Brush cytology of the biliary tract: retrospective study of 278 cases with histopathologic correlation

Advances in diagnostic liquid-based cytology

Liquid-based cytology (LBC) has changed the landscape of gynaecological cytology. A growing demand exists for LBC in diagnostic cytology, particularly for ancillary testing, such as immunocytochemistry and molecular testing. Ancillary testing solely based on conventional preparation (CP) methods remains challenging. Recently, the increased demand for specialist testing and minimally invasive techniques, such as endoscopic ultrasonography fine-needle aspiration, to obtain cellular samples has led to an increasing demand for ancillary testing on cytology LBC supernatant, slides and cell block (CB). This facilitates the diagnosis and prognosis in cytology samples enabling personalized treatment. An understanding of the history and future prospects of LBC is crucial for its application in routine diagnostics by cytopathologists and cytotechnologists. In this review, we initiated an internet search using the keyword 'liquid-based cytology', and we conducted a literature review to discuss the usefulness of combined diagnosis of LBC and CP, immunocytochemistry and molecular testing and assessed the quality of nucleic acids in diagnostic LBC. High-quality and cell-rich diagnostic LBC surpassed the CP method alone in terms of reliability and versatility of ancillary testing in cytological diagnosis. Conclusively, diagnostic LBC lends itself to various new technologies and is expected to continue evolving with innovations in the future.

Neuroendocrine Tumours of Extrahepatic Biliary Tract: Report of Four Cases with Literature Review

Neuroendocrine tumours (NETs) originating from extrahepatic bile duct are an extremely rare entity. They are typically slow growing tumours with malignant potential. Commonly presenting as obstructive jaundice, preoperative clinico-radiologic differentiation between extrahepatic biliary tract neuroendocrine tumours and cholangiocarcinoma is difficult and the final diagnosis is usually established after surgical histopathology and immunohistochemistry examination. R0 resection offers the only curative option with good long-term outcomes for well-differentiated NETs (grade1, grade2, and grade3) while the aggressive poorly differentiated neuroendocrine carcinoma (NEC) needs multimodality approach. We present our experience of management of four cases including three cases of grade II NET and one case of NEC undergoing surgical resection at a single centre with a short review of available literature.

Pronounced squamous cell contamination in biliary tract cytology: A diagnostic pitfall

Squamous cells are rarely found in biliary tract cytology specimens, and when present are typically scant in quantity. Over an 8-year time period, two cases at our institution reporting abundant squamous cells were identified. Both patients underwent endoscopic retrograde cholangiopancreatography with bile duct brushings and removal of a migrated biliary stent. The migrated stents were retrieved using rat toothed forceps and required removal of the endoscope through the esophagus with the stent exposed to esophageal and oral mucosa outside of the endoscope. Cytologic examination of the accompanying biliary stent material accordingly revealed abundant benign squamous cells. However, bile duct brushings showed benign ductal epithelial cells without squamous cells. Prior and subsequent cytology and bile duct surgical pathology specimens did not show squamous metaplasia. Migrated biliary stents that require endoscopic withdrawal increase the risk of contaminating samples with squamous cells. Recognition of this unique scenario is important, as the differential diagnosis includes squamous metaplasia and squamous neoplasia.

Predictors of Malignancy in Patients With Indeterminate Biliary Strictures and Atypical Biliary Cytology: Results From Retrospective Cohort Study

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.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Percutaneous Image-Guided Biliary Procedures

Percutaneous biliary interventions are among the commonly performed nonvascular radiological interventions. Most common of these interventions is the percutaneous transhepatic biliary drainage for malignant biliary obstruction. Other biliary procedures performed include percutaneous cholecystostomy, biliary stenting, drainage for bile leaks, and various procedures like balloon dilatation, stenting, and large-bore catheter drainage for bilioenteric or post-transplant anastomotic strictures. Although these procedures are being performed for ages, no standard guidelines have been formulated. This article attempts at preparing guidelines for performing various percutaneous image-guided biliary procedures along with discussion on the published evidence in this field.

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.

