Diagnostic approaches for cholangiocarcinoma

Application of CAPTURE Assay for Early Diagnosis and Prognosis in Bile and Blood of Cholangiocarcinoma

PURPOSE

Cholangiocarcinoma (CCA) is highly metastatic, difficult to diagnose, and characterized by extremely low 5-year survival rate. Liquid biopsy is reported as a new tool for monitoring and potential diagnosis of cancers. In this study, we developed a novel approach, CAPTURE (Cancer cell affinity probing and tracked by immunoreaction) assay, using blood and bile for the detection of CCA.

MATERIALS AND METHODS

The CAPTURE assay isolated exfoliated tumor cells (ETCs) from bile and circulating tumor cells (CTCs) from blood of patients with CCA (CCA+) using magnetic beads coated with two affinity probes: a nucleic-acid aptamer or a glycosaminoglycan octasaccharide, followed by immunostaining to track target tumor cells-bead complexes. Target-bead complexes were quantified under a fluorescent microscope (ETCs:CK17+/CK7+/Hoechst+; CTCs: CK17+/CD45-/Hoechst+). Epithelial cell adhesion molecule was also used as a comparison. The blood and bile from patients of benign biliary-related diseases (CCA-) served as control. The study was validated in a single-blind fashion.

RESULTS

Finally, numbers of CTCs of blood (82 CCA+ and 48 CCA-) and ETCs of bile (132 CCA+ and 63 CCA-) samples were quantified and validated. Sensitivities and specificities were 98.5% and 85.7% with bile tests, and 96.3% and 85.4% with blood tests. Moreover, we successfully monitored prognoses of two follow-up patients using CAPTURE assay after treatments.

CONCLUSION

ETCs in bile could be promising indicators of disease status in early through advanced stages of CCA, whereas CTCs in blood might have crucial value in diagnosing and monitoring advanced stages of CCA. Our results showed that the CAPTURE assay would be a powerful tool in CCA diagnostics and prognostics.

Disparities in Cholangiocarcinoma Research and Trials: Challenges and Opportunities in the United States

Cancer disparities are well-established across measures of cancer incidence and mortality. Cholangiocarcinoma, a common hepatic malignancy, is no exception to these inequities. Globally and within the United States, Asian, Hispanic, and Indigenous peoples of the Americas, Alaskan Natives, and Pacific Islander populations experience higher incidence rates of cholangiocarcinoma. These same groups and non-Hispanic Black individuals simultaneously experience lower disease-specific survival, highlighting the role of social factors in cholangiocarcinoma outcome inequities. Higher age-standardized death rates from cholangiocarcinoma are associated with a lower social determinant index (SDI) in Andean Latin America, Southern Latin America, and Central sub-Saharan Africa. SDI, which evaluates education, fertility, and income, can be used to model the social determinants of health (SDOH). The SDOH also affect cholangiocarcinoma survival in the United States as factors such as migratory status, insurance status, and geographic location can cause treatment delays and worsened outcomes. Despite these inequities, limited research exists on the topic of disparities in cholangiocarcinoma when compared with other malignancies, and clinical trial under-representation remains a significant concern. Representing diverse populations in cholangiocarcinoma clinical trials is exceedingly important as populations with the highest incidence are simultaneously under-represented in clinical trials. Diversity in clinical trial enrollment and research regarding cholangiocarcinoma is needed to create robust databases and biobanks that can be used to develop targeted treatments and guidelines. In addition, risk factors, including parasitic infections, infectious diseases, and environmental exposures, are associated with cholangiocarcinoma but vary by global region, highlighting the need to study unique risk factors for cholangiocarcinoma across diverse populations. Without research that represents the populations that suffer most from this cancer, incidence and mortality inequities will continue to have a disproportionate burden.

Artificial Intelligence and Radiomics in Cholangiocarcinoma: A Comprehensive Review

Cholangiocarcinoma (CCA) is a malignant biliary system tumor and the second most common primary hepatic neoplasm, following hepatocellular carcinoma. CCA still has an extremely high unfavorable prognosis, regardless of type and location, and complete surgical resection remains the only curative therapeutic option; however, due to the underhanded onset and rapid progression of CCA, most patients present with advanced stages at first diagnosis, with only 30 to 60% of CCA patients eligible for surgery. Recent innovations in medical imaging combined with the use of radiomics and artificial intelligence (AI) can lead to improvements in the early detection, characterization, and pre-treatment staging of these tumors, guiding clinicians to make personalized therapeutic strategies. The aim of this review is to provide an overview of how radiological features of CCA can be analyzed through radiomics and with the help of AI for many different purposes, such as differential diagnosis, the prediction of lymph node metastasis, the defining of prognostic groups, and the prediction of early recurrence. The combination of radiomics with AI has immense potential. Still, its effectiveness in practice is yet to be validated by prospective multicentric studies that would allow for the development of standardized radiomics models.

Cholangiocarcinoma of the Middle Bile Duct: A Narrative Review

Resectable cholangiocarcinoma (CCA) arising from the middle of the extrahepatic biliary tree has historically been classified as perihilar or distal CCA, depending on the operation contemplated or performed, namely the associated hepatectomy or pancreaticoduodenectomy, respectively. Segmental bile duct resection is a less invasive alternative for select patients harboring true middle extrahepatic CCA (MCC). A small, yet growing body of literature has emerged detailing institutional experiences with bile duct resection versus pancreaticoduodenectomy or concomitant hepatectomy for MCC. Herein, we provide a brief overview of the epidemiology, preoperative evaluation, and emerging systemic therapies for MCC, and narratively review the existing work comparing segmental resection with pancreaticoduodenectomy or less commonly, hepatectomy, for MCC, with emphasis on the surgical management and oncologic implications of the approach used.

Cholangiocarcinoma: Consistent clinical, cytological, hematological, and biochemical findings and pathomorphology of the liver and kidney in five exotic dog breeds in Abeokuta, Nigeria

Background and Aim

Cholangiocarcinomas are malignant neoplasms that originate from any part of the bile duct epithelium. It is one of the most common liver tumors in dogs. This study described the clinical, cytological, hematological, biochemical, and pathomorphological findings of five cholangiocarcinoma cases in exotic breed dogs aged 2-5 years to aid in clinical diagnosis.

Materials and Methods

This study used dogs presented at different times from 2012 to 2021 at the Veterinary Teaching Hospital, Federal University of Agriculture, Abeokuta. History, clinical signs, and vital parameters were recorded. Blood samples were collected for hematology and serum chemistry. Abdominocentesis was performed for cytological diagnosis. All dogs died during treatment, and postmortem examinations were performed. At postmortem, fine needle aspirates were collected from the liver and mesenteric lymph nodes and liver and kidney samples were fixed in 10% neutral-buffered formalin.

