ARTICLE IN PRESS

Current Diagnostic Pathology (2007) 13, 54–64

www.elsevier.com/locate/cdip

REVIEW

Pathology of cholangiocarcinoma
Trishe Y.-M. Leonga, Pongsak Wannakrairotb, Eung Seok Leec,
Anthony S.-Y. Leongd,

a
Department of Anatomical Pathology, Monash Medical Centre, Victoria, Australia
b
Department of Pathology, Chulalongkorn University, Bangkok, Thailand
c
Department of Pathology, Ansan Hospital of Korea University, Ansan City, Gyeonggi-Do, South Korea
d
Division of Anatomical Pathology, Hunter Area Pathology Service, Newcastle, Australia

KEYWORDS Summary Cholangiocarcinoma, which is endemic in certain geographic regions,

Cholangiocarcinoma; shows a strong association with liver fluke infection and hepatolithiasis, with
Histopathology; recurrent inflammation and the high consumption of nitrates, nitrites, dimethylni-
Immunohistochemis- trosamines and N-nitropyrolidines as probable mutagenic cofactors. K-ras, p53 and
try; bcl-2 have been implicated in cholangiocarcinogenesis and several immunohistolo-
Intraductal papillary gical markers have been studied, although none is a reliable predictor of outcome.
carcinoma; Three macroscopic types of cholangiocarcinoma have been characterized and
Prognosis; implicated to be of prognostic relevance, but their behaviour might be a function of
Prognostic factors their anatomical location rather than a biological characteristic. Periductal-
infiltrating tumours present at an advanced stage with infiltration of the portal
pedicle. They arise closer to the hepatic hilum than mass-forming tumours, which
tend to be peripherally located and show portal invasion and intrahepatic
recurrence. The intraductal tumour shows the best prognosis, and long-term
survival has been reported. Poor prognostic factors include large tumour size,
multifocality, lymphovascular, perineural and serosal invasion, lymph node metas-
tases and involvement of resection margins. Survival following surgical resection,
the mainstay of treatment, is generally very poor.
& 2006 Elsevier Ltd. All rights reserved.

Introduction intrahepatic, perihilar and extrahepatic tumours

of the bile ducts.1 In the context of this discussion,
‘Cholangiocarcinoma’ was originally referred only however, ‘cholangiocarcinoma’ will mean only the
to primary tumours of the intrahepatic bile ducts malignant tumour arising from intrahepatic biliary
but the term is now regarded to encompass epithelium.

Corresponding author. Division of Anatomical Pathology,

Hunter Area Pathology Service, Newcastle 2310, Australia.
Epidemiology
Tel.: +612 4921 3042; fax: +612 4921 4440.
E-mail address: [email protected] The majority of bile-duct carcinomas arise in the
(A.S.-Y. Leong). extrahepatic ducts, with intrahepatic bile-duct

0968-6053/$ - see front matter & 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cdip.2006.07.006
 ARTICLE IN PRESS
Pathology of cholangiocarcinoma 55

