Preclinical evidence for preventive and curative effects of resveratrol on xenograft cholangiocarcinogenesis.

Cholangiocarcinoma (CCA), the malignant tumor of bile duct epithelial cells, is a relatively rare yet highly lethal cancer. In this work, we tested the ability of Resveratrol (RV) to prevent and cure CCA xenograft in nude mice and investigated molecular mechanisms underpinning such anticancer effect. Human CCA cells were xenografted in mice that were or not treated prior to or after to transplantation with RV. Tumor growth was monitored and analyzed for the markers of cell proliferation, apoptosis, and autophagy. TCGA was interrogated for the molecules possibly targeted by RV. RV could inhibit the growth of human CCA xenograft when administered after implantation and could reduce the growth or even impair the implantation of the tumors when administered prior the transplantation. RV inhibited CCA cell proliferation, induced apoptosis with autophagy, and strongly reduced the presence of CAFs and production of IL-6. Interrogation of CCA dataset in TCGA database revealed that the expression of IL-6 Receptor (IL-6R) inversely correlated with that of MAP-LC3 and BECLIN-1, and that low expression of IL-6R and of MIK67, two pathways downregulated by RV, associated with better survival of CCA patients. Our data demonstrate that RV elicits a strong preventive and curative anticancer effect in CCA by limiting the formation of CAFs and their release of IL-6, and this results in up-regulation of autophagy and apoptosis in the cancer cells. These findings support the clinical use of RV as a primary line of prevention in patients exposed at risk and as an adjuvant therapeutics in CCA patients.

Development of Fruit and Vegetable Consumption Promotion Model in a High-Risk Population for Cholangiocarcinoma in Thailand: An Action Research.

OBJECTIVE: This study aimed to develop a model for promoting fruit and vegetable consumption  in Thailand's high-risk population for cholangiocarcinoma (CCA). METHODS: Action research was used as a guiding framework for model development. Participants were divided into groups for process development and evaluation. Group discussions and practice notes were utilized as tools for process development. Data were collected through questionnaires. Qualitative data were categorized and analyzed using content analysis. Descriptive and inferential statistics were applied to analyze quantitative data. RESULTS: The model development process, following the PAOR framework (Planning, Action, Observation, Reflection), involved fruit and vegetable consumption promotion.  The model, named the "NONGBO NO-CCA Model" included various components: active involvement of villagers in planning, objective sharing of experiences and brainstorming to identify CCA prevention strategies, establishment of networks to support community healthcare, enhancement of community self-reliance through utilization of local resources, and encouragement of chemical-free and environmentally friendly fruit and vegetable cultivation. Following model development, at-risk individuals demonstrated a statistically significant improvement in knowledge, attitude, and practice (p<0.001). CONCLUSION: The findings indicate that at-risk individuals exhibited improvements in knowledge, attitude, and practice. Knowledge gains may be attributed to educational training activities, improved attitudes may result from networking processes, and modifications in practice behaviors may be influenced by community participation. Therefore, active involvement in community development can serve as a guiding principle for effective proactive CCA prevention.

Epidemiology and Control of Opisthorchis viverrini Infection: Implications for Cholangiocarcinoma Prevention.

It is known that Opisthorchis viverrini (OV) is the most significant risk factor for the development of cholangiocarcinoma (CCA); hence, it is also known as carcinogenic parasite. Effective control and elimination of OV infection should significantly reduce O. viverrini-related CCA. This chapter includes details of the three recently developed innovative tools, namely the Isan cohort database software, an OV-RDT for screening of O. viverrini, and an ultrasound telecommunication system. Past and current control programs, i.e., education, medication, and sanitation were discussed and stressed the need for a comprehensive control program which encompasses primary, secondary, and tertiary patient care programs for confirmation and management of suspected CCA cases. The approach of mathematical modeling for control of OV and CCA was also briefly described. Additionally, we highlighted the current progress toward control of OV and CCA in Thailand and potential for expansion into nearby countries in Southeast Asia.

p53 protects against formation of extrahepatic biliary precancerous lesions in the context of oncogenic Kras.

