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. 2021 Oct 5;12(10):e00410.
doi: 10.14309/ctg.0000000000000410.

Primary Sclerosing Cholangitis-Associated Cholangiocarcinoma Demonstrates High Intertumor and Intratumor Heterogeneity

Eline J C A Kamp  1 , Maikel P Peppelenbosch  1 , Michail Doukas  2 , Joanne Verheij  3 , Cyriel Y Ponsioen  4 , Ronald van Marion  2 , Marco J Bruno  1 , Bas Groot Koerkamp  5 , Winand N M Dinjens  2 , Annemarie C de Vries  1
Affiliations

Primary Sclerosing Cholangitis-Associated Cholangiocarcinoma Demonstrates High Intertumor and Intratumor Heterogeneity

Eline J C A Kamp et al. Clin Transl Gastroenterol. .

Abstract

Introduction: Intertumor and intratumor heterogeneity may explain the diagnostic challenge and limited efficacy of chemotherapy for primary sclerosing cholangitis-associated cholangiocarcinoma (PSC-CCA). In this study, tumor heterogeneity was assessed through p53 and p16 protein expression analysis and next-generation sequencing (NGS) of TP53 and CDKN2A genetic alterations in PSC-associated CCA.

Methods: Formalin-fixed paraffin-embedded tissue samples from resection material of patients with PSC-CCA or patients with PSC diagnosed with biliary dysplasia were selected. Sections with CCA and foci with dysplastic epithelium were identified by 2 independent gastrointestinal pathologists. Immunohistochemical evaluation of p53 and p16 protein expression and NGS of TP53 and CDKN2A genetic alterations were performed.

Results: A total of 49 CCA and 21 dysplasia samples were identified in the resection specimens of 26 patients. P53 protein expression showed loss of expression, wild type, and overexpression in 14%, 63%, and 23% CCA and in 19%, 62%, and 19% dysplasia samples, respectively. P16 protein expression showed negative, heterogeneous, and positive results in 31%, 57%, and 12% CCA and in 33%, 53%, and 14% dysplasia samples, respectively. NGS showed high intertumor and intratumor heterogeneity of TP53 mutations and CDKN2A loss. Nearly 70% of the samples with a TP53 missense mutation demonstrated p53 overexpression, whereas all samples with a TP53 nonsense mutation demonstrated loss of p53 protein expression.

Discussion: PSC-associated CCA is characterized by high intertumor and intratumor heterogeneity of both p53/p16 protein expression and genetic alterations in TP53/CDKN2A, indicating that these tumors consist of multiple subclones with substantially different genetic makeup. The high intertumor and intratumor heterogeneity in PSC-CCA should be acknowledged during the development of diagnostic and therapeutic strategies.

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Conflict of interest statement

Guarantor of the article: Eline J.C.A. Kamp, MD, PhD.

Specific author contributions: E.J.C.A.K.: acquisition/analysis of data and drafting of the article. M.P.P.: critical revision of the article. M.D.: acquisition of data and critical revision of the article. J.V.: acquisition of data and critical revision of the article. C.Y.P.: critical revision of the article. R.v.M.: technical and material support. M.J.B.: critical revision of the article. B.G.K.: critical revision of the article. W.N.M.D.: analysis of data and critical revision of the article. A.C.d.V.: obtained funding, study supervision, and revision of the article.

Financial support: MLDS grant.

Potential competing interests: C.Y. Ponsioen has served as a speaker for Takeda, Tillotts, and Roche. He has served as an advisor for Takeda, Pliant, and Shire. He has received grant support from Takeda. No conflicts of interest for the other authors.

Figures

Figure 1.
Figure 1.
Overview of mutations, analysis of copy number variations, and immunohistochemistry in resection specimens of 26 patients with primary sclerosing cholangitis with biliary neoplasia.
Figure 2.
Figure 2.
Illustrative case of primary sclerosing cholangitis–associated cholangiocarcinoma of intratumor heterogeneity. (a) Immunohistochemistry of p53 with an abrupt transition from loss of p53 expression to overexpression (black arrow). (b) Next-generation sequencing analysis showing subclonality of TP53. The cells with p53 overexpression contained a pathogenic TP53 missense mutation (G > A), Arg273His, whereas this mutation was not observed in cells with loss of expression.
See this image and copyright information in PMC

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