Fluoroscopic percutaneous brush cytology, forceps biopsy and both in tandem for diagnosis of malignant biliary obstruction

False-negative factors of percutaneous transluminal clamp biopsy for suspected malignant biliary stricture: 194 cases analyzed from a single center

OBJECTIVE

To study the predictive factors of false negatives in the diagnosis of biliary stricture (BS) by percutaneous transluminal clamp biopsy (PTCB).

METHOD

From January 2016 to January 2021, 194 patients with a high suspicion of malignant tumors due to BS underwent PTCB during biliary drainage at our department. The final diagnosis was confirmed by postoperative pathology, other tissue or cell evidence, or medical imaging follow-up. Univariate and multivariate regression analyses were performed on the pathological results, summarizing the independent risk factors for false-negative value (FNV) to help further clinical diagnosis and treatment.

RESULTS

Of the 194 cases, 176 and 18 cases were finally diagnosed as malignant and benign BS, respectively, compared to 144 and 50 cases by PTCB, including 32 false-negative cases. The sensitivity, specificity, false-positive value, and FNV of PTCB were 81.8%, 100%, 0%, and 18.2%, respectively. Multivariate analysis showed that non-cholangiocarcinoma BS was an independent risk factor for FNV of PTCB (odds ratio 7.5 (95% CI 1.74-32.6), p < 0.01).

CONCLUSION

PTCB is an effective minimally invasive interventional technique for BS diagnosis. Non-cholangiocarcinoma BS is an independent risk factor for FNV.

CRITICAL RELEVANCE STATEMENT

Identifying factors that are predictive of false-negative results by percutaneous transluminal clamp biopsy in the setting of biliary stricture may have a guiding effect on clinical practice.

KEY POINTS

• Factors predictive of false negatives in the diagnosis of biliary stricture etiology by PTCB may aid in the interpretation of results. • Non-cholangiocarcinoma BS is an independent risk factor for FNV on PTCB. • PTCB is an effective minimally invasive interventional technique for BS diagnosis.

Percutaneous transluminal forceps biopsy with an adjustable curved sheath for obstructive jaundice

PURPOSE

To evaluate the feasibility and safety of percutaneous transluminal forceps biopsy (PTFB) with an adjustable curved sheath in patients with obstructive jaundice.

MATERIAL AND METHODS

Forty-two patients who underwent PTFB with an adjustable curved sheath were analyzed retrospectively. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and accuracy were calculated for all populations and in different situations. Technical success and safety were evaluated.

RESULTS

The technical success rate was 100%. Thirty-five of 42 cases were diagnosed malignant diseases, the sensitivity of PTFB with an adjustable curved sheath was 74.29% (26/35), the specificity was 100%, the positive predictive value was 100%, the negative predictive value was 43.75% (7/16), and the accuracy rate was 78.57% (33/42). There was a better sensitivity for bile duct malignancies when compared with non-bile duct malignancies (p = 0.012). No statistical difference was found in the sensitivity of the upper part of the biliary tree and the lower part of the biliary tree, and none in the sensitivity of different approaches (left vs. right). The complication rate was 11.90%, and no serious complications were observed.

CONCLUSIONS

PTFB with an adjustable curved sheath is an effective and safe technique, without being limited by approaches and obstruction sites.

Endobiliary biopsy

The differential diagnosis between benign and malignant biliary strictures is challenging and requires a multidisciplinary approach with the use of serum biomarkers, imaging techniques, and several modalities of endoscopic or percutaneous tissue sampling. The diagnosis of biliary strictures consists of laboratory markers, and invasive and non-invasive imaging examinations such as computed tomography (CT), contrast-enhanced magnetic resonance cholangiopancreatography, and endoscopic ultrasonography (EUS). Nevertheless, invasive imaging modalities combined with tissue sampling are usually required to confirm the diagnosis of suspected malignant biliary strictures, while pathological diagnosis is mandatory to decide the optimal therapeutic strategy. Although EUS-guided fine-needle aspiration biopsy is currently the standard procedure for tissue sampling of solid pancreatic mass lesions, its diagnostic value in intraductal infiltrating type of cholangiocarcinoma remains limited. Moreover, the "endobiliary approach" using novel slim biopsy forceps, transpapillary and percutaneous cholangioscopy, and intraductal ultrasound-guided biopsy, is gaining ground on traditional endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography endobiliary forceps biopsy. This review focuses on the available endobiliary techniques currently used to perform biliary strictures biopsy, comparing the diagnostic performance of endoscopic and percutaneous approaches.

