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Supplementary figure 1-2: Fig. S1. Fas mRNA in HCC cell lines and the effects of HuR knockdown on alternative Fas splicing. Fig S2. Effect of HuR knock-down on FasL-induced apoptosis in HepG2 cells.

Supplementary figure legends and materials

We conducted this study to characterize the incidence, clinical features, treatment, and outcomes of immune checkpoint inhibitor (ICI) hepatotoxicity.Patients who received ICIs (with either single-agent or combination regimens) from January 1, 2010, to March 31, 2018, were identified. Hepatotoxicity was defined as alanine aminotransferase (ALT)5 times the upper limit of normal (ULN), in the absence of an alternate cause, and categorized as grade 3 (ALT 5-20× ULN) or grade 4 (ALT20× ULN), according to Common Terminology Criteria for Adverse Events 4.03.Among 5,762 patients, 100 (2%) developed hepatotoxicity, occurring in a higher proportion of recipients of combination therapy (9.2%) compared with monotherapy (up to 1.7%, P0.001). ICIs were discontinued permanently in 69 and temporarily in 31 patients. Sixty-seven patients received steroids, 10 of whom (14%) had recurrent hepatotoxicity after the steroid taper. Thirty-one patients resumed ICIs after ALT improvement, 8 of whom (26%) developed recurrent hepatotoxicity. Characteristics of liver injury, response to steroids, and outcomes were similar between 38 individuals with and 62 without possible pre-existing liver disease. The severity and outcome of hepatotoxicity due to combination therapy were not significantly different from monotherapy. There were 36 deaths. Two had liver failure at the time of death, both with progression of liver metastases and grade 3 hepatotoxicity.Clinically significant ICI-related hepatotoxicity was uncommon but led to permanent ICI discontinuation in the majority. ICIs were restarted in a sizable proportion of patients, most of whom did not experience recurrent hepatotoxicity.

Background and study aims Endoscopic mucosal resection (EMR) is safe and cost-effective in management of patients with colon polyps. However, very little is known about the actions of the referring endoscopist following identification of these lesions at index colonoscopy, and the impact of those actions on the outcome of subsequent referral for EMR. The aim of this study was to identify practices at index colonoscopy that lead to failure of subsequent EMR. Patients and methods Two hundred and eighty-nine consecutive patients with biopsy-proven non-malignant colon polyps (> 20 mm) referred for EMR were analyzed to identify practices that could be improved from the time of identifying the lesion at index colonoscopy until completion of therapy. Results EMR was abandoned at colonoscopy at the EMR center in 71 of 289 patients (24.6 %). Reasons for abandoning EMR included diagnosis of invasive carcinoma (n = 9; 12.7 %), tethered lesions (n = 21; 29.6 %) from prior endoscopic interventions, and overly large (n = 22; 31 %) and inaccessible lesions (n = 17; 24 %) for complete and safe resection whose details were not recorded in the referring endoscopy report, or polyposis syndromes (n = 2; 2.8 %) that were not recognized. Conclusions In our practice, one in four EMR attempts were abandoned as a result of inadequate diagnosis or management by the referring endoscopist, which could be improved by education on optical diagnosis of polyps, comprehensive documentation of the procedure and avoidance of interventions that preclude resection.

Cholangiocarcinoma (CCA) is the second most common primary malignancy. Although it is more common in Asia, its incidence in Europe and North America has significantly increased in recent decades. The prognosis of CCA is dismal. Surgery is the only potentially curative treatment, but the majority of patients present with advanced stage disease, and recurrence after resection is common. Over the last two decades, our understanding of the molecular biology of this malignancy has increased tremendously, diagnostic techniques have evolved, and novel therapeutic approaches have been established. This review discusses the changing epidemiologic trends and provides an overview of newly identified etiologic risk factors for CCA. Furthermore, the molecular pathogenesis is discussed as well as the influence of etiology and biliary location on the mutational landscape of CCA. This review provides an overview of the diagnostic evaluation of CCA and its staging systems. Finally, new therapeutic options are critically reviewed, and future therapeutic strategies discussed.

Exposure to genotoxins such as ethanol-derived acetaldehyde leads to DNA damage and liver injury, and promotes the development of cancer. We report here a major role for the TGF-β/Smad3 adaptor β2-Spectrin (β2SP, gene Sptbn1) in maintaining genomic stability following alcohol-induced DNA damage. β2SP supports DNA repair through β2SP-dependent activation of Fancd2, a core component of the Fanconi anemia complex. Loss of β2SP leads to decreased Fancd2 levels and sensitizes β2SP mutants to DNA damage by ethanol treatment, leading to phenotypes that closely resemble those observed in animals lacking both Aldh2 and Fancd2, and resemble human fetal alcohol syndrome. Sptbn1-deficient cells are hypersensitive to DNA cross-linking agents, and have defective DNA double-strand break repair that is rescued by ectopic Fancd2 expression. Moreover, Fancd2 transcription in response to DNA damage/TGF-β stimulation is regulated by the β2SP/Smad3 complex. Thus, dysfunctional TGF-β/β2SP signaling impacts the processing of genotoxic metabolites by altering the Fanconi anemia DNA repair pathway. This article is protected by copyright. All rights reserved.

