Intrahepatic Cholangiocarcinoma with Lymph Node Metastasis ...

Surg Today (2006) 36:559–562 DOI 10.1007/s00595-006-3201-1

Intrahepatic Cholangiocarcinoma with Lymph Node Metastasis Successfully Treated by Immunotherapy with CD3-Activated T Cells and Dendritic Cells After Surgery: Report of a Case Ryota Higuchi, Masakazu Yamamoto, Takashi Hatori, Koichi Shimizu, Kenichirou Imai, and Ken Takasaki Department of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-0054, Japan

Abstract Intrahepatic cholangiocarcinoma (ICC) with lymph node (LN) metastasis is generally associated with a poor prognosis. However, we treated ICC with LN metastasis successfully by surgery and postoperative immunotherapy in a 59-year-old woman. The immunotherapy consisted of CD3-activated T cells and tumor lysate- or peptide-pulsed dendritic cells. Pathological examination confirmed a diagnosis of moderately differentiated adenocarcinoma with LN metastasis and portal vein invasion. The patient has been alive without recurrence for 3 years 6 months since her operation. Key words Intrahepatic cholangiocarcinoma · Lymph node metastasis

Introduction The outcome after surgery for intrahepatic cholangiocarcinoma (ICC) with lymph node (LN) metastasis is generally poor,1–4 and there are very few reports of long-term survivors after surgery.5–7 We report the case of a patient with ICC and LN metastasis who has not had any signs of recurrence for more than 3 years since undergoing surgery and immunotherapy.

Case Report A 59-year-old woman was admitted to our hospital for investigation and treatment of a tumor in the hepatobiliary ligament and dilatation of the intrahepatic bile ducts. The tumor had been detected at a local hospital after she presented with epigastralgia. Reprint requests to: R. Higuchi Received: April 4, 2005 / Accepted: January 17, 2006

Physical examination was unremarkable and the only laboratory studies that were abnormal were alkaline phosphatase, γ-glutamyl transpeptidase, and carbohydrate antigen 19-9, which were elevated to 451 U/l, 264 U/l, and 2320 U/l, respectively. Ultrasonography (US) and computed tomography (CT) showed a 5-mm dilatation of the intrahepatic bile ducts B2 and B3 and a solitary space-occupying lesion, 30 mm in diameter, in the hepatobiliary ligament (Fig. 1). Endoscopic retrograde cholangiography (ERC) showed an obstruction in the left hepatic duct (Fig. 2) and brushing cytology confirmed a diagnosis of class III. Angiography showed encasement of the right and left hepatic arteries, and stenosis of the portal vein. Based on these findings we made a diagnosis of ICC with LN metastasis and infiltration to the hepatic artery. About 2 months after her admission, she underwent resection of the left and caudate lobes, with resection and reconstruction of the extrahepatic duct, portal vein, and right hepatic artery. Operative Findings We performed laparotomy through a reverse T-type incision and found no ascites or dissemination. A slight atrophic change was seen in the left lobe of the liver. The tumor in the hepatobiliary ligament involved the hepatic and portal veins. Thus, we resected the left and caudate lobes, extrahepatic duct, portal vein, and the right and left hepatic arteries. We reconstructed the main trunk and right branch of the portal vein, the right hepatic duct, and the small intestine, and using microsurgery, the right hepatic and gastroduodenal arteries. The resected specimen contained a white grossly fibrous tumor, 3 cm in diameter, in the left hepatic duct (Fig. 3). Pathological examination confirmed a diagnosis of moderately differentiated adenocarcinoma with LN metastasis and invasion to the portal vein. There was no invasion to the right hepatic artery, but on the cut sur-

R. Higuchi et al.: Immunotherapy for ICC

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Fig. 1. Computed tomography scan, showing a solitary spaceoccupying lesion, 30 mm in diameter, in the hepatobiliary ligament (arrows)

Fig. 3. Resected specimen showing a white tumor, 3 cm in diameter, in the left lobe of the liver

Fig. 4. Expression of mucin core protein-1 was of the cytoplasmic type. Both the luminal surface membrane and the cytoplasm of neoplastic cells were stained, but expression in the cytoplasm was dominant Fig. 2. Endoscopic retrograde cholangiography, showing an obstruction in the left hepatic duct (arrow)

face, the tumor was 1 mm away from the right hepatic artery. The surgical margin was negative. The mucin core protein (MUC-1) expression8 was evaluated to be of the cytoplasmic type (Fig. 4). The patient was discharged on postoperative day 26. About 2 months after surgery, she underwent immunotherapy with CD3-activated T cells,9,10 with a mean cell number of 2.58 (range 0.84–4.60) × 109 / time, and tumor lysate- or peptide-pulsed dendritic cells, with a mean cell number of 1.43 (range 0.12–7.6) × 107 / time,11,12 eight times a year. The amino acid sequence of MUC-1 protein is GVTSAPDTRPAPGSTAPPAH × 5. In our institution, when the patient is found to have an area of redness larger than 10 mm in diameter around the injected lesion, we determine that this is evidence of an