Tiny but mighty: use of next generation sequencing on discarded cytocentrifuged bile duct brushing specimens to increase sensitivity of cytological diagnosis

Bile duct brushing (BDB) is used to evaluate pancreatobiliary lesions as it widely samples lesions with a low complication rate. Cytological evaluation of BDB is a specific but insensitive test. There is limited literature on the use of post-cytocentrifuged (PCC) samples, which are usually discarded, for next-generation sequencing (NGS) as an adjunct to cytological diagnosis of BDB. In this study we investigate whether molecular analysis by NGS of PCC specimens improves the sensitivity of diagnosis. PCC samples from 100 consecutive BDB specimens spanning 93 unique patients were retained. DNA was extracted and mutational analysis was performed agnostic of morphologic or clinical findings. Each BDB specimen was characterized as negative, atypical or positive based on morphological analysis by trained cytopathologists. Performance characteristics for mutational profiling and morphological analysis were calculated on the basis of clinicopathologic follow-up. There was sufficient clinicopathologic follow-up to classify 94 of 100 cases as either malignant (n = 43) or benign (n = 51). Based on morphologic analysis of cytology, these 94 cases were classified as either benign (n = 55), atypical (n = 18), or as at least suspicious or positive for malignancy (n = 21). Morphologic analysis of cytology showed a sensitivity of 49% and a specificity of 100% if atypical cases were considered negative. NGS revealed oncogenic alterations in 40/43 (93%) of malignant cases based on clinicopathologic follow-up. The most common alterations were in KRAS and TP53, observed in 77% and 49% of malignant cases respectively. No alterations were observed in the 51 benign cases classified based on clinicopathologic follow-up. Supplementing cytomorphologic analysis with molecular profiling of PCC by targeted NGS analysis increased the sensitivity to 93% and maintained specificity at 100%. This study provides evidence for the utility of NGS molecular profiling of PCC specimens to increase the sensitivity of BDB cytology samples, although studies with larger cohorts are needed to verify these findings.

Neuroendocrine carcinoma diagnosis from bile duct cytological specimens: A retrospective single-center study

Neuroendocrine carcinoma (NEC) in the extrahepatic bile duct is extremely rare and clinically aggressive. Cytological examination of bile and/or bile duct brushing specimens plays an important role in the diagnosis of carcinoma of the extrahepatic bile duct, but only a few articles have described the cytological features of NEC in this area. Thus, we retrospectively analyzed the cytological features of NEC in bile and/or bile duct brushing specimens. Patients with a histopathological diagnosis of NEC who underwent bile and/or bile duct brush cytological examination were enrolled in this study. The cytological features, including the background, arrangement, and shape of the neoplastic cells, and nuclear and cytoplasmic features were reviewed. Six patients with small cell NEC were enrolled, and two of them had pancreatic tumors directly invading the bile duct wall. The cytological specimens showed small and/or large neoplastic cell clusters with occasional single cells in all cases. The neoplastic cells had a high nuclear/cytoplasmic ratio and round-to-oval nuclei with powdery chromatin, inconspicuous nucleoli, and scant cytoplasm. Nuclear molding was a characteristic finding in all cases. One case had an adenocarcinoma component, which was also present in the cytological specimen. Cytological examination of bile and/or bile duct brushing specimens can be useful for the diagnosis of small cell NEC. This is an extremely rare but aggressive carcinoma, and its diagnosis by identifying characteristic cytological features may facilitate early detection and treatment.

Factors Impacting the Performance Characteristics of Bile Duct Brushings: A Clinico-Cytopathologic Analysis of 253 Patients

Context.—

Literature on factors impacting bile duct brushings (BDBs) performance characteristics remain limited.

Objective.—

To capture the current state of daily practice with BDB sign-out.

Design.—

Two hundred fifty-three of 444 BDBs signed out by more than 7 cytopathologists, with histopathologic and/or clinical follow-up of at least 18 months, were examined.

