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Pitman MB, Centeno BA, Reid MD, Saeig M, Siddiqui MT, Layfield LJ, Perez-Machado M, Weynand B, Stelow EB, Lozano MD, Fukushima N, Cree IA, Mehrotra R, Schmitt FC, Field AS. A brief review of the WHO reporting system for pancreaticobiliary cytopathology. J Am Soc Cytopathol 2023; 12:243-250. [PMID: 37003924 DOI: 10.1016/j.jasc.2023.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 03/09/2023]
Abstract
The World Health Organization (WHO), the International Academy of Cytology, and the International Agency for Research on Cancer have developed an approach to standardized reporting of pancreaticobiliary cytopathology. The WHO Reporting System for Pancreaticobiliary Cytopathology (WHO System) revises the Papanicolaou Society of Cytopathology (PSC) System for Reporting Pancreaticobiliary Cytology published in 2015 and replaces the 6 PSC categories with 7 categories: "Insufficient/Inadequate/Nondiagnostic"; "Benign/Negative for malignancy"; "Atypical"; "Pancreaticobiliary neoplasm, low risk/grade (PaN-low)"; "Pancreatic neoplasm, high risk/grade (PaN-High)"; "Suspicious for malignancy"; and "Malignant". In the PSC system, there is a single category for "Neoplastic" lesions that includes 2 groups, 1 for benign neoplasms and 1 named "Neoplastic-other", dominated by premalignant intraductal neoplasms primarily intraductal papillary mucinous neoplasms and low-grade malignant neoplasms (pancreatic neuroendocrine tumors (PanNET) and solid pseudopapillary neoplasms (SPN). In the WHO System, benign neoplasms with virtually no risk of malignancy are included in the "Benign" category and low-grade malignancies (PanNET and SPN) are included in the "Malignant" category, as per the 5th edition of the WHO Classification of Digestive System Tumors, while the non-invasive pre-malignant lesions of the ducts are divided by the cytomorphological grade of the epithelium into PaN-low and PaN-high with distinctly different risks of malignancy. Within each category, key diagnostic cytopathologic features and the ancillary studies for diagnostic and prognostic evaluation, as well as the implications of diagnosis for patient care and management, are outlined. Reporting and diagnostic management options recognize the variations in the availability of diagnostic and prognostic ancillary testing modalities in low- and middle-income countries.
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Affiliation(s)
- Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | | | - Michelle D Reid
- Department of Pathology, Emory University Hospital, Atlanta, Georgia
| | - Mauro Saeig
- Santa Casa Medical School, Sao Paulo, Brazil
| | - Momin T Siddiqui
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Lester J Layfield
- Pathology and Anatomic Science Department, University of Missouri, Columbia, Missouri
| | - Miguel Perez-Machado
- Department of Cellular Pathology, Royal Free Hampstead NHS Trust, London, England
| | - Birgit Weynand
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Edward B Stelow
- Department of Pathology, University of Virginia Hospital, Charlottesville, Virginia
| | - Maria D Lozano
- Department of Pathology, Clinical University of Navarra, Pamplona, Spain
| | - Noriyoshi Fukushima
- Department of Diagnostic Pathology, Jichi Medical University Hospital, Shimotsuke, Japan
| | - Ian A Cree
- International Agency for Research on Cancer (IARC), World Health Organization, Lyon, France
| | - Ravi Mehrotra
- Indian Cancer Genomic Atlas, Centre for Health, Innovation and Policy Foundation, Noida, India
| | - Fernando C Schmitt
- Department of Pathology, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Andrew S Field
- Department of Anatomical Pathology, St Vincent's Hospital, Sydney, and University of New South Wales Sydney and University of Notre Dame, Sydney, Australia
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2
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Selvaggi SM. Diagnostic pitfalls and the value of fluorescence in situ hybridization as an adjunct to cytologic evaluation of bile duct brushings in patients with primary sclerosing cholangitis. Diagn Cytopathol 2023; 51:117-122. [PMID: 36181472 PMCID: PMC10092285 DOI: 10.1002/dc.25059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/08/2022] [Accepted: 09/13/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) can present diagnostic difficulties on bile duct brushings as cytologic features mimicking adenocarcinoma may exist. This study evaluates the role of fluorescence in-situ hybridization (FISH) as an adjunct to cytologic evaluation. METHODS From January 1, 2020, through December 31, 2021, 308 bile duct brushings were processed of which 34 (11%) were malignant, 25 (8%) were suspicious, 36 (12%) were atypical, 204 (66%) were negative and 10 (3%) were nondiagnostic. Follow-up biopsies/resections were performed in the 95 cases with diagnostic cytology (atypical/suspicious/malignant) of which 12 (13%) showed primary sclerosing cholangitis and form the basis of this study. Cytologic, histologic and FISH findings are presented and discussed. RESULTS Of the 12 bile duct brushings 4 (34%) were positive/suspicious for adenocarcinoma and 8 (66%) showed atypical epithelial cells. FISH was positive in 2/4 positive/suspicious brushings and negative in the remaining 2 brushings. Histologic findings confirmed the FISH results. The cytologic features of the 2 false positive cases overlapped those of adenocarcinoma. Two of the 8 bile duct brushings with atypical epithelial cells were positive/suspicious for adenocarcinoma on FISH analysis; findings confirmed on histologic follow-up. The remaining 8 patients underwent surveillance for the development of adenocarcinoma with repeat bile duct brushings, FISH analysis and biopsies, each of which has been negative to date. CONCLUSION FISH, as an adjunct to the cytologic evaluation of bile duct brushings from patients with PSC, plays a role in improving diagnostic accuracy and serves as a surveillance tool for the potential development of adenocarcinoma.
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Affiliation(s)
- Suzanne M Selvaggi
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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3
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Giovannini D, Bailly A, Seigneurin A, Fior-Gozlan M, Eyraud PY, Roth G, Laverrière MH, McLeer A, Sturm N. Biliary cytology: A diagnostic tree for adenocarcinoma based on a cohort of 135 patients with endoscopic retrograde cholangiopancreatography for stenosis of the extrahepatic bile duct. Cancer Cytopathol 2022; 130:433-442. [PMID: 35254731 DOI: 10.1002/cncy.22565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/13/2022] [Accepted: 02/04/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The diagnosis of well-differentiated adenocarcinoma on bile aspiration is a well-known challenge. This study was aimed at improving the diagnostic performance and providing a biliary cytology learning atlas. METHODS This single-center, retrospective study included 135 cases of informative biliary samples collected between 2009 and 2018 that were classified as benign, atypical, or malignant. A double assessment was performed by a novice and a cytopathologist experienced in biliary cytology to establish the specificities, sensitivities, and inter- and intraobserver κ index agreements of 24 cytological criteria, which were illustrated in a learning atlas. RESULTS A multivariate logistic regression was used to assess whether the most specific and reproducible criteria were associated with malignancy. A scoring system was statistically determined: 6 points were attributed in the presence of a 3-dimensional (3D) cluster, anisonucleosis, and a nuclear to cytoplasmic (N:C) ratio > 0.5, whereas 4 points were given in the presence of an enhanced nuclear membrane. A score higher than 10 points resulted in a malignancy diagnosis with 96% sensitivity and 97% specificity. CONCLUSIONS A diagnostic tree of malignancy based on 4 criteria, together with a multidisciplinary approach, allows the diagnosis of adenocarcinoma with a specificity of 100% and a sensitivity of 88% or 72% depending on the presence of a single malignant cell or the presence of 3 combined criteria (a 3D cluster, anisonucleosis, and an N:C ratio > 0.5). It comes with a learning atlas useful for cytopathologist training and accuracy in this uncommon cytology.