Results

The dogs showed signs of severe malnutrition, jaundice, and bloating. The hematological analysis indicated anemia, neutrophilia without band neutrophils, and lymphopenia, indicative of a stress hemogram. The serum biochemistry test revealed lower levels of total proteins, albumin, and globulin and higher levels of serum enzymes. Abdominal fluid and mesenteric lymph node cytology revealed clusters of epithelial neoplastic cells. A postmortem examination revealed the liver's nodular enlargement with the presence of button-like ulcers. Neoplastic epithelial cells are solid masses with hyperchromatic nuclei surrounded by fibrous connective tissues.

Conclusion

Cholangiocarcinoma, diagnosed over a period of time in five exotic breeds of dog, consistently presents with the same clinical and postmortem findings, aiding in clinical diagnosis. However, the diagnosis of the disease is not possible in the early stage because of the absence of specific clinical signs. In dogs and possibly other animal species presenting with emaciation, lethargy, icterus, and distended abdomen, cholangiocarcinoma should be suspected, and cytological examination of the abdominal fluid and lymph node aspirates should be performed despite the absence of advanced equipment.

Lightweight neural network for smart diagnosis of cholangiocarcinoma using histopathological images

Traditional Cholangiocarcinoma detection methodology, which involves manual interpretation of histopathological images obtained after biopsy, necessitates extraordinary domain expertise and a significant level of subjectivity, resulting in several deaths due to improper or delayed detection of this cancer that develops in the bile duct lining. Automation in the diagnosis of this dreadful disease is desperately needed to allow for more effective and faster identification of the disease with a better degree of accuracy and reliability, ultimately saving countless human lives. The primary goal of this study is to develop a machine-assisted method of automation for the accurate and rapid identification of Cholangiocarcinoma utilizing histopathology images with little preprocessing. This work proposes CholangioNet, a novel lightweight neural network for detecting Cholangiocarcinoma utilizing histological RGB images. The histological RGB image dataset considered in this research work was found to have limited number of images, hence data augmentation was performed to increase the number of images. The finally obtained dataset was then subjected to minimal preprocessing procedures. These preprocessed images were then fed into the proposed lightweight CholangioNet. The performance of this proposed architecture is then compared with the performance of some of the prominent existing architectures like, VGG16, VGG19, ResNet50 and ResNet101. The Accuracy, Loss, Precision, and Sensitivity metrics are used to assess the efficiency of the proposed system. At 200 epochs, the proposed architecture achieves maximum training accuracy, precision, and recall of 99.90%, 100%, and 100%, respectively. The suggested architecture's validation accuracy, precision, and recall are 98.40%, 100%, and 100%, respectively. When compared to the performance of other AI-based models, the proposed system produced better results making it a potential AI tool for real world application.

Challenges in Diagnosing and Reporting Cholangiocarcinoma

Intrahepatic cholangiocarcinoma is a challenge to the practicing surgical pathologist for several reasons. It is rare in many parts of the world, and thus practical exposure may be limited. Related to the fact of its rarity is the fact that more common tumors which frequently metastasize to the liver can be morphologically indistinguishable (eg, pancreatic ductal adenocarcinoma). Immunohistochemical testing is generally non-contributory in this context. Other difficulties arise from the protean morphologic manifestations of cholangiocarcinoma (ie, small duct vs. large duct) and the existence of combined cholangiocarcinoma and hepatocellular carcinoma. These, and other issues of concern to the practicing diagnostic pathologist are discussed herein.

Bile metabolites as diagnostic biomarkers for perihilar cholangiocarcinoma

It is difficult to directly obtain pathological diagnosis of perihilar cholangiocarcinoma (pCCA). Analysis of bile in the pCCA microenvironment, based on metabolomics and statistical methods, can help in clinical diagnosis. Clinical information, bile samples, blood liver function, blood CA199, CEA, and other indicators were collected from 33 patients with pCCA and 16 patients with gallstones. Bile samples were analyzed using untargeted metabolomics methods. A combination of multivariate and univariate analyses were used to screen for potential differential metabolites Through Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment and differential metabolite remodeling, we explored changes in the pCCA pathway and potential therapeutic targets. There were significant differences in patient blood TBIL, ALT, AST, TBA, CA19-9, and CEA indices (p < 0.05, |log2(fc)| ≥ 1) between two groups. A significant correlation was found between these different indicators by Spearman's analysis. The clinical parameters were correlated with mass-to-charge ratios of 305 (Positive Ion Mode, POS) and 246 (Negative Ion Mode, NEG) in the metabolic group (|r| ≥ 0.7, P ≤ 10^-7). The result of this study indicated that bile untargeted metabolomics combined with statistical analysis techniques may be used for diagnose and treatment of pCCA.

Rapid label-free detection of cholangiocarcinoma from human serum using Raman spectroscopy

Cholangiocarcinoma (CCA) is highly prevalent in the northeastern region of Thailand. Current diagnostic methods for CCA are often expensive, time-consuming, and require medical professionals. Thus, there is a need for a simple and low-cost CCA screening method. This work developed a rapid label-free technique by Raman spectroscopy combined with the multivariate statistical methods of principal component analysis and linear discriminant analysis (PCA-LDA), aiming to analyze and classify between CCA (n = 30) and healthy (n = 30) serum specimens. The model's classification performance was validated using k-fold cross validation (k = 5). Serum levels of cholesterol (548, 700 cm-1), tryptophan (878 cm-1), and amide III (1248,1265 cm-1) were found to be statistically significantly higher in the CCA patients, whereas serum beta-carotene (1158, 1524 cm-1) levels were significantly lower. The peak heights of these identified Raman marker bands were input into an LDA model, achieving a cross-validated diagnostic sensitivity and specificity of 71.33% and 90.00% in distinguishing the CCA from healthy specimens. The PCA-LDA technique provided a higher cross-validated sensitivity and specificity of 86.67% and 96.67%. To conclude, this work demonstrated the feasibility of using Raman spectroscopy combined with PCA-LDA as a helpful tool for cholangiocarcinoma serum-based screening.

