Endoscopic retrograde cholangiopancreatography tissue sampling: when and how?

Factors Associated with Malignant Biliary Strictures in Patients with Atypical or Suspicious Cells on Brush Cytology

Background/Aims

Pathological diagnosis of biliary strictures with atypical or suspicious cells on endoscopic retrograde brush cytology and indeterminate strictures on imaging is challenging. The aim of this study was to identify markers for malignant strictures in such cases.

Methods

We retrospectively analyzed data collected from 146 consecutive patients with indeterminate biliary strictures on imaging who underwent endoscopic retrograde brush cytology from 2007 to 2013. Factors associated with malignant strictures in patients with atypical or suspicious cells on brush cytology were identified.

Results

Among the 67 patients with a malignant disease (48 cholangiocarcinoma, 6 gallbladder cancer, 5 pancreatic cancer, 5 ampulla of Vater cancer, and 3 other types), 36 (53.7%) had atypical or suspicious cells on brush cytology. Among these, the factors that independently correlated with malignant strictures were stricture length (odds ratio [OR], 5.259; 95% confidence interval [CI], 1.802– 15.294) and elevated carbohydrate antigen 19-9 (CA19-9) (OR, 3.492; 95% CI, 1.242–9.815), carcinoembryonic antigen (CEA) (OR, 4.909; 95% CI, 1.694–14.224), alkaline phosphatase (ALP) (OR, 3.362; 95% CI, 1.207–9.361), and gamma-glutamyl transpeptidase (rGT) (OR, 4.318; 95% CI, 1.512–12.262).

Conclusions

Elevated levels of CA19-9, CEA, ALP, and rGT and stricture length are associated with malignant strictures in patients with indeterminate biliary strictures on imaging and atypical or suspicious cells on brush cytology.

Endoscopic ultrasound guided brush/fine-needle aspiration cytology: A 15-month study

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become increasingly popular for the diagnosis and staging of gastrointestinal diseases and peri-gastrointestinal lesions. The application of FNA/Brush has dramatically expanded the clinical utility of EUS.

AIMS AND OBJECTIVE

To evaluate the diagnostic accuracy, study the spectrum of lesions encountered in EUS-FNAC/brush cytology of gastrointestinal and peri-gastrointestinal lesions.

MATERIALS AND METHODS

Total of 124 patients during the period from August 2015 to November 2016 was included in the study. Routine staining was done.

RESULTS

A total of 124 cases were studied with 86% (107 cases) being satisfactory for evaluation. M:F ratio was 1:1.03, mean age of 50.5 years. The most common site was common bile duct (CBD) (37%) followed by lymph node (21%), pancreas (17.7%), esophagus (17%), stomach (3.5%), liver (1.8%), gallbladder (1%), and spleen (1%). In total, 53.4% lesions were benign, in 6.5% atypical cells were seen, 12.1% were suspicious for malignancy, and 28% cases were positive for malignancy. Follow-up was available in 102 cases with cyto-histopathological concordance rate of 90%.

CONCLUSION

EUS-FNA/Brush is a reliable, sensitive, specific and minimally invasive way to establish a diagnosis. It can be utilized as a pre-operative procedure for the management of many intra-abdominal lesions and prevent unnecessary invasive procedures.

Advanced endoscopic imaging of indeterminate biliary strictures

Endoscopic evaluation of indeterminate biliary strictures (IDBSs) has evolved considerably since the development of flexible fiberoptic endoscopes over 50 years ago. Endoscopic retrograde cholangiography pancreatography (ERCP) was introduced nearly a decade later and has since become the mainstay of therapy for relieving obstruction of the biliary tract. However, longstanding methods of ERCP-guided tissue acquisition (i.e., biliary brushings for cytology and intraductal forceps biopsy for histology) have demonstrated disappointing performance characteristics in distinguishing malignant from benign etiologies of IDBSs. The limitations of these methods have thus helped drive the search for novel techniques to enhance the evaluation of IDBSs and thereby improve diagnosis and clinical care. These modalities include, but are not limited to, endoscopic ultrasound, intraductal ultrasound, cholangioscopy, confocal endomicroscopy, and optical coherence tomography. In this review, we discuss established and emerging options in the evaluation of IDBSs.

