Diagnosis of malignant obstructive jaundice by bile cytology: results improved by dilating the bile duct strictures

Advanced endoscopy meets molecular diagnosis of cholangiocarcinoma

Cholangiocarcinoma remains an aggressive and deadly malignancy that is often diagnosed late. Intrinsic tumour characteristics and the growth pattern of cancer cells contribute to the challenges of diagnosis and chemoresistance. However, establishing an early and accurate diagnosis, and in some instances identifying targetable changes, has the potential to impact survival. Primary sclerosing cholangitis, a chronic cholangiopathy prodromal to the development of a minority of cholangiocarcinomas, poses a particular diagnostic challenge. We present our diagnostic and theranostic approach to the initial evaluation of cholangiocarcinomas, focusing on extrahepatic cholangiocarcinoma. This involves a multipronged strategy incorporating advanced imaging, endoscopic methods, multiple approaches to tissue sampling, and molecular markers. We also provide an algorithm for the sequential use of these tools.

Pathological and molecular diagnoses of early cancer with bile and pancreatic juice

The dismal prognosis of pancreaticobiliary malignancies is mainly attributed to the extremely difficult detection of early-stage lesions, including intraepithelial neoplasia. To improve prognosis, several studies on the early detection of cancer have been conducted using bile and pancreatic juices for pathological or molecular analyses. One approach is liquid biopsy that includes information about the tumor, such as circulating tumor cells, circulating tumor DNA, microRNAs, and exosomes released by the tumor. Another approach is proteomics/metabolomics that reflects specific conditions in the tumor. These two approaches lead to artificial intelligence-based multiomics analyses that comprises genomics, proteomics/metabolomics, and transcriptomics. Based on the findings of molecular analysis, pathological analysis using immunohistochemical staining/fluorescence in situ hybridization has also been developed. Moreover, there have been reports of new methods/ingenuities for obtaining appropriate samples for the diagnosis of early-stage cancer. Here we review the knowledge on cutting-edge pathological and molecular analyses of bile and pancreatic juices, introduce some ingenuities in sampling and sample processing to promote effective clinical practice, and provide a basis for future studies.

Endoscopic Perspective in Cholangiocarcinoma Diagnostic Process

Cholangiocarcinoma is a malignancy arising from the epithelial lining of the intrahepatic or extrahepatic biliary tract. Timely diagnosis is challenging due to its silent clinical course. As reliable laboratory markers are lacking, diagnostic imaging plays a pivotal role. While cross-sectional imaging studies are usually conclusive for intrahepatic lesions, endoscopy plays an essential role in cases of extrahepatic tumors. Rational utilization of different diagnostic methods based on available evidence is needed. This article focuses on the diagnostic role of advanced biliary endoscopy, including endoscopic retrograde cholangiopancreatography, cholangioscopy, endoscopic ultrasonography, and intraductal sonography.

Percutaneous Intraductal Sampling for Cyto-histologic Diagnosis of Biliary Duct Strictures

Background

Percutaneous transhepatic biliary drainage (PTBD) allows ductal material to be collected for cyto-histologic examination. We evaluated the data from a large series of patients with a PTBD in whom endobiliary cyto-histologic sampling techniques were employed in order to define a strategy for their use in the diagnostic work-up.

Patients and Methods

Ductal samples for cyto-histologic examination were obtained from 409 consecutive patients with a PTBD for stenosing lesions of the biliary tree. Bile aspirate cytology was performed for all patients and ductal biopsy specimens were obtained, generally after negative cytology, from 49 of them (11.9%), all candidates for a therapeutic procedure. The cyto-histologic results of intraductal sampling were compared with pathologic surgical data in 210 patients and with clinical-radiologic follow-up in 199.

Results

Overall, 22 out of the 409 patients had a final diagnosis of benign stenosis and 177 had samples positive for neoplastic disease. The sensitivity of bile cytology was 43.8% while ductal biopsies showed a sensitivity of 60.4%. The combination of the two sampling techniques achieved a sensitivity of 65.1%. For both sampling methods the specificity was 100%. Hilar metastases from neoplastic lesions of the GI tract and primary lesions of the biliary ducts showed the highest sensitivity.

Conclusion

Cyto-histologic assessment of stenosing lesions of the biliary ducts is mandatory when highly sophisticated interventions (e.g. wide hepatic resection or liver transplantation) or non-surgical treatments are envisaged. The collection of cyto-histologic samples from bile ducts, in patients with a percutaneous bile drainage, is an easy, safe and valuable method to obtain the diagnosis. In view of the absence of false positive results in our series and in others, intraductal biopsy serves no purpose when positive exfoliative cytology is positive for malignancy. In the presence of negative cytology it is felt that an intraductal biopsy should be mandatory when the choice of a therapeutic program depends on the result of the cyto-histologic diagnosis.

Biliary Brush Cytology Revisited

PURPOSE

To evaluate the diagnostic yield of biliary brush cytology and the factors affecting positive results in patients with biliary strictures.

PATIENTS AND METHODS

The medical records of all patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with biliary brush cytology at our institution from November 2004 to December 2013 were reviewed in this retrospective study. The yield of positive brush cytology and the factors affecting positive yield, such as stricture location, age, gender and preprocedure CA 19.9 level were assessed. The final histopathology, diagnosis obtained by other methods, such as endoscopic ultrasound-guided fine-needle aspiration cytology, CT scan, Tru-Cut biopsy and/or clinical/radiological follow-up were used to identify true- and false-positive/negative results. The brush cytology results were divided into 4 main categories: malignant, benign, atypical cells and inadequate.

