Biliary stricture due to neuroma after an innocent blunt abdominal trauma

A traumatic neuroma of the biliary tract is rarely associated with biliary obstruction. However, when it arises in the common bile duct (CBD) and is associated with obstructive jaundice, it is difficult to distinguish it from bile duct cancer. We describe a patient who developed obstructive jaundice and itching, due to CBD stricture, 8 years after innocent blunt abdominal trauma. The stricture was resected and hepatico-jejunal anastomosis was performed. Histological examination revealed a traumatic neuroma and a fibrous scar around the common bile duct. Symptoms disappeared following surgical removal of the lesion. Blunt abdominal injury may cause the late onset of a fibrous scar and traumatic neuroma in the common bile duct. To our knowledge, a traumatic neuroma of the biliary tract after blunt abdominal trauma has not been reported previously. We review the clinical picture of this relatively rare problem, along with its diagnosis, pathogenesis and treatment.

Choledochal cysts in adults

HYPOTHESIS

Choledochal cyst is rarely diagnosed in adulthood. When complicated by biliary tract malignancy, the disease has a distinct presentation and carries a dismal prognosis despite radical surgical resection.

DESIGN

Retrospective study.

SETTING

Tertiary referral center.

PATIENTS

A retrospective study was performed on 30 adult patients who presented with choledochal cyst from January 1, 1989, to December 31, 2000.

MAIN OUTCOME MEASURES

The clinical presentation, management, and outcome of patients with and without biliary tract malignancy.

RESULTS

Nine patients (30%) had biliary tract malignancy complicating choledochal cyst (group A). Compared with 21 patients without malignancy (group B), group A patients had a significantly higher incidence of previous internal drainage operations for choledochal cyst (P =.049) and presentation with cholangitis (P =.03). Four patients in group A underwent pancreaticoduodenectomy and 3 received a palliative biliary drainage operation. The overall median survival of patients in group A was 12 months. Complete excision of choledochal cyst and Roux-en-Y hepaticojejunostomy were performed for all patients in group B, among whom 2 underwent concomitant hemihepatectomy. The operative morbidity and mortality were 14% and 0%, respectively, and there were no long-term complications with a median follow-up of 66 months.

CONCLUSIONS

Biliary tract malignancy complicating choledochal cyst in adults should be suspected in patients with a history of internal drainage of choledochal cyst and presentation with cholangitis. Complete excision of choledochal cyst with Roux-en-Y hepaticojejunostomy is the treatment of choice for patients without malignancy and can be performed with low operative morbidity and absence of long-term complications in adult patients.

Down-regulated p16 expression predicts poor prognosis in patients with extrahepatic biliary tract carcinomas

The prognosis of extrahepatic biliary tract cancer (EBT) patients is generally accepted to be poor. We immunohistochemically evaluated expression of p16, a cyclin-depend kinase inhibitor, in tumor specimens surgically removed from 99 EBT patients. We also examined whether there was any relationship between expression of p16 and biological malignancy of the tumor by comparing its clinicopathological factors. Consequently, we found that there were three types of p16 expression in the tumor cells; diffuse, heterogeneous and negative types, the percentages of which were 19, 41 and 39%, respectively. Heterogeneous and negative types, whose expression of p16 was considered to be down-regulated, showed scirrhous (p=0.022) and infiltrating growth (p=0.002). In addition, we found that the proportion of down-regulated expression of p16 was different, depending on the location of the tumor. We also observed that the down-regulated p16 expression was the highest in a proportion of patients with the extrahepatic bile duct carcinoma. In contrast, the proportion of down-regulated p16 expression was the least among the patients in the region of the ampulla of Vater with better prognosis, and we showed that the prognosis of patients with down-regulated expression of p16 was the poorest in terms of the cancer location where it is limited to the region of ampulla of Vater. These findings suggest that down-regulated p16 expression is evaluated as a factor of poorer prognosis and also that immunohistochemical pattern of p16 expression becomes a marker reflecting the biological malignancy of EBT patients.

NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy

OBJECTIVE

To provide health care providers, patients, and the general public with a responsible assessment of currently available data regarding the use of endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy.

PARTICIPANTS

A non-Federal, non-advocate, 13-member panel representing the fields of gastroenterology, hepatology, clinical epidemiology, oncology, biostatistics, surgery, health services research, radiology, internal medicine, and the public. In addition, experts in these same fields presented data to the panel and to a conference audience of approximately 300.

EVIDENCE

Presentations by experts; a systematic review of the medical literature provided by the Agency for Healthcare Research and Quality; and an extensive bibliography of ERCP research papers, prepared by the National Library of Medicine. Scientific evidence was given precedence over clinical anecdotal experience.

CONFERENCE PROCESS

Answering predefined questions, the panel drafted a statement based on the scientific evidence presented in open forum and the scientific literature. The draft statement was read in its entirety on the final day of the conference and circulated to the experts and the audience for comment. The panel then met in executive session to consider these comments and released a revised statement at the end of the conference. The statement was made available on the World Wide Web at http://consensus.nih.gov immediately after the conference. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.