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Affiliation(s)
- Diane Giovannini
- Pathology and Cytology Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Adeline Bailly
- Pathology and Cytology Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Arnaud Seigneurin
- Medical Evaluation and Epidemiology Unit, Taillefer Pavilion, Grenoble Alpes University Hospital, Grenoble, France.,TIMC Laboratory, Grenoble Alpes University, Grenoble, France.,Grenoble Alpes University Hospital, Grenoble, France
| | - Michèle Fior-Gozlan
- Pathology and Cytology Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Pierre-Yves Eyraud
- Hepato-Gastroenterology Department, Grenoble-Alpes University Hospital, Grenoble, France
| | - Gael Roth
- Grenoble Alpes University Hospital, Grenoble, France.,Hepato-Gastroenterology Department, Grenoble-Alpes University Hospital, Grenoble, France
| | | | - Anne McLeer
- Pathology and Cytology Department, Grenoble Alpes University Hospital, Grenoble, France.,Grenoble Alpes University Hospital, Grenoble, France.,UGA/INSERM U1209/CNRS 5309, Institute for Advanced Biosciences, La Tronche, France
| | - Nathalie Sturm
- Pathology and Cytology Department, Grenoble Alpes University Hospital, Grenoble, France.,Grenoble Alpes University Hospital, Grenoble, France.,TIMC-IMAG, Grenoble Alpes University, CNRS UMR 5525, La Tronche, France
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4
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Alali A, Moris M, Martel M, Streutker C, Cirocco M, Mosko J, Kortan P, Barkun A, May GR. Predictors of Malignancy in Patients With Indeterminate Biliary Strictures and Atypical Biliary Cytology: Results From Retrospective Cohort Study. J Can Assoc Gastroenterol 2021; 4:222-228. [PMID: 34617004 PMCID: PMC8489527 DOI: 10.1093/jcag/gwaa043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 03/15/2021] [Indexed: 11/12/2022] Open
Abstract
Background Atypical cellular features are commonly encountered in patients with indeterminate biliary strictures, which are nondiagnostic of malignancy yet cannot rule it out. This study aims to identify clinical features that could discriminate patients with indeterminate biliary strictures and atypical biliary cytology who may harbor underlying malignancy. Methods All patients with an indeterminate biliary stricture and an atypical brush cytology obtained during endoscopic brushings were identified in a large tertiary-care center. Demographical information, clinical data and the final pathological diagnosis were collected. The study cohort was divided based on the final diagnosis into benign and malignant groups. Descriptive and multivariable analyses were performed. Results A total of 151 patients were included in the analysis. Of these, 62.9% were males with mean age of 61.7 ± 16.4 years. Overall, there was an almost equal distribution of patients in the benign and malignant groups. Older age (≥65 years), jaundice, weight loss, intrahepatic biliary and pancreatic duct dilation, double-duct sign and presence of a mass were associated with malignancy in the univariate analysis. However, only older age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.00 to 1.03), jaundice (OR 3.33, 95% CI 1.11 to 9.98) and presence of a mass (OR 12.10, 95% CI 4.94 to 29.67) were significantly associated with malignancy in the multivariate analysis. High CA19-9 was associated with malignancy only in patients with primary sclerosing cholangitis. Conclusion In patients with indeterminate biliary stricture and atypical brush cytology, older age, jaundice and presence of a mass are significant predictors of malignancy. Patients with such characteristics need prompt evaluation to rule out underlying malignancy.
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Affiliation(s)
- Ali Alali
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Haya Al-Habeeb Gastroenterology and Hepatology Center, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | - Maria Moris
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Digestive Disease Department, Marqués de Valdecilla University Hospital, Cantabria University, Santander, Spain
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Catherine Streutker
- Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maria Cirocco
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey Mosko
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul Kortan
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Gary R May
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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5
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Jang SI, Nahm JH, Kwon NH, Jeong S, Lee TH, Cho JH, Kwon CI, Kim DU, Kim JM, Cho HD, Lee HS, Kim S, Lee DK. Clinical utility of methionyl-tRNA synthetase 1 immunostaining in cytologic brushings of indeterminate biliary strictures: a multicenter prospective study. Gastrointest Endosc 2021; 94:733-741.e4. [PMID: 33965384 DOI: 10.1016/j.gie.2021.04.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/27/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endobiliary brushings are routinely used in the diagnosis, treatment, and prognostication of biliary strictures. However, standard Papanicolaou (Pap) staining has a low sensitivity in this setting, and the accuracy of brush cytology has not been established for indeterminate strictures. We therefore evaluated the diagnostic merit of methionyl-transfer RNA synthetase 1 (MARS1) immunofluorescence (IF) staining in such cytologic specimens. METHODS During ERCP, endobiliary brushings were obtained from patients with extrahepatic biliary strictures prospectively enrolled at 6 tertiary hospitals. Using liquid-based cytologic preparations of these samples, we performed Pap and MARS1 IF staining. RESULTS In total, 240 patients were eligible; of these, we compared the Pap and MARS1 IF staining results of 218 (malignant, 157; benign, 61). By conventional Pap staining, the diagnoses were distributed as follows: malignant, 55; suspicious of malignancy, 60; atypical, 45; negative for malignancy, 58. MARS1 IF staining was strongly positive in malignant biliary stricture but not so in specimens negative for malignancy. The diagnostic parameters (sensitivity, specificity, positive predictive value, negative predictive value, and accuracy) of the MARS1 IF (93.6%, 96.7%, 98.7%, 85.5%, and 94.5%, respectively) and conventional Pap (73.2%, 100%, 100%, 59.2%, and 80.7%, respectively) staining methods differed significantly (P < .0001). CONCLUSIONS The high sensitivity and accuracy of MARS1 IF staining enabled the detection of malignancy in patients with biliary strictures. Further prospective studies are needed to validate our findings. (Clinical trial registration number: NCT03708445.).
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Ji Hae Nahm
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Nam Hoon Kwon
- Medicinal Bioconvergence Research Center, Institute for Artificial Intelligence and Biomedical Research, College of Pharmacy, Yonsei University, Incheon, Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University School of Medicine, Incheon, South Korea
| | - Tae Hoon Lee
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, South Korea
| | - Jae Hee Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Dong Uk Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University School of Medicine, Pusan, South Korea
| | - Joon Mee Kim
- Department of Pathology, Inha University School of Medicine, Incheon, South Korea
| | - Hyun Deuk Cho
- Department of Pathology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, South Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sunghoon Kim
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; Institute for Artificial Intelligence and Biomedical Research, College of Pharmacy & College of Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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6
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Ding SM, Lu AL, Xu BQ, Shi SH, Edoo MIA, Zheng SS, Li QY. Accuracy of brush cytology in biliopancreatic strictures: a single-center cohort study. J Int Med Res 2021; 49:300060520987771. [PMID: 33557655 PMCID: PMC7876769 DOI: 10.1177/0300060520987771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Objective False positive and negative results are associated with biliary tract cell
brushing cytology during endoscopic retrograde cholangiopancreatography
(ERCP). The causes are uncertain. The purpose of this study was to evaluate
the accuracy of diagnoses made via cell brushing in our center, and to
explore the factors influencing diagnosis. Methods The clinical data of patients who underwent cell brushing at our center from
January 2016 to August 2019 were retrospectively analyzed. These included
age, gender, stricture location, thickness of the bile duct wall in the
narrow segment, maximum diameter of the biliary duct above the stricture,
number of cell brush smears, carbohydrate antigen 19-9, and carcinoembryonic
antigen. Positive brush cytology results were compared with results of
surgical histology or tumor biopsy as well as with the patient’s clinical
course. Results Of the 48 patients who underwent cell brushing cytology, 27 (56.3%) had
positive results. The sensitivity and specificity of biliary duct cell
brushing was 79.4%, and 85.7%, respectively. None of the above-mentioned
factors were associated with positive cytology brushing results. Conclusions Cell brushing cytology remains a reliable method for diagnosis of
pancreaticobiliary malignancies.
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Affiliation(s)
- Song-Ming Ding
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, P.R. China
| | - Ai-Li Lu
- Division of Oncology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Bing-Qian Xu
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, P.R. China
| | - Shao-Hua Shi
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, P.R. China
| | - Muhammad Ibrahim Alhadi Edoo
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health; Key Laboratory of Organ Transplantation, Zhejiang Province; Hangzhou, Zhejiang, P.R. China.,Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Shu-Sen Zheng
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, P.R. China.,Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health; Key Laboratory of Organ Transplantation, Zhejiang Province; Hangzhou, Zhejiang, P.R. China.,Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Qi-Yong Li
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, P.R. China
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7
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Kamp EJCA, Dinjens WNM, Doukas M, Bruno MJ, de Jonge PJF, Peppelenbosch MP, de Vries AC. Optimal tissue sampling during ERCP and emerging molecular techniques for the differentiation of benign and malignant biliary strictures. Therap Adv Gastroenterol 2021; 14:17562848211002023. [PMID: 33948111 PMCID: PMC8053835 DOI: 10.1177/17562848211002023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/15/2021] [Indexed: 02/04/2023] Open
Abstract
Patients with cholangiocarcinoma have poor survival since the majority of patients are diagnosed at a stage precluding surgical resection, due to locally irresectable tumors and/or metastases. Optimization of diagnostic strategies, with a principal role for tissue diagnosis, is essential to detect cancers at an earlier stage amenable to curative treatment. Current barriers for a tissue diagnosis include both insufficient tissue sampling and a difficult cyto- or histopathological assessment. During endoscopic retrograde cholangiopancreatography, optimal brush sampling includes obtaining more than one brush within an individual patient to increase its diagnostic value. Currently, no significant increase of the diagnostic accuracy for the new cytology brush devices aiming to enhance the cellularity of brushings versus standard biliary brush devices has been demonstrated. Peroral cholangioscopy with bile duct biopsies appears to be a valuable tool in the diagnostic work-up of indeterminate biliary strictures, and may overcome current technical difficulties of fluoroscopic-guided biopsies. Over the past years, molecular techniques to detect chromosomal instability, mutations and methylation profiling of tumors have revolutionized, and implementation of these techniques on biliary tissue during diagnostic work-up of biliary strictures may be awaited in the near future. Fluorescence in situ hybridization has already been implemented in routine diagnostic evaluation of biliary strictures in several centers. Next-generation sequencing is promising for standard diagnostic care in biliary strictures, and recent studies have shown adequate detection of prevalent genomic alterations in KRAS, TP53, CDKN2A, SMAD4, PIK3CA, and GNAS on biliary brush material. Detection of DNA methylation of tumor suppressor genes and microRNAs may evolve over the coming years to a valuable diagnostic tool for cholangiocarcinoma. This review summarizes optimal strategies for biliary tissue sampling during endoscopic retrograde cholangiopancreatography and focuses on the evolving molecular techniques on biliary tissue to improve the differentiation of benign and malignant biliary strictures.