Hepatocellular carcinoma (HCC) is globally the second most common cause of cancer mortality. The majority of HCC patients are diagnosed at advanced stage disease for which no curative treatments exist. TGF-β has been identified as a potential therapeutic target. However, the molecular mechanisms mediating its functional switch from a tumor suppressor to tumor promoter in HCC and its interactions with other signaling pathways are poorly understood. Here, we demonstrate an aberrant molecular network between the TGF-β and c-KIT pathway that mediates the functional switch of TGF-β to a driver of tumor progression in HCC. TGF-β/SMAD2 signaling transcriptionally regulates expression of the c-KIT receptor ligand (stem cell factor [SCF]) with subsequent auto- and paracrine activation of c-KIT/JAK1/STAT3 signaling. SCF induces TGF-β1 ligand expression via STAT3, thereby forming a positive feedback loop between TGF-β/SMAD and SCF/c-KIT signaling. This network neutralizes TGF-β–mediated cell cycle inhibition and induces tumor cell proliferation, epithelial-to-mesenchymal-transition, migration, and invasion. Disruption of this feedback loop inhibits TGF-β tumor-promoting effects and restores its antiproliferative functions. Consistent with our in vitro data, we demonstrate SCF overexpression and its correlation to SMAD2 and STAT3 activation in human HCC tumors, advanced tumor-node-metastasis stages, and shorter survival. CONCLUSIONS: Canonical TGF-β and c-KIT signaling forms a positive, tumor-promoting feedback loop. Disruption of this loop restores TGF-β tumor suppressor function and provides the rationale for targeting the TGF-β/SCF axis as a novel therapeutic strategy for HCC.

Background and Aims The adenoma detection rate (ADR) is a quality metric tied to interval colon cancer occurrence. However, manual extraction of data to calculate and track the ADR in clinical practice is labor-intensive. To overcome this difficulty, we developed a natural language processing (NLP) method to identify adenomas and sessile serrated adenomas (SSAs) in patients undergoing their first screening colonoscopy. We compared the NLP-generated results with that of manual data extraction to test the accuracy of NLP and report on colonoscopy quality metrics using NLP. Methods Identification of screening colonoscopies using NLP was compared with that using the manual method for 12,748 patients who underwent colonoscopies from July 2010 to February 2013. Also, identification of adenomas and SSAs using NLP was compared with that using the manual method with 2259 matched patient records. Colonoscopy ADRs using these methods were generated for each physician. Results NLP correctly identified 91.3% of the screening examinations, whereas the manual method identified 87.8% of them. Both the manual method and NLP correctly identified examinations of patients with adenomas and SSAs in the matched records almost perfectly. Both NLP and the manual method produced comparable values for ADRs for each endoscopist and for the group as a whole. Conclusions NLP can correctly identify screening colonoscopies, accurately identify adenomas and SSAs in a pathology database, and provide real-time quality metrics for colonoscopy.

Hepatocellular carcinomas (HCC) show resistance to chemotherapy and have blunt response to apoptotic stimuli. HCC cell lines express low levels of the Fas death receptor and are resistant to FasL stimulation, whereas immortalized hepatocytes are sensitive. The variable Fas transcript levels and consistently low Fas protein in HCC cells suggest posttranscriptional regulation of Fas expression. The 3′-untranslated region (UTR) of Fas mRNA was found to interact with the ribonucleoprotein Human Antigen R (HuR) to block mRNA translation. Silencing of HuR in HCC cells increased the levels of cell surface Fas and sensitized HCC cells to FasL. Two AU-rich domains within the 3′-UTR of Fas mRNA were identified as putative HuR-binding sites and were found to mediate the translational regulation in reporter assay. Hydrodynamic transfection of HuR plasmid into mice induced downregulation of Fas expression in livers and established functional resistance to the killing effects of Fas agonist. Human HCC tumor tissues showed significantly higher overall and cytoplasmic HuR staining compared with normal liver tissues, and the high HuR staining score correlated with worse survival of patients with early-stage HCC. Combined, the protumorigenic ribonucleoprotein HuR blocks the translation of Fas mRNA and effectively prevents Fas-mediated apoptosis in HCC, suggesting that targeting HuR would sensitize cells to apoptotic stimuli and reverse tumorigenic properties. Implications: Demonstrating how death receptor signaling pathways are altered during progression of HCC will enable the development of better methods to restore this potent apoptosis mechanism. Mol Cancer Res; 13(5); 809–18. ©2015 AACR.

Background Diarrhea and colitis are the second most common immune checkpoint inhibitor (ICPI)-induced adverse events. However, a comprehensive characterization of the endoscopic and histologic features of ICPI-induced diarrhea and colitis is lacking. Therefore, we aimed to describe endoscopic and histologic features of ICPI-induced gastrointestinal toxicities and to assess their association with patients' clinical characteristics and outcomes. Methods We retrospectively reviewed records of 53 patients with ICPI-related diarrhea/colitis between 2011 and 2017. We collected data on demographics, diarrhea/colitis grade, treatment, and endoscopic and histologic findings. Long-term follow-up included repeat endoscopy findings, diarrhea recurrence, and overall survival. We compared groups by treatment, endoscopic and histologic findings, and constructed Kaplan-Meier survival curves. Results Most patients had grade 2 or higher diarrhea (87%) and colitis (60%). Thirty-one patients were successfully treated with corticosteroids, and 22 additionally required infliximab. On endoscopy, 21 (40%) patients had ulcerations and 22 (42%) had nonulcerative inflammation. Patients with ulcerations had more steroid-refractory disease (P = 0.044) and high-grade diarrhea (P = 0.033). Histology showed mostly acute (23%) or chronic (60%) inflammation. During mean follow-up duration of 18.9 months, 19 (36%) developed recurrent diarrhea. Most patients had persistent endoscopic (8/13, 62%) and histologic (9/11, 82%) inflammation. Patients with higher-grade adverse events had improved survival. Higher-grade colitis was associated with endoscopic inflammation (P = 0.039), but grade of diarrhea was not associated with endoscopic inflammation or grade of colitis. Conclusion 10.1093/ibd/izy104_video1izy104.video15808053084001.