KRAS and TP53 mutations are frequently observed in extrahepatic biliary cancer. Mutations of KRAS and TP53 are independent risk factors for poor prognosis in biliary cancer. However, the exact role of p53 in the development of extrahepatic biliary cancer remains elusive. In this study, we found that simultaneous activation of Kras and inactivation of p53 induces biliary neoplasms that resemble human biliary intraepithelial neoplasia in the extrahepatic bile duct and intracholecystic papillary-tubular neoplasm in the gall bladder in mice. However, inactivation of p53 was not sufficient for the progression of biliary precancerous lesions into invasive cancer in the context of oncogenic Kras within the observation period. This was also the case in the context of additional activation of the Wnt signaling pathway. Thus, p53 protects against formation of extrahepatic biliary precancerous lesions in the context of oncogenic Kras.

Capacity Building of a Self-Reliant Model Community for Cholangiocarcinoma Prevention by Producing Fruit and Vegetable Juice Products in a High-Risk Area of Thailand.

OJECTIVE: This participatory action research aims to develop healthy fruit and vegetable juice products (FVPs) to enhance people's income and quality of life (QOL) in a community with the highest prevalence of cholangiocarcinoma (CCA) in Thailand. METHODS: We randomly sampled study areas from 25 homes in a Thai community to solve poverty and improve QOL. Descriptive and inferential statistics were employed for data analysis. Moreover, qualitative data were analyzed by content analysis. RESULTS: The community management system relies on local resources under religious inspiration. Academics also keep developing FVPs from local raw materials planted by organic farming under "Nong Lak Rak Sukapab." The product's nutritional value was measured by In-House and Nutrition Labeling Methods from National Food Institute Laboratory (IEC/ISO17025). According to the Bureau of Nutrition, a 230 ml bottle of each wheatgrass and corn juice contains nutrients beneficial to health and necessary for the body. In addition, the community has participated in production planning, marketing, distribution, and household accounting. As a result, average monthly household income and QOL increased with statistical significance after the project implementation.  Conclusions: These findings demonstrated that improving communities' capacity to be health leaders by producing FVPs to prevent CCA in high-risk areas is critical to early disease prevention and community health care. These issues can also be applied to public policy implications for other regions and diseases in order to emphasize community health care and long-term community development.

Effects of Health Literacy Promotion Programs for Preventing Opisthorchiasis and Cholangiocarcinoma: a Systematic Review and Meta-analysis.

Cholangiocarcinoma (CCA), caused mainly by Opisthorchis viverrini (OV) infection, is a public health issue. Health literacy can play a significant role in preventing OV and CCA and adopting preventive behaviors. Therefore, this study aimed to evaluate, summarize, and synthesize the current evidence on health literacy programs for preventing OV and CCA.A systematic literature search, with Thai and English languages, was performed using electronic databases through PubMed, Google Scholar, ThaiJo, ThaiLis, and Embase to identify studies examining health literacy programs to prevent OV and CCA. We followed PRISMA 2020 guidelines. In addition, we used the RevMan software to perform a meta-analysis to analyze effect sizes using a fixed-effects model and measures of heterogeneity using Cochran's Q and I2. This meta-analysis included seven studies that met the criteria. The results showed that the people who received a program had an increased health literacy overall and in each aspect with a statistically significant (p < 0.001). So, health literacy programs can assist people in understanding their health and gaining access to health information and services. Additionally, the effect of programs (communication abilities, self-management, media and information literacy, and decision-making in practice) can help prevent OV and CCA. As a result, multi-disciplinary healthcare teams are crucial to developing preventive programs to prevent OV and CCA. Further studies need to be done and applied to these programs to modify behavior to avoid other diseases.

Impact of metformin on the incidence of human cholangiocarcinoma in diabetic patients: a systematic review and meta-analysis.