carcinoma or cholangiocarcinoma making up hepatitis B virus2 and the common precursor cells
20–25%.1 Cholangiocarcinoma is second only to for both hepatocytes and cholangiocytes—the oval
hepatocellular carcinoma (HCC) as the most fre- cells—might be susceptible to the virus. HCV core
quent primary carcinoma in the liver.2 Most cases antigen has been demonstrated in proliferating
occur after the age of 60 years and present with bile-duct epithelium,15 which is known to derive
abdominal pain and weight loss; obstructive jaun- from oval cells. It is suggested that oval cells
dice is a late presentation. In some populations in infected with HCV acquire genetic changes asso-
which HCC is uncommon, such as Danish women, ciated with carcinogenesis and develop into cho-
cholangiocarcinoma is the most frequent primary langiocytes and carcinoma, the oval cells losing the
liver cancer. The two aetiological factors that virus as they differentiate into normal cholangio-
greatly influence the regional frequency of cholan- cytes.16
giocarcinoma are infection with liver fluke and Neoplastic transformation of the biliary epithe-
hepatolithiasis. The liver flukes Clonorchis sinensis, lium is accompanied by a number of molecular and
which is endemic in southern China and Korea, and genetic events that relate to the aetiological
Opisthorchis viverrini, endemic in north-eastern factors and predispose to increased proliferative
Thailand and Laos, have been demonstrated to be activity of the biliary epithelial cells. Mutations of
closely related to the high incidence of cholangio- the K-ras and p53 genes are the most common
carcinoma in these geographic regions.3–5 Whereas genetic abnormalities identified in cholangiocarci-
hepatolithiasis is an uncommon disease in the West, noma. The most frequently mutated position in the
it is endemic in Taiwan, China, Hong Kong and K-ras gene is codon 12, involving GGT (glycine) to
Korea,5–7 and the bile stasis and bacterial infection GAT (aspartic acid), and—less frequently—in codon
invariably associated with hepatolithiasis is con- 13, involving CAA (glutamine) to CAC (histidine).17
sidered to be the underlying cause of cholangio- The incidence of K-ras mutations is variable, being
carcinogenesis. as high as 100% in English patients and as low as 4%
Recurrent pyogenic cholangitis causes stenosis, in Thai patients, with Japanese, Taiwanese and
dilatation and facilitates calculi formation. It is Korean patients showing an intermediate inci-
often found in clonorchiasis7 but not in opisthorch- dence. This variable incidence of K-ras mutations
iasis. In addition to the necrosis and inflammation might correspond with the location of the bile-duct
associated with fluke infestation and cholangitis, carcinoma, as K-ras mutation is crucial for carci-
the consumption of foodstuffs with high levels nogenesis originating downstream of the biliary
of nitrates, nitrites, dimethylnitrosamines and tree. K-ras point mutation is also frequent in the
N-nitropyrolidines, which are found in the salted fish periductal-spreading type of tumour that originates
and fermented fish sauce that are widely consumed near the hepatic hilus.18 The different incidences
in Thailand and China, has been experimentally might also reflect the different aetiologies asso-
demonstrated to be a mutagenic cofactor.8–10 ciated with this tumour.
Patients with primary sclerosing cholangitis and p53 mutations are important in cholangiocarci-
ulcerative colitis have an increased association nogenesis and 25–75% of cases show overexpression
with cholangiocarcinoma and extrahepatic bile- of the protein.19,20 Dysfunction of this gene occurs
duct carcinoma11 and cholangiocarcinoma can either by mutation or mdm-2 gene amplification.
occasionally arise in biliary malformations, such Mutations occur between exons 5 and 8, most
as solitary or multiple liver cysts, Caroli disease, commonly as an A–G transition. The mutations are
congenital hepatic fibrosis and von Myenberg random with no specific hot spot, being mostly mis-
complexes. Anabolic steroids and Thorotrast have sense mutations and less frequently non-sense
been associated with this tumour.12 mutations.18 p53 initiates cell-cycle arrest and
Cirrhosis is associated with a 10-fold risk for suppresses bcl-2 expression, so that dysfunction of
cholangiocarcinoma compared with the general p53 affects both cell-cycle arrest and apoptosis.
population.1,2 In Western countries, the liver p53 can be stabilized by forming complexes with
harbouring cholangiocarcinoma is usually non-cir- other molecules, such as WAF-1 and mdm-2, both of
rhotic but 4.7% of 85 autopsy cases of cholangio- which are frequently detected in cases positive for
carcinoma in Japanese patients had non-biliary p53 protein.19
cirrhosis,13 and as many as 13.8% of Korean patients Bcl-2 protein is expressed in bile ductules and
with cholangiocarcinoma tested positive for hepa- interlobular bile ducts but not in large intrahepatic
titis C virus (HCV) compared with 3.5% of con- bile ducts. Resistance to apoptosis through altered
trols.14 The tumours in this setting were generally expression of members of the bcl-2 family has been
small and were frequently positive for HCV. In implicated as a mechanism that contributes to
Japan, HCV appears to be more oncogenic than neoplastic and malignant transformation. The bcl-2
 ARTICLE IN PRESS
56 T.Y.-M. Leong et al.