Percutaneous Gallbladder Biopsy: Indications, Technique and Complications

Gallbladder percutaneous tissue sampling is a not-so-common technique in cytohistological diagnosis of gallbladder tissue or masses, which can be useful in cases of surgically unresectable disease and unfeasible endoscopic assessment to address the most adequate chemotherapy course. Nonetheless, gallbladder percutaneous tissue sampling can be of great utility in the patient’s diagnostic and therapeutic work-up. This article summarizes the literature evidence on gallbladder biopsy techniques, complications, and technical precautions for a safe and effective sampling.

Comparison of EUS and ERCP-guided tissue sampling in suspected biliary stricture

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are commonly used diagnostic modalities in biliary strictures. We compared the diagnostic yield of EUS and ERCP-based tissue sampling in intrinsic biliary strictures without extrinsic mass outside the bile duct.

METHODS

A total of 85 patients who underwent ERCP and EUS for diagnosis of suspected biliary strictures confined to the bile duct were analyzed retrospectively at Samsung Medical Center, Seoul, Korea, between 2010 and 2018.

RESULTS

Seventy-one patients were diagnosed with malignancy and 14 patients were diagnosed with benign strictures. EUS-based tissue sampling was more sensitive and accurate than ERCP-based tissue sampling (p = 0.038). The overall sensitivity and accuracy were 67.6% (95% confidence interval (CI) 56.1-77.3) and 72.9% (95% CI 62.7-81.2) for ERCP-based sampling, and 80.3% (95% CI 69.6-87.9) and 83.5% (95% CI 74.2-89.9) for EUS-based sampling, respectively. EUS-based sampling was superior to ERCP-based sampling in distal bile duct strictures (accuracy: 87.0% vs. 72.5%, p = 0.007), but not in perihilar strictures. In cases without intraductal mass, EUS-based tissue sampling was also superior to ERCP-based sampling (accuracy: 83.3% vs. 69.7%, p = 0.029), but not in cases with mass.

CONCLUSION

EUS-based tissue sampling was superior to ERCP-based method in intrinsic biliary stricture with no mass outside the bile duct, particularly in those without intraductal mass or those with strictures located in distal bile duct. Therefore, EUS-based sampling should be considered for making a pathological diagnosis of suspected distal bile duct strictures even in lesions without definite mass.

Impact of Cholestasis on the Sensitivity of Percutaneous Transluminal Forceps Biopsy in 93 Patients with Suspected Malignant Biliary Stricture

PURPOSE

The aim of this study was to determine the effect of hyperbilirubinemia in the sensitivity of percutaneous transluminal forceps biopsy (PTFB) in patients with suspected malignant biliary stricture.

MATERIALS AND METHODS

Ninety-three patients with suspicion of malignant biliary stricture underwent percutaneous transhepatic cholangiography followed by PTFB. Sensitivity, specificity and predictive values were analysed based on the presence or absence of hyperbilirubinemia, defined as total bilirubin equal to, or higher than 5 mg/dL. Variables included demographic and clinical features, laboratory, tumour type and localization, stricture length, therapeutic approach and histopathology. Additionally, major morbidity and mortality were assessed.

RESULTS

The overall sensitivity, specificity, positive predictive value and accuracy of PTFB were 61.1%, 100%, 100%, and 62.4%, respectively. Hyperbilirubinemia affected 57% of patients at the time of PTFB. There were 35 (37%) false negative results, none of them related to tumour type or localization, stricture length, or previous biliary intervention (i.e. PBBD (percutaneous biliary balloon dilatation), ERCP (endoscopic retrograde cholangiopancreatography)) (p > 0.05). However, when bilirubin was < 5 mg/dL, false negative results decreased globally (p = 0.024) and sensitivity increased significantly for intrahepatic and hilar localization, as well as for colorectal metastasis, gallbladder carcinoma, and pancreatic carcinoma. No major morbidity occurred.

CONCLUSION

The sensitivity of percutaneous transluminal biopsy for diagnosis of malignant stricture may significantly increase if samples are obtained in the absence of hyperbilirubinemia, without adding morbidity to the procedure.

LEVEL OF EVIDENCE

Level 3, Case- Control studies.

Endoscopic biliary stenting as the risk factor for cholangitis after endoscopic ultrasound in patients with biliary strictures

BACKGROUND AND AIM

Endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration (FNA) are established as efficient and safe diagnostic modalities. However, the risk of cholangitis after EUS/EUS-FNA (post-EUS cholangitis) in patients who have biliary strictures has not been fully examined.

METHODS

We retrospectively reviewed 136 consecutive inpatients with biliary strictures who received EUS/EUS-FNA at our hospital from April 2012 to September 2017 and evaluated complications that occurred by the next day after EUS/EUS-FNA. Patients with percutaneous biliary drainage, those in whom it was difficult to reach the duodenum, and those receiving concurrent endoscopic retrograde cholangiopancreatography were excluded.

RESULTS

We included 121 patients (147 cases); 90 patients were malignant. Endoscopic biliary stenting (EBS) with plastic stents had already been performed in 86 cases. Post-EUS cholangitis was observed in 4.1% (6/147). No other EUS-related complications were observed. The incidence of cholangitis with EBS was significantly higher than that in the cases without EBS (7.0% [6/86] vs 0% [0/61], P = 0.042). Biliary enzyme elevation was also identified as a risk factor of cholangitis.

CONCLUSION

Endoscopic biliary stenting was identified as a risk factor associated with post-EUS cholangitis in patients with biliary strictures. Endoscopists should pay attention to post-EUS cholangitis, especially in cases with EBS and biliary enzyme elevation.

Optimal tissue sampling during ERCP and emerging molecular techniques for the differentiation of benign and malignant biliary strictures

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.

Comparison between Brush Cytology and Forceps Biopsy under Fluoroscopic Guidance for the Diagnosis of Proximal Cholangiocarcinoma

BACKGROUND

Cholangiocarcinoma is the second most common malignant liver cancer. Its early diagnosis plays an important role in the success of treatment. The aim of this study was to compare the use of cold forceps biopsy without cholangioscopy with brush cytology in the diagnosis of cholangiocarcinoma.

METHODS

In this prospective study, we enrolled 19 patients. Endoscopic retrograde cholangiopancreatography (ERCP) was performed for all individuals. Sampling was performed from the narrowing site using the brush method. Then, a cold forceps biopsy was performed under fluoroscopy.

RESULTS

The mean age of the patients was 63.31 ± 11.12 years and most of them were men (63.16 %). The brush cytology and the cold forceps biopsy diagnosed 31.85% and 68.42% of the samples as cholangiocarcinoma, respectively. According to the McNemar test, there was a statistically significant difference between the diagnostic results of the brush cytology and cold forceps biopsy. So that more cholangiocarcinoma cases were diagnosed using forceps biopsy (p = 0.016). No complications such as perforation, bleeding, cholangitis, and leakage were reported during the cold forceps procedure.