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Affiliation(s)
- Eline J. C. A. Kamp
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Winand N. M. Dinjens
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Michail Doukas
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Pieter Jan F. de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Maikel P. Peppelenbosch
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Annemarie C. de Vries
- Department of Gastroenterology & Hepatology, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, Room Na-609, Rotterdam, 3015 GD, The Netherlands
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8
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Montano-Loza AJ, Allegretti JR, Cheung A, Ebadi M, Jones D, Kerkar N, Levy C, Rizvi S, Vierling JM, Alvarez F, Bai W, Gilmour S, Gulamhusein A, Guttman O, Hansen BE, MacParland S, Mason A, Onofrio F, Santamaria P, Stueck A, Swain M, Vincent C, Ricciuto A, Hirschfield G. Single Topic Conference on Autoimmune Liver Disease from the Canadian Association for the Study of the Liver. CANADIAN LIVER JOURNAL 2021; 4:401-425. [PMID: 35989897 PMCID: PMC9235119 DOI: 10.3138/canlivj-2021-0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/09/2021] [Indexed: 11/20/2022]
Abstract
Autoimmune liver disease (AILD) spans a spectrum of chronic disorders affecting the liver parenchyma and biliary system. Three main categories of AILD are autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC), and primary sclerosing cholangitis (PSC). This review condenses the presentation and discussions of the Single Topic Conference (STC) on AILD that was held in Ottawa, Ontario, in November 2019. We cover generalities regarding disease presentation and clinical diagnosis; mechanistic themes; treatment paradigms; clinical trials, including approaches and challenges to new therapies; and looking beyond traditional disease boundaries. Although these diseases are considered autoimmune, the etiology and role of environmental triggers are poorly understood. AILDs are progressive and chronic conditions that affect survival and quality of life. Advances have been made in PBC treatment because second-line treatments are now available (obeticholic acid, bezafibrate); however, a significant proportion still present suboptimal response. AIH treatment has remained unchanged for several decades, and data suggest that fewer than 50% of patients achieve a complete response and as many as 80% develop treatment-related side effects. B-cell depletion therapy to treat AIH is in an early stage of development and has shown promising results. An effective treatment for PSC is urgently needed. Liver transplant remains the best option for patients who develop decompensated cirrhosis or hepatocellular carcinoma within specific criteria, but recurrent AILD might occur. Continued efforts are warranted to develop networks for AILD aimed at assessing geo-epidemiological, clinical, and biochemical differences to capture the new treatment era in Canada.
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Affiliation(s)
- Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Jessica R Allegretti
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Angela Cheung
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Maryam Ebadi
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - David Jones
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Nanda Kerkar
- Division of Gastroenterology, Hepatology and Nutrition, Golisano Children's Hospital at Strong, University of Rochester Medical Center, New York, USA
| | - Cynthia Levy
- Schiff Center for Liver Diseases, University of Miami, Miami, Florida, USA
| | - Sumera Rizvi
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | | | - Fernando Alvarez
- Department of Pediatrics, Hôpital Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Wayne Bai
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Susan Gilmour
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Aliya Gulamhusein
- Ajmera Family Transplant Centre, Toronto General Research Institute, Departments of Laboratory Medicine and Pathobiology and Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Orlee Guttman
- Division of Gastroenterology, Hepatology and Nutrition, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Bettina E Hansen
- Ajmera Family Transplant Centre, Toronto General Research Institute, Departments of Laboratory Medicine and Pathobiology and Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Sonya MacParland
- Ajmera Family Transplant Centre, Toronto General Research Institute, Departments of Laboratory Medicine and Pathobiology and Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Mason
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Fernanda Onofrio
- Ajmera Family Transplant Centre, Toronto General Research Institute, Departments of Laboratory Medicine and Pathobiology and Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Pere Santamaria
- Department of Microbiology, Immunology & Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Ashley Stueck
- Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Mark Swain
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Catherine Vincent
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Amanda Ricciuto
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gideon Hirschfield
- Toronto Centre for Liver Disease, University Health Network & Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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9
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Wakai T, Sakata J, Katada T, Hirose Y, Soma D, Prasoon P, Miura K, Kobayashi T. Surgical management of carcinoma in situ at ductal resection margins in patients with extrahepatic cholangiocarcinoma. Ann Gastroenterol Surg 2018; 2:359-366. [PMID: 30238077 PMCID: PMC6139714 DOI: 10.1002/ags3.12196] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 06/12/2018] [Accepted: 06/24/2018] [Indexed: 12/13/2022] Open
Abstract
Recent advances in dimensional imaging, surgical technique, and perioperative patient care have resulted in increased rates of complete resection with histopathologically negative margins and improved surgical outcomes in patients with extrahepatic cholangiocarcinoma. However, achieving cancer-free resection margins at ductal stumps in surgery for this disease remains challenging because of longitudinal extension, which is one of the hallmarks of extrahepatic cholangiocarcinoma. When the ductal resection margins are shown to be positive on examination of frozen sections, discrimination between carcinoma in situ and invasive carcinoma is clinically important because residual carcinoma in situ may lead to late local recurrence whereas residual invasive carcinoma is associated with early local recurrence. Residual invasive carcinoma at the ductal margins should be avoided whenever technically feasible. Residual "carcinoma in situ" at the ductal margins appears to be allowed in resection for the advanced disease because it has less effect on survival than other adverse prognostic factors (pN1 and/ or pM1). However, in surgery for early-stage (pTis-2N0M0) extrahepatic cholangiocarcinoma, residual carcinoma in situ at the ductal margins may have an adverse effect on long-term survival, so should be avoided whenever possible. In this review, we focus on the histopathological term "carcinoma in situ," the biological behavior of residual carcinoma in situ at ductal resection margins, intraoperative histological examination of the ductal resection margins, outcome of additional resection for positive ductal margins, and adjuvant therapy for patients with positive margins.
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Affiliation(s)
- Toshifumi Wakai
- Division of Digestive and General SurgeryNiigata University Graduate School of Medical and Dental SciencesNiigataJapan
| | - Jun Sakata
- Division of Digestive and General SurgeryNiigata University Graduate School of Medical and Dental SciencesNiigataJapan
| | - Tomohiro Katada
- Division of Digestive and General SurgeryNiigata University Graduate School of Medical and Dental SciencesNiigataJapan
| | - Yuki Hirose
- Division of Digestive and General SurgeryNiigata University Graduate School of Medical and Dental SciencesNiigataJapan
| | - Daiki Soma
- Division of Digestive and General SurgeryNiigata University Graduate School of Medical and Dental SciencesNiigataJapan
| | - Pankaj Prasoon
- Division of Digestive and General SurgeryNiigata University Graduate School of Medical and Dental SciencesNiigataJapan
| | - Kohei Miura
- Division of Digestive and General SurgeryNiigata University Graduate School of Medical and Dental SciencesNiigataJapan
| | - Takashi Kobayashi
- Division of Digestive and General SurgeryNiigata University Graduate School of Medical and Dental SciencesNiigataJapan
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10
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Goyal A, Sharaiha RZ, Alperstein SA, Siddiqui MT. Cytologic diagnosis of adenocarcinoma on bile duct brushings in the presence of stent associated changes: A retrospective analysis. Diagn Cytopathol 2018; 46:826-832. [DOI: 10.1002/dc.24052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/22/2018] [Accepted: 07/17/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Abha Goyal
- Department of Pathology and Laboratory Medicine; Weill Cornell Medicine - New York Presbyterian Hospital; New York New York
| | - Reem Z. Sharaiha
- Department of Pathology and Laboratory Medicine; Weill Cornell Medicine - New York Presbyterian Hospital; New York New York
| | - Susan A. Alperstein
- Department of Pathology and Laboratory Medicine; Weill Cornell Medicine - New York Presbyterian Hospital; New York New York
| | - Momin T. Siddiqui
- Department of Pathology and Laboratory Medicine; Weill Cornell Medicine - New York Presbyterian Hospital; New York New York
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11
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Ali AH, Tabibian JH, Nasser-Ghodsi N, Lennon RJ, DeLeon T, Borad MJ, Hilscher M, Silveira MG, Carey EJ, Lindor KD. Surveillance for hepatobiliary cancers in patients with primary sclerosing cholangitis. Hepatology 2018; 67:2338-2351. [PMID: 29244227 DOI: 10.1002/hep.29730] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/25/2017] [Accepted: 12/08/2017] [Indexed: 12/19/2022]
Abstract
UNLABELLED Primary sclerosing cholangitis (PSC) is a risk factor for cholangiocarcinoma (CCA) and gallbladder carcinoma (GBCa). Surveillance for GBCa is recommended, but the clinical utility of surveillance for other hepatobiliary cancers (HBCa) in PSC, namely CCA and hepatocellular carcinoma (HCC), remains unclear. We aimed to determine whether surveillance is associated with better survival after diagnosis of HBCa in patients with PSC. Medical records of PSC patients seen at the Mayo Clinic Rochester from 1995 to 2015 were reviewed. Patients were included if they had ≥1 year of follow-up and developed HBCa. Patients were categorized according to their surveillance status (abdominal imaging, carbohydrate antigen 19-9, and alpha-fetoprotein). The primary endpoints were HBCa recurrence, HBCa-related death, and all-cause mortality. Overall survival was assessed by the Kaplan-Meier survival method; HBCa-related survival was assessed using competing risk regression. Tests of significance were two-tailed, and a P value <0.05 was considered statistically significant. From 1995 to 2015, a total of 79 of 830 PSC patients were diagnosed with HBCa. Cumulative follow-up was 712 and 283 person-years pre- and post-HBCa diagnosis, respectively. Seventy-eight percent of patients (54/79) developed CCA, 21% (17/79) HCC, 6% (5/79) GBCa, 3% (2/79) both CCA and HCC, and 1% (1/79) both HCC and GBCa. Fifty-one percent (40/79) were under HBCa surveillance, and 49% (39/79) were not. Patients in the surveillance group had significantly higher 5-year overall survival (68% versus 20%, respectively; P < 0.001) and significantly lower 5-year probability of experiencing an HBCa-related adverse event (32% versus 75%, respectively; P < 0.001) compared with the no-surveillance group. CONCLUSION This study demonstrates that HBCa surveillance significantly improves outcomes, including survival, in patients with PSC. (Hepatology 2018;67:2338-2351).