Results.—

One hundred thirty-five of 253 BDBs (53%) had histologically confirmed malignancies, 22 (9%) had cancer-related deaths, and 96 (38%) were benign. Cytologic diagnoses in the 444 BDBs were nondiagnostic (11 [2.5%]), negative (284 [64%]), atypical (62 [13.9%]), suspicious (34 [7.7%]), and malignant (53 [11.9%]). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of malignancy detection were 35%, 100%, 100%, 58%, and 66%, respectively. When atypical, suspicious, and malignant (ASM) categories were combined, sensitivity increased (58%), specificity and PPV dropped (97%), and accuracy increased (73%). Carcinoma type (bile-duct versus pancreatic-ductal) had no effect on accuracy (P = .60) or diagnostic class (P = .84), nor did time of performance (first 7.5 versus latter 7.5 years, P = .13). Interestingly, ThinPrep + cell block (n = 41) had higher sensitivity (61%) and lower specificity (80%) than ThinPrep only (versus 51% and 100%, respectively). Sensitivity and specificity were higher (47% and 100%) in nonstented than stented specimens (59% and 97%). Relative risk of malignancy for “suspicious” (2.30) and “atypical” (2.28) categories was lower but not very different from that of “malignant” category (2.41).

Conclusions.—

Bile duct brushings had fairly low sensitivity but high specificity and PPV with no false positives. Sensitivity almost doubled and specificity dipped minimally when ASM categories were combined, highlighting the need for better classification criteria for atypical/suspicious cases. Higher specificity, PPV, NPV, and accuracy but lower sensitivity in stented BDBs suggest that they be called malignant only when evidence is overwhelmingly convincing.

Cytologic predictors of malignancy in bile duct brushings: a multi-reviewer analysis of 60 cases

Diagnosing malignancy in bile duct brushings is highly challenging. Seven reviewers of variable backgrounds and levels of participation in bile duct brushing sign out blindly reviewed 60 specimens (30 malignant with histologic confirmation and 30 benign (15 stented) with resection or ≥18 months of uneventful follow-up), testing the utility of 14 malignant characteristics. Eleven characteristics were statistically significantly associated with malignancy including 3-dimensional clusters (63% in malignant vs 3% in benign, odds ratio 50, P=0.0003), pleomorphism (62 vs 3, odds ratio 48, P=0.0004), 2-cell population (60% vs 3, odds ratio 44, P=0.0005), chromatin pattern (hypo/hyperchromasia) changes (70% vs 7%, odds ratio 33, P<0.0001), high nuclear-to-cytoplasmic ratio (48 vs 3%, odds ratio 27, P=0.0023), cytoplasmic vacuoles (43 vs 3%, odds ratio 22, P=0.0042), nuclear irregularity (70 vs 10%, odds ratio 21, P<0.0001), cellular discohesion (38 vs 3%, odds ratio 18, P=0.0082), hypercellularity (23% vs 0), nuclear molding (20% vs 0) and prominent nucleoli (21% vs 0). Necrosis and infiltrating inflammation were not helpful in identifying malignancy ('neutrophil cannibalism' was noted in 43% malignant); 21/30 (70%) malignant brushings had ≥3 malignant characteristics, while 23 (77%) benign brushings had none. Of 20 brushings with ≥4 characteristics, 1(5%) proved benign and showed detachment atypia, a close malignant mimicker in brushings. Identification of 3 characteristics maximized the combined sensitivity (70%), specificity (97%) and accuracy (83%), but sensitivity dropped as number of characteristics increased. Identification of 3/11 characteristics (3-dimensional clusters, pleomorphism, high nuclear-to-cytoplasmic ratio, nuclear irregularity, hypercellularity, discohesion, chromatin changes, vacuoles, prominent nucleoli, molding and 2-cell population) improves pathologists' overall performance greatly.