CONCLUSION

Cold forceps biopsy under fluoroscopy is better than cytology brush in the diagnosis of proximal cholangiocarcinoma. It is recommended to be used as a low-cost alternative in cases where cholangioscopy is not available.

Silicon Nanowires and their Impact on Cancer Detection and Monitoring

Since the inception of silicon nanowires (SINWs)-based biosensors in 2001, SINWs employed in various detection schemes have routinely demonstrated label-free, real-time, sub femtomolar detection of both protein and nucleic acid analytes. This has allowed SiNW-based biosensors to integrate into the field of cancer detection and cancer monitoring and thus have the potential to be a paradigm shift in how cancer biomarkers are detected and monitored. Combining this with several promising fields such as liquid biopsies and targeted oncology, SiNW based biosensors represents an opportunity for cancer monitoring and treatment to be a more dynamic process. Such advances provide clinicians with more information on the molecular landscape of cancer patients which can better inform cancer treatment guidelines.

Percutaneous transhepatic cholangiography versus endoscopic retrograde cholangiography for the pathological diagnosis of suspected malignant bile duct strictures

To compare the diagnostic performance of percutaneous transhepatic cholangiography and endoscopic retrograde cholangiography for the pathological assessment of suspected malignant bile duct stricture, using brush cytology and forceps biopsy.The study group comprised 79 consecutive patients who underwent pathological assessment for suspected malignant biliary stricture, 38 of whom underwent percutaneous transhepatic cholangiography (group A) and the other 41 underwent endoscopic retrograde cholangiography (group B). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated. A subset analysis was performed to determine the effect of location and pathological type of the stricture on diagnostic performance, and complications were analyzed.The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 86.7%, 100%, 100%, 66.7%, and 89.5%, respectively, in group A, and 77.1%, 100%, 100%, 42.9%, and 80.4%, respectively, in group B. For hilar biliary strictures, the sensitivity and accuracy were superior in group A than in group B. Mild complications (transient c and bile leakage) were identified in 7 cases in each group, all resolved spontaneously within 3 to 5 days.Both brush cytology and forceps biopsy performed during percutaneous transhepatic cholangiography and endoscopic retrograde cholangiography provided good diagnostic sensitivity and accuracy. Therefore, both diagnostic approaches can play an important role in planning therapeutic strategy. However, for strictures located at the hilum, pathology sampling via percutaneous transhepatic cholangiography is preferable to endoscopic retrograde cholangiography, as it provides higher sensitivity and accuracy.

[Personalized treatment of cholangiocellular carcinoma (CCA)]

Cholangiocellular carcinoma (CCA) is one of the primary liver tumors and overall represents a rare malignancy; however, in recent years the incidence, particularly of intrahepatic CCA (iCCA) has increased worldwide. Due to the high mortality, CCAs cause a significant proportion of cancer-related deaths also in Germany. Because the diagnosis is often made in advanced stages of the disease, in many cases a surgical approach with curative intention is not possible. For locally advanced or metastatic CCA the combination of gemcitabine and cisplatin currently remains the only approved systemic treatment. As the average survival time is only approximately 12 months even under first-line treatment with gemcitabine/cisplatin, research is focused on developing new molecularly targeted and immunological treatment options. Various studies are currently being carried out to investigate approval options for targeted treatment, which could be considered for genetically altered tumors, e.g. in fibroblast growth factor receptor (FGFR) fusion and isocitrate dehydrogenase (IDH) mutations. Additionally, initial clinical data on immune checkpoint inhibitors are available for CCA. Due to the complex selection and partially limited applicability of current treatment options in patients with CCA, an early collaboration with a gastroenterology and oncology center with the possibility of supervision by a tumor board consisting of gastroenterological oncologists, surgeons, radiologists and radio-oncologists or in advanced stages by a molecular tumor board is essential.

Clinical presentation, diagnosis and staging of cholangiocarcinoma

Cholangiocarcinoma (CCA) is a heterogeneous group of tumours, derived from cells of the biliary tree, which represent the second most frequent primary liver tumour. According to the most recent classifications, CCA can be subdivided into intrahepatic (iCCA) and extrahepatic (eCCA) which include perihilar (pCCA) and distal (dCCA) CCA. CCA are usually identified at advanced stages, when the primary tumour grows enough to produce a large liver mass or when jaundice has developed because of biliary tree obstruction. The ongoing challenges in the identification of risk factors and definition of a specific population at higher risk of developing CCA are the main challenges for the development of screening programs. Therefore, late diagnosis remains an unresolved issue in CCA. Imaging plays an important role in the detection and characterization of CCA, helping with radiological diagnosis, guiding biopsy procedures and allowing staging of the tumour. This review focuses on clinical presentations and diagnosis and staging techniques of CCA.

The clinical value of ERCP-guided cholangiopancreatoscopy using a single-operator system

BACKGROUND

Single-operator, per-oral cholangiopancreatoscopy (SOPCP) enables direct biliopancreatic ductal visualization, targeted tissue sampling, and therapeutic intervention. At Karolinska University Hospital, SOPCP was introduced early and has since been extensively utilized according to a standardized protocol. We analysed the clinical value of SOPCP in the diagnosis and treatment of biliopancreatic diseases in a single high volume center.

METHODS

All SOPCP procedures performed between March 2007 and December 2014 were retrospectively reviewed. Each procedure's diagnostic yield and therapeutic value was evaluated using a predefined 4 grade scale; 1 - no diagnostic or therapeutic value, 2 - information gained did not impact clinical decision-making and in case of a therapeutic intervention, did not alter the clinical course of the patient, 3 - information gained had an impact on clinical decision-making and in the case of a therapeutic intervention, assisted subsequent disease management, and finally, 4 - information gained was essential and critical for clinical decision-making and in case of a therapeutic intervention, solved the clinical problem requiring no further therapeutic actions. Descriptive statistics were used to analyse results, with uni- and multivariate analyses completed to assess risk of adverse events.

RESULTS

During the study period, 365 SOPCP procedures were performed. We found SOPCP of pivotal importance (grade 4) in 19% of cases, and of great clinical significance (grade 3) in 44% of cases. SOPCP did not affect clinical decision-making or alter clinical course (grade 1 and 2) in 37% of cases.

CONCLUSION

SOPCP offers direct access to the biliopancreatic ducts for both diagnostic and therapeutic purposes, adding significant clinical value in 64% of cases.