protein is generally expressed in bile-duct epithe- with a change to high density on the post-contrast
lium and cholangiocarcinoma, and a high bcl-2 scan. The mass-forming cholangiocarcinoma pro-
mRNA content has been found in most cases of duces a defined, expansive, rounded mass in the
cholangiocarcinoma,16 although the rate of over- liver parenchyma with spread as intrahepatic
expression has been variably reported, perhaps due metastases (Fig. 1). They are devoid of capsule
to different methods of detection. and show compression of biliary ducts. Occasion-
A number of other molecular alterations have ally, they exhibit biliary invasion with segmental
been speculated to have a role in cholangiocarci- bile-duct stenosis, or intraluminal growth. Micro-
nogenesis. Several cytokines, including interleukin- scopically, direct invasion of the bile-duct wall
6 (IL-6), hepatocyte growth factor (HGF), trans- and/or invasion along the portal pedicle is not a
forming growth factor-b, epidermal growth factor, feature of this type of tumour.22 Instead, mass-
c-erbB-2 and heterogeneous immunoglobulin A forming cholangiocarcinoma tends to invade the
have been described to have mitogenic or prolif- liver via the portal vein system to form intrahepatic
erative effects on biliary cells. For example, with metastatic nodules, and, at a later stage with
reactive proliferation, there is an up-regulation of increase in size, invades along Glisson’s capsule and
HGF and IL-6 in peribiliary stromal and haemato- lymph nodes via lymphatics.24
lymphoid cells, and their receptors met and IL-6R
protein are also upregulated in the biliary epithe-
Periductal-infiltrating type
lium. IL-6 stimulates DNA synthesis directly and
inhibits apoptosis. Non-neoplastic biliary epithe-
The periductal-infiltrating type of cholangiocarci-
lium that is stressed or injured has been shown in
noma is usually detected by ultrasound, which
vitro to produce and secrete IL-6, which can act in
shows biliary dilatation. A small tumour mass
an autocrine manner. Telomerase activity is ex-
central to the dilated peripheral segmental ducts
pressed in a heterogenous and focal manner in
might be detectable on CT scan and cholangiogra-
areas of dysplastic biliary epithelium and homo-
phy can help localize the involved segmental ducts.
genously in cholangiocarcinoma. In contrast, telo-
This tumour tends to originate in the hepatic hilar
merase signals are not found in non-dysplastic
area and extends mainly longitudinally along the
epithelial cells in hepatolithiasis and normal livers,
portal pedicle and bile ducts, and beneath Glisson’s
suggesting a role for telomerase activity at an early
capsule (Fig. 2). It is often associated with
stage in the development of cholangiocarcinoma.21
dilatation of the peripheral ducts. High-quality
cholangiograms can demonstrate the extent of
invasion by calibre changes with narrowing and/or
Macroscopic types rigidity of bile ducts, and there is also separation of
intrahepatic segmental ducts at the hepatic hilum.
Macroscopically, cholangiocarcinomas are firmer CT scans reveal a diffuse, low-density mass
and whiter than HCCs because of a greater amount that predominantly infiltrates along the portal
of fibrous stroma; they are often multicentric.
Three fundamental macroscopic types of cholan-
giocarcinoma have been recognized and are
suggested to correlate with prognosis, although
long-term data are lacking as the majority of
patients die within a few years of surgery.
Cholangiocarcinoma has been separated into: (1)
mass-forming (40–42%); (2) periductal-infiltrating
(8–20%) and (3) intraductal growth (8–14%) types. A
fourth category comprising mixtures of mass-form-
ing and periductal-infiltrating tumours makes up
the remaining 26–42% of cholangiocarcinoma.21–23