Systematic review and meta-analysis of percutaneous transluminal forceps biopsy for diagnosing malignant biliary strictures

OBJECTIVES

To perform a systematic review and meta-analysis to determine the diagnostic performance of percutaneous transluminal forceps biopsy (PTFB) for differentiating malignant from benign biliary stricture.

METHODS

A comprehensive literature search of the PubMed, EMBASE, and Ovid MEDLINE databases was conducted to identify original articles published between January 2001 and January 2021 reporting the diagnostic accuracy of PTFB. A random-effects model was used to summarize the diagnostic odds ratio and other measures of accuracy.

RESULTS

Fourteen studies involving 1762 patients met the inclusion criteria and were included in the meta-analysis. The meta-analysis summary estimates of PTFB for diagnosis of malignant biliary strictures were as follows: sensitivity 81% (95% confidence interval [CI], 78-81%); specificity 100% (95% CI, 98-100%); diagnostic odds ratio 85.34 (95% CI, 38.37-189.81). The area under the curve of PTFB was 0.948 in the diagnosis of malignant biliary strictures. The diagnostic sensitivity was higher in intrinsic (85%) than in extrinsic (73%) biliary strictures. The pooled rate of all complications was 10.3% (95% CI, 7.0-14.2%), including a major complication rate of 3.1%.

CONCLUSION

These data demonstrate that PTFB is sensitive and highly specific for diagnosing malignancy in biliary strictures. PTFB should be incorporated into future guidelines for tissue sampling in biliary cancer, especially in cases with failed endoscopic management.

KEY POINTS

• PTFB had a good overall diagnostic performance for differentiating malignant from benign biliary strictures, with a meta-analysis summary estimate of 81% for sensitivity and 100% for specificity. • PTFB had higher sensitivity for cholangiocarcinoma (85%) than for other cancers (73%). • PTFB had a 100% technical success rate and a 10.3% rate for complications, including a 3.1% rate for major complications.

CIRSE Standards of Practice on Percutaneous Transhepatic Cholangiography, Biliary Drainage and Stenting

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing percutaneous transhepatic cholangiography, biliary drainage and stenting. It has been developed by an expert writing group established by the CIRSE Standards of Practice Committee.

Percutaneous endobiliary forceps biopsy of biliary strictures for histopathologic examination

PURPOSE

We aimed to investigate the feasibility, accuracy and safety of percutaneous endobiliary cholangio-forceps biopsy of biliary strictures in our institution.

METHODS

A total of 13 percutaneous transhepatic endobiliary biopsies (7 men and 6 women, mean age 66.85±16.76 years) were performed between January 2015 and March 2019 using a transluminal forceps biopsy device. Technical success, rate of complications, number of biopsy specimens, procedure and fluoroscopy time, mean radiation exposure were evaluated; sensitivity and accuracy were calculated.

RESULTS

Technical success, i.e., acquisition of at least three (median, 3.00; range, 3-5) macroscopic representative samples, could be achieved in all 13 biopsies. Access was gained via the right liver lobe in 12 of 13 cases (92.3%). All patients presented blood work indicative of cholestasis prior the intervention, with mean bilirubin 4.72±3.72 µmol/L, mean γ-glutamyl transferase 574.16 ± 360.92 IU/L, and median alkaline phosphatase 407 IU/L (165-1366 IU/L). In 12 of 13 cases (92.3%), biopsied material was sufficient for the pathologist to make a histopathologic diagnosis. Analysis revealed cases of malignancy in eight of 13 cases (61.5%), all of which turned out to be cases of cholangiocarcinoma. In four benign cases (30.8%), diagnosis was considered to be confirmed by further imaging or clinical follow-ups, which showed no signs of progressive disease. There was one case (7.7%) of a false-negative result with proof of malignancy in subsequent surgical tissue extraction. A calculation of diagnostic performance yielded a sensitivity rate of 88.9% and an accuracy rate of 92.3%. There was one case of minor and one case of major complication in our study collective, leading to an overall complication rate of 15.4%.

