (n=3) or too small for adequate interpretation (n=2). Thus, 57 patients were included in this study (Fig. 1). Peripheral ICC was diagnosed on the basis of clinical and radiological data and confirmed by histology, according to the criteria of the WHO classification of tumors. The histological diagnosis of peripheral ICC was made on the basis of the histopathologic finding of a gland-forming neoplasm with variable amounts of fibrotic stroma separating the individual glands positive for CK 7 and negative for CK 20 and the exclusion of another primary source by a physical examination; contrast-enhanced computed tomography of the chest, abdomen, and pelvis, upper endoscopy, total colonoscopy, and mammography (for women) was also performed as appropriate.
Assessment of patient’s characteristics
Data on the history of primary liver cancer, autoimmune hepatitis, Wilson’s disease, α-1 antitrypsin deficiency, potential carcinogenic compound exposure, arterial hypertension, diabetes type 2, hyperlipidemia, and chronic alcohol intake were collected from the medical records of all patients. Metabolic syndrome was defined according to the OMS classification 11. Heavy chronic alcohol consumption was defined as a daily alcohol intake higher than 50 g/day of alcohol for more than 5 years. Tobacco smoking was reported as a binary response (yes or no). Hepatitis B surface antigen, HCV, and HIV antibodies were detected in the serum using standard procedures. Detection of the C282Y mutation of the HFE gene was carried out in case of suspicion of hemochromatosis. Only patients with diabetes type 2 diagnosed more than 1 year before the diagnosis of ICC were considered as diabetic. Patients receiving hypolipemic treatment or those with a total serum level of cholesterol and/or triglyceride higher than 6.4 and 1.80 mmol/l, respectively, were considered to have hyperlipidemia.
Histopathologic assessment of the nontumorous livers
In nonoperated patients, a liver biopsy at a distance from the tumor was systematically performed in addition to a biopsy of the tumor. In resected patients, the non-neoplastic tissue was evaluated only in areas distant from the tumor to avoid changes such as inflammation, cholestasis, and fibrosis caused by the proximity of the tumor itself. No patient had received chemotherapy at the time of liver biopsy or surgical resection. All liver specimens were fixed in formalin or Bouin’s liquid, embedded in paraffin, cut at 3 μm, and stained with hematoxylin–eosin–safran, picrosirius red, and Perl’s staining, and Gordon and Sweet for reticulin. The control group included specimen of distant nontumoral liver of patients with liver metastasis (colon, pancreas, breast, ovary, or chest) matched according to age and sex, obtained before chemotherapy. Histopathologic analysis was carried out simultaneously by two pathologists. Macrovesicular steatosis was graded as absent, mild (<10%), moderate (10–30%), and intense (>30%). Iron overload was assessed semiquantitatively according to the Searle classification and graded as follows: absent (granules absent or barely discernible), moderate (granules barely discernible, ×250; easily confirmed, ×400; or discrete granules resolved, ×100), and intense (discrete granules resolved, ×25; or masses visible, ×10; or the naked eye). Only hepatocyte iron overload was considered. The presence of a lesion of steatohepatitis as defined by Brunt 12 and fibrosis were assessed. We scored the stage of fibrosis as follows: stage 0=absence of fibrosis; stage 1=portal fibrosis without septa; stage 2=portal fibrosis with septa; stage 3=septal fibrosis without cirrhosis; and stage 4=cirrhosis 13. The presence of large liver cell dysplasia or glycogenic storing foci was also recorded.
Patients’ characteristics are shown in Table 1.
Fifty-seven White patients (60% male) with a mean age of 59.3±10 years and a mean BMI of 26.5±4 kg/m2 at the time of diagnosis were included in this study. The mean tumor size of the larger tumor was 70±40 mm in diameter. Elevated level of CA 19-9 (>40 UI/ml) was observed in 11 patients (20%) and elevated AFP (>15 ng/ml) in one patient; 18 patients had elevated ALT (>2 UN), 14 patients had elevated alkaline phosphatase, and 29 patients had level of GGT more than 2 UN. The risk factors of chronic liver injury were alcohol abuse [20 patients (20%)] and metabolic syndrome [22 patients (37%)] according to the OMS classification. Overweight/obesity and/or diabetes mellitus was observed in 37 patients (65%). Diabetes was treated by insulin (n=2), insulin secretagogues (n=12), metformin (n=2), or diet alone (n=6). Three patients had hereditary hemochromatosis (C282Y mutation) and were regularly iron depleted by phlebotomy. Three patients had viral B chronic infection, and two patients were HCV positive, including one patient with cutaneous porphyria tarda. Of the 50 patients with known tobacco habits, 22 patients had chronic tobacco consumption and two patients had a cutaneous porphyria tarda. One patient was working in an energy atomic center (Table 1).