CONCLUSIONS

In the diagnosis of choledocholithiasis, magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and ERCP have comparable sensitivity and specificity. Patients undergoing cholecystectomy do not require ERCP preoperatively if there is low probability of having choledocholithiasis. Laparoscopic common bile duct exploration and postoperative ERCP are both safe and reliable in clearing common bile duct stones. ERCP with endoscopic sphincterotomy (ES) and stone removal is a valuable therapeutic modality in choledocholithiasis with jaundice, dilated common bile duct, acute pancreatitis, or cholangitis. In patients with pancreatic or biliary cancer, the principal advantage of ERCP is palliation of biliary obstruction when surgery is not elected. In patients who have pancreatic or biliary cancer and who are surgical candidates, there is no established role for preoperative biliary drainage by ERCP. Tissue sampling for patients with pancreatic or biliary cancer not undergoing surgery may be achieved by ERCP, but this is not always diagnostic. ERCP is the best means to diagnose ampullary cancers. ERCP has no role in the diagnosis of acute pancreatitis except when biliary pancreatitis is suspected. In patients with severe biliary pancreatitis, early intervention with ERCP reduces morbidity and mortality compared with delayed ERCP. ERCP with appropriate therapy is beneficial in selected patients who have either recurrent pancreatitis or pancreatic pseudocysts. Patients with type I sphincter of Oddi dysfunction (SOD) respond to endoscopic sphincterotomy (ES). Patients with type II SOD should not undergo diagnostic ERCP alone. If sphincter of Oddi manometer pressures are >40 mmHg, ES is beneficial in some patients. Avoidance of unnecessary ERCP is the best way to reduce the number of complications. ERCP should be avoided if there is a low likelihood of biliary stone or stricture, especially in women with recurrent pain, a normal bilirubin, and no other objective sign of biliary disease. Endoscopists performing ERCP should have appropriate training and expertise before performing advanced procedures. With newer diagnostic imaging technologies emerging, ERCP is evolving into a predominantly therapeutic procedure.

Mortality from hepatocellular and biliary cancers: changing epidemiological trends

OBJECTIVES

The incidence of hepatocellular carcinoma may be rising in the United States. The aim of this study was to determine the epidemiological trends in mortality from hepatocellular carcinoma (HCC) and biliary cancers (BCs) in Maryland during the last 3 decades.

METHODS

The number of deaths due to HCC and BCs from 1970 to 1997 were obtained from the Maryland State Department of Health & Hygiene vital statistics database. Malignant neoplasms of the gallbladder and intrahepatic and extrahepatic bile ducts were grouped together as biliary cancers. To determine the trend in mortality, the total time period was divided into seven 4-yr periods.

RESULTS

Mortality from HCC increased from 0.94 to 1.84 per 100,000 population (rate ratio = 1.94, CI = 1.87-2.03) and that from BCs increased from 1.28 to 1.7 per 100,000 population (rate ratio = 1.31, CI = 1.26-1.36) over the study period. Although mortality due to HCC doubled in men (1.34 to 2.7 per 100,000) during this period, only a modest increase was observed among women (0.59 to 1.06 per 100,000). Because of a marked increase in the number of deaths among white Americans, the difference in HCC-related mortality between white Americans and African Americans decreased considerably during this period. Mean age at death increased steadily for BCs from 67 to 73 yr, whereas there was no real trend for HCC. Among African Americans, the death from HCC remained stable, but there was a 2-fold increase in BC-related death.

CONCLUSIONS

There was a marked increase in deaths from HCC over the past 3 decades in Maryland. This increase was more evident among men and white Americans. Deaths due to BCs increased modestly during the same period of observation. The marked rise in BC-related deaths among African Americans remains unexplained.

The combination of stricture dilation, endoscopic needle aspiration, and biliary brushings significantly improves diagnostic yield from malignant bile duct strictures

BACKGROUND

Brush cytology, routinely performed at ERCP to assess malignant-appearing biliary strictures, is limited by relatively low sensitivity and negative predictive value. This study assessed whether the combination of stricture dilation, endoscopic needle aspiration, and biliary brushing improves diagnostic yield.

METHODS

In a prospective nonrandomized study, 46 consecutive patients were evaluated with malignant-appearing biliary strictures at ERCP. Twenty-four patients (Group A) underwent standard brush cytology alone and 22 patients (Group B) underwent stricture dilatation to 10F, endoscopic needle aspiration, and subsequent biliary brushing by using the Howell biliary system. The diagnostic yields for both techniques were compared.

RESULTS

Of the 46 patients, 34 had proven malignant strictures (14 Group A, 20 Group B). Compared with brushing alone, the combination of stricture dilatation, endoscopic needle aspiration, and subsequent biliary brushing significantly increased both the sensitivity (57% vs. 85%, p < 0.02) and specificity (80% vs. 100%, p < 0.02) of cytology with positive brushings in all patients with pancreatic or gallbladder carcinoma.

CONCLUSIONS

The combination of stricture dilation, endoscopic needle aspiration, and biliary brushing significantly improves diagnostic yield for malignant bile duct strictures and may particularly be of benefit for extrinsic strictures caused by pancreatic or gallbladder carcinoma.