TRIAL REGISTRATION

As this is a purely observational and retrospectively registered study in which the assignment of the medical intervention was not at the discretion of the investigator, it has not been registered in a registry.

Cholangiocarcinoma

This article focuses on cholangiocarcinoma, both intrahepatic and extrahepatic. The various classification schemes based on anatomic location, macroscopic growth pattern, microscopic features, and cell of origin are outlined. The clinicopathologic, immunohistochemical and molecular differences between intrahepatic cholangiocarcinoma and extrahepatic cholangiocarcinoma, as well as differences in the 2 subtypes of intrahepatic cholangiocarcinoma, are discussed. Finally, precursor lesions, prognosis, treatment, and promising new potential targeted therapies are reviewed.

A comparison of the efficiency of 22G versus 25G needles in EUS-FNA for solid pancreatic mass assessment: A systematic review and meta-analysis

Our aim in this study was to compare the efficiency of 25G versus 22G needles in diagnosing solid pancreatic lesions by EUS-FNA. We performed a systematic review and meta-analysis. Studies were identified in five databases using an extensive search strategy. Only randomized trials comparing 22G and 25G needles were included. The results were analyzed by fixed and random effects. A total of 504 studies were found in the search, among which 4 randomized studies were selected for inclusion in the analysis. A total of 462 patients were evaluated (233: 25G needle/229: 22G needle). The diagnostic sensitivity was 93% for the 25G needle and 91% for the 22G needle. The specificity of the 25G needle was 87%, and that of the 22G needle was 83%. The positive likelihood ratio was 4.57 for the 25G needle and 4.26 for the 22G needle. The area under the sROC curve for the 25G needle was 0.9705, and it was 0.9795 for the 22G needle, with no statistically significant difference between them (p=0.497). Based on randomized studies, this meta-analysis did not demonstrate a significant difference between the 22G and 25G needles used during EUS-FNA in the diagnosis of solid pancreatic lesions.

Diagnosis and Management of Intrahepatic and Extrahepatic Cholangiocarcinoma

Cholangiocarcinomas (CC) are rare tumors which usually present late and are often difficult to diagnose and treat. CCs are categorized as intrahepatic, hilar, or extrahepatic. Epidemiologic studies suggest that the incidence of intrahepatic CCs may be increasing worldwide. In this chapter, we review the risk factors, clinical presentation, and management of cholangiocarcinoma.

Liver Masses: What Physicians Need to Know About Ordering and Interpreting Liver Imaging

PURPOSE OF REVIEW

This paper reviews diagnostic imaging techniques used to characterize liver masses and the imaging characteristics of the most common liver masses.

RECENT FINDINGS

The role of recently adopted ultrasound and magnetic resonance imaging contrast agents will be emphasized. Contrast-enhanced ultrasound is an inexpensive exam which can confirm benignity of certain liver masses without ionizing radiation. Magnetic resonance imaging using hepatocyte-specific gadolinium-based contrast agents can help confirm or narrow the differential diagnosis of liver masses.

Cholangiocarcinoma: New Insights

Cholangiocarcinoma is a malignant neoplasm originating from biliary epithelial cells. The incidence and mortality of this cancer are rising in the world. Currently, cholangiocarcinoma is accepted as a stem cell disease with many risk factors. Diagnosis is relatively simple but therapy is extremely difficult. Surgery is the mainstay of treatment for early stage patients. Endobiliary approaches, chemotherapy and radiotherapy are other therapeutic approaches.

Intrahepatic cholangiocarcinoma: current perspectives

Intrahepatic cholangiocarcinoma (ICC) is the second most common malignancy arising from the liver. ICC makes up about 10% of all cholangiocarcinomas. It arises from the peripheral bile ducts within the liver parenchyma, proximal to the secondary biliary radicals. Histologically, the majority of ICCs are adenocarcinomas. Only a minority of patients (15%) present with resectable disease, with a median survival of less than 3 years. Multidisciplinary management of ICC is complicated by large differences in disease course for individual patients both across and within tumor stages. Risk models and nomograms have been developed to more accurately predict survival of individual patients based on clinical parameters. Predictive risk factors are necessary to improve patient selection for systemic treatments. Molecular differences between tumors, such as in the epidermal growth factor receptor status, are promising, but their clinical applicability should be validated. For patients with locally advanced disease, several treatment strategies are being evaluated. Both hepatic arterial infusion chemotherapy with floxuridine and yttrium-90 embolization aim to downstage locally advanced ICC. Selected patients have resectable disease after downstaging, and other patients might benefit because of postponing widespread dissemination and biliary obstruction.

The Detection of Cholangiocarcinoma in Primary Sclerosing Cholangitis Patients: Single Center Experience

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.

Biliary Interventions: Tools and Techniques of the Trade, Access, Cholangiography, Biopsy, Cholangioscopy, Cholangioplasty, Stenting, Stone Extraction, and Brachytherapy

Therapeutic access to the biliary system is generally limited to endoscopic or percutaneous approaches. A variety of percutaneous transhepatic biliary interventions are applicable for the diagnosis and treatment of biliary system pathologies, the majority of which may be performed in conjunction with one another. The backbone of nearly all of these interventions is percutaneous transhepatic cholangiography for opacification of the biliary tree, after which any number of therapeutic or diagnostic modalities may be pursued. We describe an overview of the instrumentation and technical approaches for several fundamental interventional procedures, including percutaneous transhepatic cholangiography and internal/external biliary drainage, endobiliary biopsy techniques, cholangioscopy, cholangioplasty and biliary stenting, biliary stone extraction, and intraluminal brachytherapy.

Cholangiocarcinoma associated with limbic encephalitis and early cerebral abnormalities detected by 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography-positron emission tomography: a case report

Background

Limbic encephalitis was originally described as a rare clinical neuropathological entity involving seizures and neuropsychological disturbances. In this report, we describe cerebral patterns visualized by positron emission tomography in a patient with limbic encephalitis and cholangiocarcinoma. To our knowledge, there is no other description in the literature of cerebral positron emission tomography findings in the setting of limbic encephalitis and subsequent diagnosis of cholangiocarcinoma.