AIM Immunocompromised patients can develop chronic hepatitis E virus (HEV) infection and progress to cirrhosis. Hepatitis C virus (HCV)-infected cancer patients who have received chemotherapeutic agents experience accelerated liver fibrosis progression. Our aim was to investigate the prevalence and impact of HEV seropositivity on liver-related outcomes in HCV-infected cancer patients. METHODS As part of a prospective study of HCV-infected cancer patients conducted at our center, we investigate the characteristics associated with progression of their liver disease. RESULTS Of the 115 patients tested, 13 (11%) were positive for HEV immunoglobulin G. HEV seropositivity was associated with advanced age (P = 0.004), race (P = 0.02), place of birth outside the USA (P = 0.021), cirrhosis (P = 0.027), history of reused needles/syringes during massive vaccination campaigns (P = 0.015) and coronary artery disease (P = 0.039). Overall, 47 (41%) of the patients had cirrhosis. Factors independently associated with cirrhosis were male sex (odds ratio [OR], 2.8; P = 0.028) and HEV seropositivity (OR, 4.1; P = 0.032). CONCLUSION HEV seropositivity is present in 11% of HCV-infected cancer patients and seems to be associated with cirrhosis. Our results suggest that HEV screening should be implemented in HCV-infected patients with cancer.

Multiple cellular processes, including DNA replication and repair, DNA recombination, and gene expression, require interactions between proteins and DNA. Therefore, DNA-protein interactions regulate multiple physiological, pathophysiological, and biological functions, such as cell differentiation, cell proliferation, cell cycle control, chromosome stability, epigenetic gene regulation, and cell transformation. In eukaryotic cells, the DNA interacts with histone and nonhistone proteins and is condensed into chromatin. Several technical tools can be used to analyze DNA-protein interactions, such as the Electrophoresis (gel) Mobility Shift Assay (EMSA) and DNase I footprinting. However, these techniques analyze the protein-DNA interaction in vitro, not within the cellular context. Chromatin immunoprecipitation (ChIP) is a technique that captures proteins at their specific DNA binding sites, thereby allowing for the identification of DNA-protein interactions within their chromatin context. It is done by fixation of the DNA-protein interaction, followed by immunoprecipitation of the protein of interest. Subsequently, the genomic site that the protein was bound to is characterized. Here, we describe and discuss ChIP and demonstrate its analytical value for the identification of the Transforming Growth Factor-β (TGF-β)-induced binding of the transcription factor SMAD2 to SMAD Binding Elements (SBE) within the promoter region of the tyrosine-protein kinase Kit (c-KIT) receptor ligand Stem Cell Factor (SCF).

Background Adult hemophagocytic lymphohistiocytosis is a secondary immunopathologic phenomenon, mainly secondary to malignancy, infection, or autoimmune disorders. The performance of diagnostic criteria, studied in the pediatric population, is yet to be validated in the adult population. Some of the criteria include cytopenias and organomegaly that are inherent features to malignant processes, thus making the diagnosis of hemophagocytic lymphohistiocytosis a challenge in patients with cancer. Case presentation We describe the case of a 54-year-old white man with history of metastatic maxillary sinus adenoid cystic carcinoma who had severe liver injury and cytopenias with progressive clinical deterioration. We performed an evaluation, by flow cytometry, of the expression of surface markers in his natural killer cells that revealed remarkable abnormalities. His syndrome eventually fulfilled criteria for hemophagocytic lymphohistiocytosis and he received therapy with steroids with interval clinical improvement. Unfortunately, he refused further cytotoxic treatment and died 2 weeks later. Conclusions The conventional criteria for the diagnosis of hemophagocytic lymphohistiocytosis are suboptimal for adult patients with cancer resulting in delays in diagnosis and timely initiation of treatment. The diagnostic criteria have to be re-evaluated in patients with cancer; novel, easily available, and accurate diagnostic methods are needed.

Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of severe immune activation and dysregulation resulting in extreme and often life-threatening inflammation. HLH has been well recognized in pediatric populations, and most current diagnostic and therapeutic guidelines are based on pediatric HLH. Recently there has been recognition of HLH in adults, especially secondary to immune deregulation by an underlying rheumatologic, infectious, or malignant condition. This review is focused on malignancy-associated HLH (M-HLH), in which possible mechanisms of pathogenesis include severe inflammation, persistent antigen stimulation by the tumor cells, and loss of immune homeostasis because of chemotherapy, hematopoietic stem cell transplantation, or infection. Previously considered rare, M-HLH may occur in up to 1% of patients with hematologic malignancies. M-HLH is often missed or diagnosed late in most published studies, and it has been associated with a poor median survival of less than 2 months. Identification of the clinical and laboratory features specific to M-HLH in adults may allow early detection, consultation with HLH experts, and intervention. Improved management of adult M-HLH with optimal combinations of T-lympholytic and immunosuppressive agents and the incorporation of novel agents based on the pediatric experience hopefully will improve outcomes in adults with M-HLH. Cancer 2017;123:3229-40. © 2017 American Cancer Society.