CONCLUSION

Percutaneous transhepatic biliary drainage (PTBD)-based forceps biopsy via the transhepatic drainage tract in patients with biliary obstruction of unknown origin is a technically feasible and safe technique with good diagnostic value rates. The procedure should be considered in patients not suitable for endoscopic strategies with indication for establishment of PTBD.

[Diagnostic quality of transluminal biopsy in undetermined biliary duct stenosis by primary PTCD with "cross and push" technique - a prospective monocentric pilot study]

BACKGROUND

 Histological characterisation of a biliary duct stenosis can be essential for further therapeutic steps. Access to the stenosis is not given in every patient by endoscopic retrograde cholangiography. In these cases, a percutaneous transhepatic cholangiodrainage (PTCD) may be helpful. The optimal preparation and diagnostic precision of taking a biopsy by PTCD is not sufficiently evaluated.

METHODS

 After a training phase of 10 patients, PTCDs in 30 patients with a biliary duct stenosis and lack of adequate drainage by ERC were done in a time range of 24 months. The stenosis was passed with a wire and then a directed forceps-biopsy was performed in a "cross and push" technique (Transluminal Biliary Biopsy Forceps Set, Cook Medical™), using a wire-guided introducer (7 Fr. inner diameter). The result of the histological survey was then correlated with the definite diagnosis. The follow-up time was 18 months.

RESULT

 Out of 30 patients, there were 22 (73 %) with a malignant stenosis (10 biliary duct neoplasms, 12 non-biliary carcinoma/metastases/lymphomas). Eight (27 %) out of 30 patients had a benign stenosis. In case of all 30 patients, there was enough tissue gained by biopsy for histologic survey. Sub-group analysis was performed for biliary duct cancer and non-biliary cancer. Thereby, 8 out of 10 patients with biliary duct neoplasms were also classified as malignant by histology (sensitivity 80 %); whereas, only 8 out of 12 non-biliary cancers could be histologically classified as malignant (sensitivity 66.6 %, difference not significant, p = 0.0577). In all patients with benign stenosis, histological evaluation of biopsies revealed benign histology (specificity 100 %). There were no intervention-related complications.

CONCLUSION

 This prospective cohort-study shows a high diagnostic precision for the percutaneous transductal biopsy-set to evaluate an undetermined biliary duct stenosis-particularly in biliary processes. Because it can be difficult to gain histology in malignant biliary duct processes using different methods, the "cross and push" biopsy completes the spectrum of diagnostic procedures.

Percutaneous management of malignant biliary disease

Percutaneous biliary interventions have established their role in the management of benign and malignant biliary disease. There are limited data comparing procedures performed by gastroenterologists and interventional radiologists in managing malignant biliary obstruction. Endoscopic procedures performed by gastroenterologists are not completely benign with reported complications ranging from 2% to 15%. It is important that gastroenterologists and interventional radiologists collaborate to form algorithms for management of malignant biliary obstruction which provide safe and efficacious care to these patients.

Percutaneous transhepatic cholangiobiopsy

Most tumors of the biliary tract are too small to have specific imaging characteristics or for percutaneous puncture to provide sufficient material for diagnosis. Percutaneous transhepatic biliary drainage, in addition to being a well-established technique in the treatment of obstructive jaundice, provides adequate access for sampling obstructive lesions. In cases of biliary lesions, percutaneous transhepatic biopsy of the biliary tract has proven to be a useful diagnostic technique, with a reported accuracy of over 90% at some referral centers.