Improved endoscopic retrograde cholangiopancreatography brush increases diagnostic yield of malignant biliary strictures

AIM

To determine if a new brush design could improve the diagnostic yield of biliary stricture brushings.

METHODS

Retrospective chart review was performed of all endoscopic retrograde cholangiopancreatography procedures with malignant biliary stricture brushing between January 2008 and October 2012. A standard wire-guided cytology brush was used prior to protocol implementation in July 2011, after which, a new 9 French wire-guided cytology brush (Infinity sampling device, US Endoscopy, Mentor, OH) was used for all cases. All specimens were reviewed by blinded pathologists who determined whether the sample was positive or negative for malignancy. Cellular yield was quantified by describing the number of cell clusters seen.

RESULTS

Thirty-two new brush cases were compared to 46 historical controls. Twenty-five of 32 (78%) cases in the new brush group showed abnormal cellular findings consistent with malignancy as compared to 17 of 46 (37%) in the historical control group (P = 0.0003). There was also a significant increase in the average number of cell clusters of all sizes (21.1 vs 9.9 clusters, P = 0.0007) in the new brush group compared to historical controls.

CONCLUSION

The use of a new brush design for brush cytology of biliary strictures shows increased diagnostic accuracy, likely due to improved cellular yield, as evidenced by an increase in number of cellular clusters obtained.

Predictors for detection of cancer in patients with indeterminate biliary stricture and atypical cells on endoscopic retrograde brush cytology

OBJECTIVE

The management of atypical cells on endoscopic retrograde brush cytology (ERBC) in patients with indeterminate biliary stricture is unclear. This study aimed to investigate the detection of cancer (pancreatic and biliary carcinoma) in patients with atypical cells on ERBC and the factors predicting it.

METHODS

From a prospectively maintained cytology database in a tertiary care center, patients with indeterminate biliary stricture and atypical cells on ERBC from 1996 to 2012 were studied. The date of the initial ERBC with atypical cells was identified as time zero. The primary outcome was to study the incidences and Kaplan-Meier estimates for detecting cancer.

RESULTS

In all, 104 patients with 182.8 person-years of follow-up were identified. In 38 (36.5%) patients cancer was detected (19 cholangiocarcinoma, 15 pancreatic cancer, three ampullary cancer and one gallbladder carcinoma) over a mean follow-up of 4.4 months. On Cox regression analysis, the presence of clinical jaundice (hazard ratio [HR] 4.08, 95% CI 1.41-11.8), active alcohol consumption (HR 7.33, 95% CI 1.85-29.1) and elevated carbohydrate antigen 19-9 (CA19-9) level (>33 U/mL) (HR 8.42, 95% CI 1.75-40.6) at the time of ERBC were associated with increased risk for the detection of cancer. Detection of cancer was more common during the first 6 months of follow-up than at any time period thereafter.

CONCLUSION

Elevated CA19-9 level, the presence of clinical jaundice and current alcohol consumption are associated with increased detection of cancer in patients with indeterminate biliary stricture and atypical cells on ERBC.

Intraductal aspiration: a promising new tissue-sampling technique for the diagnosis of suspected malignant biliary strictures

BACKGROUND

Brushing is the most commonly used technique for biliary sampling at ERCP, despite its limited sensitivity.

OBJECTIVE

To evaluate intraductal aspiration (IDA) as a new combined endoscopic technique for cytodiagnosis, its cellular adequacy, diagnostic accuracy for cancer detection, feasibility, and safety.

DESIGN

Prospective, observational study.

SETTING

Single tertiary referral center.

MAIN OUTCOME MEASUREMENTS

IDA cellular adequacy, diagnostic accuracy for cancer detection, feasibility, and safety.