WT1 is an integral component of an antibody panel to distinguish pancreaticobiliary and some ovarian epithelial neoplasms

We investigated whether a panel of antibodies including WT1 could separate pancreaticobiliary and ovarian carcinomas by staining 64 pancreaticobiliary adenocarcinomas, 41 ovarian serous carcinomas, and 12 primary ovarian mucinous neoplasms with WT1, cytokeratin (CK) 17, CK20, carcinoembryonic antigen (CEA), and CA-125. Moderate or strong intensity reactivity in more than 25% of cells was a positive result. Of the ovarian serous carcinomas, 38 (93%) were WT1 reactive and 22 (54%) WT1 positive, 9 (22%) had CK20 reactivity, and 3 (7%) were CK20 positive in fewer than 50% of cells. All were CK17 or CEA nonreactive. Of the ovarian mucinous neoplasms, all were WT1 and CK17 nonreactive and 11 (92%) were CEA reactive, 8 (67%) CEA positive, 10 (83%) CK20 reactive, and 6 (50%) CK20 positive. Of the pancreaticobiliary adenocarcinomas, 19 (30%) were CK20 positive, 27 (42%) CK17 positive, and 52 (81%) CEA positive. All were WT1 nonreactive. A panel including WT1, CK17, CK20, and CEA is useful to distinguish pancreaticobiliary and ovarian serous carcinomas. Extensive CK17 reactivity is supportive of a pancreaticobiliary adenocarcinoma when the differential diagnosis includes ovarian mucinous neoplasm. None of the antibodies positively identified ovarian mucinous neoplasms.

A critical appraisal of laparoscopic staging in hepatobiliary and pancreatic malignancy

Prognosis for patients with hepatobiliary and pancreatic cancers is dismal. Surgery is the best therapeutic option for those with tumors which have not yet metastasized. Standard radiologic tests such as computed tomography (CT) scan and trans-abdominal ultrasound are useful in identifying patients for whom an attempt at resection would be futile. Staging laparoscopy with laparoscopic ultrasound allows greater precision in identifying those for whom resection would be helpful with less morbidity than an open exploration. Metastatic disease can be identified more precisely than with radiologic tests and can be characterized by biopsy techniques. Palliative procedures are now being performed laparoscopically with low morbidity and short hospital stays. The use of laparoscopy prior to open exploration for patients with hepatobiliary and pancreatic tumors is advantageous.

Expression of oncogene products HER2/Neu and Ras and fibrosis-related growth factors bFGF, TGF-beta, and PDGF in bile from biliary malignancies and inflammatory disorders

The expression of several growth factors and K-ras gene mutation in bile were studied to better understand the pathogenesis and improve early diagnosis of bile duct cancers. Bile samples were collected from 12 cholangiocarcinomas (CLC), 10 ampullary cancers (APC), 3 gallbladder cancers (GBC), 7 pancreatic cancers (PNC), 9 biliary tract infection (BTI), 8 biliary stone disease (ST), and 5 normal controls (NC). The highest mean value of TGF-beta in bile was in patients with BTI; the mean levels of bFGF and PDGF were highest in CLC, and patients with APC and CLC had higher expression of HER2/Neu than other groups. In bile, a K-ras gene codon 12 mutation was found in 5 of 6 (83%) cases of CLC by the PCR-RFLP method. The results suggest overexpression of bFGF, PDGF, and HER2/Neu and the presence of K-ras mutation are important for carcinogenesis of bile duct cancers, and detection of the above abnormalities in bile is helpful for early diagnosis.

[Pancreatic and biliary tract cancers]

There are several tumor markers for pancreatic and biliary tract cancers, such as carcinoembryonal antigen, pancreatic enzyme, carbohydrate antigen and tumor associated gene. CA19-9 and SPan-1, which are type I carbohydrate antigens, are especially useful among these tumor markers. Combination assays of these tumor markers improve the positive rate for these cancers. These tumor markers are useful not only in diagnosis but also in assessing the therapeutic efficacy and early detection of recurrence after operation.

Surveillance of pre-malignant disease of the pancreatico-biliary system

Technical advancements in ultrasonography, contrast-enhanced computed tomography and magnetic resonance imaging, as well as the wider availability of these ultramodern imaging techniques, have resulted in the early detection and a better classification of various asymptomatic and symptomatic pancreatico-biliary lesions. Pre-malignant biliary and pancreatic lesions are rare disorders, and no clear data are available to define their malignant potential. Because of the lack of controlled epidemiological data, the time span for malignant transformation and its frequency cannot be defined in the majority of these lesions. Adenomyomatosis of the gallbladder and gallbladder polyps larger than 10 mm should be treated by cholecystectomy even in asymptomatic patients because of an increased risk of malignant transformation. Chronic cholangitis, primary sclerosing cholangitis and choledochal cysts are also pre-malignant conditions. The timing of surgery, once it is advised for a pre-malignant condition that is still benign, should, however, be individualized to the particular patient situation. In patients with chronic pancreatitis, surgery may be indicated for disease-related complications. In as much as chronic pancreatitis predisposes to a higher risk of pancreatic cancer, any suspicion of malignancy should warrant a surgical exploration. Intraductal papillary tumours and mucin-producing pancreatic tumours are other pre-malignant pancreatic lesions whose malignant potential cannot be precisely determined pre-operatively. They should be resected in situations where there is a high degree of suspicion even without a clear objective diagnosis. In conclusion, pre-malignant hepato-biliary and pancreatic lesions of uncertain pathology should undergo early resection in view of treatment limitations and the dismal prognosis of established cancers. While hepato-biliary and pancreatic surgery is nowadays performed in specialized centres, with a low post-operative morbidity and mortality, it is equally important to understand that observation alone with regular computed tomography or magnetic resonance imaging control can no longer be recommended in the management of these lesions.