RESULTS

A total of 1,168 patients underwent ERCP during this 9-year period. Out of these, 142 patients had ERCP and biliary brushings for diagnosis. The mean age of the patients at presentation was 58.7 years (range 23-84 years; 64.8% males). The indication for referral was obstructive jaundice in all patients. Of the 142 patients, 77 (54.2%) had a distal common bile duct (CBD) stricture and 65 (45.8%) had a proximal /complex hilar stricture. The strictures were classified as proximal or distal, based on their relationship with the cystic duct; those below the cystic duct insertion were classified as distal and those above it were considered proximal. The diagnostic yield of brush cytology was 58.5%. The diagnostic yield was higher for proximal than for distal CBD strictures (67 vs. 50%; p = 0.047). It was also higher for females (58 vs. 57.6%; p = 0.94), patients >50 years (60 vs. 50%; p = 0.29) and those with a CA 19.9 level >300 IU/ml (59.4 vs. 55.5%; p = 0.65) but did not reach statistical significance for any of these parameters. Complete follow-up data were available for 96 patients and 46 patients were lost to follow-up. The sensitivity, specificity, positive predictive value and negative predictive value were 65.3, 100, 100 and 27%, respectively. When patients with atypia were included in the group with positive results, the diagnostic yield increased to 65.5% with a diagnostic sensitivity of 68.6%. There were 27 false-negative diagnoses, 10 patients were true-negative and no patients had a false-positive diagnosis.

CONCLUSION

Biliary brush cytology is a safe and simple initial diagnostic procedure in patients with biliary strictures and can be performed at the time of therapeutic ERCP. If performed correctly and then interpreted by a dedicated cytopathologist, it has a good diagnostic yield and sensitivity. We feel that the low rates of success with this technique reported in some earlier studies have led to a feeling that this is not a particularly useful technique. We recommend that this topic should be revisited, and that the technique should be used more often.

The diagnostic value of brush cytology alone and in combination with tumor markers in pancreaticobiliary strictures

Aim. Differentiation of malignant and benign strictures constitutes a problem despite the increasing experience of the endoscopists, radiologists, and pathologists. The aim of our study is to determine the factors that affect the efficacy of the ERCP guided brush cytology in PBS and to evaluate its diagnostic success when used alone and together with tumor markers. Method. The data from brush cytologies of 301 PBS patients were collected retrospectively and analyzed. The final diagnosis was approved based on the histological examination of the tissue taken surgically or by other methods. In the absence of a histological diagnosis, the final diagnosis was based on radiological studies or the results of a 12-month clinical follow up. Results. A total of 28 patients were excluded from the study. From the remaining 273 patients 299 samples were analyzed. The sensitivity and the specificity of brush cytology in diagnosing malignancy are 62.4% and 97.7, respectively. The sensitivity of brush cytology increased to 94.1% when combined with CA-19.9 and CA-125. Conclusion. Brush cytology is a useful method in diagnosing pancreaticobiliary strictures. Advanced age, stricture dilatation before sampling, the presence of a mass identified by radiological studies, high levels of CA-19.9, ALT, and total bilirubin increase the sensitivity of brush cytology.

Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis

BACKGROUND

Evaluation of indeterminate biliary strictures typically involves collection and analysis of tissue or cells. Brush cytology and intraductal biopsies that are routinely performed during ERCP to assess malignant-appearing biliary strictures are limited by relatively low sensitivity.

OBJECTIVE

To study the comparative effectiveness of brushings for cytology and intraductal biopsies in the etiology of biliary strictures.

DESIGN

Meta-analysis.

SETTING

Referral center.

PATIENTS

PUBMED and Embase databases were reviewed for studies published to April 2014 where diagnostic correlation of histology was available.

INTERVENTION

Database and review of study findings.

MAIN OUTCOME MEASUREMENTS

Sensitivity and specificity.

RESULTS

The pooled sensitivity and specificity of brushings for the diagnosis of malignant biliary strictures was 45% (95% confidence interval [CI], 40%-50%) and 99% (95% CI, 98%-100%), respectively. The pooled diagnostic odds ratio to detect malignant biliary strictures was 33.43 (95% CI, 14.29-78.24). For intraductal biopsies, the pooled sensitivity and specificity were 48.1% (95% CI, 42.8%-53.4%) and 99.2% (95% CI, 97.6%-99.8%), respectively. The pooled diagnostic odds ratio to detect malignant biliary strictures was 43.18 (95% CI, 19.39-95.83). A combination of both modalities only modestly increased the sensitivity (59.4%; 95% CI, 53.7%-64.8%) with a specificity of 100% (95% CI, 98.8%-100.0%). The Begg-Mazumdar and Egger tests indicated a low potential for publication bias.

LIMITATIONS

Inclusion of low-quality studies.

CONCLUSION

Our study suggests that both brushings and biopsy are comparable and have limited sensitivity for the diagnosis of malignant biliary strictures. A combination of both only modestly increases the sensitivity.

Cholangioscopy in liver disease

Since its introduction, cholangioscopy has been used diagnostically and therapeutically. The working channel size has increased, permitting direct visualization for tissue sampling and to guide application of lithotripsy for difficult stones. Cholangioscopy utilizes endoscope and catheter-based systems. The application of slim gastroscopes for direct cholangioscopy provides better image resolution than conventional systems. Cholangioscopy has proven effective in the management of large biliary stones and for the diagnosis and exclusion of biliary tumors. Commercially available cholangioscopes are fiberoptic; those with digital video technology remain in a prototype development phase. This review covers available cholangioscope technologies, indications, technique, efficacy, and complications.