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Affiliation(s)
- Ahmad Hassan Ali
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ.,Texas Tech University Health Sciences Center, Amarillo, TX
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Ryan J Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | | | - Moira Hilscher
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Marina G Silveira
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT
| | - Elizabeth J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ.,Arizona State University, Phoenix, AZ
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12
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Role of endoscopy in primary sclerosing cholangitis: European Society of Gastrointestinal Endoscopy (ESGE) and European Association for the Study of the Liver (EASL) Clinical Guideline. J Hepatol 2017; 66:1265-1281. [PMID: 28427764 DOI: 10.1016/j.jhep.2017.02.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 02/14/2017] [Indexed: 02/06/2023]
Abstract
This guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE) and of the European Association for the Study of the Liver (EASL) on the role of endoscopy in primary sclerosing cholangitis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations.
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13
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Cost utility of ERCP-based modalities for the diagnosis of cholangiocarcinoma in primary sclerosing cholangitis. Gastrointest Endosc 2017; 85:773-781.e10. [PMID: 27590963 DOI: 10.1016/j.gie.2016.08.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 08/17/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Cholangiocarcinoma (CCA) is a leading cause of morbidity and mortality in patients with primary sclerosing cholangitis (PSC). Although several ERCP-based diagnostic modalities are available for diagnosing CCA, it is unclear whether one modality is more cost-effective than the others. The primary aim of this study was to compare the cost-effectiveness of ERCP-based techniques for diagnosing CCA in patients with PSC-induced biliary strictures. METHODS We performed a cost utility analysis to assess the net monetary benefit for accurately diagnosing CCA using 5 different diagnostic strategies: (1) ERCP with bile duct brushing for cytology, (2) ERCP with brushings for cytology and fluorescence in situ hybridization (FISH)-trisomy, (3) ERCP with brushings for cytology and FISH-polysomy, (4) ERCP with intraductal biopsy sampling, and (5) single-operator cholangioscopy (SOC) with targeted biopsy sampling. A Monte Carlo simulation assessed outcomes including quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio (ICER). Sensitivity analyses were also performed. RESULTS SOC with targeted biopsy sampling, as compared with ERCP with brushing for FISH-polysomy, produced an incremental QALY gain of .22 at an additional cost of $8562.44, resulting in a base case ICER of $39,277.25. Deterministic and probabilistic sensitivity analyses demonstrated that diagnosis with SOC was cost-effective at conventional willingness-to-pay thresholds of $50,000 and $100,000. SOC was the most cost-effective diagnostic strategy. CONCLUSIONS SOC with biopsy sampling is the most cost-effective diagnostic modality for CCA in PSC strictures.
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14
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Layfield LJ, Esebua M, Frazier SR, Hammer RD, Bivin WW, Nguyen V, Ersoy I, Schmidt RL. Accuracy and Reproducibility of Nuclear/Cytoplasmic Ratio Assessments in Urinary Cytology Specimens. Diagn Cytopathol 2017; 45:107-112. [DOI: 10.1002/dc.23639] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 09/21/2016] [Accepted: 11/02/2016] [Indexed: 01/16/2023]
Affiliation(s)
- Lester J. Layfield
- Department of Pathology and Anatomical Sciences; University of Missouri; Columbia Missouri
| | - Magda Esebua
- Department of Pathology and Anatomical Sciences; University of Missouri; Columbia Missouri
| | - Shellaine R. Frazier
- Department of Pathology and Anatomical Sciences; University of Missouri; Columbia Missouri
| | - Richard D. Hammer
- Department of Pathology and Anatomical Sciences; University of Missouri; Columbia Missouri
| | - William W. Bivin
- Department of Pathology and Anatomical Sciences; University of Missouri; Columbia Missouri
| | - Van Nguyen
- Department of Pathology and Anatomical Sciences; University of Missouri; Columbia Missouri
| | - Ilker Ersoy
- Department of Pathology and Anatomical Sciences; University of Missouri; Columbia Missouri
| | - Robert L. Schmidt
- Department of Pathology and Laboratory Medicine/ARUP Laboratories; Salt Lake City Utah
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15
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Kuzu UB, Ödemiş B, Suna N, Yıldız H, Parlak E, Dişibeyaz S, Torun S, Akpınar MY, Coşkun O, Turhan N, Yüksel M, Kayaçetin E. The Detection of Cholangiocarcinoma in Primary Sclerosing Cholangitis Patients: Single Center Experience. J Gastrointest Cancer 2016; 47:8-14. [PMID: 26537791 DOI: 10.1007/s12029-015-9777-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease. Cholangiocarcinoma (CCA) is one of the feared complications of PSC. In our study, we aim to establish the success of brush cytology and CA 19-9 in putting the diagnosis of CCA. METHODS The data of 30 PSC patients was retrospectively screened whom had brush cytology performed due to dominant strictures. The definitive diagnosis was established by histopathological examination or via radiological/clinic follow-up for at least 12 months. RESULTS A total of four patients were excluded from the study. Twenty-six patients diagnosed with PSC, six of which were also diagnosed with CCA, were included in the study. The sensitivity and the specificity of the brush cytology in the diagnosis of CCA in PSC patients were 66.7 and 95%, respectively. CA 19-9 had high correlation with bilirubin level. The optimal level of CA 19-9 in the diagnosis of CCA was determined to be 138.5 U/ml. Superiority of Ramage scoring over CA 19-9 in the diagnosis of CCA in PSC patients was not established (sensitivity and specificity were 50%, 94.7% and 83.3%, 85%, respectively). CONCLUSION Brush cytology has moderate sensitivity in differentiating strictures in PSC patients. CA 19-9 has high sensitivity but bilirubin level can affect the CA 19-9. Therefore, advanced techniques and parameters are needed for detecting CCA in PSC patients.
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Affiliation(s)
- Ufuk Barış Kuzu
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Education and Research Hospital, Sıhhiye, Ankara, Turkey.
| | - Bülent Ödemiş
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Education and Research Hospital, Sıhhiye, Ankara, Turkey
| | - Nuretdin Suna
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Education and Research Hospital, Sıhhiye, Ankara, Turkey
| | - Hakan Yıldız
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Education and Research Hospital, Sıhhiye, Ankara, Turkey
| | - Erkan Parlak
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Education and Research Hospital, Sıhhiye, Ankara, Turkey
| | - Selçuk Dişibeyaz
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Education and Research Hospital, Sıhhiye, Ankara, Turkey
| | - Serkan Torun
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Education and Research Hospital, Sıhhiye, Ankara, Turkey
| | - Muhammet Yener Akpınar
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Education and Research Hospital, Sıhhiye, Ankara, Turkey
| | - Orhan Coşkun
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Education and Research Hospital, Sıhhiye, Ankara, Turkey
| | - Nesrin Turhan
- Department of Pathology, Turkiye Yuksek Ihtisas Education and Research Hospital, Sıhhiye, Ankara, Turkey
| | - Mahmut Yüksel
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Education and Research Hospital, Sıhhiye, Ankara, Turkey
| | - Ertuğrul Kayaçetin
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Education and Research Hospital, Sıhhiye, Ankara, Turkey
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16
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Wirth TC, Vogel A. Surveillance in cholangiocellular carcinoma. Best Pract Res Clin Gastroenterol 2016; 30:987-999. [PMID: 27938792 DOI: 10.1016/j.bpg.2016.11.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 10/28/2016] [Accepted: 11/04/2016] [Indexed: 01/31/2023]
Abstract
Cholangiocellular carcinoma is the most frequent malignant neoplasm originating from the epithelium of intra- or extrahepatic bile ducts. In the past decades, the incidence of cholangiocarcinoma has been shown to increase while overall mortality has remained high with an approximate 5-year overall survival below 20%. Surgery remains the only curative option while systemic treatment is limited to palliative chemotherapy. Therefore, surveillance strategies for patients at risk of developing cholangiocarcinoma are urgently needed, particularly in patients with primary sclerosing cholangitis and patients infected with liver flukes. Here we summarize the currently available data on surveillance of risk populations and methods for the detection of cholangiocarcinoma.