Detection of telomerase reverse transcriptase mRNA in biopsy specimens and bile for diagnosis of biliary tract cancers

Human telomerase reverse transcriptase (hTERT), which codes for the catalytic subunit of telomerase, is essential for telomerase activity. Recent studies revealed that levels of hTERT mRNA as well as telomerase activity are high in neoplasm. The purpose of this study was to correlate the expression of hTERT mRNA with telomerase activity in biopsy specimens and bile from biliary tract cancers and to evaluate the potential diagnostic value of hTERT mRNA analysis for biliary malignancy. We analyzed hTERT mRNA and telomerase activity in biopsy specimens and exfoliated bile cells from patients with cholangiocarcinoma, gallbladder carcinoma and bile duct stones. hTERT was detected by either nested reverse transcriptase-polymerase chain reaction (PCR) or real-time PCR. Telomerase activity was examined by a fluorescence-based telomeric repeat amplification protocol assay. Six of 10 malignant biopsy specimens had detectable hTERT and 7 of 10 had telomerase activity. All cases with hTERT expression had telomerase activity. In bile, 7 of 10 malignant patients had detectable hTERT and 3 of 10 had telomerase activity. Importantly, there were no false positive results in tissue specimens or bile examined in 6 non-cancerous cases. In conclusion, the detection of hTERT mRNA in biopsy specimens and bile cells, in combination with routine histologic and cytologic examination may improve the diagnosis of biliary tract cancers.

[Polyps of the biliary tract: is their preoperative diagnosis possible?]

Bile duct polyps are a very uncommon cause of obstructive jaundice. We present our experience of three patients diagnosed in the last 10 years. Initial presentation usually takes the form of obstructive jaundice associated with abdominal pain, which simulates biliary lithiasis. The diagnosis is usually surgical. Although in some cases radiological studies and endoscopic retrograde cholangiopancreatography (ERCP) may sometimes detect bile duct polyps, exact diagnosis before surgery is very unusual. The radiological signs that suggest the existence of a bile duct polyp in the ERCP seem to be the presence of repletion defects, fixed unilaterally to the biliary conduit, without meniscus and without circumferential stenosis of the affected conduit. The most frequently found polyps are fibroinflammatory, and less frequently adenomatous.

Infrequent microsatellite instability in biliary tract cancer

BACKGROUND AND OBJECTIVES

Microsatellite instability (MSI) has been reported in several tumors. However, few reports are available concerning MSI in biliary tract cancers. We investigated MSI and allelic loss at the hMLH1 and hMSH2 gene loci in biliary tract cancers.

METHODS

We analyzed microsatellite alterations using 7 microsatellite markers in 38 cases of extrahepatic bile duct (EHBD) cancer and 16 cases of ampullary cancer using polymerase chain reaction and an automated fluorescent DNA sequencer.

RESULTS

A MSI prevalence of 13.2% (5/38) was observed for EHBD cancer and a prevalence of 12.5% (2/16) was observed for ampullary cancer. Loss of heterozygosity at the hMLH1 and hMSH2 gene loci were observed in 4% (1/25 informative cases) and 6.1% (2/33) of EHBD cancer cases, respectively; and in 11.1% (1/9) and 8.3% (1/12) of ampullary cancer cases, respectively. The cumulative survival rate of patients with MSI was significantly better than that of patients without MSI in EHBD cancer. However, MSI was not an independent prognostic factor.

CONCLUSIONS

Our results suggest that genetic defects in the DNA mismatch repair system and MSI do not play an important role in the majority of biliary tract cancers.

Therapeutic biliary endoscopy

Therapeutic biliary endoscopy is continuing to evolve; some small but important developments were seen during the last year. Competing techniques are continuing to develop.

[Biliary tract cancers]

Biliary tract cancer is the second most common primary hepatobiliary cancer, after hepatocellular carcinoma. The most frequent localisation is the gallbladder. Mean age of diagnosis is 65 years. The exact cause remains unknown despite well documented risk factors. The majority of these tumours are adenocarcinomas. Symptoms, frequently non specific, are occasionally typical including jaundice, right upper quadrant mass or fatigue and weight loss. Magnetic resonance imaging is becoming the main diagnostic tool, replacing retrograde or transhepatic cholangiography. Surgical resection remains the only treatment that may allow long term survival. However, it is possible in only one third of patients.

Malignant transformation of biliary cystadenoma: a difficult diagnosis

The case is described of a 63-year-old female with a multilocular liver cyst diagnosed as cystadenoma after imaging and fine needle aspiration. The lesion, however, proved to be an invasive cystadenocarcinoma at surgery. Cystadenoma cannot be differentiated, preoperatively, from cystadenocarcinoma and should always be considered for surgical resection.

Gallbladder bile tumor marker quantification for detection of pancreato-biliary malignancies

BACKGROUND

The pre-operative differentiation of tumors of the pancreas, Papilla of Vater and the biliary tract is still unsatisfactory. Tumor marker analysis of the pancreatic juice did not improve the pre-operative diagnosis by a great deal.

METHODS

Bile from resected gallbladders of patients suffering from carcinomas of the pancreato-biliary system was analysed for CA 19-9, CEA, CA 72-4, CA 125 and AFP concentrations. The results were compared to patients suffering from acute cholecystitis, cholecystolithiasis as well as those suffering from benign tumors of the pancreato-biliary region.