Case presentation

We describe a case of a 77-year-old Caucasian man who exhibited persistent cognitive changes 2 years before his death. A cerebral scan obtained at that time by 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography-positron emission tomography showed low radiotracer uptake in the frontal and temporal lobes. Cerebrospinal fluid analysis indicated the presence of voltage-gated potassium channel antibodies. Three months before the patient’s death, a lymph node biopsy indicated a cholangiocarcinoma, and a new cerebral scan obtained by 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography-positron emission tomography showed an increment in the severity of metabolic deficit in the frontal and parietal lobes, as well as hypometabolism involving the temporal lobes. Two months before the patient’s death, cerebral metastases were detected on a contrast-enhanced computed tomographic scan. Postmortem examination revealed a cholangiocarcinoma with multiple metastases including the lungs and lymph nodes. The patient’s brain weighed 1300 g, and mild cortical atrophy, ex vacuo dilation of the ventricles, and mild focal thickening of the cerebellar leptomeninges, which were infiltrated by neoplastic epithelial cells, were observed.

Conclusions

These findings support the need for continued vigilance in malignancy surveillance in patients with limbic encephalitis and early cerebral positron emission tomographic scan abnormalities. The difficulty in early diagnosis of small tumors, such as a cholangiocarcinoma, is discussed in the context of the clinical utility of early cerebral hypometabolism detected by 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography-positron emission tomography in patients with rapidly progressive dementia.

Intraductal biopsies in indeterminate biliary stricture: Evaluation of histopathological criteria in fluoroscopy- vs. cholangioscopy guided technique

BACKGROUND

Differentiating malignancy from benign disease in indeterminate biliary stricture by imaging modalities is limited. Definite diagnosis relies on histopathological diagnosis.

AIMS

To assess accuracy of histopathological diagnosis of fluoroscopy-guided vs. cholangioscopy-directed intraductal biopsies in indeterminate biliary stricture.

METHODS

All patients with indeterminate biliary stricture and fluoroscopically (n=68) or cholangioscopy-directed (working channel 2mm, n=38) biopsies were included. Histopathological results of biopsies were classified into inflammatory lesion (class 1), dysplasia/intraepithelial neoplasia (class 2) and malignancy (class 3) and results as well as macroscopic diagnosis were compared with final diagnosis.

RESULTS

Sensitivity and specificity of fluoroscopy-guided vs. cholangioscopy-directed biopsies were 22.9% and 100% vs. 25.0% and 100% for class 1+2 vs. class 3 lesions, respectively. Sensitivity for class 1 vs. class 2+3 lesions was 45.7% (p=0.044) vs. 58.3% (p=0.214) for fluoroscopy-guided vs. cholangioscopy-directed biopsies, respectively, while specificity was 100% in both. There was no difference in size of the obtained sample (p=0.992). True positive diagnosis rate increased with the number of biopsies taken (p=0.028).

CONCLUSION

Fluoroscopy-guided and cholangioscopy-directed intraductal biopsies are equally limited in establishing the diagnosis of malignancy in indeterminate biliary stricture. Categorizing dysplasia or intraepithelial neoplasia as malignancy increases sensitivity without decrease in specificity. By taking more biopsies, diagnostic yield is increased.

[The efficacy of endoscopic endosonography in diagnosis of benign and malignant stenoses of common bile duct]

AIM

To define criteria and to estimate diagnostic significance of endosonography in differential diagnosis of benign and malignant stenoses of common bile duct.

MATERIAL AND METHODS

We presented the results of survey and treatment of 57 patients with benign and malignant stenoses of common bile duct. The technique of endosonography is described. We have formulated major criteria of differential diagnostics of tumoral and non-tumoral lesion of extrahepatic bile ducts. Comparative analysis of endosonography, ultrasound, computed tomography and magnetic resonance cholangiopancreatography was performed.

RESULTS

Sensitivity, specificity and accuracy of endosonography in diagnosis of stenosis cause is 97.7%, 100% and 98.2% respectively. So it exceeds the efficacy of other diagnostic X-ray methods. In modern surgical clinic endosonography should be mandatory performed. It is necessary for final diagnostics of cause of common bile duct stenosis especially in case of its low location.

Evaluation and management of intrahepatic and extrahepatic cholangiocarcinoma

Cholangiocarcinomas are rare biliary tract tumors that are often challenging to diagnose and treat. Cholangiocarcinomas are generally categorized as intrahepatic or extrahepatic depending on their anatomic location. The majority of patients with cholangiocarcinoma do not have any of the known or suspected risk factors and present with advanced disease. The optimal evaluation and management of patients with cholangiocarcinoma requires thoughtful integration of clinical information, imaging studies, cytology and/or histology, as well as prompt multidisciplinary evaluation. The current review focuses on recent advances in the diagnosis and treatment of patients with cholangiocarcinoma and, in particular, on the role of endoscopy, surgery, transplantation, radiotherapy, systemic therapy, and liver-directed therapies in the curative or palliative treatment of these individuals. Cancer 2016;122:1349-1369. © 2016 American Cancer Society.

Triple modality testing by endoscopic retrograde cholangiopancreatography for the diagnosis of cholangiocarcinoma

OBJECTIVES

Brush cytology has a low sensitivity for the diagnosis of cholangiocarcinoma. This study aimed to compare the standard approach (brush cytology) with a triple modality approach utilizing brush cytology, forceps biopsy and fluorescence in situ hybridization in terms of sensitivity and specificity for the diagnosis of cholangiocarcinoma.

METHODS

In a retrospective study at a single academic center, 50 patients underwent triple modality testing. Additionally, 61 patients underwent brush cytology alone. Intervention was endoscopic retrograde cholangiopancreatography with brush cytology, fluorescence in situ hybridization, and forceps biopsy. The main outcome measures included sensitivity, specificity, positive predictive value and negative predictive value.

RESULTS

Overall, 50 patients underwent triple tissue sampling, and 61 patients underwent brush cytology alone. Twenty-two patients were eventually diagnosed with cholangiocarcinoma. Brush cytology had a sensitivity of 42%, specificity of 100%, positive predictive value of 100% and negative predictive value of 88%. Triple tissue sampling had an overall sensitivity of 82%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 87%. Within the triple test group, brush cytology had a sensitivity of 27%, forceps biopsy had a sensitivity of 50%, and fluorescence in situ hybridization analysis had a sensitivity of 59%.

CONCLUSIONS

A triple modality approach results in a marked increase in sensitivity for the diagnosis of cholangiocarcinoma compared with single modality testing such as brush cytology and should be considered in the evaluation of indeterminate or suspicious biliary strictures.