Techniques for cytologic sampling of pancreatic and bile duct lesions: The Papanicolaou Society of Cytopathology Guidelines

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pancreatobiliary cytology, including indications for endoscopic ultrasound guided fine-needle aspiration biopsy, techniques of the endoscopic retrograde cholangiopancreatography, terminology and nomenclature of pancreatobiliary disease, ancillary testing, and postbiopsy management. All documents are based on the expertise of the authors, a review of literature, discussions of the draft document at several national and international meetings over an 18 month period and synthesis of online comments of the draft document on the Papanicolaou Society of Cytopathology website [www.papsociety.org]. This document presents the results of these discussions regarding the use of sampling techniques in the cytological diagnosis of biliary and pancreatic lesions. This document summarizes the current state of the art for techniques in acquiring cytology specimens from the biliary tree as well as solid and cystic lesions of the pancreas.

Imaging of malignancies of the biliary tract- an update

Malignancies of the biliary tract include cholangiocarcinoma, gallbladder cancers and carcinoma of the ampulla of Vater. Biliary tract adenocarcinomas are the second most common primary hepatobiliary cancer. Due to their slow growing nature, non-specific and late symptomatology, these malignancies are often diagnosed in advanced stages with poor prognosis. Apart from incidental discovery of gall bladder carcinoma upon cholecystectomy, early stage biliary tract cancers are now detected with computed tomography (CT) and magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP). Accurate characterization and staging of these indolent cancers will determine outcome as majority of the patients' are inoperable at the time of presentation. Ultrasound is useful for initial evaluation of the biliary tract and gallbladder masses and in determining the next suitable modality for further evaluation. Multimodality imaging plays an integral role in the management of the biliary tract malignancies. The imaging techniques most useful are MRI with MRCP, endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS) and positron emission tomography (PET). In this review we will discuss epidemiology and the role of imaging in detection, characterization and management of the biliary tract malignancies under the three broad categories of cholangiocarcinomas (intra- and extrahepatic), gallbladder cancers and ampullary carcinomas.

Randomized controlled trial on timing and number of sampling for bile aspiration cytology

BACKGROUND

The issue on timing and number of bile sampling for exfoliative bile cytology is still unsettled.

METHODS

A total of 100 patients with cholangiocarcinoma undergoing resection after external biliary drainage were randomized into two groups: a 2-day group where bile was sampled five times per day for 2 days; and a 10-day group where bile was sampled once per day for 10 days (registered University Hospital Medical Information Network/ID 000005983). The outcome of 87 patients who underwent laparotomy was analyzed, 44 in the 2-day group and 43 in the 10-day group.

RESULTS

There were no significant differences in patient characteristics between the two groups. Positivity after one sampling session was significantly lower in the 2-day group than in the 10-day group (17.0 ± 3.7% vs. 20.7 ± 3.5%, P = 0.034). However, cumulative positivity curves were similar and overlapped each other between both groups. The final cumulative positivity by the 10th sampling session was 52.3% in the 2-day group and 51.2% in the 10-day group. We observed a small increase in cumulative positivity after the 5th or 6th session in both groups.

CONCLUSIONS

Bile cytology positivity is unlikely to be affected by sample time.

Prospective randomized controlled study comparing cell block method and conventional smear method for bile cytology

BACKGROUND AND AIM

There is a paucity of data on the cell block (CB) method for bile cytology. We compared the diagnostic efficacy of the CB method with that of conventional smear cytology for bile obtained by endoscopic retrograde cholangiopancreatography (ERCP) in a randomized controlled trial manner.

METHODS

A total of 137 patients with biliary tract lesions suspicious of malignancy who had undergone bile collection under ERCP were recruited to this study. After sampling, the bile was randomized to the CB method (n = 69) or to smear cytology (n = 68). CB sections were prepared using the sodium alginate method and subjected to hematoxylin-eosin, Alcian blue-periodic acid-Schiff stain, and immunohistochemical stains. Both Papanicolaou and Giemsa stains were used for smear cytology.

RESULTS

The final diagnosis was malignancy in 94 patients: bile duct cancer, 42; pancreatic head cancer, 34; gallbladder cancer, 16; and ampullary cancer, two. The diagnostic accuracy of the CB method and that of smear cytology were 64% and 53%, respectively (P = 0.20). The sensitivity of the CB method (53%) was significantly better than that of smear cytology (28%; P = 0.014). Their respective sensitivities were 80% and 31% (P = 0.002) for bile duct cancer, 20% and 15% (P = 1.0) for pancreatic head cancer, and 30% and 67% (P = 0.30) for gallbladder cancer.

CONCLUSION

The CB method for bile cytology showed a higher diagnostic yield than smear cytology. Its diagnostic sensitivity was satisfactory in cases of bile duct cancer.

Usefulness of brush cytology combined with pancreatic juice cytology in the diagnosis of pancreatic cancer: significance of pancreatic juice cytology after brushing

OBJECTIVES

Pancreatic juice cytology (PJC) and brush cytology (BC) performed during endoscopic retrograde cholangiopancreatography could make a definite diagnosis of pancreatic cancer. The aim of this study was to improve the diagnostic value of cytology performed during endoscopic retrograde cholangiopancreatography in the diagnosis of pancreatic cancer.

METHODS

The subjects comprised 127 patients with pancreatic ductal adenocarcinoma (PDAC) and 74 with benign pancreatic duct stricture mimicking PDAC. Final diagnosis was confirmed based on histopathology by resection or on more than 1 year of follow up. Pancreatic juice cytology was examined before and after BC. And the sensitivity of PJC combined with BC was examined.

RESULTS

No malignancy was detected by PJC or by BC in patients with benign pancreatic duct strictures (specificity, 100%). In those with PDAC, the sensitivity of PJC before and after brushing was 21.3% and 40.9%, respectively; that of BC was 48.8%. Of 65 patients with PDAC, in whom neither PJC before brushing nor BC indicated malignancy, 16 were diagnosed with pancreatic cancer using PJC after brushing. Brush cytology combined with PJC after brushing significantly raised the diagnostic sensitivity for PDAC to 61.4%.

