Relationship of lntrahepatic Bile Duct Hyperplasia to Cholangiocellular Carcinoma

MASANORI KURASHINA, MD,' SADAO KOZUKA, MD,t NOBUO NAKASIMA, MD,* NORIO HIRABAYASI, M D , ~ AND MASAFUMI ITO, MDII

To investigate the relationship between intrahepatic bile duct hyperplasia and cholangiocellular carci- noma, 27 patients with cholangiocellular carcinoma (including biliary cystadenocarcinoma) and 303 controls were histologically examined. Livers with cholangiocellular carcinoma were closely associated with hyperplasia (loo%), atypical hyperplasia (77.8%), and carcinoma in siru (51.9%). Transition from hyperplasia to atypical hyperplasia, and from atypical hyperplasia to carcinoma, was often observed. In the controls, hyperplasia was frequent in those older than 30 years of age, whereas carcinoma was frequent in patients from 50 to 80 years of age. Of the intrahepatic bile ducts examined, the large duct showed the highest incidence of hyperplasia, atypical hyperplasia, and carcinoma in situ. All 27 cases of cholangiocellular carcinoma originated in, or near, the hilus of the liver. These findings suggest that cholangiocellular carcinoma frequently develops from bile duct hyperplasia.

Cancer 61:2469-2474. 1988.

HOLANGIOCELLULAR CARCINOMA of the liver is C relatively rare and little is known about its patho- genesis. Development of cholangiocellular carcinoma from bile duct hyperplasia has been reported in some cases associated with hepatolithiasis, ' J clonorchis sin- ensis infe~tion,~-~ biliary cystadenocarcinoma,6-* intra- ductal papillomat~sis,~ v. Meyenburg complex," and developmental liver cysts. ''-" Bile duct hyperplasia is frequently observed in the autopsied liver, but whether or not bile duct hyperplasia is a common predisposing factor in ordinary cholangiocellular carcinoma is not known. The current study attempts to investigate the histogenesis of cholangiocellular carcinoma by: ( 1) studying the histologic transition between hyperplasia and cholangiocellular carcinoma; (2) comparing the local incidence of hyperplasia and carcinoma in situ, and locations of cholangiocellular carcinoma; and (3) the analysis of age- and sex-incidence of bile duct hy- perplasia in cases where there is no cholangiocellular carcinoma.

From the Departments of *Medical Technology and ?Physical Ther- apy, College of Medical Technology, Nagoya University, Nagoya; the $Pathological Division of Central Clinical Laboratory and the §Faculty of Pathology, Nagoya University Hospital, Nagoya; and the ((Pathol- ogy of Nagoya University, Nagoya, Japan.

Address for reprints: Masanori Kurashina, MD, Department of Medical Technology, College of Medical Technology, Nagoya Univer- sity, 1-20, Daikominami- 1, Higashi-ku, Nagoya 46 1, Japan.

Accepted for publication December 1 1, 1987.

Materials and Methods

Two hundred fifty consecutive autopsy livers without cholangiocellular carcinoma were obtained from Na- goya University Hospital and Anjo Kosei Hospital. Twenty-seven livers with cholangiocellular carcinoma, of which 18 were surgically lobectomized and nine were autopsied, and an additional 53 autopsy livers with the other various hepatic and biliary tract disorders were obtained from Nagoya University Hospital and nine other hospitals.

From two to ten histologic specimens, some taken from the hepatic hilar region, were obtained from each liver and stained with hematoxylin and eosin. Histologic specimens also were stained by periodic acid-Schiff (PAS) reaction with and without diastase pretreatment in order to differentiate cholangiocellular carcinoma from mixed hepatocholangiocellular carcinoma.

The intrahepatic bile ducts were classified according to Nakanuma's criteria with slight modifications as fol- lows: (1) large duct, (2) periductal gland, (3) septal duct, (4) interlobular duct, and ( 5 ) duct~1e.I~ A large duct was defined as a duct surrounded by periductal glands (Fig. l), consisting of five or more lobulated glands and their excretory ducts, connected to the large duct. The septal duct was defined as a duct without periductal glands, but with accompanying arteries whose shortest diameter was at least 95 pm. Any duct smaller than a septal duct, excluding ductules, was defined as an interlobular duct.

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2470 CANCER June 15 1988 Vol. 61

FIG. 1. Normal and hyperpiastic penductal glands. Normal glands have low cuboidal epithelial cells, whereas hyperplastic glands have low cuboidal epithelial cells (H & E, X350).

