Cholangiocarcinoma (CCA) is a highly lethal, epithelial cell malignancy that occurs anywhere along the biliary tree and/or within the hepatic parenchyma. CCA displays features of cholangiocyte differentiation and probably arises predominantly from the epithelial cells lining the bile ducts, which are termed cholangiocytes; however, the cancers may also develop from peribiliary glands and hepatocytes, depending on the underlying liver disease and location [1][2][3][4] . These cancers are heterogeneous and are best classified according to the primary, anatomic subtype as intrahepatic CCA (iCCA), perihilar CCA (pCCA) or distal CCA (dCCA) 5,6 (Fig. 1). iCCA is located proximally to the second-order bile ducts within the liver parenchyma, pCCA is localized between the second-order bile ducts and the insertion of the cystic duct into the common bile duct, and dCCA is confined to the common bile duct below the cystic duct insertion. The true incidence of pCCA and iCCA is unclear owing to the extensive misclassification of pCCA as iCCA in national databases 6,7 . In addition, enhanced diagnostic capabilities have enabled increased clinical distinction between carcinoma of unknown primary and iCCA 8,9 . These factors have, in part, contributed to the reported increase in incidence of iCCA over the past two or three decades. Each of the anatomic subtypes is characterized by unique genetic aberrations, clinical presentations and management options 10 . However, many databases categorize both pCCA and dCCA as extrahepatic CCA. Most CCAs are adenocarcinomas and other histological subtypes, such as adenosquamous carcinoma or clear cell carcinoma, are encountered rarely 11 . These cancers are highly desmoplastic and are enmeshed in dense networks of inflammatory cells and matrix termed the tumour immune microenvironment [12][13][14] .The epidemiology of these cancers varies worldwide. Infections with specific trematodes (flatworm parasites, commonly called flukes) are a major cause of CCA in some regions. For example, in Southeast Asia, the liver fluke Opisthorchis viverrini is the leading cause of CCA 15 . CCA occurring secondary to fluke infestation can arise anywhere within the biliary tree and present as any one of the three anatomic subsets. Fluke-related CCA may have a specific pathogenesis, especially genetic aberrations, but the diagnosis and management are not different from non-fluke-related CCA. In the Western world, most patients with CCA do not have an identifiable risk factor, except for some with primary sclerosing cholangitis (PSC) 7,10 . Further insights into the epidemiology, risk factors and biology of CCA are needed to improve its prevention and therapy.In this Primer, we discuss the epidemiology and pathophysiological mechanisms of liver-fluke-related and non-liver-fluke-related CCA and associated risk factors and summarize diagnosis and management of C holangiocarcinoma

Cholangiocarcinomas are devastating cancers that are increasing in both their worldwide incidence and mortality rates. The challenges posed by these often lethal biliary tract cancers are daunting, with conventional treatment options being limited and the only hope for long-term survival being that of complete surgical resection of the tumor. Unfortunately, the vast majority of patients with cholangiocarcinoma typically seek treatment with advanced disease, and often these patients are deemed poor candidates for curative surgery. Moreover, conventional chemotherapy and radiation therapy have not been shown to be effective in prolonging long-term survival, and although photodynamic therapy combined with stenting has been reported to be effective as a palliative treatment, it is not curative. Thus, there is a real need to develop novel chemopreventive and adjuvant therapeutic strategies for cholangiocarcinoma based on exploiting select molecular targets that would impact in a significant way on clinical outcome. This review focuses on potential preventive targets in cholangiocarcinogenesis, such as inducible nitric oxide synthase, cyclooxygenase-2, and altered bile acid signaling pathways. In addition, molecular alterations related to dysregulation of cholangiocarcinoma cell growth and survival, aberrant gene expression, invasion and metastasis, and tumor microenvironment are described in the context of various clinical and pathological presentations. Moreover, an emphasis is placed on the importance of critical signaling pathways and postulated interactions, including those of ErbB-2, hepatocyte growth factor/Met, interleukin-6/glycoprotein130, cyclooxygenase-2, vascular endothelial growth factor, transforming growth factor-␤, MUC1 and MUC4, ␤-catenin, telomerase, and Fas pathways as potential molecular therapeutic targets in cholangiocarcinoma. (HEPATOLOGY 2005;41:5-15.)