Cholangiocarcinoma (CCA) is the second most common liver cancer. Diabetes is a well-known risk factor; however, treatment with metformin has been reported to be protective for several cancers, but data on CCA are still sparse and heterogeneous. We performed this meta-analysis to investigate the role of metformin as a potential protective factor for CCA. In this systematic review and meta-analysis, we searched PubMed/MEDLINE and EMBASE databases, from the date of inception to November 2022, for studies analyzing CCA rate in patients taking metformin. Twenty-nine articles were initially identified, of which four were eligible and included in our systematic review and meta-analysis, from which we estimated the relative risk (RR). The rate of CCA was lower for diabetic patients taking metformin than diabetic patients without metformin intake when comparing two highest quality studies [RR, 0.38; 95% confidence interval (CI), 0.290-0.508; P < 0.001], and three studies with similar inclusion criteria (RR, 0.34; 95% CI, 0.51-0.35; P < 0.001) without significant statistical heterogeneity among them (I2 = 29.83%, P = 0,2326 and I2 = 35.08%; P = 0.2143, respectively). Our study demonstrated a significant impact of metformin in reducing the risk of CCA by nearly 62-66% in diabetic patients taking metformin.

Chimeric immune checkpoint protein vaccines inhibit the tumorigenesis and growth of rat cholangiocarcinoma.

Cholangiocarcinoma (CCA) is the second most common primary liver malignancy and carries a dismal prognosis due to difficulties in achieving an optimal resection, and poor response to current standard-of-care systemic therapies. We previously devised a CTLA4-PD-L1 DNA cancer vaccine (DNA vaccine) and demonstrated its therapeutic effects on reducing tumor growth in a thioacetamide (TAA)-induced rat intrahepatic CCA (iCCA) model. Here, we developed a CTLA4-PD-L1 chimeric protein vaccine (Protein vaccine), and examined its effects in the rat iCCA model. In a therapeutic setting, iCCA-bearing rats received either DNA plus Protein vaccines or Protein vaccine alone, resulting in increased PD-L1 and CTLA-4 antibody titers, and reduced iCCA tumor burden as verified by animal positron emission tomography (PET) scans. Treating iCCA-bearing rats with Protein vaccine alone led to the increase of CTAL4 antibody titers that correlated with the decrease of tumor SUV ratio, indicating regressed tumor burden, along with increased <i>CD8</i> and granzyme A (<i>GZMA</i>) expression, and decreased PD-L1 expression on tumor cells. In a preventive setting, DNA or Protein vaccines were injected in rats before the induction of iCCA by TAA. Protein vaccines induced a more sustained PD-L1 and CTLA-4 antibody titers compared with DNA vaccines, and was more potent in preventing iCCA tumorigenesis. Correspondingly, Protein vaccines, but not DNA vaccines, downregulated PD-L1 gene expression and hindered the carcinogenesis of iCCA. Taken together, the CTLA4-PD-L1 chimeric protein vaccine may function both as a therapeutic cancer vaccine and as a preventive cancer vaccine in the TAA-induced iCCA rat model.

Inflammatory pathways and cholangiocarcinoma risk mechanisms and prevention.

Cholangiocarcinoma (CCA), a neoplasm burdened by a poor prognosis and currently lacking adequate therapeutic treatments, can originate at different levels of the biliary tree, in the intrahepatic, hilar, or extrahepatic area. The main risk factors for the development of CCA are the presence of chronic cholangiopathies of various etiology. To date, the most studied prodromal diseases of CCA are primary sclerosing cholangitis, Caroli's disease and fluke infestations, but other conditions, such as metabolic syndrome, nonalcoholic fatty liver disease and obesity, are emerging as associated with an increased risk of CCA development. In this review, we focused on the analysis of the pro-inflammatory mechanisms that induce the development of CCA and on the role of cells of the immune response in cholangiocarcinogenesis. In very recent times, these cellular mechanisms have been the subject of emerging studies aimed at verifying how the modulation of the inflammatory and immunological responses can have a therapeutic significance and how these can be used as therapeutic targets.

Effects of Integration of Social Marketing and Health Belief Model for Preventing Cholangiocarcinoma in High-Risk Areas of Thailand: A Community Intervention Study.