The ductule was defined as the terminal bile duct lo- cated adjacent to, or in, the hepatic lobule.

The age- and sex-incidence of cholangiocellular carci- noma in autopsy patients was examined previ0us1y.l~

Results

Histologic Features of Hyperplasia, Atypical Hyperplasia, and Carcinoma In Situ

Hyperplasia in the intrahepatic bile ducts was charac- terized by the enlargement of epithelial cells (Figs. 1 and 2). In the current study, hyperplasia in the large ducts, periductal glands, septal ducts, and interlobular ducts was defined as when epithelial cells of these ducts had slightly larger and more hyperchromatic nuclei than those of normal nuclei, or when epithelial cells with normally sized nuclei were more than twice as large as normal epithelial cells. Hyperplasia epithelial cells sometimes showed papillary proliferation, but pseudo- stratification and nuclear enlargement of these cells were slight. Hyperplasia of ductules was characterized

by the intense proliferation of ductules, but cellular size was not a criterion for classifying ductular hyperplasia.

In the absence of evidence for cancerous changes, atypical hyperplasia was characterized by papillary pro- liferation of epithelial cells with sharp epithelial pseu- dostratification, usually associated with enlargement of nuclear size and preserving the long axis of most nuclei in the vertical position to the basement membrane (Fig. 2). Papillary growth of epithelial cells in atypical hyper- plasia was most prominent in large ducts, but in pen- ductal glands and septal ducts it was usually less sharp.

Carcinoma in situ was characterized by one or more of the following: papillary projection of epithelial cells without fibrous core, glandular fusion, or sharp enlarge- ment of nuclei (Fig. 3 ) . The nuclear atypia of invasive lesions was generally more conspicuous than that of car- cinoma in situ.

Transition between hyperplasia and atypical hyper- plasia, and between atypical hyperplasia and carcinoma, was often observed in the large duct (Fig. 3 ) . Atypically hyperplastic lesions were often surrounded with hyper- plastic lesions and usually were found in the area adja- cent to hyperplastic lesions. Borderline changes between

No. 12 HYPERPLASIA AND CHOLANGIOCELLULAR CARCINOMA - Kurashina et al. 247 1

FIG. 2. Hyperplasia and atypical hyperplasia in the large duct. Tall columnar cells with moderately enlarged nuclei and mildly enlarged nucleoli are atypical-hyperplastic and show severe epithelial pseudostratification (H & E, X700).

atypical hyperplasia and carcinoma in situ were found in some patients. Foci of carcinoma in situ were some- times surrounded with atypically hyperplastic lesions.

Frequency of Hyperplasia, Atypical Hyperplasia, and Carcinoma In Situ in Various Conditions

In our study, the comparison of the frequency of in- trahepatic bile duct hyperplasia in various conditions of the liver was made using patients older than 30 years of age. Two hundred ninety eight cases was divided into six groups as shown in Table 1, but the obstructive jaundice cases overlapped with cases in other groups. Hyperplasia and atypical hyperplasia in the large ducts, periductal glands, and septa1 ducts were the most frequent in the cholangiocellular carcinoma group. Liver cirrhosis and/ or hepatocellular carcinoma, and biliary tract diseases and carcinoma of the pancreatic head groups, also showed a significantly high frequency of hyperplasia in almost all bile duct sites. The frequency of atypical hy- perplasia was significantly high only in the cholangio- cellular carcinoma group.

Foci of carcinoma in situ were detected in 14 of 27 livers (5 1.9%) with cholangiocellular carcinoma. Of these 27 livers, two livers with biliary cystadenocarci-

noma and one infected by clonorchis had carcinoma in situ. The foci of carcinoma in situ also were observed in 11 of the remaining 24 livers (45.8%).

In order to investigate the factors that cause bile duct hyperplasia, the frequency of the hyperplasia in the noncancerous patients was compared between patients with various histologic changes of bile ducts and those without these changes. The frequency of hyperplasia in the large duct was high in patients with the following changes: periductal fibrosis, 63% (85 of 134); periductal inflammatory cell infiltration, 79% (44 of 56); ductal dilatation, 74% (34 of 46); and irregular changes of duc- tal shape, 80% (20 of 25). However, it was low in pa- tients without these changes (14% [12 of 851). A chi- square test showed that these histologic disorders were possibly related to bile duct hyperplasia (P < 0.00 1).