Of the 57 consecutive nontumoral livers, 21 were needle biopsies and 36 were surgical specimens. No change was observed in 10 (18%) liver specimens. Macrovesicular steatosis more than 10% was observed in 38 cases (66%) and 11 cases (20%) had steatohepatitis. Hepatocyte iron overload was graded as moderate or intense in 22 cases (38%); two-thirds of the patients with hemochromatosis had no hepatic iron overload on biopsy. Glycogenic storage foci were found in 11 cases and large cell dysplasia in one case. Fibrosis was present in 16 patients (29%) and graded as F1 in 11 and F2 in five patients. Steatosis more than 10% associated with a moderate or an intense iron overload was observed in 20 (35%) patients. Details and comparison with the control group of histopathologic changes in the nontumoral liver are summarized in Table 2.
This study shows that ∼22% of the ICC seen in one medical and one surgical liver institution over a 16-year period are of the peripheral form and that, around two-thirds of this form occurred in patients without cirrhosis or chronic bile duct disease.
In those patients, we observed a high prevalence of risk factors of chronic liver disease and frequent histopathologic changes in the nontumoral liver, mainly macrovesicular steatosis and hepatocyte iron overload.
As in previous epidemiologic studies, we observed a higher prevalence of alcohol abuse, diabetes mellitus, hemochromatosis, and viral hepatitis in our series when compared with the general French population 14–17. We also found a high prevalence of the presence of metabolic syndrome. Overweight/obesity and diabetes were two and three times more frequent, respectively, in comparison with the general French population of the same age 18. In a large case–control study of patients older than 65 years of age, Welzel et al. 15 reported a higher rate of obesity in patients with ICC in comparison with those with extrahepatic cholangiocarcinoma, but in a large Danish case–control study, obesity did not attain statistical significance in comparison with the controls (6/758 in the ICC group and 12/3044 in the control group during the study period). This can in part be explained by the overall low prevalence of obesity and underestimation of the impact of weight as being overweight was not considered 14. Conversely, in a large epidemiologic cohort study reported by Calle et al. 19, obesity was strongly associated with mortality because of primary liver tumors, including CC.
As reported previously, we found a high prevalence of the hepatitis B virus and HCV infections. HCV RNA has been detected in ICC cells 17–20 and bile duct epithelial cell injuries with inflammation are frequent in the liver of patients with active HCV 21,22. In our series, hepatocyte iron overload was reported to be moderate to intense in 38% of patients, and our patients had predisposition factors of iron overload including hemochromatosis, cutaneous porphyria tarda, and alcoholic and nonalcoholic fatty liver diseases (NAFLDs). The direct role of iron overload in liver carcinogenesis is suspected. In the study by Morcos et al. 23 comparing primary liver occurring in patients with genetic hemochromatosis, the proportions of ICC, IHC–CCC, and HCC were 3/20, 4/20, and 13/20, respectively.
Macrovesicular steatosis associated or not with steatohepatitis was the other histopathologic change observed the most, and with predisposing factors such as alcohol abuse, diabetes, overweight/obesity, or hyperlipidemia. Thus, the clinical factors (alcohol abuse, overweight, iron overload, and viral infections) and histopathologic changes (macrovesicular steatosis and/or iron overload) observed in this study are superposables to what is reported in noncirrhotic Western patients who develop nonfibrolamellar HCCs 24–28. In the past, we have reported a prevalence of mild or moderate iron overload and macrovesicular steatosis in 68 and 67% of patients, respectively, and in 54 and 52% of patients in Bralet et al.’s 26 study of the nontumoral liver of patients who develop HCC in the absence of cirrhosis.
It has been shown that (a) peripheral ICC had similar molecular alterations to HCC-CC, and HCCs positive for CK 19 in Western patients, (b) HCC positive for CK 7 and 19 (suspected to originate from progenitor cells), mostly occur in noncirrhotic livers 29, and (c) some ICCs expressed hepatocyte progenitor markers 10. Therefore, it is tempting to speculate that iron overload, alcoholic liver disease (ALD), or NAFLD could predispose to ICC in a similar manner as for HCC in noncirrhotic Western patients. Interestingly, Paradis et al. 27 showed that HCC developed in patients with features of metabolic syndrome as the only risk factor of liver disease mainly occurs in the absence of significant fibrosis. If the role of steatohepatitis suggested in this study is confirmed by other large Western cohort series, one would expect an increased incidence of this tumor in the future because of the increasing incidence of obesity in Western countries. The role of iron depletion in this context should be determined in a randomized trial.
Our study has some limitations because of its retrospective nature. The assessment of alcohol consumption on the basis of medical records could have been underestimated and data on tobacco consumption were only bimodal. Data on the duration of exposure and the amount of tobacco use were not available. Also, the rate of noncirrhotic liver in our series was similar to those reported by others 5,30, and our study was carried out in medical and surgical liver centers, reducing the bias related to surgical or medical recruitment.
Patients with histological lesions of ALD and/or NAFLD, hepatosiderosis on liver biopsy may be considered at risk of peripheral ICC and should be managed accurately to reduce these lesions. Keeping in mind the high frequency of hepatosiderosis in NAFLD and ALD in patients with either CC or HCC 30, the possibility of iron depletion in this condition should be debated.
Conflicts of interest
There are no conflicts of interest.
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