INTRODUCTION/OBJECTIVE: To examine the effects of applying social marketing and Health Belief Model (HBM) in preventing cholangiocarcinoma (CCA) in high-risk areas of Thailand. METHODS: About 2 randomized high-risk areas of CCA from multiple-stage sampling were assigned as study areas. The 150 participants were allocated to the experimental group, which received a 12-week health education program that applied social marketing and HBM. The comparison group received the usual services. Data were collected by a questionnaire created by the researchers. We employed descriptive, inferential statistics (paired t-test and independent t-test) for normal distribution, while Analysis of Covariance (ANCOVA) was used for mean scores differing before the experiment. RESULTS: After the experiment, the mean scores of the perceived risk of CCA, perceived severity of CCA, perceived benefits of CCA prevention, perceived barriers to CCA prevention, and correct behaviors of CCA prevention in the experimental group were significantly higher than those before the experiment the .05 level. They were also considerably higher than those of the comparison group at the .05 level. CONCLUSION: This is the first study to integrate social marketing and HBM for CCA prevention. Therefore, formulating policies or measures to prevent disease through public communication will form a model to avoid CCA and create a channel for distributing useful information to the general public.

Cholangiocarcinoma protective factors in Greater Mekong Subregion: Critical issues for joint planning to sustainably solve regional public health problems.

Although Opisthorchis viverrini (OV), lifestyle, and diet co-factors have a relatively high prevalence in the Greater Mekong Subregion (GMS) population, cumulative (0-74) incidence rates of cholangiocarcinoma (CCA) do not reach 5% in this region. Other co-factors must influence, but in this study, we only highlighted positive factors for guiding joint planning to address public health problems at the regional level. Therefore, we aimed to study prevalence and factors associated with CCA incidence focusing only on protective factors. A cross-sectional analytic study was carried out from June to October 2017. Participants with informed consent completed the questionnaires. Descriptive statistics were used to analyze general information. Primary variables were classified into high and low levels by mean. Logistic regression was employed to investigate the correlation between interesting variables and the overall risk level of CCA. The overall prevalence of CCA protective factors of the whole region was knowledge (61.39%), health beliefs (42.32%), prevention behavior (31.93%), and community participation (14.53%). When considering the proportions at a high level, they were 49.53%, 53.72%, 35.37%, and 49.67%, respectively. Significant factors associated with CCA prevention were females with secondary or vocational education, a high level of perceived seriousness and benefits, and community participation. These findings are likely to be helpful for both the public and administrators. First, it can be information for people to be aware of CCA risk. Second, policy-driven authorities at the local or regional level should apply the critical issues from this study for joint planning to sustainably solve regional public health problems.

Aspirin, Statins, Non-aspirin NSAIDs, Metformin, and the Risk of Biliary Cancer: A Swedish Population-Based Cohort Study.

BACKGROUND: Chemoprevention for biliary tract cancers (BTC), which comprise intrahepatic cholangiocarcinoma (iCCA), extrahepatic cholangiocarcinoma (eCCA), and gallbladder cancer, is controversial. We examined associations between low-dose aspirin, statins, NSAIDs, and metformin with BTC risk. METHODS: We used a population-based cohort of 5.7 million persons over age 18 without personal history of cancer (except nonmelanoma skin cancer), receiving at least one commonly prescribed drug between July 1, 2005, and December 31, 2012, from the Swedish Prescribed Drug Registry. Hazard ratios (HR) were calculated using age-scaled multivariable-adjusted Cox models. RESULTS: 2,160 individuals developed BTC. Low-dose aspirin was not associated with BTC risk [HR, 0.93; 95% confidence interval (CI), 0.81-1.07], iCCA (HR, 1.21; 95% CI, 0.93-1.57), eCCA (HR, 0.80; 95% CI, 0.60-1.07), or gallbladder cancer (HR, 0.87; 95% CI, 0.71-1.06). Statins were associated with lower risk of BTC (HR, 0.66; 95% CI, 0.56-0.78), iCCA (HR, 0.69; 95% CI, 0.50-0.95), eCCA (HR 0.54; 95% CI, 0.38-0.76), and gallbladder cancer (HR, 0.72; 95% CI, 0.57-0.91). For all BTC subtypes, combined low-dose aspirin and statins were not associated with lower risk than statins alone. NSAIDs were associated with higher risk of BTC and its subtypes. Metformin was not associated with BTC risk (HR, 0.98; 95% CI, 0.82-1.18), iCCA (HR, 1.06; 95% CI, 0.77-1.48), eCCA (HR, 1.15; 95% CI, 0.82-1.61), or gallbladder cancer (HR, 0.84; 95% CI, 0.63-1.11). CONCLUSIONS: Statins were associated with a decreased risk of BTC and its subtypes. Low-dose aspirin alone was not associated with a decreased risk, and use of both was not associated with further decrease in risk beyond statins alone. IMPACT: Statins were most consistently associated with a decreased risk of BTC and its subtypes.