Intrahepatic cholangiocarcinoma (iCCA) has over the last 10‐20 years become the focus of increasing concern, largely due to its rising incidence and high mortality rates worldwide. The significant increase in mortality rates from this primary hepatobiliary cancer, particularly over the past decade, has coincided with a rapidly growing interest among clinicians, investigators, and patient advocates to seek greater mechanistic insights and more effective biomarker‐driven targeted approaches for managing and/or preventing this challenging liver cancer. In addition to discussing challenges posed by this aggressive cancer, this review will emphasize recent epidemiological, basic, and translational research findings for iCCA. In particular, we will highlight emerging demographic changes and evolving risk factors, the critical role of the tumor microenvironment, extracellular vesicle biomarkers and therapeutics, intertumoral and intratumoral heterogeneity, and current and emerging targeted therapies regarding iCCA. Specifically, recent evidence linking non–bile duct medical conditions, such as nonalcoholic fatty liver disease and nonspecific cirrhosis, to intrahepatic cholangiocarcinogenesis together with geographic and ethnic variation will be assessed. Recent developments concerning the roles played by transforming growth factor‐β and platelet‐derived growth factor D in driving the recruitment and expansion of cancer‐associated myofibroblasts within cholangiocarcinoma (CCA) stroma as well as their therapeutic implications will also be discussed. In addition, the potential significance of extracellular vesicles as bile and serum biomarkers and therapeutic delivery systems for iCCA will be described. An integrated systems approach to classifying heterogeneous iCCA subtypes will be further highlighted, and recent clinical trials and emerging targeted therapies will be reviewed, along with recommendations for future translational research opportunities. Established international CCA networks are now facilitating collaborations aimed at advancing iCCA translational and clinical research.

Cholangiocarcinoma (CCA) cells paradoxically express the death ligand TRAIL, and, therefore, are dependent upon potent survival signals to circumvent TRAIL cytotoxicity. CCAs are also highly desmoplastic cancers with a tumor microenvironment rich in myofibroblasts (MFBs). Herein, we examine a role for MFB-derived CCA survival signals. We employed human KMCH-1, KMBC, HuCCT-1, TFK-1, and Mz-ChA-1 CCA cells as well as human primary hepatic stellate and myofibroblastic LX-2 cells for these studies. In vivo experiments were conducted using a syngeneic rat orthotopic CCA model. Co-culturing CCA cells with myofibroblastic human primary HSCs or LX-2 cells significantly decreased TRAIL-induced apoptosis in CCA cells, a cytoprotective effect abrogated by neutralizing PDGF-BB-antiserum. Cytoprotection by PDGF-BB was dependent upon Hedgehog (Hh) signaling as it was abolished by the smoothened (the transducer of Hh signaling) inhibitor cyclopamine. PDGF-BB induced PKA-dependent trafficking of smoothened to the plasma membrane resulting in GLI2 nuclear translocation and activation of a consensus GLI reporter gene-based luciferase assay. A genome-wide mRNA expression analysis identified 67 target genes to be commonly up- (50 genes) or downregulated (17 genes) by both SHH and PDGF-BB in a cyclopamine-dependent manner in CCA cells. Finally, in a rodent CCA in vivo-model, cyclopamine administration increased apoptosis in CCA cells resulting in tumor suppression. Conclusions Myofibroblast-derived PDGF-BB protects CCA cells from TRAIL cytotoxicity by a Hh signaling-dependent process. These results have therapeutical implications for the treatment of human cholangiocarcinoma.