MRI of cholangiocarcinoma

Cholangiocarcinomas are the second most common primary hepatobiliary tumors after hepatocellular carcinomas. They can be categorized either based on their location (intrahepatic/perihilar/extrahepatic distal) or their growth characteristics (mass-forming/periductal-infiltrating/intraductal) because they exhibit varied presentations and outcomes based on their location and or pattern of growth. The increased risk of cholangiocarcinoma in PSC necessitates close surveillance of these patients by means of imaging and laboratory measures; and because currently surgical resection is the only effective treatment for cholangiocarcinoma, the need for accurate pre-operative staging and assessment of resectability has emphasized the role of high quality imaging in management. Today magnetic resonance imaging (MRI) is the modality of choice for detection, pre-operative staging and surveillance of cholangiocarcinoma.

Imaging bile duct tumors: pathologic concepts, classification, and early tumor detection

Cholangiocarcinoma is the most common primary malignancy of the bile ducts which has several predisposing factors such as hepatolithiasis and primary sclerosing cholangitis, and can develop from precancerous conditions such as biliary intraepithelial neoplasia and intraductal papillary neoplasm of the bile duct. As surgical resection of early stage cholangiocarcinoma or precancerous lesions may provide better prognosis, early detection of those lesions is very important. Imaging studies play important roles in the diagnosis of bile duct tumors followed by appropriate management. Indeed, not only diagnosis of cholangiocarcinoma but also appropriate categorization of bile duct tumors based on their morphologic features and location on cross-sectional imaging studies, including computed tomography and magnetic resonance imaging, is important to predict their biologic behaviors, and choose relevant treatment strategies. We herein review the classification system of the bile duct tumors with their radiologic and pathologic findings as well as role of imaging in the early detection of bile duct tumors.

Clinical application of a single-operator direct visualization system improves the diagnostic and therapeutic yield of endoscopic retrograde cholangiopancreatography

BACKGROUND

Single-operator cholangioscopy enables direct diagnostic visualization and therapeutic intervention in the biliary tree. There is increasing evidence of its clinical utility in the assessment of biliary strictures and treatment of difficult stones.

OBJECTIVE

To describe the first reported Canadian experience with managing biliary disease using single-operator cholangioscopy.

METHODS

The present study was a retrospective analysis of data collected from all sequential patients undergoing single-operator cholangioscopy for assessment of biliary strictures and treatment of biliary stones. The main outcome measures were the ability to make an overall diagnosis of stricture (based on visual appearances and tissue histology), and to fragment and extract biliary stones.

RESULTS

Thirty patients (17 women), mean age 66 years (range 41 to 89 years) underwent single-operator cholangioscopy. In biliary strictures (20 patients), overall accuracy for visual and tissue diagnosis was 84% and 81%, respectively. Successful electrohydraulic lithotripsy with stone clearance was achieved in 90% of the 10 patients who failed previous conventional therapy. The mean (± SD) procedure time was 61±21 min (range 20 min to 119 min). One patient developed mild postendoscopic retrograde cholangioscopy pancreatitis.

CONCLUSION

The results of this experience reaffirms the clinical utility and safety of single-operator cholangioscopy for the management of biliary pathology. Further improvements can be achieved with increasing operator experience and refinements in optical technology.

Cholangioscopy: the biliary tree never looked so good!

PURPOSE OF REVIEW

Endoscopists have long awaited advances in the equipment and techniques for cholangiopancreatoscopy. Since the turn of the millennium, endoscopists have witnessed an explosion in the development and refinement of the capabilities of cholangioscopes as they move from being almost exclusive to tertiary care academic settings to a wider range of practices.

RECENT FINDINGS

Studies have tested and constructively critiqued the procedure, hoping to increase the success rate of diagnostic and therapeutic interventions. Many have found significant improvement upon the limitations of radiographic imaging in diagnosing diseases and achieving full clearance of biliary stones. Image quality has improved with a range of features. However, most of these still need to be studied further. The addition of balloon catheters and overtubes has improved stability and access to the biliary ducts, but comes with complications that need to be studied further.

SUMMARY

Although we still have improvements to yearn for, the future looks bright. As endoscopists continue their commitment to the promise of direct visualization of the biliary trees and the complementary tools for diagnosis and treatment, we are continuing to raise quality of care for patients with complicated biliary diseases.

An Oncocytic Variant of Intraductal Papillary Neoplasm of the Bile Duct that Formed a Giant Hepatic Cyst

Intraductal papillary neoplasms of the bile duct (IPNB) is the collective term used to refer to papillary bile duct tumors, mucin producing bile duct tumors, and cystic bile duct tumors. Pathologically, these tumors may be considered a highly differentiated adenocarcinoma or a tumor of borderline malignant potential. IPNB is classified into one of four variants based on cell differentiation. The rarest, oncocytic, is characterized by oxyphilic granular cytoplasm and no mucous cell differentiation. The patient, a 59-year old man, was admitted with a complaint of abdominal fullness and a 30×25 cm cystic mass in the right hepatic lobe demonstrated on computed tomography (CT). The mass had no malignant features on CT or magnetic resonance imaging; however, a portion was FDG avid on ¹⁸F-fluorodeoxyglucose positron emission tomography scan (FDG-PET). A fenestration operation was performed for the presumed diagnosis of a hepatic cyst. Pathological examination of the cyst contents demonstrated some atypical cells suspicious for malignancy. After eight months of observation, abnormal FDG uptake was again observed at the residual cyst. A partial hepatectomy was performed to excise the cyst. Pathological examination demonstrated adenocarcinoma in situ derived from an oncocytic IPNB variant. Following the resection, the patient remained disease free for 40 months. This is an extremely rare case of an oncocytic variant of IPNB that was difficult to distinguish clinically from a solitary hepatic cyst.

The role of peroral video cholangioscopy in patients with IgG4-related sclerosing cholangitis

BACKGROUND

The cholangioscopic features of IgG4-related sclerosing cholangitis (IgG4-SC) remain undefined. The aim of this study was to clarify these endoscopic features using peroral video cholangioscopy (PVCS) in IgG4-SC patients.

METHODS

PVCS was performed in 33 patients: IgG4-SC (n = 13); primary sclerosing cholangitis (PSC; n = 5); and cholangiocarcinoma (n = 15), which included hilar cholangiocarcinoma (HCCA; n = 5) and distal cholangiocarcinoma (DCCA; n = 10).

RESULTS

The most frequent findings on PVCS in the IgG4-SC patients were dilated (62 %) and tortuous (69 %) vessels, and absence of partially enlarged vessels. The incidence of dilated and tortuous vessels was significantly higher in IgG4-SC patients than in PSC patients (p = 0.015). Scarring and pseudodiverticula were found significantly more often in PSC patients than in IgG4-SC patients (p = 0.001 and p = 0.0007, respectively). The incidence of partially enlarged vessels was significantly higher in DCCA patients than in IgG4-SC patients (p = 0.004). In contrast, the incidence of dilated vessels was significantly higher in IgG4-SC patients than in HCCA patients (p = 0.015). PVCS performed after corticosteroid therapy showed resolution of bile duct stenosis and dilated, tortuous, or partially enlarged vessels, as well as resolution of friability in all patients with IgG4-SC.