CONCLUSIONS

Diagnosis of pancreatic cancer based on BC combined with PJC after brushing was more reliable than PJC before brushing or BC.

Gallbladder cancer: past, present and an uncertain future

Although gallbladder cancer (GBC) is the most common malignancy of the biliary tract, its relatively low incidence and confounding symptomatology result in advanced disease at the time presentation, contributing to the poor prognosis and decreased survival associated with this disease. It is therefore increasingly important to understand its pathogenesis and risk factors to allow for the earliest possible diagnosis. To date, gallbladder cancer is poorly understood compared to other malignancies, and is still most commonly discovered incidentally after cholecystectomy. Moreover, while much is known about biliary neoplasms as a whole, understanding the clinical and molecular nuances of GBC as a separate disease process will prove a cornerstone in the development of early intervention, potential screening and overall more effective treatment strategies. The present work reviews the most current understanding of the pathogenesis, diagnosis, staging and natural history of GBC, with additional focus on surgical treatment. Further, review of current adjuvant therapies for unresectable and advanced disease as well as prognostic factors provide fertile ground for the development of future studies which will hopefully improve treatment outcomes and affect overall survival for this highly morbid, poorly understood malignancy.

Focal intrahepatic strictures: a review of diagnosis and management

INTRODUCTION

Focal intrahepatic strictures are becoming more common owing to more prevalent and accurate cross-sectional imaging. However, data relating to their management are lacking. The purpose of the present review was to synthesize the current evidence regarding these lesions and to formulate a strategy for diagnosis and management.

METHODS

A literature search of relevant terms was performed using Medline. References of papers were subsequently searched to obtain older literature.

RESULTS

Focal intrahepatic strictures involve segmental hepatic ducts and/or left and right main hepatic ducts during their intrahepatic course. Most patients are asymptomatic while the minority present with vague abdominal pain or recurrent sepsis and only rarely with jaundice. Investigations used to distinguish benign from malignant aetiologies include blood tests (CEA, Ca19.9), imaging studies [ultrasonography (US), computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP) and fluorodeoxyglucose-positron emission tomography (FDG-PET)], endoscopic modalities [endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic ultrasound (EUS)/cholangioscopy] and tissue sampling (brush cytology/biopsy).

CONCLUSIONS

A focal intrahepatic stricture requires thorough investigation to exclude malignancy even in patients with a history of biliary surgery, hepatolithiasis or parasitic infection. If during the investigative process a diagnosis or suspicion of malignancy is demonstrated then surgical resection should be performed. If all diagnostic modalities suggest a benign aetiology, then cholangioscopy with targeted biopsies should be performed.

Prospective study of biliary cytology in suspected perihilar cholangiocarcinoma

BACKGROUND

The diagnostic value of biliary cytology for hilar bile duct stricture is uncertain. This study prospectively examined three methods for the evaluation of biliary cytology in a consecutive group of patients.

METHODS

Preoperative bile sampling by aspiration through a drainage catheter (aspiration samples), saline flush through a drainage catheter (saline samples) or direct sampling from a drainage bag (bag samples) was performed in consecutive patients with suspected perihilar cholangiocarcinoma who underwent resection after endoscopic nasobiliary drainage or percutaneous transhepatic biliary drainage. All bile sampling was performed three times on separate days. The accuracy of cytology in the diagnosis of carcinoma was determined.

RESULTS

Of 100 consecutive patients with hilar strictures, 97 had histologically proven cholangiocarcinoma. The proportion of these 97 patients who had a positive finding on cytology in at least one of three sampling sessions was 55 per cent for aspiration samples, 48 per cent for bag samples and 38 per cent for saline samples (P = 0·021, aspiration versus saline). Tumour length correlated significantly with overall positivity. For aspiration samples, sensitivity was 55 per cent, specificity was 100 per cent and accuracy 56·0 per cent.

CONCLUSION

For biliary cytology, sampling by catheter aspiration is more effective than catheter flushing or sampling from a drainage bag. Repeated sampling increases sensitivity. Biliary cytology has modest diagnostic yield, but is easy to perform, highly specific, and can provide a definitive diagnosis.

Tratamento endoscópico das lesões biliares

As técnicas cirúrgicas convencionais ofertam uma apropriada condição de cura na maioria dos pacientes com estreitamento biliar benigno. Nesta condição, no entanto, o reparo cirúrgico está associado com recorrência tardia da re-estenose em 10% a 30% dos pacientes. Neste contexto, os avanços tecnológicos na endoscopia terapêutica promoveram a possibilidade alternativa do tratamento efetivo destas obstruções benignas. Considerações em relação ao tempo de reospitalização e de procedimentos devem ser averiguados em detalhes e ponderados em relação á cirurgia. Estenoses malignas estão relacionadas á colangite, icterícia e dor e, consequentemente, com as alterações sistêmicas relacionadas com a sepsis biliar. A conduta endoscópica cria uma derivação do suco biliar para o duodeno, sendo uma verdadeira derivação biliodigestiva endoscópica e utilizando-se próteses plásticas ou metálicas. O propósito desta revisão é ofertar aos leitores a eficácia do tratamento endoscópico na estenose benigna e maligna biliopancreática.