Mass-forming type

Preoperative imaging reveals the mass-forming Figure 1 Mass-forming cholangiocarcinoma in the left
type as a rounded tumour in a non-cirrhotic liver. lobe of the liver. Smaller, discrete tumour nodules are
Ultrasound usually reveals a hypo-echoic mass and also present in the rest of the left lobe and there is
pre-contrast CT scan shows a low-density tumour, dilatation of bile ducts and some periductal extension.
 ARTICLE IN PRESS
Pathology of cholangiocarcinoma 57

respectively.26 Mass-forming tumours were fre-

quently associated with remnant hepatic recur-
rences, whereas periductal-infiltrating cholangio-
carcinomas produced strictures or obstruction of
intrahepatic bile ducts, and following excision,
seldom resulted in remnant liver recurrence.21,27
Tumours of the mixed mass-forming and periductal
infiltration type had shorter survivals compared to
those of mass-forming types, and showed a greater
association with perineural invasion, lymphatic
invasion and nodal metastasis, positive resection
margins and portal vein thrombosis.26,27 The
Figure 2 Periductal-infiltrating type arising close to the
curative resection rate was significantly lower in
hilum of the liver. Note the linear extension along bile
ducts with periductal nodular infiltration. There is also
patients with mixed mass-forming and periductal-
distinct spread beneath Glisson’s capsule (arrows). infiltrating tumours than those with either mass-
forming or intraductal tumours alone.21
The intraductal type of cholangiocarcinoma is
confined within the dilated portion of the bile duct
pedicle.22 Macroscopically, the whitish-yellow tu- with abundant mucocele-like distensions of the
mour can often be shown to encircle or infiltrate obstructed distal branches and little or no exten-
large vessels in the portal pedicle. Besides peri- sion beyond the confines of the biliary system.28,29
portal infiltration, this tumour type invades along Long-term survivors with intraductal tumours have
Glisson’s capsule via the lymphatics, and shows a been reported following resection30,31 and this
low incidence of portal vein infiltration.24 tumour is considered to be analogous histologically
and phenotypically to intraductal papillary muci-
nous neoplasm of the pancreas with a similar slowly
Intraductal growth type progressive course.32

The intraductal growth type of cholangiocarcinoma

is associated with marked biliary dilatation and/or Mixed mass-forming and periductal-
cystic lesions that are readily detected by ultra- infiltrating type
sound or CT scan. However, determination of the
extent of this tumour is difficult because of the This mixed type shows a combination of the
ambiguity caused by the abundant mucin secreted characteristics of both mass-forming and periduc-
and also by the superficial mucosal spread along the tal-infiltrating tumours.
bile duct, which is a characteristic of this tumour.
Cholangiography reveals polypoid tumours and
abundant mucin that produce filling defects in the Other macroscopic types
biliary tract. Macroscopically, the polypoid tumours
have a reddish granular appearance and are largely A rare multicystic type of cholangiocarcinoma
contained within dilated bile ducts. Biliary stones accounting for o1% of cholangiocarcinomas has
might be present25 and obstructed ducts can been described.33,34 This tumour type can be
become cystic. Smaller tumour nodules can be grossly differentiated from biliary mucinous cysta-
seen around the dilated ducts and these represent denocarcinoma and the intraductal cholangiocarci-
tumour invasion or adenomatous hyperplasia of noma. Biliary mucinous cystadenocarcinoma forms
periductal glands. larger multiloculated cysts with thick fibrous walls
Prognosis is reported to be influenced by the containing an ovarian-like mesenchymal stroma,
macroscopic appearance of the tumour, which also especially in female patients. By contrast, the
determines the extent and type of surgical resec- highly aggressive and rapidly progressing multi-
tion. The intraductal growth type has been de- cystic cholangiocarcinoma presents as multiple
scribed to have the best outcome, followed by the small irregular mucin-filled cysts that produce a
mass-forming type, and the periductal-infiltrating honeycomb appearance and has a lining of varying
type, with 10-year survival for the intraductal numbers of tumour cells that range from papillary
growth type of 58%, and 3- and 5-year survival to signet ring in appearance. There is also frequent
rates for the mass-forming and periductal-infiltrat- invasion into the hepatic parenchyma and this
ing types of 40 and 21%, and 26 and 7%, tumour is often admixed with peribiliary glands,
 ARTICLE IN PRESS
58 T.Y.-M. Leong et al.