Cholangiocarcinoma (CCA) is a malignancy arising in the biliary tree. Its incidence rates have increased, and it has surpassed gallbladder carcinoma as the most common biliary tract malignancy. Most patients are diagnosed with advanced stage disease and are not amenable to potentially curative surgical therapies. The prognosis is dismal with a median survival of

Severe hepatitis C reactivation as an early complication of hematopoietic cell transplantation

Cholangiocarcinoma is the most frequent biliary malignancy. It is difficult to diagnose owing to its anatomic location, growth patterns and lack of definite diagnostic criteria. Currently, cholangiocarcinoma is classified into the following types according to its anatomic location along the biliary tree: intrahepatic, perihilar or distal extrahepatic cholangiocarcinoma. These cholangiocarcinoma types differ in their biological behavior and management. The appropriate stratification of patients with regard to the anatomic location and stage of cholangiocarcinoma is a key determinate in their management. Staging systems can guide this stratification and provide prognostic information. In addition, staging systems are essential in order to compare and contrast the outcomes of different therapeutic approaches. A number of staging systems exist for cholangiocarcinoma-several early ones have been updated, and new ones are being developed. We discuss the emerging diagnostic criteria as well as the different staging systems for cholangiocarcinoma, and provide a critical appraisal regarding these advances in biliary tract malignancies.

A 66-year-old male patient who is hepatitis C RNA positive, without cirrhosis, has been found to have a mass on ultrasound examination of the liver. Physical examination is unremarkable. The hemoglobin, white cell count and platelet counts are normal. The alkaline phosphatase is mildly elevated to 212 U/L(normal

Cholangiocarcinoma (CCA) is the most common biliary malignancy. Unfortunately, its incidence is increasing in several Western countries.1 Therapeutic options for CCA are limited, and the overall prognosis for patients with CCA is dismal, with median survival being less than 24 months. New insights into the biology of this cancer may provide a framework for targeted therapeutic approaches. CCA, similar to hepatocellular carcinoma and colorectal cancer, often arises in an inflammatory environment.2,3 Inflammation-associated carcinogenesis is, in part, mediated by dysregulated cytokine signaling pathways,4 which potentially can be therapeutically targeted for treatment of this cancer. Members of the signal transducers and activators of transcription (STAT) family are key signal transducers in cytokine and growth factor signaling. Especially STAT3 has been shown to be an essential signaling molecule in carcinogenesis through its transcriptional activity on genes regulating apoptosis, proliferation, differentiation, and angiogenesis.5,6 One of the main activators of STAT3 in CCA cells is interleukin-6 (IL-6) via Janus kinases (JAK).7 IL-6 is a cytokine secreted by inflammatory cells (i.e., macrophages) but also by CCA cells where it activates STAT3 by autocrine and paracrine mechanisms.2,3,8,9 Under physiologic conditions, the JAK/STAT3 signaling pathway is tightly regulated through negative feedback mechanisms including protein phosphatases.7 In CCA, IL-6–mediated JAK/STAT3 signaling was found to be dysregulated due to epigenetic silencing of suppressor of cytokine signaling-3.10 Interestingly, interruption of JAK/STAT3 signaling either through JAK inhibitors or STAT3 small interfering RNA (siRNA) resulted in sensitization to tumor necrosis factor–related apoptosis-inducing ligand (TRAIL)-mediated apoptosis through down-regulation of the STAT3 transcriptional target Mcl-1, an antiapoptotic Bcl-2 family protein.8 Sorafenib was developed as a c-Raf kinase inhibitor, although it also targets several other Raf-kinases (wild-type b-Raf, b-Raf V600) as well as other receptor tyrosine kinases.11 Sorafenib prolongs survival of patients with hepatocellular carcinoma.12 Recently, inhibition of STAT3 phosphorylation by sorafenib was observed in medulloblastoma and esophageal carcinoma.13,14 These studies were predominantly observational, and the mechanisms by which sorafenib inhibits STAT3 phosphorylation were not elucidated. Given this information, the effect of sorafenib on STAT3 regulation in CCA warrants exploration as a potential therapeutic agent. The objective of this study was to examine the effect of sorafenib on the JAK/STAT3 signaling cascade in CCA cells. The results of this study suggest that sorafenib inhibits the JAK/STAT3 signaling axis at the level of STAT3 phosphorylation, resulting in down-regulation of Mcl-1, thereby sensitizing human CCA cells to TRAIL-mediated apoptosis. The inactivation of phospho-STAT3 occurs by a phosphatase shatterproof 2 (SHP2)-dependent mechanism which appears to be stimulated by Raf-kinase inhibition. Furthermore, in an orthotopic, syngeneic rodent CCA model, sorafenib achieves significant tumor suppression.

Cholangiocarcinoma (CCA) is an epithelial cancer originating from the bile ducts with features of cholangiocyte differentiation.1 CCA is the second most common primary hepatic malignancy, and epidemiologic studies suggest its incidence is increasing in Western countries.2 Advanced CCA has a devastating prognosis, with a median survival of

Attenuated measles viruses (MVs) propagate selectively in human tumor cells, and phase I clinical trials are currently underway to test their oncolytic activity. A major theoretical impediment to systemic MV application is the presence of pre-existing antiviral immunity. We hypothesized that autologous MV-infected cells might be a more reliable vehicle than cell-free virions to deliver the infection to tumor cells in subjects with neutralizing titers of anti-measles antibodies. Our in vitro studies, using a dual-color fluorescent model, demonstrated efficient cell-to-cell transfer of infection via heterofusion. In contrast to infection by naked virions, heterofusion between infected cell carriers and tumor cells was more resistant to antibody neutralization. Infected monocytic, endothelial, or stimulated peripheral blood cells could deliver oncolytic MV to tumor lesions in vivo, after intravenous (i.v.) or intraperitoneal (i.p.) administration. Single or repeated i.p. injections of monocytic carriers significantly improved survival of animals bearing human ovarian cancer xenografts. Systemic or i.p. injection of MV-infected cells successfully transferred infection by heterofusion to Raji lymphomas or hepatocellular carcinoma tumors in the presence of neutralizing antibodies. These results suggest a novel strategy for systemic delivery of oncolytic virotherapy in cancer patients that can "bypass" the pre-existing humoral immunity against MV.