Proteomic analysis of human bile from malignant biliary stenosis induced by pancreatic cancer

Stenosis of the common bile duct may be either due to benign (chronic pancreatitis) or malignant (cholangiocarcinoma, pancreatic adenocarcinoma) conditions. The benign nature of the stricture should be first confirmed in order to ensure appropriate therapy. Therefore, the identification of markers allowing discrimination between malignant and benign biliary stenosis would be very valuable in clinical practice. To this intent, we performed a proteomic analysis of bile samples from patients having a biliary stenosis caused by pancreatic adenocarcinoma. Bile samples were collected during endoscopic retrograde cholangiopancreatography and purified using different methods. The extracted proteins were then analyzed by SDS-PAGE and LC-MS/MS. A total of 127 proteins were identified, 34 of which have not been previously detected in proteomic studies of bile. Among them, several proteins have been described as potential biomarkers of pancreatic cancer. We extended our investigation by studying the expression of some of these pancreatic cancer markers in bile samples collected from patients with various etiologies of biliary stenosis including pancreatic cancer, cholangiocarcinoma, chronic pancreatitis, as well as gallstone-induced stenosis. Our data showed a conspicuous overexpression of CEACAM6 and MUC1 (CA19-9) in pancreatic cancer and cholangiocarcinoma samples, according to the hypothesis that bile fluid collects cancer-associated protein leaking from the tumor microenvironment. These results underline the interest of using bile as a source of biomarkers for the diagnosis of malignant biliary stenosis.

How many cytological examinations should be performed for the diagnosis of malignant biliary stricture via an endoscopic nasobiliary drainage tube?

BACKGROUND AND AIM

The sensitivity of bile cytology is recognized as being low. Repeating cytological sampling is likely to improve the sensitivity. The aim of this study is to determine the optimal number of repeated cytological sampling of bile obtained via an endoscopic nasobiliary drainage (ENBD) tube for the diagnosis of malignant biliary stricture.

METHODS

Ninety-eight patients with malignant biliary stricture who underwent ENBD were enrolled. Diagnoses included bile duct carcinoma (n = 53), pancreatic carcinoma (n = 28), carcinoma of the major papilla (n = 8), gallbladder carcinoma (n = 6), and hepatocellular carcinoma (n = 3). Bile was aspirated via an ENBD tube once a day and immediately evaluated cytologically.

RESULTS

The median number of cytological samplings via an ENBD tube was 2.8 times (range, 1-10). In 40 of 98 patients with malignant biliary stricture, cytology was positive at the first cytological sampling (sensitivity 40.8%). Cytology was cumulatively positive in 71 of 98 patients (sensitivity 72.4%) from which repeated samples were taken. In 71 patients with positive cytology, correlation of the positive rate and the number of cytological samplings performed was investigated. In 68 of 71 (95.8%) patients with positive cytology, positive results were obtained by or at the sixth examination.

CONCLUSIONS

Bile cytology via an ENBD tube is an easy method, and has been shown to have relatively high sensitivity. The optimal number of repeated cytological samplings using bile obtained via an ENBD tube for the diagnosis of malignant biliary stricture was concluded to be six.

Cholangiocarcinoma: natural history, treatment, and strategies for surveillance in high-risk patients

Cholangiocarcinoma is a primary malignancy of biliary epithelium. Risk factors for cholangiocarcinoma include primary sclerosing cholangitis and other conditions that produce chronic inflammation of the biliary tree. The diagnosis of cholangiocarcinoma can be elusive; it is often not made until advanced disease is present and at a stage when a curative surgical resection is not feasible. Currently used diagnostic modalities include serum and bile tumor markers, radiologic and endoscopic imaging, and pathologic analysis. Surveillance strategies to increase the chance of early diagnosis should be strongly considered in individuals at high risk for cholangiocarcinoma. Patients with long-standing primary sclerosing cholangitis would be the ideal candidates for a screening program.

Biliary brush cytology: Factors associated with positive yields on biliary brush cytology

AIM: To evaluate the yield of brushing biliary strictures and the factors associated with a positive result in biliary strictures.

METHODS: Data on all consecutive patients (01/02-10/05) who were identified to have a biliary stricture and who underwent biliary brush cytology were collected. The yield of positive biliary brush cytology was evaluated and compared to results with the gold standard for diagnosis (defined as either definitive surgical histology or clinical course). Additionally, associated factors of positive results including stricture location, gender, age, mass size, length of stricture, and dilatation prior to brushing cytology were assessed.

RESULTS: From 199 patients who had brushing cytology samples (10 patients were excluded due to lack of gold standard diagnosis), 77 patients had positive brushing cytology (yield 41%). Variables associated with positive cytology brushing on initial endoscopic retrograde cholangiography were age 1.02 (1.00-1.05), mass size > 1 cm 2.22 (1.01-4.89) and length of stricture > 1 cm 3.49 (1.18-10.2). The sensitivity of biliary brushing was 61%, its specificity 98%, the positive predictive value reached 99%, and the negative predictive value was 57%.

CONCLUSION: Our results revealed a 41% positive yield from brushing cytology. The sensitivity of biliary brushing cytology in our center was 61% and the specificity was 98%. Predictors of positive yield include older age, mass size > 1 cm, and stricture length of > 1 cm.

Is preoperative histological diagnosis necessary before referral to major surgery for cholangiocarcinoma?

Major surgical resection is often the only curative treatment for cholangiocarcinoma. When imaging techniques fail to establish the accurate diagnosis, biopsy of the lesion is unavoidable. However, biopsy is not necessarily required for topography of the cholangiocarcinoma (intrahepatic or extrahepatic). 1) In extrahepatic cholangiocarcinoma (ECC), clinical features and radiological imaging relate to biliary obstruction. Provided that between 8% and 43% of bile duct strictures are not ECC, the lesions mimicking ECC that should be ruled out are gallbladder cancer, Mirizzi syndrome, primary sclerosing cholangitis (PSC), autoimmune pancreatitis and portal biliopathy. Systematic biopsy is usually difficult and has poor sensitivity, but a good knowledge of these mimicking ECC diseases, along with precise analysis of clinical and imaging semiology, may lead to a correct diagnosis without the need for biopsy. 2) Intrahepatic cholangiocarcinoma (ICC) developing in normal liver appears as a hypovascular tumour with fibrotic component and capsular retraction that can be confused with fibrous metastases such as breast and colorectal cancers. The lack of the primary site, a relatively large tumour size and ancillary findings such as bile duct dilatation may provide a clue to the diagnosis. If not, we advocate local resection with lymph node dissection, since ICC is the most likely diagnosis and surgery is the only curative treatment. In the event of adenocarcinoma from unknown primary, surgery is an effective treatment even if prognosis is poor.