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Affiliation(s)
- Thomas C Wirth
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School Hannover, 30625 Hannover, Germany
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School Hannover, 30625 Hannover, Germany.
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17
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Njei B, McCarty TR, Varadarajulu S, Navaneethan U. Systematic review with meta-analysis: endoscopic retrograde cholangiopancreatography-based modalities for the diagnosis of cholangiocarcinoma in primary sclerosing cholangitis. Aliment Pharmacol Ther 2016; 44:1139-1151. [PMID: 27696456 DOI: 10.1111/apt.13817] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 05/18/2016] [Accepted: 09/13/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND The accuracy of current endoscopic modalities for diagnosing cholangiocarcinoma in primary sclerosing cholangitis (PSC) is suboptimal. AIM To evaluate the comparative effectiveness of endoscopic retrograde cholangiopancreatography (ERCP)-based modalities, independently or in combination, for the diagnosis of cholangiocarcinoma in patients with PSC-induced biliary strictures. METHODS Searches of PubMed, EMBASE, Web of Science and the Cochrane Library databases were performed through December 2015. Measured outcomes included sensitivity and specificity of all diagnostic modalities independently or in combination. A bivariate model was used to compute the pooled sensitivity and specificity, and to plot the summary receiver operating characteristics curve with summary point and corresponding 95% confidence interval (95% CI). A logistic regression model was used to impute the incremental performance of combining two diagnostic tests. RESULTS Twenty-one studies met inclusion criteria: 13 on bile duct brushing for cytology, 7 on fluorescence in situ hybridisation (FISH), 2 on probe-based confocal laser endomicroscopy, and 4 on single-operator cholangioscopy with targeted biopsies. Single-operator cholangioscopy with targeted biopsies was the most accurate diagnostic modality at 96% (95% CI, 94-97%). The pooled sensitivity and specificity of single-operator cholangioscopy for diagnosis of cholangiocarcinoma in patients with PSC was 65% (95% CI, 35-87%) and 97% (95% CI, 87-99%), respectively. The pooled diagnostic odds ratio to detect cholangiocarcinoma was 59 (95% CI, 10-341). CONCLUSIONS Single-operator cholangioscopy with targeted biopsies appears to be the most accurate ERCP-based modality for diagnosing cholangiocarcinoma in primary sclerosing cholangitis. However, future large, well-designed comparative diagnostic studies are warranted to validate these findings.
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Affiliation(s)
- B Njei
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA.,Investigative Medicine Program, Yale Center of Clinical Investigation, New Haven, CT, USA
| | - T R McCarty
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - S Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, FL, USA
| | - U Navaneethan
- Center for Interventional Endoscopy, Florida Hospital, Orlando, FL, USA
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18
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Ilyas SI, Eaton JE, Gores GJ. Primary Sclerosing Cholangitis as a Premalignant Biliary Tract Disease: Surveillance and Management. Clin Gastroenterol Hepatol 2015; 13:2152-65. [PMID: 26051390 PMCID: PMC4618039 DOI: 10.1016/j.cgh.2015.05.035] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 05/20/2015] [Accepted: 05/22/2015] [Indexed: 02/07/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a premalignant biliary tract disease that confers a significant risk for the development of cholangiocarcinoma (CCA). The chronic biliary tract inflammation of PSC promotes pro-oncogenic processes such as cellular proliferation, induction of DNA damage, alterations of the extracellular matrix, and cholestasis. The diagnosis of malignancy in PSC can be challenging because inflammation-related changes in PSC may produce dominant biliary tract strictures mimicking CCA. Biomarkers such as detection of methylated genes in biliary specimens represent noninvasive techniques that may discriminate malignant biliary ductal changes from PSC strictures. However, conventional cytology and advanced cytologic techniques such as fluorescence in situ hybridization for polysomy remain the practice standard for diagnosing CCA in PSC. Curative treatment options of malignancy arising in PSC are limited. For a subset of patients selected by using stringent criteria, liver transplantation after neoadjuvant chemoradiation is a potential curative therapy. However, most patients have advanced malignancy at the time of diagnosis. Advances directed at identifying high-risk patients, early cancer detection, and development of chemopreventive strategies will be essential to better manage the cancer risk in this premalignant disease. A better understanding of dysplasia definition and especially its natural history is also needed in this disease. Herein, we review recent developments in our understanding of the risk factors, pathogenic mechanisms of PSC associated with CCA, as well as advances in early detection and therapies.
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Affiliation(s)
- Sumera I Ilyas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - John E Eaton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Gregory J Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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19
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Trilianos P, Selaru F, Li Z, Gurakar A. Trends in pre-liver transplant screening for cholangiocarcinoma among patients with primary sclerosing cholangitis. Digestion 2014; 89:165-73. [PMID: 24577150 DOI: 10.1159/000357445] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 11/12/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Cholangiocarcinoma (CCA) is the most common hepatobiliary malignancy complicating primary sclerosing cholangitis (PSC). Unfortunately, timely diagnosis of CCA in PSC patients remains challenging. AIM To investigate the strategies among liver centers regarding pre-transplant screening for CCA in patients with PSC. METHODS An online survey was returned from 46 US transplant centers, inquiring on the frequency of screening, the use of specific tests, or tactical approaches to high-grade dysplasia (HGD) or CCA. RESULTS Most centers screen their PSC patients for CCA prior to orthotopic liver transplantation (OLT) (89%). Serum carbohydrate antigen 19-9 and magnetic resonance cholangiopancreatography are first-line screening tools (93 and 84% respectively). Endoscopic retrograde cholangiopancreatography with biliary brushings is routinely performed in only 30% of the centers. In the case of HGD, 61% would choose close monitoring. In the event of non-resectable CCA, 37% have an OLT protocol, 33% resort to palliative treatment and the remaining 30% make an outside referral. Finally, half the participating centers perform CCA surveillance among their listed PSC patients every 6 months. CONCLUSION Screening for CCA among PSC patients prior to OLT varies greatly among centers. Serum carbohydrate antigen 19-9 and magnetic resonance cholangiopancreatography are widely used. HGD warrants surveillance rather than intervention among most experts. Protocolized chemoradiation followed by OLT has yet to become a widely accepted approach. The very poor survival of PSC patients who develop CCA underlines the importance of an effective and universally accepted screening process that will aid in its earlier detection.
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Affiliation(s)
- Panagiotis Trilianos
- Division of Gastroenterology and Hepatology, Transplant Hepatology Section, The Johns Hopkins School of Medicine, Baltimore, Md., USA
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20
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Trikudanathan G, Navaneethan U, Njei B, Vargo JJ, Parsi MA. Diagnostic yield of bile duct brushings for cholangiocarcinoma in primary sclerosing cholangitis: a systematic review and meta-analysis. Gastrointest Endosc 2014; 79:783-9. [PMID: 24140129 DOI: 10.1016/j.gie.2013.09.015] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 09/12/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND The most ominous adverse event of primary sclerosing cholangitis (PSC) is development of cholangiocarcinoma (CCA). There is a wide variation in the reported diagnostic yield of bile duct brush cytology in PSC strictures. OBJECTIVE To determine the diagnostic utility of biliary brush cytology for CCA detection in patients with PSC. DESIGN Meta-analysis. Systematic search of PubMed, EMBASE, Web of Science, and the Cochrane Library for relevant studies published up to December 2012. SETTING Meta-analysis of diagnostic parameters. PATIENTS A total of 747 patients in studies (both retrospective and prospective) in which histopathologic correlation of CCA was available. INTERVENTION Meta-analysis. Construction of 2 × 2 contingency data. MAIN OUTCOME MEASUREMENTS Sensitivity, specificity, likelihood ratio, and pooled diagnostic odds ratio. RESULTS The search yielded 54 studies of which 11, involving 747 patients, were included in our meta-analysis. The pooled sensitivity and specificity of bile duct brushings for a diagnosis of CCA in patients with PSC were 43% (95% confidence interval [CI], 35%-52%) and 97% (95% CI, 95%-98%), respectively. The pooled diagnostic odds ratio to detect CCA was 20.23 (95% CI, 8.75-46.79). The heterogeneity indices of χ(2) statistics, I(2) measure of inconsistency, and the Cochran Q test were 0.156, 14.4, and 30.5%, respectively. Visual inspection of the funnel plot showed low potential for publication bias. LIMITATIONS Inclusion of low-quality studies, study heterogeneity. CONCLUSION Our study suggests that bile duct brushing is a simple and highly specific technique for detection of CCA in patients with PSC. However, the modest sensitivity from bile duct brushing precludes its utility as a diagnostic tool for early detection of CCA in patients with PSC.