The oncolytic measles virus Edmonston strain (MV-Edm), a nonpathogenic virus targeting cells expressing abundant CD46, selectively destroys neoplastic tissue. Clinical development of MV-Edm would benefit from noninvasive monitoring strategies to determine the speed and extent of the spread of the virus in treated patients and the location of virus-infected cells. We evaluated recombinant MV-Edm expressing carcinoembryonic antigen (CEA) or the human sodium iodide symporter (hNIS) for oncolytic potential in hepatocellular carcinoma (HCC) and efficiency in tracking viruses in vivo by noninvasive monitoring. CD46 expression in human HCC and primary hepatocytes was assessed by flow cytometry and immunohistochemistry. Infectivity, syncytium formation, and cytotoxicity of recombinant MV-Edm in HCC cell lines were evaluated by fluorescence microscopy, crystal violet staining, and the MTS assay. Transgene expression in HCC cell lines after infection with recombinant MV-Edm in vitro and in vivo was assessed by CEA concentration, 125I-uptake, and 123I-imaging studies. Toxicology studies were performed in Ifnar(KO)xCD46 transgenic mice. The CD46 receptor was highly expressed in HCC compared to nonmalignant hepatic tissue. Recombinant MV-Edm efficiently infected HCC cell lines, resulting in extensive syncytium formation followed by cell death. Transduction of HCC cell lines and subcutaneous HCC xenografts with recombinant MV-Edm resulted in high-level expression of transgenes in vitro and in vivo. MV-Edm was nontoxic in susceptible mice. Intratumoral and intravenous therapy with recombinant MV-Edm resulted in inhibition of tumor growth and prolongation of survival with complete tumor regression in up to one third of animals. In conclusion, engineered MV-Edm may be a potent and novel cancer gene therapy system for HCC. MV-Edm expressing CEA or hNIS elicited oncolytic effects in human HCC cell lines in vitro and in vivo, enabling the spread of the virus to be monitored in a noninvasive manner.

Nonalcoholic steatohepatitis describes a hepatic disorder with the typical characteristics of an alcoholic pathogenesis without alcohol consumption. It was first described in 1962 and named NASH by Ludwig et al. 1980. Many researchers worked on this disease since this time. It represents the hepatic manifestation of the syndrome X. The pathogenesis is a two-hit phenomenon. The first hit leads to steatosis hepatis and makes the liver vulnerable to the second hit. Central factors of the second hit are oxygen-radicals, oxidative stress, lipid-peroxidation and cytokines. The exact pathogenic mechanisms are still unknown. NASH is a hepatic disease which can end up in liver cirrhosis and liver failure. Up to now a curative drug therapy does not exist. The poor prognosis in some cases, the increasing incidence in western populations and the lack of therapeutic options renders NASH to a serious problem. The aim of this article is to show the actual knowledge of this disease, especially focussed on the pathogenesis, by review of the literature from 1979 up to the present time.

67 Background: Immune-based cancer treatment (IBCT) is increasingly used to treat a variety of cancers. Despite the promising results, adverse events such as dermatitis, colitis, and hepatitis remain a concern. Hepatitis is usually mild but may be severe, requiring modification or cessation of treatment. Here, we describe several cases of immune-mediated hepatitis. Methods: We identified patients enrolled in clinical trials using IBCT through the Department of Investigational Cancer Therapeutics at The University of Texas MD Anderson Cancer Center, between January 2010 and July 2015. Charts were reviewed for mention of “autoimmune hepatitis”, “hepatitis” or abnormal transaminases, all of which were attributed to IBCT by the treating physician. Hepatotoxicity was graded based on CTCAE v4.0. Results: We identified 12 cases of immune-related hepatotoxicity out of 290 patients. Three patients (1.03%) had grade 3 elevation of transaminases, designated as “autoimmune hepatitis.” Each required systemic steroids and transaminases returned to baseline within a month. IBCT was temporarily held in 2 cases and was permanently discontinued in the third due to grade 4 myositis rather than hepatitis. One patient (0.3%) had grade 2, and eight patients (2.8%) had grade 1 transaminases elevations that were possibly attributable to immunotherapy, but which resolved spontaneously without alteration in treatment. Other significant reported immune-related toxicities ≥ grade 3 were: dermatitis (n = 4), enterocolitis (n = 3), myasthenia gravis (n = 2), myositis (n = 2), pneumonitis, pleuritis, and pancreatitis (n = 1 each). Conclusions: 1.03% of patients experienced grade 3 elevation of transaminases that were attributable to immune therapy. Hepatic adverse events related to immunotherapy in our study were manageable. Further studies are needed to develop biomarkers to identify patients at risk to develop such toxicities. [Table: see text]