RESULTS

Extreme high CA 19-9 concentrations were found in bile. Evaluations of the tumor-antigens CA 19-9, CA 72-4 and CEA in gallbladder bile were superior to any serum and pancreatic juice examination with respect to sensitivity and specificity. Observed sensitivities amounted to 100% for patients suffering from bile duct carcinoma (CA 19-9) and papillary carcinoma (CEA) at a specificity of 100%. CA 19-9 showed a sensitivity of 76.5% for pancreatic carcinomas at a specificity of 96.4%. CA 19-9 showed significant differences for the local tumor burden and for the degree of lymph node metastasis. Examination of tumor antigens in the gallbladder results in a high degree of discrimination for malignant and benign lesions of the subhepatic pancreato-biliary system.

CONCLUSIONS

CA 19-9 must follow a entero-hepatic circulation, since it showed raised bile concentrations (factor: 10(4)) compared to serum analysis. Analysis of CA 19-9, CEA and CA 72-4 gives an opportunity for improvement in the detection of cancers of the pancreato-biliary system. Since the clinical important differentiation of tumors of the head of the pancreas (carcinoma vs. pancreatitis) remains unclear, an improvement by bile analyses must be assumed.

Implantation metastasis following external biliary drainage in biliary tract cancers--cause for concern!

Three patients with periampullary cancer developed tumor seedings along the T-tube choledochostomy tract, thus precluding curative resection in two patients and an early recurrence at the choledochostomy exit site in the third patient. External biliary drainage and intraoperative bile spill should be avoided in patients with curable biliary tract neoplasms.

Magnetic resonance cholangiography in patients with biliary disease: its role in primary sclerosing cholangitis

BACKGROUND/AIM

Magnetic resonance cholangiography (MRC) is a non-invasive diagnostic procedure whose role in the management of patients with primary sclerosing cholangitis (PSC) is unclear. The aim of this study was to determine the usefulness of MRC in the evaluation of the biliary tree in patients with suspected biliary disease, and in particular, PSC.

METHODS

MRC and invasive cholangiography (ERCP or PTC) were both performed in 73 patients, (33 male, 40 female, mean age 56 years) with clinical and/or biochemical evidence of cholestasis. Images were interpreted by two radiologists unaware of the results of other studies.

RESULTS

Forty-two patients (58%) had benign biliary disease, including 23 patients (32%) with PSC; 9 patients (12%) had malignant biliary disease; and 22 patients (30%) had a normal biliary tree. Diagnostic quality images were obtained in 73/73 (100%) of MRC, and in 70/73 (96%) of invasive cholangiography (68 ERCP's, 2 PTC's) procedures. Using ERCP/PTC findings as the reference standard, MRC had an accuracy greater than 90% in the diagnosis of normal bile ducts, biliary dilatation, biliary obstruction, bile duct stones, and PSC. Using the final diagnosis, MRC had an overall diagnostic accuracy of 90% in the detection of biliary disease compared to 97% for invasive cholangiography. Additional diagnostic/therapeutic interventions were performed during ERCP in 73% of patients with PSC and in 43% of patients without PSC (p=0.02).

CONCLUSIONS

MRC has excellent diagnostic accuracy in the presence of biliary disease. Because of its noninvasive nature, MRC may have advantages over invasive cholangiography when diagnosis is the major goal of the procedure.

[Current diagnosis and combined and radiation therapy of pancreato-biliary cancer in patients with jaundice]

The effectiveness of therapy of pancreato-biliary cancer in jaundice patients has been raised due to introduction of sparing slightly-invasive (percutaneous, transhepatic) procedures for suppression of choleostasis and restoring biliary return to intestine. Also, such measures as pancreato-digestive anastomosis, radical surgery to compensate jaundice-related functional and morphological disorders and changes in the liver as well as perfection of procedures of combined and radiation therapy were used.

Elevated tumour marker CA19-9: clinical interpretation and influence of obstructive jaundice

AIMS

The tumour marker CA19-9 has been promoted as a reliable test for the detection of pancreatobiliary malignancy, yet its diagnostic role remains poorly defined. In this study the clinical interpretation of a raised serum CA19-9 level has been evaluated, with particular reference to obstructive jaundice.

METHODS

One hundred and sixty-four patients with a CA19-9 level above 33 U/ml were studied. Serum CA19-9 was compared with clinical diagnosis and correlated with serum bilirubin level. In a subgroup of jaundiced patients (16 benign and 15 malignant cases), follow-up CA19-9 levels were determined 2 weeks after biliary drainage.

RESULTS

The median CA19-9 level was lower in benign cases (102 (IQR 50-264) U/ml) than those with pancreatobiliary tumours (910 (IQR 263-6170) U/ml; P<0.01), although the overlap was substantial. In benign jaundiced cases, a positive correlation was observed between bilirubin and CA19-9 elevation (R=0.41, P<0.01). Relief of jaundice was associated with a fall in CA19-9 level in all benign cases and in nine of the 15 with malignancy.

CONCLUSION

Confident discrimination between benign and malignant disease could not be made on the basis of a solitary elevated CA19-9 measurement. Hyperbilirubinaemia was associated with a further deterioration in specificity and caution is warranted when interpreting the results in jaundiced patients. Overall, only one half of patients with an elevated CA19-9 level ultimately proved to harbour a malignancy.