A Microfluidic Chip for Detecting Cholangiocarcinoma Cells in Human Bile

Cholangiocarcinoma (CCA), a biliary tract malignancy, accounts for 20% of all liver cancers. There are several existing methods for diagnosis of CCA, though they are generally expensive, laborious, and suffer from low detection rates. Herein we first developed a means of partially purifying human bile for consequent injection into a microfluidic chip. Then, the novel microfluidic system, which featured 1) a cell capture module, 2) an immunofluorescence (IF) staining module featuring two CCA-specific biomarkers, and 3) an optical detection module for visualization of antibody probes bound to these CCA marker proteins, was used to detect bile duct cancer cells within partially purified bile samples. As a proof of concept, CCA cells were successfully captured and identified from CCA cell cultures, blood samples inoculated with CCA cells, and clinical bile specimens. In 7.5 ml of bile, this system could detect >2, 0, and 1 positive cells in advanced stage patients, healthy patients, and chemotherapy-treated patients, respectively. In conclusion, our microfluidic system could be a promising tool for detection of cancer cells in bile, even at the earliest stages of CCA when cancer cells are at low densities relative to the total population of epithelial cells.

A multistep cytological approach for patients with jaundice and biliary strictures of indeterminate origin

AIMS

Fluorescence in situ hybridisation (FISH) increases the sensitivity for detecting pancreatobiliary tract cancer over routine cytology. In this study, diagnostic accuracy and costs of cytology and FISH in detecting cancer in patients with jaundice with biliary strictures were assessed.

METHODS

Brushing specimens from 109 patients with jaundice were obtained during endoscopic retrograde cholangiopancreatography and examined by cytology and FISH. The specimens were considered FISH-positive for malignancy if at least five polysomic cells or 10 cells with homozygous or heterozygous 9p21/p16 deletion were detected. Definitive diagnosis of the stricture as benign or malignant relied on surgical pathology (45 cases) or clinical-radiological follow-up >18 months (64 cases). We calculated costs of cytology and FISH based on the reimbursement from the Piedmont region, Italy (respectively, €33 and €750).

RESULTS

Ninety of 109 patients had evidence of malignancy (44 pancreatic carcinomas, 36 cholangiocarcinomas, 5 gallbladder carcinomas, 5 other cancers), while 19 had benign strictures. Routine cytology showed 42% sensitivity, but 100% specificity for the diagnosis of malignancy, while FISH-polysomy showed 70% sensitivity with 100% specificity and FISH-polysomy plus homozygous or heterozygous 9p21/p16 deletion showed 76% sensitivity with 100% specificity. The cost per additional correct diagnosis of cancer obtained by FISH, in comparison with cytology, was €1775 using a sequential cytological approach (ie, performing FISH only in patients with negative or indeterminate cytology).

CONCLUSIONS

FISH should be recommended as the second step in detecting cancer in patients with jaundice with pancreatobiliary tract strictures and cytology negative or indeterminate for malignancy.

Interobserver agreement for evaluation of imaging with single operator choledochoscopy: what are we looking at?

BACKGROUND

Single operator choledochoscopy is a platform used to assist in the confirmation of diagnosis of biliary lesions. However, there are little data regarding the interobserver agreement of imaging interpretation. Our objective was to assess the interobserver agreement in single operator choledochoscopy interpretation.

METHODS

38 De-identified SPY Choledochoscopy video clips were sent to 7 interventional endoscopists. They were asked to score the videos on presence of four criteria selected by the investigators: growth, stricture, hyperplasia, and ulceration. Observers also chose a final diagnosis from the categories of cancer, hyperplasia, inflammation, or normal. Kappa scores were calculated for the scoring of the four criteria and for the selection of the final diagnosis.

RESULTS

The overall interobserver agreement was fair in scoring for the presence of a growth (K=0.28, SE 0.035) and stricture (K=0.32, SE 0.035). Scoring for ulceration was slight to fair (K=0.17, SE 0.035). There was only slight agreement for the presence of hyperplasia (K=0.11, SE 0.035); and presumed final diagnosis based on imaging (K=0.18, SE 0.022).

CONCLUSION

The results of this study support the need for an effort to identify and validate cholangioscopy imaging criteria for biliary pathology. This may assist in improving the reliability of the diagnostic value of cholangioscopy as its use becomes more widespread.

Role of biliary tract cytology in the evaluation of extrahepatic cholestatic jaundice

Background:

Endoscopic evaluation is critical in assessing the cause of obstructive jaundice. Cytological techniques including bile aspiration and biliary brushings have become the initial diagnostic modality.