Comparison between endoscopic brush cytology performed before and after biliary stricture dilation for cancer detection

BACKGROUND: Confirmation of malignancy within biliary strictures is endoscopically challenging. Dilation of strictures has been reported to enhance cytological diagnosis. AIM: To compare brush cytology results before and after biliary stricture dilation. PATIENTS AND METHODS: Patients with extra-hepatic biliary stricture at endoscopic retrograde cholangiopancreatography were included in the study. Brushing was performed before and immediately after dilation using a 10 Fr dilating catheter. Cytology samples were classified as: negative for malignancy, presence of atypical cells, insufficient material, suspicious for malignancy or positive for malignancy. Final diagnosis was established by surgery, biopsy or follow-up. RESULTS: Biliary brush cytology was performed in 50 patients, with an overall sensitivity of 40% and 27.5%, before and after dilation, respectively. The combination of results increased cancer detection rate to 45%. There were 5/50 (10%) minor complications and one death related to the procedure. CONCLUSIONS: Brush cytology performed before biliary stricture dilation has a similar cancer detection rate to that following dilation, although the combination of results enhances sensitivity.

Effectiveness of a new long cytology brush in the evaluation of malignant biliary obstruction: a prospective study

BACKGROUND

Cancer detection rates with biliary brush sampling remain disappointingly low. A low cellular yield is often the limiting factor in making a diagnosis of malignancy. The new Cytolong brush (Cook Endoscopy, Winston-Salem, NC) is 3 mm in diameter, 5 cm long, with stiffer bristles oriented at 45 degrees on a 7F sheath. We hypothesized that this new brush might improve cancer detection rates by increasing cellular yield.

METHODS

Patients found to have a biliary stricture suspicious for neoplasia on ERCP were randomized to undergo brush sampling for cytology with a standard Geenen brush (GB; Cook Endoscopy, Winston-Salem, NC) [3 mm in diameter, 1.5 cm long, bristles oriented at 90 degrees on a 6F sheath] or the Cytolong brush (CB). Repeat sampling was then performed with the other brush. Stricture dilation was not performed prior to brushing. Specimen results were considered normal, atypical (considered benign), highly atypical (suspicious for cancer), or malignant. All specimens were assigned a cellularity score (0 to 3, insufficient to excellent). Final diagnosis was based on cytologic results plus surgery, EUS, autopsy, or clinical follow-up.

RESULTS

From November 2001 to July 2003, 102 patients had specimens obtained from 94 malignancies (47% pancreatic cancer). The cancer detection rate was 25 of 94 (27%) using CB and 28 of 94 (30%) with GB (p = NS). No patient had positive cytology results with CB and negative cytology results with GB. The yield of the two brushes combined was 28 of 94 (30%). Cancer detection rates of 28% (18 of 64) and 31% (20 of 64) were found for CB and GB, respectively, in distal biliary strictures, and 23% (7 of 30) and 27% (8 of 30) in proximal strictures (p = NS). Insufficient or limited cellularity was seen less frequently with CB (11 of 98) than with GB (17 of 98), and the mean cellular yield was greater with CB than GB (2.6 vs 2.4, p = 0.006).

SUMMARY

Despite improved cellularity, cancer detection rates were not improved by using the larger Cytolong brush in this study. There was no statistical difference between the brushes in both proximal and distal biliary strictures.

CONCLUSIONS

The yield of biliary brush cytology at ERCP remains low. Increasing brush size and bristle stiffness does not increase detection rates. Newer devices and processing techniques are required to allow detection rates to approach those attained in other GI tract malignancies.

Palliative management of hilar cholangiocarcinoma

Around 80% of the patients with hilar cholangiocarcinoma are candidates for palliative management due to extensive co-morbidity for major surgery, metastases or advanced loco-regional disease. The primary aim of treatment is to provide biliary drainage with long-term relief from pruritus, cholangitis, pain and jaundice. Endoscopically placed self-expanding metallic biliary stent has low procedure-related complications and is probably the modality of choice for patients with unresectable tumour on preoperative assessment. Percutaneous biliary drainage has comparable results and is an alternative when endoscopic expertise is not available or has failed or there are multiple isolated segments with cholangitis. Surgical cholangiojejunostomy provides lasting biliary drainage but has limitations of associated morbidity and mortality. In the absence of high-quality studies, comparing these modalities the choice of biliary drainage procedure should be guided by the available local expertise. Other modalities of treatment like radiotherapy, chemotherapy and photodynamic therapy currently remain investigational.

A comparison of routine cytology and fluorescence in situ hybridization for the detection of malignant bile duct strictures

BACKGROUND AND AIM

The aim of this study was to assess the relative sensitivities and specificities of fluorescence in situ hybridization (FISH) and routine cytology for the detection of malignancy in biliary tract strictures.

METHODS

Bile duct brushing and aspirate specimens were collected from 131 patients being evaluated for possible malignant bile duct strictures. Both specimen types were assessed by FISH but only brushing specimens were assessed by cytology. The FISH assay used a mixture of fluorescently-labeled probes to the centromeres of chromosomes 3, 7, and 17 and chromosomal band 9p21 (Vysis UroVysion) to identify cells having chromosomal abnormalities. A case was considered positive for malignancy if five or more cells exhibited polysomy.