Immunocompromised patients can develop chronic hepatitis E virus (HEV) infection and progress to cirrhosis. Hepatitis C virus (HCV)-infected cancer patients who have received chemotherapeutic agents experience accelerated liver fibrosis progression. Our aim was to investigate the prevalence and impact of HEV seropositivity on liver-related outcomes in HCV-infected cancer patients.As part of a prospective study of HCV-infected cancer patients conducted at our center, we investigate the characteristics associated with progression of their liver disease.Of the 115 patients tested, 13 (11%) were positive for HEV immunoglobulin G. HEV seropositivity was associated with advanced age (P = 0.004), race (P = 0.02), place of birth outside the USA (P = 0.021), cirrhosis (P = 0.027), history of reused needles/syringes during massive vaccination campaigns (P = 0.015) and coronary artery disease (P = 0.039). Overall, 47 (41%) of the patients had cirrhosis. Factors independently associated with cirrhosis were male sex (odds ratio [OR], 2.8; P = 0.028) and HEV seropositivity (OR, 4.1; P = 0.032).HEV seropositivity is present in 11% of HCV-infected cancer patients and seems to be associated with cirrhosis. Our results suggest that HEV screening should be implemented in HCV-infected patients with cancer.

Unsere Wohlstandsgesellschaft fuhrt in Folge von ubermasigem Alkoholkonsum, Ubergewicht und Bewegungsmangel zu einer steigenden Pravalenz der Fettleber (Steatosis hepatis). Die vorliegende Ubersicht beschreibt Definition und pathogenetische Vorstellungen von Fettleber und Fettleberhepatitis. Die diagnostischen Moglichkeiten zur Differenzierung dieser Entitaten werden aufgezeigt. Darauf aufbauend werden Konzepte zur Therapie der alkoholischen und nichtalkoholischen Fettleber vorgestellt. Diese ist zunachst auf die Ausschaltung der pathogenetischen Faktoren ausgerichtet und umfasst erst in zweiter Linie eine symptomatische medikamentose Therapie.

Cholangiocarcinoma (CCA) is the second most common primary hepatic malignancy. It is classified into intrahepatic and extrahepatic forms, the latter including perihilar (involvement of right and/or left hepatic ducts and their union to form the common hepatic duct) and distal bile duct CCA. Growth patterns are differentiated into periductal-infiltrating, mass-forming and papillary or intraductal growth. The different forms of CCA are distinct and differ clinically, etiologically, pathophysiologically and in management [1]. Global incidence rates of intrahepatic cholangiocarcinoma (ICC) have significantly increased while annual incidence rates of the more common extrahepatic form has remained relatively stable throughout the last four decades [2]. The prognosis of CCA is devastating with survival of

Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy. Its incidence and prevalence is globally heterogeneous with the highest rates in Southeast Asia and Sub-Saharan Africa. In Western Industry nations, its incidence has significantly increased throughout the previous three decades. Its global heterogeneity is in part a reflection of the global distribution of its risk factors. Its prognosis is dismal with a 5-year survival of 11 %. The only potentially curative treatment is surgical with either resection or orthotopic liver transplantation. However, the majority of HCC patients are diagnosed at an advanced stage at which surgical therapies are not feasible. HCC is considered chemotherapy-resistant-a characteristic thought to be mediated in part through stem-like tumor initiating cells (STICs). Recent studies have provided significant insights in the hepatocarcinogenesis and the molecular signaling pathways of this malignancy resulting in the development of novel, molecular targeted therapies with modest therapeutic benefit. Our growing understanding of the biology of this malignancy will help in the development of novel, molecular-targeted therapies.

Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy. Its incidence and prevalence is globally heterogeneous with the highest rates in Southeast Asia and Sub-Saharan Africa. In Western Industry nations, its incidence has significantly increased throughout the previous three decades. Its global heterogeneity is in part a reflection of the global distribution of its risk factors. Its prognosis is dismal with a 5-year survival of 11 %. The only potentially curative treatment is surgical with either resection or orthotopic liver transplantation. However, the majority of HCC patients are diagnosed at an advanced stage at which surgical therapies are not feasible. HCC is considered chemotherapy-resistant—a characteristic thought to be mediated in part through stem-like tumor initiating cells (STICs). Recent studies have provided significant insights in the hepatocarcinogenesis and the molecular signaling pathways of this malignancy resulting in the development of novel, molecular targeted therapies with modest therapeutic benefit. Our growing understanding of the biology of this malignancy will help in the development of novel, molecular-targeted therapies.

Paracrine signaling between hepatic stellate cells (HSCs) and liver endothelial cells (LECs) modulates fibrogenesis, angiogenesis, and portal hypertension. However, mechanisms regulating these processes are not fully defined. Sorafenib is a receptor tyrosine kinase inhibitor that blocks growth factor signaling in tumor cells but also displays important and not yet fully characterized effects on liver nonparenchymal cells including HSCs and LECs. The aim of this study was to test the hypothesis that sorafenib influences paracrine signaling between HSCs and LECs and thereby regulates matrix and vascular changes associated with chronic liver injury. Complementary magnetic resonance elastography, micro–computed tomography, and histochemical analyses indicate that sorafenib attenuates the changes in both matrix and vascular compartments that occur in response to bile duct ligation–induced liver injury in rats. Cell biology studies demonstrate that sorafenib markedly reduces cell–cell apposition and junctional complexes, thus reducing the proximity typically observed between these sinusoidal barrier cells. At the molecular level, sorafenib down-regulates angiopoietin-1 and fibronectin, both released by HSCs in a manner dependent on the transcription factor Kruppel-like factor 6 , suggesting that this pathway underlies both matrix and vascular changes associated with chronic liver disease. Conclusion: Collectively, the results of this study demonstrate that sorafenib inhibits both matrix restructuring and vascular remodeling that accompany chronic liver diseases and characterize cell and molecular mechanisms underlying this effect. These data may help to refine future therapies for advanced gastrointestinal and liver diseases characterized by abundant fibrosis and neovascularization. (HEPATOLOGY 2011;)