suggesting that this might be the source of the

tumour.34,35
The hepatic parenchyma in cholangiocarcinoma
is often not cirrhotic but might display a fine
nodularity as a result of the portal fibrosis that
accompanies chronic cholangitis. Dilatation of the
biliary tree might be evident from tumour obstruc-
tion and stenosis.

Histological types

The World Health Organization classifies the histo-

logical types of cholangiocarcinoma as: adenocar-
cinoma, adenosquamous and squamous carcinoma, Figure 3 Cholangiocarcinoma showing marked variability
cholangiocellular carcinoma, lymphoepithelioma- in differentiation. Glandular structures are visible in the
left lower field, whereas the tumour infiltrating the
like carcinoma, clear-cell variant and mucoepider-
hepatic cords is composed of poorly differentiated non-
moid carcinoma.17 cohesive epithelial cells and some poorly formed tubular
Adenocarcinoma is by far the most common, structures. Note the desmoplastic response of fibroblasts
making up 90% in one series. It can be of varying and inflammatory cells.
grades of differentiation, with remote metastases
being observed more frequently in less-differen-
tiated tumours.36 Adenocarcinomas are character-
ized by a tubular, acinar or trabecular pattern
formed of columnar or cuboidal cells. Nuclei are
vesicular and contain discernable nucleoli that are
generally not as prominent and eosinophilic as in
HCC. The cytoplasm is usually pale, eosinophilic or
vacuolated; it can be clear and abundant or
resemble goblet cells. Cord-like or micropapillary
patterns are also seen and the degree of differ-
entiation is variable, so that pleomorphic tumour
cells might predominate, especially within invasive
foci (Fig. 3). When large ducts are involved,
intraductal papillary and micropapillary formations
of tumour with intraductal spread might be seen,
but when there is invasion beyond the duct wall,
the tumour cells tend to be moderately or poorly Figure 4 Poorly differentiated cholangiocarcinoma com-
differentiated (Fig. 4) and associated with a posed of polygonal cells with ill-defined tubular struc-
marked desmoplastic response (Fig. 5) with con- tures. The tumour cells have eosinophilic cytoplasm and
striction or obliteration of the duct lumen. The vesicular nuclei with coarsely clumped chromatin and
tumour cells are often mucin secreting and are small nucleoli.
PAS-diastase positive. The intraductal papillary
carcinoma shows papillary projections of true lation does not occur. Lymphovascular and peri-
fibrovascular cores covered by well-differentiated neural invasion can be seen, especially in large
columnar to cuboidal tumour cells. portal tracts. Varying degrees of atypia can be
Cholangiocarcinoma is frequently associated with found in the epithelium lining dilated ducts
a marked desmoplastic response of abundant adjacent to the tumour, especially in the intraduc-
fibrous stroma, which can be focally calcified, and tal type (Fig. 7), and the transition from benign to
there is frequently an accompanying acute on dysplastic to frankly neoplastic epithelium can
chronic inflammatory reaction (Fig. 6). Mucin and sometimes be difficult to demarcate.
bile might be incorporated in the stroma and the Most of the other histological types of cholangio-
tumour can abut directly onto hepatocytes and carcinoma are variations of adenocarcinoma. Abun-
infiltrate along adjacent portal tracts so that they dant mucin can be produced in mucinous carcinoma
mimic non-neoplastic bile ducts. Fibrous encapsu- and a clear-cell variant exists in which the
 ARTICLE IN PRESS
Pathology of cholangiocarcinoma 59

cinomas are very rare tumours in which the

adenocarcinoma is associated with areas of un-
differentiated lymphoepitheliomatous lesions in
which Epstein-bar-virus-coded nuclear RNA is de-
monstrable.37