Local Incidence of Hyperplasia, Atypical Hyperplasia, and Carcinoma In Situ, and Location of Cholangiocellular Carcinoma

Hyperplasia in the noncancerous group was found in all parts of the intrahepatic bile ducts. However, the large ducts were most frequently associated with both hyperplasia and atypical hyperplasia. The second most

2472 CANCER June15 1988 Vol. 61

FIG. 3. Transition from atypical hyperplasia to carcinoma in sifu. Carcinomatous epithelium is characterized by papillary projection without fibrous core (H & E, X400).

frequent occurrence of hyperplasia was in the periductal glands. The local incidence of hyperplasia and atypical hyperplasia in 250 consecutive autopsy cases was as fol- lows: large duct, 44% and 1.2% respectively; periductal glands, 38% and 0%; septa1 duct, 22% and 0%; interlob- ular duct, 10% and 0%; and ductule, 22% and 0%. Foci of carcinoma in situ were most frequently located in the large ducts (Table 1).

Of 27 cases of cholangiocellular carcinoma, 23 origi- nated in the hepatic hilus and four originated on the

right or left lobe near the hilus of the liver. Cancers, the greater part of which were in the intrahepatic bile ducts, were observed in five cases.

The Age- and Sex-Incidence of Bile Duct Hyperplasia, Atypical Hyperplasia, and Cholangiocellular Carcinoma

Intrahepatic bile duct hyperplasia in the noncan- cerous group (patients without cholangiocellular carci- noma) was more frequent in patients older than 30 years

TABLE 1. Incidence of Intrahepatic Bile Duct Hyperplasia and Carcinoma In Situ in Various Disorders in the Liver and Biliary Tract in Patients Older Than 30 Years of Age

Large duct Penductal gland Septa1 duct Interlobular duct Ductule No. of

Disorder cases H(%) A(%) C(%) H(%) A ( % ) C(%) H(%) A(%) C(%) H(%) A ( % ) C(%) H(%) A(%) C(%)

Cholangio. 27 100* 66.7* 48.1 88.9* 7.4 7.4 88.9; 0 0 40.7* 0 0 18.5t 0 0 Hepatitis 40 65.0* 0

Biliary t. 44 70.5* 2.3 - 56.8t 0 (obst. j. 22 63.6t 0

10.0 0 - 25.0* 0 - 47.1* 1.5 - 39.7* 0 - 67.6* 0 -

47.7* 0 - 34.1* 0 - 54.5* 0 - 31.8* 0 -

Control 119 31.9 2.5 - 31.9 0 - 13.4 0 - 3.4 0 - 2.5 0 -

- 5 7 3 0 - 22.5 0 -

- 59.1* 0 - - 50.0 0 - 54.5* 0 -

Cirr. hep. 68 (36) 72.1* 0 - 66.2* 0 -

H: hyperplasia; A: atypical hyperplasia; C: carcinoma in situ; Cho- langio.: cholangiocellular carcinoma; Cirr. hep.: cirrhosis and/or he-

biliary t.: biliary tract diseases and carcinoma of the pancreatic head;

obst. j.: obstructive jaundice. * X2 > P = 0.001.

patocellular carcinoma; ( ): no. of cases of hepatocellular carcinoma; t x2 > P = 0.01.

No. 12 HYPERPLASIA AND CHOLANGIOCELLULAR CARCINOMA * Kurashina el a/. 2473

TABLE 2. Age- and Sex-Incidence of Cholangiocellular Carcinoma in Autopsy Patients in Japan During 1977 to 1981

Male Female Total

Age range (yr) Cancerous Total Percent Cancerous Total Percent Cancerous Total Percent

0-9 0 13,677 0 0 10,527 0 0 24,204 0 10-19 0 1239 0 0 734 0 0 1973 0 20-29 4 1717 0.23 0 1279 0 4 2966 0.13 30-39 19 3434 0.55 6 242 1 0.25 25 5855 0.43 40-49 49 8482 0.58 35 4673 0.75 84 13,155 0.64 50-59 123 13,194 0.93 71 7398 0.96 194 20,592 0.94

70-79 136 15,995 0.85 144 10,067 1.43 280 26,062 1.07 80-89 36 4637 0.78 37 3650 1.01 73 8287 0.88 90- 3 35 1 0.85 2 440 0.45 5 79 1 0.63