immunological response to the tumor antigens. After a skin reaction was seen in our patient, the number of peripheral blood lymphocytes (PBL) rose to a median of 1795 (range 440–2330) × 103/µl, and the PBL count rose to a median of 38.8% (range 6.1%–47%). After 1 year, she obtained an immunological response to the tumor antigens. Subsequently, we gave her immunotherapy once every 2–3 months to maintain the immunological response. She has remained well without any evidence of recurrence for 3 years 6 months since undergoing surgery and immunotherapy.

Discussion According to the report of the 15th follow-up survey of primary liver cancer, ICC accounts for 3.3% of all pri-

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Fig. 5. Clinical course of the patient according to the laboratory data. Diamonds, carcinoembryonic antigen (ng/ml); triangles, carbohydrate antigen 19-9 (ng/ml); circles, peripheral blood lymphocytes (×103/µl)

mary liver cancers.13 For patients without LN metastasis, the 5-year survival rate after curative resection ranges from 23% to 45%;1,2,4 however, in those with LN metastasis, the 5-year survival rate drops to 0%–8%.2,4 Inoue et al. reported that LN dissection did not appear to improve patient survival,3 and others reported that outcomes in patients with infiltrating-spread type and vessel resection were poor.2,4 For patients with ICC and LN metastasis, there is no difference in prognosis according to the site or the number of LN metastases. Large tumors of the mass-forming type have a low curative resection rate, a high intrahepatic metastasis rate, a high vascular involvement rate, and a high postoperative recurrence rate.1 According to Inoue et al., the finding of LN metastasis should contraindicate hepatectomy.3 In our hospital, we routinely give postoperative immunotherapy after surgery for ICC. One method consists of an adoptive transfer of T cells activated with recombinant interleukin-2 and monoclonal antibody to CD3− in vitro,9,10 and the other method consists of an intradermal injection of tumor lysate- or peptide-pulsed dendritic cells11,12 near an inguinal nodal lesion. Leukapheresis is performed at each treatment, then immunotherapy is given until the patient obtains an immunological response to the tumor antigens. At present, no established method has been proven to be reliable for evaluating the effect of immunotherapy. However, several studies have shown that a specific immunological response to the tumor antigen in vivo was obtained in patients with positive skin reactions. It

has also been reported14 that skin reaction and clinical outcome is correlated. We have found that the PBL levels increase in patients who show positive skin reactions to tumor antigens. Investigations of lymphocytes in vitro from patients who had positive skin reactions revealed specific immunological responses to the tumor antigen. Since November 2000, we have followed this procedure to treat ICC with LN metastasis in 13 patients. All four patients who obtained an immunological response to the tumor antigen survived for at least 2 years after the operation, but the other nine patients who did not obtain an immunological response to the tumor antigen suffered early recurrence (unpublished data). Considering that the 2-year survival rate of patients who underwent resection for ICC with LN metastasis was reported to range from 7% to 20%,1–4 we suggest that postoperative recurrence can be controlled with immunotherapy if the patient obtains an immunological response. Takayama et al.10 reported the efficacy of an adoptive transfer of CD3− activated T cells to lower the postoperative recurrence rate of HCC; however, the efficacy of specific immunotherapy combined with ICC has not been reported. Matsumura et al.8 reported that the expression pattern of MUC-1 is an independent prognostic factor in mass-forming ICC. They studied 50 cases and classified three types, namely, ductal, cytoplasmic, and negative, with 75% being of the cytoplasmic type. The 5-year survival rates were 49.4%, 6.7%, and 43.8%, respectively, for the ductal, cytoplasmic, and negative types. The ICC in our patient was of the cytoplasmic type and another ICC, which we reported in a patient who was alive 8 years after surgery, was of the ductal type.5 The latter was ICC with a tumor 3.5 cm in diameter in segment 4 of the liver with LN metastasis of the posterior pancreatic lesion. This patient was treated with surgery alone. The MUC-1 pattern and therapy in the patient in the present report were different from those in the other patients and we cannot explain the long-term survival of this patient who, despite a poor prognosis, has had no sign of recurrence for more than 3 years since surgery. There is a possibility that immunotherapy promotes the inhibition of tumor recurrence. The outcome of ICC with LN metastasis is generally poor and long-term survivors are rarely reported. Thus, further investigations are needed to reveal the characteristics of patients who survive long term after treatment for ICC.

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