Cholangiocarcinoma (CCA) cells paradoxically express tumor necrosis factor–related apoptosis-inducing ligand (TRAIL), a death ligand that, failing to kill CCA cells, instead promotes their tumorigenicity and especially the metastatic behaviors of cell migration and invasion. Second mitochondria-derived activator of caspase (smac) mimetics are promising cancer therapeutic agents that enhance proapoptotic death receptor signaling by causing cellular degradation of inhibitor of apoptosis (IAP) proteins. Our aim was to examine the in vitro and in vivo effects of the smac mimetic JP1584 in CCA. Despite JP1584-mediated loss of cellular inhibitor of apoptosis-1 (cIAP-1) and cIAP-2, TRAIL failed to induce apoptosis in KMCH-1, TFK-1, and BDEneu CCA cells; a finding consistent with a downstream block in death signaling. Because cIAP-1 and cIAP-2 also promote nuclear factor kappa B (NF-κB) activation by the canonical pathway, the effect of JP1584 on this signaling pathway was examined. Treatment with JP1584 inhibited TRAIL-induced NF-κB activation as well as TRAIL-mediated up-regulation of the NF-κB target gene, matrix metalloproteinase 7 (MMP7). JP1584 also reduced TRAIL-mediated CCA cell migration and invasion in vitro. Finally, in a syngeneic rat orthotopic CCA model, JP1584 administration reduced MMP7 messenger RNA levels and extrahepatic metastases. Conclusion: Although the smac mimetic JP1584 does not sensitize cells to apoptosis, it reduces TRAIL-induced CCA cell metastatic behavior. These data support the emerging concept that IAPs are prometastatic and represent targets for antimetastatic therapies. Hepatology 2010

Apoptosis induction by BH3 mimetics is a therapeutic strategy for human cancer. These mimetics exert single-agent activity in cells “primed” for cell death. Primed cells are dependent upon antiapoptotic Bcl-2 proteins for survival and are characterized by the ability of the BH3 mimetic to induce cytochrome c release from their isolated mitochondria. Our aim was to examine the single-agent activity of obatoclax, a BH3 mimetic in cholangiocarcinoma cell lines. In clonogenic assays, inhibition of colony formation was observed by obatoclax treatment. Despite single-agent activity by obatoclax, the mitochondria from these cells did not release cytochrome c after incubation with this BH3 mimetic. However, immunofluorescence and cell fractionation studies identified Bax activation and translocation to mitochondria after treatment with obatoclax. shRNA targeted knockdown of Bax doubled the IC50 for obatoclax but did not abrogate its cytotoxicity, whereas knockdown of Bak did not alter the IC50. In a cell-free system, obatoclax induced an activating conformational change of Bax, which was attenuated by a site-directed mutagenesis of a previously identified protein activation site. Finally, the drug also elicited a significant in vivo response in a rodent model of this disease. In conclusion, single-agent obatoclax treatment results in Bax activation, which contributes, in part, to cell death in cholangiocarcinoma cells. These data indicate that BH3 mimetics may also function as direct activators of Bax and induce cytotoxicity in cells not otherwise primed for cell death. Cancer Res; 70(5); 1960–9

Cholangiocarcinoma (CCA) is the most common biliary tract cancer and the second most common primary hepatic malignancy. Its incidence has significantly increased in Western countries and in areas of Asia it is the most common hepatic malignancy. Its prognosis is dismal with a median survival of 4.6 months following diagnosis. The only potentially curative surgery is resection or liver transplantation; however, only the majority of patients qualify for surgical management at the time of diagnosis. Hence, there is an urgent need to identify new therapeutic approaches. In the recent past, our understanding of this disease, its etiology and especially its molecular pathogenesis and genetic alterations have increased, thereby potentially helping us to identify patients at risk, prognostic factors and new therapeutic targets. This chapter aims in providing a concise overview of the current knowledge of the etiology and genetics of this disease.