Effectiveness of Village Health Volunteer Parallel Program for Proactive Action to Reduce Risk Factors for Cholangiocarcinoma in Two High-Risk Countries in the Greater Mekong Subregion.

Thailand and Laos were classified as risk areas for cholangiocarcinoma (CCA) in a 2017 assessment in the Greater Mekong Subregion. In 2019, the potential of village health volunteers (VHVs) in both risk areas was developed. The VHVs trained in 2014 (VHV-A) were mentors transferring knowledge of CCA prevention to the trainees (known as VHV-B) in a parallel manner. After that, VHV-Bs in each area educated people to change their behavior. Both parties worked in the same direction to reduce risk factors. In 2020, data were collected after the program was organized in the same populations. The people were aged 30-69 years, whose names were in the civil registration, and had lived in that area for at least five years. Afterward, no less than 172 participants from each location were randomly selected. The research tools used were intervention and questionnaires. Descriptive and inferential statistics were employed for data analysis. After the experiment, all the experimental group's risk factors were significantly different from those of the control group. This study's outcome was an effective program for proactive action in reducing risk factors in the risk areas. Therefore, it should be applied to reduce risk factors for CCA in other regions.

Intracellular IL-33 Attenuates Extracellular IL-33-induced Cholangiocarcinoma Cell Proliferation and Invasion via NF-κB and GSK-3ß Pathways.

BACKGROUND/AIM: The functions of interleukin 33 (IL-33) in cholangiocarcinoma (CCA) are unclear. This study aimed to evaluate the roles of IL-33 in CCA progression. MATERIALS AND METHODS: The effect of intracellular IL-33 using shIL-33 knocked down KKU-055 (IL-33KD-KKU-055) compared to parental (Pa) KKU-055 and extracellular IL-33 using recombinant human IL-33 (rhIL-33) treatment on the proliferation and invasion of CCA cells grown in 3D cultures was studied. Relevant markers were determined by western blot or ELISA. RESULTS: IL-33KD-KKU-055 cells showed increased proliferation and invasion in 3D cultures compared to Pa-KKU-055 cells, with NF-κB and IL-6 up-regulation. Treatment with 2 ng/ml rhIL-33 promoted Pa-KKU-055 cell proliferation by inducing NF-κB and IL-6 expressions. Upon GSK-3ß inactivation and increased nuclear full-length IL-33 (flIL-33), 20 ng/ml rhIL-33 had no effect on proliferation. Both 2 and 20 ng/ml rhIL-33 induced proliferation and invasion of IL-33-negative KKU-213 cells in 3D cultures, as well as NF-κB and IL-6 up-regulation. CONCLUSION: Intracellular and extracellular IL-33 have distinct roles in the mechanisms of CCA progression.

Risk Communication Through Health Beliefs for Preventing Opisthorchiasis-Linked Cholangiocarcinoma: A Community- Based Intervention in Multicultural Areas of Thailand.

OBJECTIVE: This research aimed to study the effects of the risk communication program through the Cambodian folk song to prevent Opisthorchiasis-linked cholangiocarcinoma (OV-CCA). METHODS: We conducted the quasi-experimental research between August and December 2017 in the Cambodian communities, one-fourth of ethnic minorities residing in multicultural areas of Sisaket Province, Thailand. The samples consisted of 94 equally people divided into experimental group and control group. The experimental group included 47 people at-risk of OV-CCA who received the program for 12 weeks, while the control group received regular services. We collected data by using a questionnaire with a reliability of 0.93. Descriptive and inferential statistics were used for data analysis. RESULTS: The study indicated that the socioeconomic information of both groups was not different. The mean scores of all issues (health beliefs, social support, and prevention behavior in the experimental group were higher than those of the control group with statistical significance. Closer inspection showed that the mean difference of the health beliefs was 55.61 points (95%CI: 52.39-57.42, p<0.001), social support was 9.09 points (95%CI: 8.12-10.05, p<0.001), and prevention behavior was 6.38 points (95%CI: 5.43-7.33, p<0.001). CONCLUSION: Through the Cambodian folk song, the risk communication program by applying the health beliefs and social support to prevent OV-CCA is beneficial for behavior modification in areas with similar cultures.