RESULTS

Sixty-six of the 131 patients had surgical pathologic and/or clinical evidence of malignancy. Thirty-nine patients had cholangiocarcinoma, 19 had pancreatic carcinoma, and 8 had other types of malignancy. The sensitivity of cytology and FISH for the detection of malignancy in bile duct brushing specimens in these patients was 15% and 34% (p < 0.01), respectively. The sensitivity of FISH for the bile aspirate specimens was 23%, and the combined sensitivity of FISH for aspirate and brushing specimens was 35%. The specificity of FISH and cytology brushings were 91% and 98% (p= 0.06), respectively.

CONCLUSIONS

FISH is significantly more sensitive than and nearly as specific as conventional cytology for the detection of malignant biliary strictures in biliary brushing specimens. FISH may improve the clinical management of patients who are being evaluated for malignancy in bile duct strictures.

Influence of stricture dilation and repeat brushing on the cancer detection rate of brush cytology in the evaluation of malignant biliary obstruction

BACKGROUND

The sensitivity for cancer detection of brush cytology at ERCP is relatively low. Manipulation of the stricture and repeated tissue sampling may increase the yield. This study compared the cancer detection rate of brush cytology before and after biliary stricture dilation.

METHODS

In patients with a biliary stricture at ERCP of suspected malignant origin, the stricture was sampled with a cytology brush and then dilated with either a graduated dilating catheter or a dilating balloon (4-8 mm). Brushing was then repeated in all patients. Specimens were interpreted as normal, atypical (benign), highly atypical (suspicious for cancer), and malignant. Final diagnoses were based on cytology plus surgery, EUS, percutaneous biopsy, autopsy, or clinical follow-up.

RESULTS

A total of 139 patients with suspected malignant obstructive jaundice underwent 143 ERCPs (116 ultimately found to have malignant obstruction, and 27 benign disease). Dilation was performed with a catheter in 68 cases, balloon in 73, and both in 2. Brush cytology had a sensitivity of 34.5% (40/116) before dilation and 31% (36/116) after dilation (p = NS). However, sensitivity with predilation and postdilation brushing specimens combined was 44% (51/116), which was higher than that for either the predilation or postdilation brush cytology (p = 0.001). Cancer detection rates were 34.7% (17/49) after dilation with the catheter and 27.7% (18/65) after balloon dilation (p = NS).

CONCLUSIONS

Stricture dilation does not improve the sensitivity of brush cytology for the detection of cancer, which remains relatively low. However, repeat brushing increases the diagnostic yield and should be performed when sampling biliary strictures with a cytology brush at ERCP.

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.

Gallbladder cancer

Gallbladder cancer has a reputation for being aggressive and incurable. Single institution series, however, have defined successful management strategies in which the extent of resection is based on the stage of the tumor at presentation. Careful ultrasound screening for abnormalities in the gallbladder wall, and CA19-9 serum determination prior to routine cholecystectomy may heighten awareness for cancer in this population. For tumors confined to the muscular layer of the gallbladder a simple cholecystectomy is associated with an almost 100% cure rate. Tumors invading through the muscle wall (Stage II) should be managed with extended cholecystectomy, including resection of hepatic segments IVb and V, and an extensive lymph node dissection of the porta hepatis, posterior pancreaticoduodenal, and interaortocaval lymph nodes. This operation for Stage II gallbladder cancer is associated with a 90% to 100% 3-year survival rate. Simple cholecystectomy fails in the majority of Stage II patients. Patients with Stage III and IV tumors may also benefit from an extended cholecystectomy. Patients with bulky primary tumors without lymph node metastases (T4N0) seem to have a better prognosis than those with distant lymph node metastases, and should be treated aggressively when possible. It is advantageous to perform the appropriate extent of surgery for gallbladder cancer at the initial operation. Heightened awareness of the presence of cancer and the knowledge of appropriate management are important. For patients whose cancer is an incidental finding on pathologic review, re-resection is indicated for all disease except Stage I. This review will discuss the epidemiology, pathology, and staging of gallbladder cancer and describe the appropriate surgical management based on the stage of the cancer.

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.

Endoscopic retrograde wire-guided cytology of malignant biliary strictures using a novel scraping brush

BACKGROUND

Tissue sampling to differentiate benign from malignant pancreatobiliary strictures remains problematic despite the availability of several new sampling methods. A new device is described which attempts to correct some of the drawbacks.

METHODS

The device consists of a 10F dilator which has an attached pad of Velcro. The Velcro has semi-rigid, mushroom-shaped bristles. A cytologic sample is obtained by the abrasive action of the brush when it is passed through the stricture. Fifteen patients with obstructive jaundice underwent brushing of the bile duct using this device.

RESULTS

Cytologic samples obtained with this device were positive for malignancy in all 15 patients. Diagnostic confirmation was obtained by assessment of clinical course, radiologic findings, and during surgery.

CONCLUSION

Preliminary experience indicates that this new device enhances the yield of tissue sampling from malignant bile duct strictures.

Relative contribution of Ki-ras gene analysis and brush cytology during ERCP for the diagnosis of biliary and pancreatic diseases

BACKGROUND

Ki-ras mutation analysis from material collected during ERCP has been claimed to improve the diagnosis of pancreatic and bile duct carcinomas as compared with conventional cytology. Our aim was to study the relative contribution of both Ki-ras analysis and brush cytology in patients with a significant stricture at ERCP.

METHODS

Brushings were collected in duplicate for both analyses in 142 patients in whom a definitive diagnosis was obtained by histology or a minimal follow-up of 6 months.

RESULTS

For pancreatic strictures, sensitivity, specificity, and accuracy of Ki-ras analysis vs. cytology in detecting malignancy were 81% vs. 66%, 72% vs. 100%, and 70% vs. 74%, respectively. For biliary strictures, they were 25% vs. 42%, 100% vs. 100%, and 35% vs. 43%, respectively. The combination of the two methods only marginally increased their sensitivity and accuracy in both types of strictures.