Paraganglionoma of extrahepatic biliary tract causing obstructive jaundice

We report a young woman with paraganglionoma arising from the extrahepatic bile duct presenting with acute obstructive jaundice. The patient underwent excision of the gall bladder and extrahepatic bile duct with the tumor, and Roux-en-Y hepaticojejunostomy. She is asymptomatic 9 months later, with normal biochemical investigations and imaging.

[Use of magnetic resonance tomography in the diagnosis of gastrointestinal diseases]

BACKGROUND

Magnetic resonance imaging (MRI) is a promising method for examination of the gastrointestinal tract. In this article we present the present status and potential of MRI.

MATERIAL AND METHODS

The review is based on personal experience and selected published, international papers.

RESULTS

Magnetic resonance cholangio-pancreatography (MRCP) and MRI of the liver are well documented examinations which are widely performed. These examinations partly replace existing modalities such as CT and ERCP and represent additional possibilities for examining this anatomic area. MRI is not as yet accepted as the standard examination of the pancreas, but it is regarded as comparable to CT. The adrenals may be examined even more accurately with MRI than with CT. MRI examinations of the oesophagus and gastric ventricle seem promising, but it should be said that they are in an early and not well documented phase. MRI of the small and large bowels is not common. With the exception of preoperative staging of rectal cancers, it is still experimental. MR angiography, functional MRI studies and perfusion studies are not yet in common abdominal diseases. We may, however, believe that they will become important diagnostic tools.

INTERPRETATION

MRI is rapidly increasing its share of gastrointestinal imaging examinations. This is mainly due to the increased speed of newer machines. The diagnostic quality has improved, and will improve more. It is thus likely that MRI will, in a large amount of abdominal imaging, replace CT, and to some extent other diagnostic modalities. It is, however, not possible to replace CT for emergencies, and we will probably look forward to more and better imaging with more diagnostic modalities in the future.

Triple-tissue sampling at ERCP in malignant biliary obstruction

BACKGROUND

Procurement of cytologic samples by brushing is common practice at endoscopic retrograde cholangiopancreatography (ERCP) but has low sensitivity for cancer detection. Limited data are available on other techniques, including endoluminal fine-needle aspiration and forceps biopsy. This series reviews the yield of these three stricture sampling methods.

METHODS

In this prospective study, patients with biliary obstruction with a clinical suspicion of malignancy underwent triple-tissue sampling at one ERCP session. Final cancer diagnosis was based on all sampling methods plus surgery, autopsy, and clinical follow-up. Tissue specimens were reported as normal, atypia, or malignant.

RESULTS

A total of 133 patients were evaluated: 104 had cancer and 29 had benign strictures. Tissue sampling sensitivity varied according to the type of cancer; the highest yield was seen in ampullary cancers (62% to 85%). The cumulative sensitivity of triple-tissue sampling in the cancer patients was as follows: sensitivity was 52% if atypia was considered benign and 77% if it was considered malignant. The addition of a second or third technique increased sensitivity rates in most instances. No serious complications occurred from the tissue sampling methods.

CONCLUSIONS

Tissue sampling sensitivity varied according to the type of cancer. Combining a second or third method increased sensitivity; general use of at least two sampling methods is therefore recommended.

Objective assessment of the contribution of each diagnostic test and of the ordering sequence in jaundice caused by pancreatobiliary carcinoma

BACKGROUND

Computer-assisted diagnostic systems are not substantially more accurate than the clinician in the differential diagnosis of jaundice but may help in optimal selection and sequencing of tests. The present study aimed to assess with an electronic diagnostic tool the pattern of ordering tests and the diagnostic contribution and related financial cost of each test in jaundiced patients with pancreatobiliary carcinoma, in an effort to make the clinician's diagnostic behaviour more efficient and economical.

METHODS

Clinical and diagnostic test data were prospectively gathered from 356 jaundiced patients with pancreatobiliary carcinoma and entered in a Bayesian diagnostic programme. The test results were added to the existing diagnostic evidence, and the programme calculated the diagnostic contribution of each test.

RESULTS

A total of 1804 diagnostic tests were ordered. Quantitative assessment of the diagnostic contribution of each test showed that percutaneous transhepatic cholangiography and computed tomography were associated with the highest provision of information. The most cost-effective tests were ultrasonography and liver function tests.

CONCLUSIONS

It is possible to determine objectively the diagnostic contribution of each test in establishing the diagnosis of pancreatobiliary carcinoma. The observed physician behaviour in ordering the various diagnostic tests might be improved with regard to its efficacy and its cost-effectiveness profile.

Multidisciplinary considerations for patients with cancer of the pancreas or biliary tract

The past century has been nearly all of the growth in knowledge about the anatomy and pathophysiology associated with cancers of the pancreas and surrounding biliary structures. Through advances in imaging technology, endoscopic practice, improvement in surgical technique and perioperative care, anesthesia advances, and a better appreciation for the usefulness of adjuvant chemotherapy and radiation therapy, physicians can offer patients some hope for long-term survival and a better quality of life when they are faced with these devastating tumors. Although surgical intervention is the "last best hope" for these patients, advances in the nonoperative disciplines will be required for substantial further improvement in patient outcomes.