CONCLUSION

Cholangioscopy was useful in differentiating IgG4-SC from PSC. In addition, monitoring the patterns of proliferative vessels on PVCS may be useful to differentiate IgG4-SC from cholangiocarcinoma.

Endomicroscopy of the pancreaticobiliary system

It is often difficult to accurately differentiate between benign and malignant pancreaticobiliary strictures, and some are interpreted as indeterminate despite ERCP, EUS, or radiological imaging techniques, thereby making it difficult for the clinician to make appropriate management decisions. Probe-based confocal laser endomicroscopy (pCLE) is an innovative imaging tool integrating real-time in vivo imaging of these difficult-to-interpret strictures in the pancreaticobiliary system during endoscopy. Recent studies of endomicroscopy have shown a promising role with improved accuracy in distinguishing these lesions, thus paving the way for future research addressing improving precise interpretation, training, and long long-term impact.

Tissue yield and diagnostic efficacy of fluoroscopic and cholangioscopic techniques to assess indeterminate biliary strictures

BACKGROUND & AIMS

Evaluation of indeterminate biliary strictures typically involves collection and analysis of tissue or cells. Single-operator, peroral, cholangioscopic techniques have been developed that allow for a biopsy sample to be obtained from a specific area of the visualized stricture. We investigated whether standard fluoroscopic-guided and cholangioscopic-directed (SpyGlass Direct Visualization System; Boston Scientific, Natick, MA) biopsy collection provide adequate tissue for histologic assessment.

METHODS

We examined 110 consecutive bile duct specimens collected from 89 patients with indeterminate biliary strictures at a single institution using fluoroscopy or cholangioscopy (from October 2007 to March 2010). Because of the small nature of the intraductal biopsy fragments, special procedures were followed in the pathology laboratory to maximize the amount of tissue for histopathology analysis.

RESULTS

Only 4 specimens (3.6%) had insufficient material for a diagnosis. More tissue was obtained from standard fluoroscopic-guided than cholangioscopic-directed biopsies (more biopsy fragments, P = .018; larger total biopsy size, P = .001). Fluoroscopy-guided biopsies assessed indeterminate biliary strictures with 76% sensitivity and 88% accuracy; these values were 57% and 78%, respectively, for cholangioscopic-directed biopsies. Each procedure had 100% specificity.

CONCLUSIONS

Analysis of bile duct biopsies is important in management of patients with indeterminate biliary strictures. Use of a special handling protocol for these small biopsies could reduce the number of cases with insufficient material for diagnosis. Increasing the sample size (either by using larger biopsy forceps or obtaining more biopsy bites) could improve the sensitivity of the SpyGlass technique. As endoscopists and pathologists gain more experience in collecting and handling small biopsies, the diagnostic efficacy of intraductal biopsies will continue to improve.

Characteristic MR and CT imaging findings of hepatobiliary paragonimiasis and their pathologic correlations

BACKGROUND

Hepatobiliary paragonimiasis (HP) is not commonly encountered and may be confused with hepatobiliary tumors; however, computed tomography (CT) and magnetic resonance imaging (MRI) features of HP allow this entity to be distinguished from other diseases.

PURPOSE

To present the CT and MRI findings in patients with HP and to describe some specific imaging findings along with their pathological correlations.

MATERIAL AND METHODS

Imaging and clinical findings of 21 patients (9 boys/men and 12 girls/women; age range 3-67 years; mean age 40 years) who were diagnosed with HP were retrospectively evaluated. Among these patients, 16 underwent CT examination only, two had MR examination only, and three underwent both CT and MR. All patients underwent surgery, and the HP diagnosis was confirmed by the surgical and histopathologic results.

RESULTS

Chronic abdominal pain or back pain was reported by 14 patients, severe abdominal pain with acute onset was reported by one patient, and six patients were asymptomatic and were discovered incidentally. Peripheral eosinophilia was present in 14 patients (14/21, 66.7%), and abnormal liver function tests were found in 16 patients (16/21, 76.2%). Of the 19 patients who underwent CT imaging, 17 patients showed multiple mixed hypodense lesions or multiple cysts with inlaying septation with separate irregular rims or circular enhancement on post-contrast CT images. Tunnel-shaped microabscesses and necrotic cavities were found in the lesions of 12 of those 17 patients. The other two patients showed smaller cystic masses. MRI showed faveolate T1 hypointense and T2 hyperintense areas in the liver parenchyma with rim or peripheral enhancement. Nodular or circular hyperintense materials were found scattered in the lesions on T1-weighted imaging.

CONCLUSION

CT and MRI can reveal the radiological-pathological features of HP. Together with laboratory findings, MRI and CT findings may provide diagnostic clues, especially in endemic areas, that are very important for the selection of treatment methods.

A novel method of forceps biopsy improves the diagnosis of proximal biliary malignancies

BACKGROUND AND AIMS

Tissue specimen collection represents a cornerstone in diagnosis of proximal biliary tract malignancies offering great specificity, but only limited sensitivity. To improve the tumor detection rate, we developed a new method of forceps biopsy and compared it prospectively with endoscopic transpapillary brush cytology.

PATIENTS AND METHODS

43 patients with proximal biliary stenoses, which were suspect for malignancy, undergoing endoscopic retrograde cholangiography were prospectively recruited and subjected to both biopsy [using a double-balloon enteroscopy (DBE) forceps under a guidance of a pusher and guiding catheter with guidewire] and transpapillary brush cytology. The cytological/histological findings were compared with the final clinical diagnosis.

RESULTS

35 out of 43 patients had a malignant disease (33 cholangiocarcinomas, 1 hepatocellular carcinoma, 1 gallbladder carcinoma). The sensitivity of cytology and biopsy in these patients was 49 and 69%, respectively. The method with DBE forceps allowed a pinpoint biopsy of the biliary stenoses. Both methods had 100% specificity, and, when combined, 80% of malignant processes were detected. All patients with non-malignant conditions were correctly assigned by both methods. No clinically relevant complications were observed.

CONCLUSIONS

The combination of forceps biopsy and transpapillary brush cytology is safe and offers superior detection rates compared to both methods alone, and therefore represents a promising approach in evaluation of proximal biliary tract processes.