PATIENTS AND METHODS

From April 2009 to September 2010, 42 consecutive patients with suspected malignant biliary stricture underwent ERCP, with tissue sampling obtained with IDA. IDA included performance of standard brushing in all patients. After standard brushing, to perform IDA, we removed the brush from its catheter and used the tip of the catheter as a scraping device. The tip was scraped back and forth across the stricture at least 10 times. The catheter and a suction line were connected to a specimen trap to obtain intraductal aspiration of fluids and samplings.

RESULTS

Our cytopathologists found adequate cellular yield in 39 of the 42 IDA samples (92.8%) versus 15 of the 42 brushing samples (35.7%) (P < .001). IDA showed a significantly higher sensitivity than brushing (89% vs 78% for adequate samples and 89% vs 37% for all samples) and provided significantly superior cellular adequacy (92.8% vs 35.7%).

LIMITATIONS

Observational study, small number of patients.

CONCLUSIONS

IDA significantly improves brushing cellular adequacy and has high sensitivity for cancer detection. It was also safe, simple, rapid, and applicable during routine diagnostic ERCP, with no additional costs.

Factors affecting the yield of brush cytology for the diagnosis of pancreatic and biliary cancers

OBJECTIVE

Pancreatobiliary malignancies often present as biliary strictures. Biliary brush cytology is an established diagnostic technique in the investigation of such strictures. The main shortcoming of the test, however, is its low sensitivity. The aim of this was to identify factors associated with a positive yield on biliary brush cytology.

METHODS

Consecutive patients who had brush cytology for investigation of biliary strictures from 2005 to 2007 were included. Association of several factors with a positive result on brush cytology was studied using univariable and multivariable logistic regression analyses.

RESULTS

Two hundred eighty patients were evaluated. One hundred nineteen (42.5%) patients had a final diagnosis of malignancy; of whom, 55 had a positive brush cytology (sensitivity, 46%; specificity, 100%). On multivariable analysis, age (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.06-10.4 per 5-year increase), total serum bilirubin levels (OR, 1.3; 95% CI, 1.01-1.6 per 5-unit increase), and presence of a mass on cross-sectional imaging (OR, 11.7; 95% CI 5.1-27.2) were independent predictors of a positive brush cytology result.

CONCLUSIONS

Increasing age, higher serum bilirubin levels, and presence of a mass on cross-sectional imaging are independent factors associated with a positive result on biliary brush cytology. These findings suggest use of complementary tissue acquisition techniques in selected cases.

DNA methylation alterations in endoscopic retrograde cholangiopancreatography brush samples of patients with suspected pancreaticobiliary disease

BACKGROUND & AIMS

Molecular markers of pancreatic neoplasia could aid in the evaluation of suspicious pancreatic lesions where cytology is nondiagnostic. We evaluated the utility of detecting and measuring aberrantly methylated DNA as markers of pancreatic and other periampullary cancers.

METHODS

Methylation analysis was performed on endoscopically obtained brush samples from the biliary and pancreatic ducts from 130 individuals with biliary tract strictures: 41 with pancreatic ductal adenocarcinoma, 10 with biliary tract cancers, 13 with other periampullary neoplasms, and 66 with non-neoplastic strictures including 27 with primary sclerosing cholangitis and 39 with other benign strictures. Brush DNA concentrations of methylated Cyclin D2, NPTX2, and TFPI2 promoter DNA were measured by real-time quantitative methylation-specific polymerase chain reaction (QMSP). Conventional MSP was also performed with a 5-gene panel.

RESULTS

QMSP could accurately distinguish patients with pancreatic cancer and other periampullary cancers from those with benign periampullary disease; 73.2% of patients with pancreatic ductal adenocarcinoma had at least 1 gene positive for methylation by QMSP (defined as > or =1% TFPI-2 DNA and > or =3% methylated NPTX2 and Cyclin D2 DNA) in their brush samples, compared with 80% of patients with a biliary tract cancer and only 13.6% of patients with a benign stricture (P < .001). Cytology had 19.5% sensitivity and 100% specificity. QMSP had significantly better overall diagnostic accuracy than both cytology and MSP.

CONCLUSIONS

The detection and quantification of aberrantly methylated DNA in endoscopic brush samples are a promising tool to differentiate benign from malignant biliary strictures.