Effectiveness of Leader Village Health Volunteers Training Program on Preventing Cholangiocarcinoma in Thailand: Advantages for High-Risk Area with Limited Public Health Personnel.

Cholangiocarcinoma (CCA) still affects the health of rural people in northeast Thailand. Most people had a high level of overall risk according to CCA risk assessment in 2014. The question is how to make prevention of CCA as cost-effective as possible. The most appropriate answer is that someone should become a health leader to transfer knowledge to the public. This is the reason for developing the training program for village health volunteers (VHVs)-who play the role of change agents-to transfer knowledge to villagers. As for the evaluation of success, it is not evaluated if VHVs have increased knowledge or not, but it is assessed if people have better knowledge/attitudes, which lead to the correct behavior modification or not. After the program had been implemented for 2 years, people were evaluated on knowledge, attitudes, perception, and satisfaction with the operation of VHVs in providing people with the knowledge and ability to prevent CCA. It was found that people had a higher level of knowledge and attitudes in preventing CCA than before implementing the program. Also, they perceived that VHVs transferred knowledge to villagers so that they had the ability to prevent CCA. Nowadays, VHVs in the digital era (VHVs 4.0) is very useful in solving CCA problems in Thailand because they are the main drivers of success. Potential development of VHVs together with use of digital technology is an advantage for high-risk area with limited public health personnel.

Decreased risk of cholangiocarcinoma in diabetic patients treated with metformin.

BACKGROUND: Cholangiocarcinoma is an important biliary tract cancer. The high incidence of this cancer is observed in tropical Asia. Several underlying factors are mentioned for this cancer including to diabetes mellitus. The use of the antidiabetic drug, metformin, is mentioned for possibility for decreasing risk for cholangiocarcinoma. METHODS: The work is aimed to estimate the change in risk of local people in the endemic area of cholangiocarcinoma in scenario that diabetic patients are treated with metformin in the highly endemic area of cancer in Thailand. RESULTS: In this study, the authors estimated the change in risk of local people in the endemic area of cholangiocarcinoma in scenario that diabetic patients are treated with metformin. CONCLUSION: The results show a slight decreased risk of cholangiocarcinoma in that scenario.

Spatial analysis of hepatobiliary abnormalities in a population at high-risk of cholangiocarcinoma in Thailand.

Cholangiocarcinoma (CCA) is a serious health challenge with low survival prognosis. The liver fluke, Opisthorchis viverrini, plays a role in the aetiology of CCA, through hepatobiliary abnormalities: liver mass (LM), bile duct dilation, and periductal fibrosis (PDF). A population-based CCA screening program, the Cholangiocarcinoma Screening and Care Program, operates in Northeast Thailand. Hepatobiliary abnormalities were identified through ultrasonography. A multivariate zero-inflated, Poisson regression model measured associations between hepatobiliary abnormalities and covariates including age, sex, distance to water resource, and history of O. viverrini infection. Geographic distribution was described using Bayesian spatial analysis methods. Hepatobiliary abnormality prevalence was 38.7%; highest in males aged > 60 years (39.8%). PDF was most prevalent (20.1% of males). The Standardized Morbidity Ratio (SMR) for hepatobiliary abnormalities was highest in the lower and upper parts of the Northeast region. Hepatobiliary abnormalities specifically associated with CCA were also more common in males and those aged over 60 years and distributed along the Chi, Mun, and Songkram Rivers. Our findings demonstrated a high risk of hepatobiliary disorders in Northeast Thailand, likely associated with infection caused by O. viverrini. Screening for CCA and improvement of healthcare facilities to provide better treatment for CCA patients should be prioritized in these high-risk areas.