Differential diagnosis

Cholangiocarcinoma requires distinction from HCC

and metastatic carcinoma.38 The presence of a
marked stromal fibroblastic response with accom-
panying acute on chronic inflammation helps
separation from the other entities. Whereas duct
dilation might be the result of obstruction from
Figure 5 Marked desmoplasia is present and the dense metastatic lesions and HCC, the presence of varying
fibrous stroma contains entrapped tumour with mucin degrees of atypia in the biliary epithelium is a
and inflammatory cells. pointer to cholangiocarcinoma.39 Cholangiocarci-
noma can grow in a cord-like manner similar to the
trabeculae of HCC, but the cords are always
separated by connective tissue stroma rather than
by sinusoids, and canaliculi and bile are also
absent. Cholangiocarcinoma, like their benign
counterparts, stain for CK7 and CK19 but HCC is
seldom positive. HepPar1, a marker of hepatocytes,
is immunoexpressed by HCC but not cholangiocar-
cinoma or metastatic carcinoma40 (Fig. 9) and CD34
demonstrates the characteristic arterialization of
sinusoids in HCC, but not in cholangiocarcinoma or
metastatic deposits (Fig. 10). CD10 and polyclonal
carcinoembryonic antigen help identify bile cana-
liculi among benign and neoplastic hepatocytes.38
CK20 immunoexpression identifies metastasis from
the gastrointestinal tract and CK7 is more common
in cholangiocarcinoma. Combined HCC and cholan-
Figure 6 Cholangiocarcinoma with desmoplasia and a
giocarcinoma retain features of both tumours and
marked acute inflammatory response that commonly
their characteristic immunophenotype (Fig. 10).
accompanies this tumour.
Other markers to distinguish HCC from cholan-
giocarcinoma and metastatic carcinoma, such as
neoplastic cells of the tubules have clear cytoplasm
a-fetoprotein, are of limited use.38,41 Periductal
that contains mucin. The signet-ring type of
extension of cholangiocarcinoma can be difficult to
cholangiocarcinoma is characterized by a predomi-
distinguish from sclerosing cholangitis, especially in
nance of discrete non-cohesive tumours cells that
needle-core biopsies, and is largely dependent on
contain mucin vacuoles and show displaced cres-
the presence of severe cytological atypia, archi-
centic nuclei, but cholangiocarcinomas composed
tectural atypia and the presence of lymphovascular
only of signet-ring cells are very rare. Adenosqua-
and perineural invasion.
mous and squamous-cell carcinomas show varying
proportions of tumour, with squamous cells identi-
fied either by the presence of epithelial pearls or
intercellular bridges. A mucoepidermoid subtype Treatment and prognosis
similar to that in the salivary glands is also found.
Poorly differentiated cholangiocarcinomas can Surgical resection remains the mainstay of treat-
show varying areas of tumour with spindled ment, although prognosis after resection is poor
morphology and, when such areas predominate, compared with that of HCC. Early detection of
they can mimic fibrosarcoma or malignant fibrous cholangiocarcinoma is difficult and survival de-
histiocytoma and are called sarcomatous cholan- pends largely on the feasibility of complete surgical
giocarcinoma (Fig. 8). Lymphoepithelioma-like car- resection, with highest survival among patients
 ARTICLE IN PRESS
60 T.Y.-M. Leong et al.

Figure 7 Intraductal growth type of cholangiocarcinoma with papillary growths of atypical cells contained within a
dilated duct (left panel). The adjacent ducts display varying degrees of hyperplasia with tufting and pseudostratifica-
tion of the epithelium which is lined by columnar cells with elongated, hyperchromatic nuclei (right panel).