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Affiliation(s)
- Guru Trikudanathan
- Department of Gastroenterology, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Basile Njei
- Department of Internal Medicine, University of Connecticut Medical Center, Farmington, Connecticut, USA
| | - John J Vargo
- Digestive Disease Institute, The Cleveland Clinic, Cleveland, Ohio, USA
| | - Mansour A Parsi
- Digestive Disease Institute, The Cleveland Clinic, Cleveland, Ohio, USA
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21
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Serum levels of preoperative α-fetoprotein and CA19-9 predict survival of hepatic carcinoma patients after liver transplantation. Eur J Gastroenterol Hepatol 2014; 26:553-61. [PMID: 24589829 PMCID: PMC3979888 DOI: 10.1097/meg.0000000000000070] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this study was to assess serum levels of presurgical α-fetoprotein (AFP) and carbohydrate antigen 19-9 (CA19-9) as prognostic markers in patients with hepatic carcinoma after liver transplantation (LT). METHODS A total of 226 patients were recruited for the analysis of serum AFP and CA19-9 levels, on the basis of which the tumor marker type (TMT) was defined and evaluated for prognostic prediction. Overall survival (OS) and relapse-free survival (RFS) were analyzed using Kaplan-Meier curves, and univariate and multivariate Cox models. RESULTS One-year and 5-year OS were 79.0 and 58.0%, respectively, whereas RFS were 70.3 and 62.2%, respectively, in this cohort of patients. There were six variables predicting both OS and RFS, including TMT, tumor size, number of tumor lesions, extrahepatic or vascular invasion, and histopathological grade. Among these, TMT, tumor size, and extrahepatic invasion were all independent predictors of OS and RFS among these patients. Further, on the basis of TMT, novel LT selection criteria for patients with hepatic carcinoma, which supplemented the Milan criteria, were adopted, because the patients within the Milan criteria (n=107) and those exceeding Milan but fulfilling the proposed criteria (n=30) had similar 5-year OS (77.8 vs. 79.3%, P=0.862) and RFS (85.5 vs. 75.1%, P=0.210) rates. CONCLUSION The data from this study showed that serum levels of preoperative AFP and CA19-9 were able to predict survival of patients with hepatic carcinoma after LT. This study included novel criteria, adding serum AFP and CA19-9 levels to the selection criteria for LT eligibility of patients, in addition to the Milan criteria.
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22
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Brass V, Kuhlmann JB, Blum HE. Current state of nonsurgical therapies for cholangiocarcinoma. Hepat Oncol 2014; 1:135-142. [PMID: 30190947 DOI: 10.2217/hep.13.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cholangiocarcinomas (CCCs) are rare tumors that are derived from the epithelial cell lining of the bile ducts. They can be classified as intrahepatic, extrahepatic-perihilar and extrahepatic-distal tumors. The prognosis of CCCs is poor as, in many cases, they are diagnosed at advanced stages, at which point curative surgical resection is not possible. Furthermore, most patients will experience a tumor recurrence despite initial complete CCC resection. Therefore, alternative/additional therapeutic strategies are needed to improve tumor- and recurrence-free survival after surgery as well as tumor control in patients with advanced disease. In clinical practice, apart from systemic chemotherapies for the therapeutic management of CCCs, locoregional as well as multimodal strategies are available, including external and internal radiation therapies. This review focuses on the currently available nonsurgical therapies for patients with CCCs, alone or in combination with other modalities, and on evolving therapeutic concepts that are being explored in clinical studies.
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Affiliation(s)
- Volker Brass
- Department of Medicine II, University of Freiburg, Hugstetter Strasse 55, D-79106 Freiburg, Germany
| | - Jan B Kuhlmann
- Department of Medicine II, University of Freiburg, Hugstetter Strasse 55, D-79106 Freiburg, Germany
| | - Hubert E Blum
- Department of Medicine II, University of Freiburg, Hugstetter Strasse 55, D-79106 Freiburg, Germany
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Higuchi R, Takada T, Strasberg SM, Pitt HA, Gouma DJ, Garden OJ, Büchler MW, Windsor JA, Mayumi T, Yoshida M, Miura F, Kimura Y, Okamoto K, Gabata T, Hata J, Gomi H, Supe AN, Jagannath P, Singh H, Kim MH, Hilvano SC, Ker CG, Kim SW. TG13 miscellaneous etiology of cholangitis and cholecystitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 20:97-105. [PMID: 23307005 DOI: 10.1007/s00534-012-0565-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This paper describes typical diseases and morbidities classified in the category of miscellaneous etiology of cholangitis and cholecystitis. The paper also comments on the evidence presented in the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG 07) published in 2007 and the evidence reported subsequently, as well as miscellaneous etiology that has not so far been touched on. (1) Oriental cholangitis is the type of cholangitis that occurs following intrahepatic stones and is frequently referred to as an endemic disease in Southeast Asian regions. The characteristics and diagnosis of oriental cholangitis are also commented on. (2) TG 07 recommended percutaneous transhepatic biliary drainage in patients with cholestasis (many of the patients have obstructive jaundice or acute cholangitis and present clinical signs due to hilar biliary stenosis or obstruction). However, the usefulness of endoscopic naso-biliary drainage has increased along with the spread of endoscopic biliary drainage procedures. (3) As for biliary tract infections in patients who underwent biliary tract surgery, the incidence rate of cholangitis after reconstruction of the biliary tract and liver transplantation is presented. (4) As for primary sclerosing cholangitis, the frequency, age of predilection and the rate of combination of inflammatory enteropathy and biliary tract cancer are presented. (5) In the case of acalculous cholecystitis, the frequency of occurrence, causative factors and complications as well as the frequency of gangrenous cholecystitis, gallbladder perforation and diagnostic accuracy are included in the updated Tokyo Guidelines 2013 (TG13). Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.
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Affiliation(s)
- Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
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Barr Fritcher EG, Voss JS, Jenkins SM, Lingineni RK, Clayton AC, Roberts LR, Halling KC, Talwalkar JA, Gores GJ, Kipp BR. Primary sclerosing cholangitis with equivocal cytology: fluorescence in situ hybridization and serum CA 19-9 predict risk of malignancy. Cancer Cytopathol 2013; 121:708-17. [PMID: 23839915 DOI: 10.1002/cncy.21331] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 05/31/2013] [Accepted: 06/04/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients diagnosed with primary sclerosing cholangitis (PSC) and dominant strictures often undergo endoscopic retrograde cholangiopancreatography with brush cytology to exclude or confirm the development of malignancy. Equivocal (atypical or suspicious) routine cytologic results may confound patient management decisions, especially in the absence of a mass on imaging. The objective of the current study was to identify independent predictors of malignancy in patients with PSC with an equivocal cytology diagnosis. METHODS Patients with PSC underwent brush cytology for routine cytology and fluorescence in situ hybridization (FISH) during endoscopy as per standard care. FISH slides were classified as polysomy if at least 5 cells displayed a gain of ≥ 2 probes. A retrospective search identified 102 patients without a mass lesion noted on initial imaging studies, an equivocal routine cytology, and ≥ 2 years of follow-up. RESULTS Of 102 patients, 30 (29%) with an equivocal cytology result developed cancer within 2 years. Serum carbohydrate antigen 19-9 (CA 19-9) levels ≥ 129 U/mL (hazard ratio [HR] 3.19; P = .001) and polysomy (HR 8.70; P < .001) were each found to be predictive of cancer. Of 10 patients who had elevated CA 19-9 levels and polysomy, all went on to develop cancer (9 within 2 years). Although only 10 patients were included in this subset, the combination of elevated CA 19-9 and polysomy was found to be predictive of cancer (HR 10.92; P < .001). CONCLUSIONS Polysomy by FISH identified those patients most likely to have or develop malignancy in the challenging clinical scenario of PSC with no mass at baseline and equivocal cytology. The combination of an elevated serum CA 19-9 level with polysomy is highly suspicious for the presence of malignancy.
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Affiliation(s)
- Emily G Barr Fritcher
- Department of Laboratory Medicine and Pathology, Mayo Clinic and Foundation, Rochester, Minnesota
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25
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Kipp BR, Barr Fritcher EG, Pettengill JE, Halling KC, Clayton AC. Improving the accuracy of pancreatobiliary tract cytology with fluorescence in situ hybridization. Cancer Cytopathol 2013; 121:610-9. [DOI: 10.1002/cncy.21303] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 03/21/2013] [Accepted: 04/01/2013] [Indexed: 12/22/2022]
Affiliation(s)
- Benjamin R. Kipp
- Department of Laboratory Medicine and Pathology; Mayo Clinic College of Medicine; Rochester Minnesota
| | - Emily G. Barr Fritcher
- Department of Laboratory Medicine and Pathology; Mayo Clinic College of Medicine; Rochester Minnesota
| | - Jennifer E. Pettengill
- Department of Laboratory Medicine and Pathology; Mayo Clinic College of Medicine; Rochester Minnesota
| | - Kevin C. Halling
- Department of Laboratory Medicine and Pathology; Mayo Clinic College of Medicine; Rochester Minnesota
| | - Amy C. Clayton
- Department of Laboratory Medicine and Pathology; Mayo Clinic College of Medicine; Rochester Minnesota
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Abstract
Cholestasis develops either from a defect in bile synthesis, impairment in bile secretion, or obstruction to bile flow, and is characterized by an elevated serum alkaline phosphatase and gamma-glutamyltransferase disproportionate to elevation of aminotransferase enzymes. Key elements to the diagnostic workup include visualization of the biliary tree by cholangiography and evaluation of liver histology. The hope is that recent advances in understanding the genetic factors and immune mechanisms involved in the pathogenesis of cholestasis will lead to newer therapeutic interventions in the treatment of these diseases.