Detection of telomerase activity in exfoliated cancer cells obtained from bile

Telomerase is detected by the telomeric repeat amplification protocol (TRAP) assay in more than 85% of primary cancers. In the present study, we determined telomerase activity using exfoliated bile cells obtained from biliary tract neoplasia specimens. The aim of this study was to provide additional information regarding minimally invasive approaches to the detection of biliary tract cancer in combination with routine cytologic examination. We analyzed for telomerase activity bile juice from patients with gallbladder carcinoma, cholangiocarcinoma, cholecystitis and cholangitis. Semiquantitative determination of telomerase activity was performed using both a fluorescence-based TRAP assay on cell extracts and at the cellular level by an in situ TRAP assay. The fluorescence-based TRAP assay detected bile telomerase activity in samples from 4 of 10 patients with biliary tract cancer. In contrast, the in situ TRAP assay detected telomerase positive cells in samples from 6 of 10 patients with biliary tract cancer. However, only one of these samples showed class V cytology. A combination of semiquantitative analysis and an in situ TRAP assay to detect telomerase positive cells may improve the diagnosis of biliary tract cancers with the combination of routine cytologic examination.

Essentials in biliopancreatic staging: a decision analysis

Two possible strategies for diagnosis and staging of patients with suspected biliopancreatic cancer and obstructive jaundice were tested in a decision analysis. One strategy was called 'surgical' strategy and consisted of only Ultrasonography and (spiral) CT scan and exploratory laparotomy in all patients without irresectable disease or distant metastases according to this work-up. The other strategy was called 'non-surgical' strategy and consisted of the above strategy, but also included ERCP and endoscopic internal drainage (stent) and diagnostic laparoscopy and laparoscopic ultrasound. In the decision analysis incidences of the outcomes after the two strategies were estimated based on the literature and our own experience, and a utility (0-1) was attributed to each separate outcome, according to the expected quality of life as judged by the team. Total utility of each strategy was calculated. It could be concluded that a non-surgical strategy would lead to a somewhat higher total utility in case the yield (i.e. prevention of unnecessary laparotomies) could be high and supposed that a beneficial effect of pre-operative internal biliary drainage was present. In case of low yield of diagnostic laparoscopy the superiority of the 'non-surgical' strategy is doubtful.

The association between biliary tract cancers and cancers of other sites

OBJECTIVE

Cancers of the biliary tract, including cancers of the gallbladder and bile duct, generally carry a very poor prognosis. Little is known about their etiology. The pattern of co-occurrence of two cancers may give clues to shared etiological risk factors. We therefore investigated the association of biliary tract cancer with other cancers, especially with estrogen- and tobacco-related cancers.

METHODS

We used data from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute. Associations between biliary tract cancer and other cancers were evaluated using the standardized incidence ratio as an estimate of the relative risk of a second primary malignancy.

RESULTS

Estrogen-related cancers of the breast and uterine corpus and smoking-related upper aerodigestive tract cancers were not associated with biliary tract cancer. The risk of gallbladder cancer was inversely related to the risk of prostate cancer in men, but positively related to the risk of cervical cancer in women.

CONCLUSIONS

This study suggests that smoking and estrogen exposure have minimal roles in the pathogenesis of biliary tract cancer. Our finding of an inverse relationship between prostate cancer and gallbladder cancer requires confirmation by further studies.

A new strategy for the application of CA19-9 in the differentiation of pancreaticobiliary cancer: analysis using a receiver operating characteristic curve

OBJECTIVE

Clinicians might be misled in interpreting an elevated CA19-9 when differentiating pancreaticobiliary cancer from benign clinical conditions such as acute cholangitis or cholestasis, because in these conditions, the concentration of CA19-9 may also be elevated. The aims of our study were to calculate new individual cutoff values for CA19-9 according to clinical situations using a receiver operating characteristic (ROC) curve and to define a new strategy for interpreting CA19-9 in pancreaticobiliary cancer.

METHODS

One hundred sixty patients with pancreatic diseases (cancer 90, benign disease 70), 322 patients with biliary tract diseases (biliary cancer 152, benign disease 170), and 20,035 asymptomatic controls were enrolled in the present study. An ROC curve was described by plotting the sensitivity on the y-axis against 1-specificity on the x-axis for each of several cutoff values.

RESULTS

The area under the ROC curve was significantly greater for pancreatic cancer than for biliary cancer (p < 0.05). For patients with pancreatic cancer, CA19-9 proved to be useful. At a cutoff value of 37 U/ml, sensitivity and specificity were 76.7% and 87.1%, respectively. For patients with biliary cancer, CA19-9 was not helpful. However, when patients with biliary disease were divided into two groups according to the presence of cholangitis or cholestasis, CA19-9 proved to be more useful for the group without cholangitis or cholestasis than for the group with cholangitis or cholestasis (p < 0.05). In the former group, the sensitivity and specificity of CA19-9 were 77.6% and 83%, respectively, at the cutoff value of 37 U/ml. For the latter group, the sensitivity and specificity of CA19-9 were 74% and 41.5% respectively, whereas the specificity reached 87% at 300 U/ml. CA19-9 in diagnosing pancreatic cancer was useful regardless of accompanying acute pancreatitis or cholestasis. The serum concentration of CA19-9 in asymptomatic individuals was 9.42 +/- 9.95 U/ml. Only 1 of 157 patients with a concentration of CA19-9 above 37 U/ml was found to have gallbladder cancer. The positive and negative predictive values were 0.65% and 0.78%, respectively.

CONCLUSIONS

The use of CA19-9 for the differentiation of pancreaticobiliary cancer should be applied individually, depending on the clinical situation.