Total 545 79.888 0.68 424 5 1,573 0.82 969 131,46 I 0.74

60-69 I75 17,162 1.02 129 10,384 1.24 304 27,546 1.10

of age (47% of 218 patients in the large ducts) than in patients less than 30 years of age (19% of 32 patients in the large duct). The incidence of ductal hyperplasia in the large duct reached a maximum of 5 1% for patients 60 to 69 years of age. Atypical hyperplasia in the non- cancerous group was found exclusively in patients older than 30 years of age (1.4%). In the large duct, the male- female ratio in the incidence of ductal hyperplasia was 1.35. Cholangiocellular carcinoma was found in 0.7% of autopsies at major hospitals in Japan during 1977 to 198 1. The incidence gradually increased with advancing age (>20 years of age), reaching a maximum of 1.43% for women 70 to 79 years of age. Sex differences in the frequency of cholangiocellular carcinoma were slight (male-female, 0.83: 1 .O; Table 2).

Discussion

The current study showed many reasons why intrahe- patic bile duct hyperplasia is a potent precursor of cho- langiocellular carcinoma. The foci of carcinoma in situ and atypical hyperplasia were usually found in bile ducts associated with epithelial hyperplasia, and transitions from hyperplasia to atypical hyperplasia and from atypi- cal hyperplasia to carcinoma in situ were often histologi- cally traceable. Hyperplastic epithelium usually had slightly enlarged nuclei. In atypical hyperplasia, nuclear size tended to be between that of normal and cancerous nuclei. Cell size also was enlarged in both cancerous and hyperplastic cells. Bile duct hyperplasia was present in all livers with cholangiocellular carcinoma, and atypical hyperplasia was extremely frequent in these livers. The foci of carcinoma in situ in hyperplastic lesions were seen in 14 of 27 livers (51.9%) with cholangiocellular carcinoma. Papillary adenocarcinoma was most fre- quently observed in cholangiocellular carcinoma and papillary growth was common in atypical hyperplasia of bile ducts, with the exception of interlobular ducts and

ductules. Bile duct hyperplasia appeared at an earlier age in patients than cholangiocellular carcinoma and was frequent in patients older than 30 years of age. Atypical hyperplasia also was seen in patients older than 30 years of age. Cholangiocellular carcinoma was not found in younger patients (<20 years of age), and was most fre- quently found in patients 50 to 80 years of age. The incidence of cholangiocellular carcinoma in 13 1,46 1 autopsies was 0.7%. In 250 noncancerous cases, the in- cidence of atypical hyperplasia was 1.270, whereas that of bile duct hyperplasia was much higher at 43.6%. Cholangiocellular carcinoma was most frequently present in the hepatic hilus, whereas carcinoma of the extrahepatic bile ducts was most frequent in the upper region of the bile ducts. As favorable sites for these two cancers were contiguous and the histologic structures of the bile ducts in these two areas resembled each other, a similar process for the development of cancer in these two areas was assumed. In the extrahepatic bile ducts, de nova cancer was rare and most carcinomas arose from preexisting adenoma. l 5 Therefore, the presence of some precancerous changes corresponding with adenoma in the extrahepatic bile ducts was expected in the hepatic hilus. In histologic features, hyperplasia in the intrahe- patic bile ducts resembled pancreatic duct hyperplasia, which is a potent precursor of pancreatic duct carci- noma.16

Therefore, bile duct hyperplasia, especially atypical hyperplasia, is a condition corresponding with adenoma in other organs (ie., the extrahepatic bile ducts,” gall- bladder,I7 Vater’s papilla, ’* and large intestine). I 9

Pathogenesis of bile duct hyperplasia has not been confirmed. In the current study, hyperplasia was sig- nificantly frequent in bile ducts undergoing inflamma- tory changes (i.e., fibrosis and infiltration of inflamma- tory cells in the periductal areas, and epithelial injury). Nakanuma et aI.* reported a high frequency of atypi- cal hyperplasia in patients with hepatolithiasis not as-

2474 CANCER June 15 1988 Vol. 61

sociated with cholangiocellular carcinoma. Recurrent destruction and regeneration of the epithelial cells over a long period made the transformation of epithelial cells into bile duct hyperplasia possible. Similarly, pan- creatic duct hyperplasia was caused by necrotizing pan- creatitis.*'

In summary, most cholangiocellular carcinomas may develop from a base of bile duct hyperplasia. One of the important causative factors of hyperplasia may be chronic inflammation of the bile duct.

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