Aim:

The aim of this study is to evaluate the role of endoscopic biliary tract cytology as a diagnostic tool in the evaluation of extrahepatic cholestatic jaundice.

Materials and Methods:

A total of 56 biliary tract specimens including 34 bile aspirations and 22 biliary brushings from 41 consecutive patients who had presented with obstructive jaundice and underwent endoscopic retrograde cholangiopancreatography (ERCP) were assessed by cytological examination. The smears prepared were analyzed for standard cytological features.

Results:

Cytologic diagnosis was adenocarcinoma in 13 (31.7%) cases, atypical in 2 (4.9%), reactive in 3 (7.3%) and benign changes in 19 (46.3%) cases. 4 (9.8%) cases were non-diagnostic. Serum bilirubin was significantly elevated in the malignant group. Biliary stricture was the most common finding on ERCP (68.3%). On cytological examination, presence of solitary, intact atypical cells, enlarged nuclei, irregular nuclear membrane, coarse chromatin and nucleoli were important cytologic criteria for differentiating malignant from benign biliary specimens.

Conclusions:

Regular use of bile cytology and brushings during ERCP evaluation of extrahepatic cholestatic jaundice is invaluable in obtaining a morphologic diagnosis. A systematic approach, use of strict cytomorphologic criteria and inclusion of significant atypia as malignant diagnosis may improve the sensitivity.

Primary sclerosing cholangitis with equivocal cytology: fluorescence in situ hybridization and serum CA 19-9 predict risk of malignancy

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.

A proposal of a diagnostic algorithm with validation of International Consensus Diagnostic Criteria for autoimmune pancreatitis in a Japanese cohort

BACKGROUND

Among many diagnostic criteria for autoimmune pancreatitis (AIP), the International Consensus Diagnostic Criteria (ICDC) first enabled us to diagnose and compare type 1 and type 2 AIP, which permitted tailoring individual diagnostic algorithms depending on local expertise. We compared them and validated ICDC with special reference to levels 1 and 2, and proposed a diagnostic algorithm for AIP in Japan.

METHODS

The diagnostic sensitivity of 5 major criteria (ICDC, Korean, Japanese-2011, Asian, and HISORt criteria) was compared, using 61 patients with AIP. Fifty six patients with pancreatic cancer served as a control. Pancreas imaging on computed tomography (CT) and endoscopic retrograde pancreatography (ERP) were independently evaluated by 3 pancreatologists (5, 10, and 20 years of career experience) and each diagnostic criterion of ICDC was validated with special reference to levels 1 and 2.

RESULTS

The sensitivities of 5 major criteria were 95.1% (ICDC), 90.2% (Korean), 86.9% (Japanese), 83.6% (Asian), and 83.6% (HISORt) with 100% of specificity in each. In the evaluation of pancreas imaging, diagnostic sensitivities of combination with CT and ERP in segmental/focal type AIP were significantly higher than single imaging (26% in CT (P < 0.01) or 35% in ERP (P < 0.05) vs 63% in CT + ERP), but not significantly different in the diffuse type.

CONCLUSIONS

Of the 5 criteria, ICDC is the most sensitive and useful for diagnosing AIP. We have proposed a diagnostic algorithm with CT for the diffuse type of AIP, and combination with CT + ERP followed by EUS-FNA for the segmental/focal type.

Bile aspiration cytology in diagnosis of bile duct carcinoma: factors associated with positive yields

BACKGROUND/PURPOSE

In bile duct carcinoma (BDC) patients, bile aspiration cytology (BAC) is an established method for cytodiagnosis. However, almost all previous reports investigated the biliary strictures caused not only by BDC but also by gallbladder and pancreatic carcinomas. Therefore, BAC in BDC patients only has not yet been investigated sufficiently. The aim of this study was to evaluate the actual sensitivity of BAC and to evaluate the factors that affect positive yields of BAC in patients with defined BDC.

METHODS

Data on 47 consecutive patients with definite BDC, who underwent BAC via endoscopic nasobiliary drainage (ENBD) or percutaneous transhepatic cholangiodrainage (PTCD), were retrospectively collected. Fourteen factors were studied for association with positive BAC.