Figure 8 Sarcomatoid cholangiocarcinoma. The tumour Figure 9 Cholangiocarcinoma in which HepPar1 stains
cells stained positive for CK19 and negative for HepPar1 the hepatocytes but not the cholangiocarcinoma cells.
(not shown).

with negative resection margins. The 5-year survi- quently the periductal-infiltrating and mixed mass-
val for cholangiocarcinoma is 9–18% and is reported forming and periductal-infiltrating types) show a
to vary with site and macroscopic type of cholan- median survival of 12–24 months, compared with
giocarcinoma.1 Those with hilar involvement (fre- 18–30 months for those without hilar involvement
 ARTICLE IN PRESS
Pathology of cholangiocarcinoma 61

well-differentiated group. Contemporary textbooks

do not grade cholangiocarcinomas.12,42 Tumour
size, multifocality, lymphovascular, perineural and
serous membrane invasion, lymph node metastasis
and involvement of resection margins are recog-
nized to be poor prognostic indicators.23,25
The intraductal growth type43 is recognized to be
a subtype of cholangiocarcinoma with a relatively
better prognosis.26,44 When employed as a micro-
scopic criterion, defined as cancer cells growing in
a papillary fashion into the lumen of large bile
duct, this finding was also found to be a good
prognostic factor in a recent multivariate analysis
of 35 patients with cholangiocarcinoma.45
The literature suggests that mass-forming tu-
Figure 10 CD34 staining in a combined hepatocellular mours have better outcomes than periductal-
carcinoma (HCC)-cholangiocarcinoma. There is staining infiltrating tumours.23,26,29 The difference might
of the arterialized sinusoids in the HCC in the upper left
reflect the anatomical location rather than specific
field, whereas the cholangiocarcinoma does not show this
sinusoidal pattern of vessels (arrows).
biological differences. Periductal-infiltrating tu-
mours tend to originate from major ducts near
the hilum and their location results in interstitial
infiltration or lymphatic extension of the portal
(frequently mass-forming type), although 5-year pedicle, which can lead to obstructive jaundice and
survivals of up to 40% have been reported for an advanced stage at presentation. The same is
intrahepatic cholangiocarcinoma in Japan,1 espe- observed with the mixed mass-forming and peri-
cially since the advent of an increasingly radical ductal-infiltrating cholangiocarcinoma. By con-
approach over the past 10 years. However, peri- trast, mass-forming tumours originate from small,
operative mortality has also risen, with more peripheral bile ducts and invade the adjacent liver
extensive operations than wide local excisions. parenchyma directly through the sinusoids with
Regional lymph-node metastases are common with minimal portal pedicle involvement.35 Infiltration
hilar cholangiocarcinomas but there is no evidence of the porta hepatis makes complete resection very
that extended nodal dissection improves survival. difficult and it has been shown that the outcome
Liver transplantation for unresectable tumours is following resection of such centrally located
currently contraindicated because of a high recur- tumours was significantly poorer than peripherally
rence rate—of up to 90%—within 2 years, although located tumours because complete clearance was
long-term survival has been recorded in carefully more difficult to achieve.29 This finding suggests
selected patients.1 There is no evidence to support that anatomical location is a more important
post-surgical adjuvant chemotherapy or radiation prognostic criterion, as central lesions that infil-
therapy outside a clinical trial setting.1 trate the hepatic hilum are more often of the
Besides the macroscopic appearance, histological periductal-infiltrating or mixed types, and not the
grading of the adenocarcinoma is said to provide mass-forming lesions, which are frequently periph-
some indication of prognosis with those tumours eral in location. It seems unlikely that the macro-
displaying well-differentiated features showing a scopic types have specific biological properties,
better outcome than those with moderate and poor particularly when mixtures of the two main types
differentiation.17 There is often marked hetero- are the most common, making up 26–42% of
geneity of differentiation within the same tumour cholangiocarcinomas. Furthermore, cholangiocar-
and our review of the English literature fails to cinoma shows infiltration of both intrahepatic and
provide convincing evidence that histological grad- extrahepatic tissues at an early stage of the
ing is reproducible or of prognostic relevance. tumour,46,47 so that stage of disease rapidly super-
Nakajima et al.36 suggested that well-differen- sedes histological grading of the tumour.
tiated adenocarcinomas were most frequent (90%)
and were associated with a low incidence of
remote-organ metastases than less-differentiated Immunohistological markers
tumours. However, their groupings were based on
nine histological types of cholangiocarcinoma and The immunoexpression of a number of proteins has
heterogenous entities were included among the been studied to identify surrogate markers that
 ARTICLE IN PRESS
62 T.Y.-M. Leong et al.