CONCLUSION

Ki-ras analysis is a sensitive method for diagnosing pancreatic but not biliary carcinoma. However, its specificity is lowered by a high frequency of Ki-ras mutations in patients with chronic pancreatitis (25%) who did not manifest cancer development within a 6-month follow-up period. In pancreatic duct strictures, brush cytology appears to be more specific in detecting malignancy; specificity for Ki-ras and cytology are equivalent for the diagnosis of malignant bile duct strictures. Therefore, making a clinical decision on the sole basis of Ki-ras analysis is probably not justified in the majority of the cases.

Progress in the endoscopic management of benign biliary strictures

Benign biliary strictures can now be effectively treated with endoscopic therapy in a variety of clinical situations. Despite recent developments in imaging techniques (endoscopic ultrasound and magnetic resonance imaging), it is often difficult to differentiate benign from malignant biliary strictures. The sensitivity of tissue diagnosis (cytology and needle biopsy) at endoscopic retrograde cholangiopancreatography (ERCP) remains poor (40-50%), and further diagnostic methods are required. Endoscopic therapy offers a definitive treatment in 70-90% of patients following post-operative biliary stricture, including anastomotic strictures following liver transplant. Endoscopic therapy successfully achieves symptomatic, biochemical, and cholangiographic response, and may improve survival in patients with primary sclerosing cholangitis. Strictures secondary to chronic pancreatitis are resistant to standard endoscopic therapy and metallic endoprotheses have been trialed with varying success. Endoscopic therapy is technically difficult and should be performed in specialized centres using a multidisciplinary approach.

Biliary stent replacement cytology

Using fluoroscopic guidance, polyethylene biliary stents are replaced endoscopically or percutaneously when bile duct stenosis recurs. To improve the sensitivity of conventional biliary cytology, we examined cells recovered from removed stents. Biliary stents removed endoscopically from each of 11 patients were rinsed with saline; next, the rinse was centrifuged and the sediment smeared and Papanicolaou stained. Three patients with choledocholithiasis had biliary stent replacement cytology (BSRC) to exclude a neoplastic etiology. Eight patients with clinicoradiologic evidence of hepatobiliary or pancreatic carcinoma had BSRCs performed for pathologic documentation of carcinoma. BSRC from six of eight patients with clinicoradiologically malignant biliary strictures contained malignant cells, predominantly in loose clusters, but also singly (sensitivity 75%, specificity 100%; positive predictive value 75%, negative predicative value 60%). Reparative epithelial atypia was also present in all cases. BSRC from two patients with clinicoradiological evidence of carcinoma of the biliary region and from three with choledocholithiasis contained only bile pigment, leukocytes, and benign epithelial cells. The sampling of cells which have accumulated on, or in biliary stents, improves the sensitivity of biliary cytology. This is most applicable when 1) a patient is inoperable, 2) tissue biopsy is neither feasible nor diagnostic, 3) prior brush, suction, percutaneous, or endoscopic needle aspiration cytology is inconclusive, and 4) permanent metal stent is needed.

Endoscopic retrograde forceps biopsy and brush cytology of biliary strictures: a prospective study

BACKGROUND

Nonsurgical pathologic confirmation of malignant bile duct strictures is desirable for defining subsequent treatment and prognosis. Endoscopic retrograde cholangiopancreatography is frequently performed in patients suspected of having pancreaticobiliary obstruction, but there exists no standardized method for defining the nature of obstructing lesions by ERCP.

METHODS

We prospectively evaluated the yields of endoscopic retrograde brush cytology and biopsy for the diagnosis of malignant bile duct strictures. Fluoroscopically guided endobiliary biopsy and brush cytology (52) or cytology alone (42) were performed during endoscopic retrograde cholangiopancreatography in 94 consecutive patients, 64 with malignant strictures and 30 with benign strictures. A single cytopathologist classified the results of these studies as positive or negative for malignancy.

RESULTS

The sensitivities of the two procedures were identical (53%) and the gain achieved by combining the two techniques (61%) was small. Specificity proved excellent for both methods. One major complication that occurred was perforation of the common hepatic duct with leakage of bile, which was managed by surgical oversewing. This complication was ascribed to biopsy and untimely removal of the nasobiliary drain by the patient herself.

CONCLUSIONS

This study indicates that endoscopic retrograde brush cytology alone may be sufficient in daily practice, at least in centers that have access to experienced cytopathologists. We recommend use of forceps biopsy in selected cases where brush cytology is negative.

Value of endobiliary brush cytology and biopsies for the diagnosis of malignant bile duct stenosis: results of a prospective study

BACKGROUND

Before considering a nonsurgical method of management of a bile duct stenosis, a tissue diagnosis is highly desirable. In a prospective study we have evaluated the feasibility and reliability of endobiliary brush cytology and biopsies performed at the time of endoscopic retrograde cholangiography.

METHODS

Two hundred thirty-three consecutive patients underwent an attempt at endobiliary brush cytology and biopsies of bile duct stenosis when no mass was detected on ultrasound and CT scan.

RESULTS

The material for cytology was sufficient for analysis in 210 cases (90%) and biopsies were obtained in 128 cases (55%). One hundred fifteen patients had both cytology and biopsies (49%). For the diagnosis of malignant stenosis, the sensitivity was 35% for cytology, 43% for biopsies, and 63% for the combination of cytology and biopsies. For both cytology and biopsies, the specificity was 97%. In the cases of cancer primarily involving the bile ducts, the sensitivity was 86% when combining both cytology and biopsies.

CONCLUSIONS

Endobiliary sampling is technically difficult and has a limited sensitivity for the diagnosis of malignant biliary stenosis. Biopsies should be combined with cytology to increase the sensitivity.