RESULTS

The number of cytological samplings ranged from 1 to 14 times. The cumulative diagnostic yield was 72.3% (34/47), and 32 positive results were obtained at a maximum of six samplings. Independent factors associated with positive BAC were perihilar location, stricture length ≥ 2 cm, and macroscopic papillary type.

CONCLUSION

In BDC patients with ENBD or PTCD, repeated BAC is useful, and six times was the optimum number of repeat samplings. Although the sensitivity of BAC is not sufficient for the preoperative diagnosis of malignant biliary stricture, the three independent factors noted above predict positive yields and indicate whether or not BAC should be repeated up to six times.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Identification of factors predictive of malignancy in patients with atypical biliary brushing results obtained via ERCP

Biliary brushings obtained during ERCP can have one of three cellular interpretations: benign, malignant, or "atypical." Atypical interpretations usually result in further testing, and may cause controversy over management and increases in cost. We evaluated a large cohort of patients with atypical biliary brushings for analysis and risk stratification. All biliary brushing specimens collected between January 1, 2001 and December 31, 2010 that had an atypical result were included. Hospital electronic records were reviewed for these patients to include: demographics, indication for ERCP, endoscopist/pathologist impressions, serologic testing, stricture site, and information relating to the final clinical diagnosis. Eighty-six patients were included. Totally, 60/86 patients (70%) had malignancies while 26/86 (30%) had no evidence of malignancy during long term follow up. Univariate analysis showed that the risk of malignant outcomes was significantly associated with older age, suspicious/malignant endoscopic impression, pancreatic mass, indications including jaundice and/or dilated bile ducts, stricture location within the common bile duct, PSC, and CA 19-9 levels >300 U/mL. We created a novel scoring system for prediction of malignancy based on clinical and endoscopic factors. We identified parameters that are typically available to the clinician to categorize patients with an "atypical" bile duct brushing results into "high risk" and "lower risk" classifications. Our proposed scoring system would allow such risk stratification to take place.

Differentiation of multiple types of pancreatico-biliary tumors by molecular analysis of clinical specimens

Timely and accurate diagnosis of pancreatic ductal adenocarcinoma (PDAC) is critical in order to provide adequate treatment to patients. However, the clinical signs and symptoms of PDAC are shared by several types of malignant or benign tumors which may be difficult to differentiate from PDAC with conventional diagnostic procedures. Among others, these include ampullary cancers, solid pseudopapillary tumors, and adenocarcinomas of the distant bile duct, as well as inflammatory masses developing in chronic pancreatitis. Here, we report an approach to accurately differentiate between these different types of pancreatic masses based on molecular analysis of biopsy material. A total of 156 bulk tissue and fine needle aspiration biopsy samples were analyzed using a dedicated diagnostic cDNA array and a composite classification algorithm developed based on linear support vector machines. All five histological subtypes of pancreatic masses were clearly separable with 100% accuracy when using all 156 individual samples for classification. Generalized performance of the classification system was tested by 10 × 10-fold cross validation (100 test runs). Correct classification into the five diagnostic groups was demonstrated for 81.5% of 1,560 test set predictions. Performance increased to 85.3% accuracy when PDAC and distant bile duct carcinomas were combined in a single diagnostic class. Importantly, overall sensitivity of detection of malignant disease was 92.2%. The molecular diagnostic approach presented here is suitable to significantly aid in the differential diagnosis of undetermined pancreatic masses. To our knowledge, this is the first study reporting accurate differentiation between several types of pancreatico-biliary tumors in a single molecular analytical procedure.

Benign biliary strictures: a current comprehensive clinical and imaging review

OBJECTIVE

There is a wide spectrum of nonneoplastic causes of biliary stricture that can pose a significant challenge to clinicians and radiologists. Imaging plays a key role in differentiating benign from malignant strictures, defining the extent, and directing the biopsy. We describe the salient clinical and imaging manifestations of benign biliary strictures that will help radiologists to accurately diagnose these entities.

CONCLUSION

Accurate diagnosis and management are based on correlating imaging findings with epidemiologic, clinical, and laboratory data. Cross-sectional imaging modalities permit precise localization of the site and length of the segment involved, thereby serving as a road map to surgery, and permit exclusion of underlying malignancy.