Cholangiocarcinoma (CCA) is a devastating disease with features of bile duct epithelial differentiation. Considerable progress has been made regarding the imaging characteristics of this disease, diagnostic criteria, surgical approaches and palliative management. Conversely, progress regarding medical therapy for advanced CCA has been limited. The design and implementation of Phase II trials has been hampered by the lack of staging systems to stratify patient populations. Until refined stratification schemes are available, results from Phase II trials, even randomized Phase II trials, will be difficult if not impossible to interpret due to marked patient heterogeneity. In this commentary, we will propose schemes to help stratify patients with CCA based on our current understanding of the disease. Biliary tract malignancies include intrahepatic cholangiocarcinoma, ductal cholangiocarcinoma, gallbladder cancers and cancers of the ampulla of Vater. Often, all of these biliary tract cancer subsets are included in medical trials on biliary tract cancers. However, gallbladder cancers, CCA and cancers of the ampulla of Vater are distinct entities with unique molecular signatures, mechanisms of disease dissemination and natural history. Furthermore, CCA exists as two types of cancer, intrahepatic mass forming cancers and cancers involving the large bile ducts. We propose that these two subsets be defined as intrahepatic CCA and ductal CCA (Table 1). Intrahepatic CCA would be classified as intrahepatic mass lesions without causing bile duct obstruction or jaundice. Ductal CCA would involve cancers of the common bile duct, common hepatic duct, right and/or left hepatic ducts including their secondary bifurcation. Terms such as Klatskin tumor, or perihilar CCA, which is a form of ductal CCA should be discouraged. Likewise, the erroneous classification by the Surveillance, Epidemiology, End Result (SEER) database of perihilar CCA as intrahepatic CCA must be corrected [1]. Biliary tract cancers should not be ‘lumped’ together in clinical trials, but rather examined and treated as individual, distinct subsets of biliary tract cancers. Clinical trials should be limited to each specific subset of these cancers including unique trials for intrahepatic and ductal CCA. Staging systems of gallbladder cancer have been well defined [2,3] and therefore, this cancer population can be appropriately stratified and emerging therapies assessed. Table 1 Proposed classification of cholangiocarcinoma Recently, a staging system for intrahepatic CCA has been proposed [4]. This classification is based on number of intrahepatic lesions, presence or absence of vascular invasion and lymph node metastases. In contrast, there is no proposed staging system for ductal CCA. Prior staging systems such as the Bismuth-Collette and the Memorial Sloan Kettering staging system pertain to selection of patients for surgery but were never meant to correlate with survival and do not pertain to patients with advanced disease [5,6]. The optimal staging system for ductal CCA should take into account the following parameters: the stage of the tumor; magnitude of ductal and vascular obstruction and their functional consequences for hepatic function and selection for surgery; the performance status of the patient; and the availability and effectiveness of therapy. Such a staging system has been developed for hepatocellular carcinoma and has been externally validated [7–10]. The tumor stage should take into account the size of the primary lesion, vascular encasement, the presence or absence of lobar atrophy and extrahepatic spread of the disease. Most primary ductal CCA are difficult to visualize as mass lesions and lack a measurable radial diameter. These neoplasms have a tropism for bile and as such, often encircle and stricture the bile duct causing jaundice. Given this tropism, the cancers also grow longitudinally along the bile duct before growing radially away from the biliary apparatus. Therefore, the identification of mass should be considered as a more advanced cancer than nonvisualized lesions, despite the lack of metastases or a similar clinical presentation (e.g. painless jaundice). We also propose that mass lesions be stratified as 3 cm or less or more than 3 cm based upon our experience. Vascular encasement (a frequent occurrence in this disease) and lobar atrophy (due to longstanding lobar bile duct and/or vascular obstruction) have been identified as adverse prognostic features in surgical studies [5,11]. Such features often suggest a prolonged disease interval between disease development and presentation; a feature favoring sufficient time to develop regional micrometastases. Also, lobar bile duct involvement (e.g. right hepatic duct) with contralateral vascular encasement (e.g. left portal vein encasement) precludes surgical resection, the only established, potentially curative therapy for ductal CCA. Thus, each of these tumor/liver anatomic relationships needs to be incorporated into the staging system. Extrahepatic spread signifies metastases and is always an adverse prognostic finding in any human cancer. CCA has three types of regional metastases: lymphatic spread into regional and more distant lymph nodes; venous invasion with intrahepatic metastases; and peritoneal metastases. Which one of these features portends the more adverse prognosis is not readily apparent and will require further study. Lymph node metastases can be regional with involvement of hilar lymph nodes, periduodenal lymph nodes and/or periaortic lymph nodes. Likely, the more distant the lymph node metastases are from the primary tumor, the worse the prognosis; but again, this is a concept that requires careful validation. Although the presence or absence of lymph node metastases can be difficult to confirm by imaging criteria, the use of endoscopic ultrasound with fine needle aspirates for lymph node cytology has made this distinction more reliable. The ability to relieve cholestasis with placement of biliary stents must also be taken into effect. A recent study suggests that if the bilirubin is less than or equal to 10 mg/dl, jaundice (defined as a serum bilirubin >3 mg/dl) should resolve within 3 weeks [12]. For bilirubin values more than 10mg/dl, it may take 6 weeks to obtain resolution of jaundice. Given these data, the parameters for jaundice resolution would be bilirubin and time-dependent. The inability to relieve jaundice results in impaired liver function secondary to persistent cholestasis and impacts on the overall heath and performance status of the patient. This cholestatic liver dysfunction adversely effects survival and, therefore, is a critical component of the staging system. Also, whether surgical exploration is or is not feasible (the only current therapy) will also affect patient outcomes. Based on this analysis and the rationale developed for HCC, we have assimilated these factors into a proposed staging system (Table 2). Any positive parameter within a column would relegate the patient to this stage. Table 2 Proposed staging system for ductal cholangiocarcinoma This proposed staging system is virtual at this point in time; however, we are in the process of validating this stratification scheme. Perhaps other objective parameters will also help add precision to this staging system (e.g. serum CA19-9 values >1000 U/ml, CCA complicating primary sclerosing cholangitis, etc.). We encourage others to also validate and refine this proposed schema. We also hope this commentary will galvanize a multidisciplinary effort to develop staging systems for this disease, perhaps lead by a major society (e.g. the American Association for the Study of Liver Diseases, American Society of Clinical Oncology, etc.). Only once such a staging system has been validated can randomized Phase II trials be reliably conducted with more homogenous patient populations for ductal CCA. This is a pressing need as promising targeted therapies are being developed and need to be applied to this subset of biliary tract cancers.