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Affiliation(s)
- Asma Siddique
- Department of Gastroenterology, Center for Liver Disease, Digestive Disease Institute, Seattle, WA 98111, USA
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Marsh RDW, Alonzo M, Bajaj S, Baker M, Elton E, Farrell TA, Gore RM, Hall C, Nowak J, Roy H, Shaikh A, Talamonti MS. Comprehensive review of the diagnosis and treatment of biliary tract cancer 2012. Part I: diagnosis-clinical staging and pathology. J Surg Oncol 2012; 106:332-8. [PMID: 22488652 DOI: 10.1002/jso.23028] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 12/08/2011] [Indexed: 12/20/2022]
Abstract
Biliary tract cancers (gallbladder cancer, intra- and extra-hepatic cholangiocarcinoma, and selected periampullary cancers) accounted for 12,760 new cases of cancer in the USA in 2010. These tumors have a dismal prognosis with most patients presenting with advanced disease. Early, accurate diagnosis is essential, both for potential cure where possible and for optimal palliative therapy in all others. This review examines the currently available and emerging technologies for diagnosis and treatment of this group of diseases.
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Affiliation(s)
- Robert de W Marsh
- Kellogg Cancer Center, NorthShore University Health System, Evanston, Illinois, USA.
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Nallamothu G, Hilden K, Adler DG. Endoscopic retrograde cholangiopancreatography for non-gastroenterologists: what you need to know. Hosp Pract (1995) 2011; 39:70-80. [PMID: 21576899 DOI: 10.3810/hp.2011.04.396] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) represents the most powerful and widely employed platform for pancreaticobiliary interventions. Endoscopic retrograde cholangiopancreatography allows diagnosis and treatment of a broad spectrum of diseases of the pancreaticobiliary tree that are both benign and malignant in nature. Endoscopic retrograde cholangiopancreatography continues to evolve rapidly, and non-gastroenterologists need to understand the indications, contraindications, limitations, and role of ERCP to effectively manage and coordinate the care of patients with known or suspected pancreaticobiliary disease. This article will review the role of ERCP in detail to further an understanding of the procedure as a whole and to assess when referral of a patient for an ERCP or other related test is indicated.
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Affiliation(s)
- Geetha Nallamothu
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Huntsman Cancer Center, Salt Lake City, UT 84312, USA
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Huddleston BJ, Lamb RD, Gopez EV, Adler DG, Collins BT. Cholangiocarcinoma in a 17-year-old boy with primary sclerosing cholangitis and UroVysion™ fluorescent in situ hybridization. Diagn Cytopathol 2011; 40:337-41. [PMID: 22431323 DOI: 10.1002/dc.21629] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 11/27/2010] [Indexed: 01/17/2023]
Abstract
Primary sclerosing cholangitis (PSC) is uncommon in the younger age range and bile duct brushing cytology can present unique challenges. We describe the case of a 17-year-old boy with a new diagnosis of PSC who presented with cholangiocarcinoma. The clinical history, endoscopic features, cytomorphologic findings, and results of UroVysion™ fluorescent in situ hybridization (FISH) on the bile duct brush are described. UroVysion FISH on bile duct brushings is an ancillary study that can improve the diagnostic sensitivity for malignancy, specially in challenging cases where the cytomorphologic or clinical characteristics of the case are not typical. The occurrence of cholangiocarcinoma in young age group with PSC is uncommon, and the utilization of UroVysion FISH has been rarely described.
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Campion MB, Kipp BR, Humphrey SK, Zhang J, Clayton AC, Henry MR. Improving cellularity and quality of liquid-based cytology slides processed from pancreatobiliary tract brushings. Diagn Cytopathol 2010; 38:627-32. [PMID: 19937946 DOI: 10.1002/dc.21255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Cytology has been reported to have suboptimal sensitivity for detecting pancreatobiliary tract cancer in biliary tract specimens partly as a result of low specimen cellularity and obscuring noncellular components. The goal of this study was to determine if the use of a glacial acetic acid wash prior to processing would increase the cellularity and improve the quality of ThinPrep slides when compared to standard non-gyn ThinPrep processing. Fifty consecutive pancreatobiliary tract specimens containing 20 ml of sample/PreservCyt were divided equally for standard non-gyn ThinPrep (STP) and glacial acetic acid ThinPrep processing (GATP). A manual drop preparation was also performed on residual STP specimen to determine the number of cells left in the vial during STP processing. Twenty-six (52%) specimens had more epithelial cell groupings with the GATP methodology while 19 (38%) had equivalent cellularity with both methods. The STP method produced more epithelial cell groupings in 5 (10%) of the specimens. Of the 26 specimens that had less cells with the STP method, 14 (54%) had > or = 50 cell groupings on the manual drop slide processed from the residual STP specimen suggesting that many cells remain in the vial after STP processing. The GATP method was preferred in 25 (50%) of the specimens, the STP method in 5 (10%), while both methodologies provided similar findings in the remaining 20 (40%) of specimens. The data from this study suggests that the GATP method results in more cells being placed on the slide and was preferred over the STP method in a majority of specimens.
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Affiliation(s)
- Michael B Campion
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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31
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Pitman MB. Liver. Diagn Cytopathol 2010. [DOI: 10.1016/b978-0-7020-3154-0.00008-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Etzel JP, Eng SC, Ko CW, Lee SD, Saunders MD, Tung BY, Kimmey MB, Kowdley KV. Complications after ERCP in patients with primary sclerosing cholangitis. Gastrointest Endosc 2008; 67:643-8. [PMID: 18061595 DOI: 10.1016/j.gie.2007.07.042] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Accepted: 07/23/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND There are conflicting data regarding the role of ERCP in patients with primary sclerosing cholangitis (PSC) and the risk of procedure-related complications. OBJECTIVE We compared the complication rate after ERCP in a consecutive series of patients with PSC compared with control patients with biliary strictures who did not have PSC. DESIGN Retrospective cross-sectional study. SETTING A tertiary referral academic hospital. MAIN OUTCOME MEASUREMENTS Incidence of complications after ERCP. PATIENTS AND RESULTS A total of 85 ERCPs among 30 patients with PSC and 70 ERCPs among 45 control patients were reviewed. There was no significant difference in the overall complication rates between patients with and without PSC (11/85 [12.9%] vs 6/70 [8.6%], P = .45). Complications in PSC were more likely to occur after ERCP done to evaluate an acute sign or symptom than in elective cases (7/24 [29.2%] vs 4/61 [6.6%], P = .01). Patients with PSC who had complications had more total and acute ERCPs than did those without complications. There was no significant difference in the rate of complications in diagnostic versus therapeutic ERCPs nor between stent placement and dilation-only therapeutic ERCPs in the PSC population. LIMITATIONS Retrospective study design and limited power related to the small sample sizes. CONCLUSIONS Elective ERCP is safe and carries a modest risk in patients with PSC; however, ERCP for acute indications greatly increases the probability of postprocedure complications. The overall complication rate after therapeutic ERCP in patients with PSC is similar to that in patients without PSC.
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Affiliation(s)
- Jason P Etzel
- Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
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Wu Y, Johlin FC, Rayhill SC, Jensen CS, Xie J, Cohen MB, Mitros FA. Long-term, tumor-free survival after radiotherapy combining hepatectomy-Whipple en bloc and orthotopic liver transplantation for early-stage hilar cholangiocarcinoma. Liver Transpl 2008; 14:279-86. [PMID: 18306329 DOI: 10.1002/lt.21287] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This retrospective study reviews our experience in surveillance and early detection of cholangiocarcinoma (CC) and in using en bloc total hepatectomy-pancreaticoduodenectomy-orthotopic liver transplantation (OLT-Whipple) to achieve complete eradication of early-stage CC complicating primary sclerosing cholangitis (PSC). Asymptomatic PSC patients underwent surveillance using endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) with multilevel brushings for cytological evaluation. Patients diagnosed with CC were treated with combined extra-beam radiotherapy, lesion-focused brachytherapy, and OLT-Whipple. Between 1988 and 2001, 42 of 119 PSC patients were followed according to the surveillance protocol. CC was detected in 8 patients, 6 of whom underwent OLT-Whipple. Of those 6 patients, 4 had stage I CC, and 2 had stage II CC. All 6 OLT-Whipple patients received combined external-beam and brachytherapy radiotherapy. The median time from diagnosis to OLT-Whipple was 144 days. One patient died 55 months post-transplant of an unrelated cause, without tumor recurrence. The other 5 are well without recurrence at 5.7, 7.0, 8.7, 8.8, and 10.1 years. In conclusion, for patients with PSC, ERCP surveillance cytology and intralumenal endoscopic ultrasound examination allow for early detection of CC. Broad and lesion-focused radiotherapy combined with OLT-Whipple to remove the biliary epithelium en bloc offers promising long-term, tumor-free survival. All patients tolerated this extensive surgery well with good quality of life following surgery and recovery. These findings support consideration of the complete excision of an intact biliary tree via OLT-Whipple in patients with early-stage hilar CC complicating PSC.