Activation of telomerase and its diagnostic application in biopsy specimens from biliary tract neoplasms

BACKGROUND

Telomerase activity has been reported to have potential as a useful diagnostic marker for cancer in various organs. The authors previously reported that telomerase activity in pancreatic juice differentiates pancreatic ductal carcinoma from adenoma and pancreatitis. In the current study, the usefulness of semiquantitatively determined telomerase activity in the diagnosis of malignant biliary tract neoplasms was investigated.

METHODS

The samples examined included 61 surgically resected biliary tract tissues (11 gallbladder carcinomas, 5 bile duct carcinomas, 1 gallbladder adenoma, 30 cholecytitis cases, 7 cholesterol polyps, 1 normal gallbladder, and 6 normal common bile duct tissues), 42 bile samples from patients with biliary tract or pancreatic disease (19 cases of malignant biliary tract disease, 11 cases of benign biliary tract disease, 10 cases of malignant pancreatic disease, and 2 cases of benign pancreatic disease), and 14 bile duct biopsy specimens collected by percutaneous transhepatic choledochoscopy or endoscopic retrograde cholangiopancreatography (8 bile duct carcinoma specimens, 1 bile duct adenoma specimen, and 5 hepatolithiasis specimens).

RESULTS

In biliary tract tissues, a telomerase ladder was detected in 73% of gallbladder carcinomas, 40% of bile duct carcinomas, and none of the other biliary tract tissues. One gallbladder adenoma showed a weak telomerase ladder. The telomerase ladder was detected in the bile sample from 1 patient (5.3%) with malignant biliary tract disease, none of the patients with benign biliary tract disease, 5 patients (50%) with malignant pancreatic disease, and none of the patients with benign pancreatic disease. In biopsy specimens, the telomerase ladder was detected in 75% of patients with bile duct carcinoma but not in any of the patients with hepatolithiasis. The median value of relative telomerase activity in the patients with bile duct carcinoma was significantly higher than that in the patients with hepatolithiasis. The diagnosis of bile duct carcinoma was confirmed preoperatively by histopathologic examination in only 25% of the biopsy specimens.

CONCLUSIONS

The results of the current study indicate that telomerase is highly activated in biliary tract carcinomas and that the detection of a telomerase ladder in biopsy samples is an excellent tool for the diagnosis of bile duct carcinomas.

Pancreaticobiliary carcinoma associated with a large choledochal cyst: role of MRI and MR cholangiopancreatography in diagnosis and preoperative assessment

The role of magnetic resonance (MR) imaging and MR cholangiopancreatography is demonstrated in a case of pancreaticobiliary carcinoma associated with a large choledochal cyst. The size of the cyst presented considerable difficulty in evaluation with both endoscopic retrograde cholangiopancreatography and computed tomography.

Rabdomyosarcoma of the biliary tree

Rabdomyosarcoma of the biliary tree is one of the rare causes of biliary tract obstruction in childhood. Nevertheless it is the most common cause of obstructive jaundice due to neoplastic biliary obstruction. We present a two-year-old child with obstructive jaundice secondary to an embryonal rhabdomyosarcoma of the biliary tree. She underwent surgery and, after total excision of the mass, a hepaticojejunostomy and Roux-en-Y anastomosis were performed. She was referred to the Pediatric Oncology Group for follow-up. Rhabdomyosarcoma of the bilary tree, although rare, must be considered in the etiology of obstructive jaundice in children.

Endosonography and endoscopic magnetic resonance imaging

Endosonography is an important modality for the diagnosis and staging of oesophageal, gastric, colorectal and pancreatobiliary malignancy. It is also recognized as a reliable method for the evaluation of submucosal tumours of the gastrointestinal tract, for differentiating benign lesions from giant gastric folds, and for the localization of pancreatic endocrine tumours. The latest development, that of endosonographic fine-needle aspiration, provides for the cytological diagnosis of gastrointestinal tumours. This new technique may also be used for endoscopic therapy. High-frequency probes can be used to make a more accurate diagnosis of superficial carcinoma of the gastrointestinal tract, for three-dimensional imaging of gastrointestinal tumours and for intraductal ultrasonography of the bile duct and pancreatic duct. Endoscopic magnetic resonance imaging provides information not obtainable with endosonography or other modalities. It has high potential in the diagnosis and staging of gastrointestinal and pancreatobiliary tumours.

Fast MR imaging for evaluating the pancreaticobiliary system

Due to physiological movement clinical MR applications for abdominal organs got off to a very slow start compared to MR imaging of other organs. However, with recent cutting-edge hardware technologies such as high performance gradient systems and phased-array capability, as well as software innovations including short TR fast spoiled gradient recalled acquisition in the steady state (GRASS), snapshot imaging such as single shot fast spin echo sequence (SSFSE) and echo planar imaging (EPI), scan times have been further reduced to make breath-hold imaging clinically viable and to enable semi-fluoroscopic, kinematic imaging recognition. The elimination of physiological motion has contributed to the significant improvement in image quality, or more specifically, the physiological motion that had long been problematic has been turned into a source of physiological information about pancreaticobiliary pathologies. In this article, the author reviewed the current status of fast MR technologies for examining pancreaticobiliary pathologies, stressing the functional and physiological aspects of the corresponding anatomy. The technologies included secretin MRCP, which became a powerful tool when combined with kinematic imaging.