might predict the behaviour of cholangiocarcinoma.  K-ras, p53 and bcl-2 genes are implicated in
However, like other clinicopathological factors stu- cholangiocarcinogenesis.
died to date, this suffers from the drawback that the  Three fundamental macroscopic types of
correlations are weak because long-term survival cholangiocarcinoma are recognized: mass-
following resection for this tumour is poor. A forming, periductal-infiltrating and intra-
significant correlation between overexpression of ductal growth types. All have distinct
HER2/neu and lymph-node metastasis has been anatomical locations and patterns of
noted,48 and we have shown that overexpression of spread.
HER2/neu correlated with nuclear translocation of b-  Microscopic types include adenocarcinoma,
catenin and that both markers were significantly adenosquamous and squamous carcinoma,
correlated with high histological grade and high and uncommon subtypes.
Ki-67 index in 31 cases of cholangiocarcinoma. In  Tumours tend to show heterogenous differ-
addition, reduced immunoexpression of FAT, a newly entiation with poor differentiation in in-
described member of the cadherin superfamily, and vasive foci. Marked desmoplasia and
of E-cadherin at their normal membranous location inflammation are commonly present.
might be potential markers of poor prognosis.49  Differential diagnoses include HCC and
Overexpression of c-Met, the receptor for HGF, metastatic carcinoma, and distinction is
has been suggested to be of prognostic relevance made on cytomorphology with aid of im-
and an indicator of longer survival compared to munohistochemistry.
those tumours that were c-Met negative.50 The  Except for the intraductal growth type,
immunoexpression of CDX2 and MUC2 has been prognosis is generally very poor and pre-
employed to help identify tumours of the intra- sentation is often at advanced stage.
ductal papillary type,32 and MUC2 is suggested to  Prognostic factors include tumour size,
be a good prognostic marker associated with bile- multifocality, lymphovascular, perineural
duct cystadenocarcinoma and intraductal and/or and serous membrane invasion, lymph node
periductal-infiltrating tumours compared with low metastasis, involvement of resection mar-
expression in mass-forming cholangiocarcinoma.51 gins and importantly macroscopic type. The
In contrast, MUC1 expression correlated with mass- latter most is likely due to the location of
forming tumours and poor patient outcome.51,52 the tumour rather than to a specific
K-ras and p53 mutations have been reported to biological property.
correlate with the gross morphologic type of  Immunohistological markers of potential
cholangiocarcinoma with a higher prevalence of prognostic relevance include Her2/neu, Ki-
K-ras alterations in the periductal-infiltrating type 67, MUC2, MUC4, c-Met, bcl-2, cyclin D1,
compared to the slower growing mass-forming k-ras and p53.
type, whereas p53 mutations were very common
in the latter tumour.53,54
A number of other immunohistochemical markers Research directions
have been studied in an attempt to identify those
of potential prognostic significance. These include  Prevention, especially in geographic regions
bcl-2, transforming growth factor-b, telomerase,20 with established aetiological associations.
MUC4,55 p275556 and cyclin D157; none has yet  Development of investigations for earlier
proven reliable. detection.
 Search for immunohistological and molecu-
Practice points lar markers of prognostic relevance.

 The incidence of intrahepatic cholangiocar-

cinoma is highest in Thailand, China, Korea,
Hong Kong and Japan.
 Liver fluke infection and hepatolithiasis are References
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