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Affiliation(s)
- Youmin Wu
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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Schulick RD. Primary sclerosing cholangitis: detection of cancer in strictures. J Gastrointest Surg 2008; 12:420-2. [PMID: 17999125 DOI: 10.1007/s11605-007-0345-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2007] [Accepted: 09/11/2007] [Indexed: 01/31/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a significant risk factor for developing cholangiocarcinoma. Tests currently used to screen patients with PSC include serum tumor markers, invasive biliary imaging and sampling techniques, and noninvasive biliary imaging. The most commonly used serum markers are carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA). Invasive biliary imaging includes endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC). In addition to standard cytology, the bile can be tested for CA 19-9 levels, as well as other novel tumor markers. In addition, the brushed cells can be analyzed for chromosomal abnormalities using digital image analysis (DIA) or fluorescence in situ hybridization (FISH). Nonivasive imaging techniques include computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and positron emission tomography (PET).
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Affiliation(s)
- Richard D Schulick
- Johns Hopkins University, 1650 Orleans Street, Baltimore, MD 21231, USA.
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Abstract
Cholangiocarcinoma is a primary hepatic malignancy originating from bile duct epithelium. It is the second most common primary hepatic neoplasia, and its incidence has increased within the last 3 decades. Although several risk factors have been identified, especially chronic biliary tract inflammation, most patients with cholangiocarcinoma have no identifiable risk factors. Recent developments in radiologic and molecular diagnostic methods have helped in the diagnosis of this disease. The only curative therapy is surgical resection or liver transplantation. For patients with advanced stage disease, survival remains limited. With growing understanding of the molecular and cellular etiology of this disease, new targeted therapies are being developed.
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Affiliation(s)
- Boris R A Blechacz
- Division of Gastroenterology and Hepatology, Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Cholangiocarcinoma: natural history, treatment, and strategies for surveillance in high-risk patients. J Clin Gastroenterol 2008; 42:178-90. [PMID: 18209589 DOI: 10.1097/mcg.0b013e31806daf89] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Abstract
Cholangiocarcinoma is suspected based on signs of biliary obstruction, abnormal liver function tests, elevated tumor markers (carbohydrate antigen 19-9 and carcinoembryonic antigen), and ultrasonography showing a bile stricture or a mass, especially in intrahepatic cholangiocarcinoma. Magnetic resonance imaging (MRI) or computed tomography (CT) is performed for the diagnosis and staging of cholangiocarcinomas. However, differentiation of an intraductal cholangiocarcinoma from a hypovascular metastasis is limited at imaging. Therefore, reasonable exclusion of an extrahepatic primary tumor should be performed. Differentiating between benign and malignant bile duct stricture is also difficult, except when metastases are observed. The sensitivity of fluorodeoxyglucose positron emission tomography is limited in small, infiltrative, and mucinous cholangiocarcinomas. When the diagnosis of a biliary stenosis remains indeterminate at MRI or CT, endoscopic imaging (endoscopic or intraductal ultrasound, cholangioscopy, or optical coherence tomography) and tissue sampling should be carried out. Tissue sampling has a high specificity for diagnosing malignant biliary strictures, but sensitivity is low. The diagnosis of cholangiocarcinoma is particularly challenging in patients with primary sclerosing cholangitis. These patients should be followed with yearly tumor markers, CT, or MRI. In the case of dominant stricture, histological or cytological confirmation of cholangiocarcinoma should be obtained. More studies are needed to compare the accuracy of the various imaging methods, especially the new intraductal methods, and the imaging features of malignancy should be standardized.
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Affiliation(s)
- B E Van Beers
- Diagnostic Radiology Unit, Université Catholique de Louvain, St-Luc University Hospital, Brussels, Belgium.
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39
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Buc E, Lesurtel M, Belghiti J. Is preoperative histological diagnosis necessary before referral to major surgery for cholangiocarcinoma? HPB (Oxford) 2008; 10:98-105. [PMID: 18773064 PMCID: PMC2504385 DOI: 10.1080/13651820802014585] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- E. Buc
- Department of HBP Surgery, Hospital BeaujonClichyFrance
| | - M. Lesurtel
- Department of HBP Surgery, Hospital BeaujonClichyFrance
| | - J. Belghiti
- Department of HBP Surgery, Hospital BeaujonClichyFrance
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Walker SL, McCormick PA. Diagnosing cholangiocarcinoma in primary sclerosing cholangitis: an “evidence based radiology” review. ACTA ACUST UNITED AC 2007; 33:14-7. [PMID: 17874262 DOI: 10.1007/s00261-007-9314-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Cholangiocarcinoma is a serious but common complication of primary sclerosing cholangitis (PSC) that is often difficult to diagnose. The aim of this study was to conduct an evidence based radiology review of the diagnostic modalities used to identify cholangiocarcinoma in patients with PSC. A systematic review of the current best evidence was carried out and a diagnostic algorithm for cholangiocarcinoma in PSC is proposed.
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Affiliation(s)
- Sarah L Walker
- National Liver Unit, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
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41
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Halling KC, Kipp BR. Fluorescence in situ hybridization in diagnostic cytology. Hum Pathol 2007; 38:1137-44. [PMID: 17640552 DOI: 10.1016/j.humpath.2007.04.015] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2007] [Accepted: 04/25/2007] [Indexed: 12/17/2022]
Abstract
Fluorescence in situ hybridization (FISH) is a technique that uses fluorescently labeled DNA probes to detect chromosomal alterations in cells. FISH can detect various types of cytogenetic alterations including aneusomy (ie, abnormalities of chromosome copy number), duplication, amplification, deletion, and translocation. Because tumor cells generally contain chromosomal alterations, FISH is able to detect cells that have chromosomal abnormalities consistent with neoplasia in exfoliative and aspiration cytology specimens. This review will discuss the utility of FISH for the detection of bladder, lung, pancreatobiliary, and esophageal carcinoma in cytologic specimens.
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Affiliation(s)
- Kevin C Halling
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA.
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42
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Papachristou GI, Smyrk TC, Baron TH. Endoscopic retrograde cholangiopancreatography tissue sampling: when and how? Clin Gastroenterol Hepatol 2007; 5:783-90. [PMID: 17628333 DOI: 10.1016/j.cgh.2007.04.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A 69-year-old man presented with obstructive jaundice. Endoscopic retrograde cholangiopancreatography was performed for biliary tree decompression and diagnostic tissue acquisition. Techniques, indications, methodologic considerations, and interpretation of tissue sampling at endoscopic retrograde cholangiopancreatography in patients with biliary/pancreatic strictures are discussed. This case-based educational presentation focuses on the importance of interdisciplinary communication between endoscopists and pathologists for optimal tissue sampling, interpretation, and diagnostic accuracy.
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Affiliation(s)
- Georgios I Papachristou
- Department of Medicine, Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Moreno Luna LE, Gores GJ. Advances in the diagnosis of cholangiocarcinoma in patients with primary sclerosing cholangitis. Liver Transpl 2006; 12:S15-9. [PMID: 17051561 DOI: 10.1002/lt.20938] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Laura E Moreno Luna
- Division of Gastroenterology and Hepatology, Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Baskin-Bey ES, Moreno Luna LE, Gores GJ. Diagnosis of cholangiocarcinoma in patients with PSC: a sight on cytology. J Hepatol 2006; 45:476-9. [PMID: 16901574 DOI: 10.1016/j.jhep.2006.07.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
PURPOSE OF REVIEW Primary sclerosing cholangitis is a chronic cholestatic liver disease characterized by strictures of the biliary tree complicated by cirrhosis and cholangiocarcinoma. It is immune mediated although the precise etiology remains unknown. RECENT FINDINGS Research into etiopathogenesis, epidemiology, the relationship with inflammatory bowel disease, diagnosis of cholangiocarcinoma, medical therapy, and the outcome of liver transplantation are discussed. SUMMARY It is likely that a number of patients previously diagnosed with primary sclerosing cholangitis have autoimmune pancreatitis in association with primary sclerosing cholangitis, a syndrome with distinct clinicopathological features including steroid responsiveness. Primary sclerosing cholangitis-inflammatory bowel disease probably represents a distinct inflammatory bowel disease phenotype, which has implications for colonoscopic surveillance of these patients. CA19-9 plays no surveillance role for the early detection of cholangiocarcinoma. The best-studied drug in primary sclerosing cholangitis is ursodeoxycholic acid, which, despite a range of potentially valuable actions on the cholestatic liver, has not yet been proved to make a substantial impression on the course of the disease. Orthotopic liver transplantation remains the only established long-term treatment for primary sclerosing cholangitis.
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Affiliation(s)
- George R MacFaul
- Department of Gastroenterology, John Radcliffe Hospital, Oxford, UK
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Jamidar P. Bile duct brushings for the early detection of cholangiocarcinoma. J Clin Gastroenterol 2006; 40:279-80. [PMID: 16633096 DOI: 10.1097/01.mcg.0000210107.05113.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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