Peroral cholangioscopy in the new millennium

Peroral cholangioscopy was first described in 1970s and has recently gained popularity. Peroral cholangioscopy is appealing to therapeutic endoscopists because a direct intraluminal view of the biliary duct system offers possibilities for diagnosis and interventions beyond that which other imaging or endoscopic modalities can provide. As the image quality of cholangioscopies improves, so too does their diagnostic capability, and as their durability and maneuverability increases, so too does their potential use for therapeutic applications. This editorial is intended to provide a brief review of recent developments in peroral cholangioscopy and current indications for its use.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Improving cellularity and quality of liquid-based cytology slides processed from pancreatobiliary tract brushings

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.

Comparison of KRAS mutation analysis and FISH for detecting pancreatobiliary tract cancer in cytology specimens collected during endoscopic retrograde cholangiopancreatography

Pancreatobiliary tract strictures result either from malignancies of the biliary tract and pancreas or from nonmalignant etiopathogenesis. The goal of this study was to determine whether KRAS mutations could be identified in residual pancreatobiliary stricture brushings and to compare the performance characteristics of KRAS mutation analysis to cytology and fluorescence in situ hybridization (FISH) for the detection of carcinoma. Residual brushing cytology cell pellets were retrieved from 132 patients with subsequent clinicopathologic follow-up of cholangiocarcinoma (n = 41), pancreatic adenocarcinoma (n = 35), gallbladder cancer (n = 2), and nonmalignant strictures (n = 54). All specimens had a prior cytology and FISH UroVysion results as part of clinical practice. KRAS mutation analysis was performed using the quantitative PCR DxS KRAS Mutation Test Kit. KRAS mutation analysis was successful in 130 of 132 specimens. KRAS mutations and polysomic (ie, positive) FISH results were identified in 24 (69%) and 22 (63%) pancreatic adenocarcinoma specimens, respectively, with a combined sensitivity of 86% (30/35). KRAS mutations and polysomic FISH results were identified in 12 (29%) and 17 (41%) cholangiocarcinoma specimens, with a combined sensitivity of 54% (22/41). KRAS mutations were identified in two patients with primary sclerosing cholangitis, and benign follow-up. Residual cytology specimens can be used to detect KRAS mutations by quantitative PCR. Combined KRAS mutation and FISH analysis appear to increase the cancer detection rate in patients with pancreatobiliary strictures.

Advanced cytologic approaches for the diagnosis of pancreatobiliary cancer

PURPOSE OF REVIEW

The review will provide information on the use of advanced cytologic techniques such as fluorescence in-situ hybridization (FISH) and digital image analysis (DIA) for the detection of pancreatobiliary malignancy.

RECENT FINDINGS

FISH and DIA are techniques that can be used to assess cells for chromosomal alterations. Since tumor cells are frequently aneuploid, FISH and DIA can be used to detect malignancy. Recent studies have shown that the application of FISH and DIA to pancreatobiliary brushing specimens increases the sensitivity of detection of malignancy over conventional cytology.

SUMMARY

The diagnosis of malignancy in the pancreatobiliary tract confers a bleak prognosis due to the aggressive nature of these tumors and ineffective treatment options. Early detection of tumor is more likely to provide the patient with the option of surgical resection, which offers the best chance for cure. Current pathologic testing techniques, namely biopsy and routine cytology, are limited in their ability to detect tumor. FISH and DIA increase the sensitivity of pancreatobiliary malignancy compared to routine cytology.

S100A4 mRNA is a diagnostic and prognostic marker in pancreatic carcinoma

OBJECTIVE

The aim of this study is to evaluate the clinical significance of S100A4 mRNA expression in pancreatic cancer.

MATERIALS AND METHODS

We obtained invasive ductal carcinoma (IDC) cells from ten lesions, intraductal papillary mucinous neoplasm (IPMN) cells from 20 lesions, and normal ductal cells from 20 normal pancreatic tissues by laser microdissection of frozen tissues. S100A4 expression was examined in the microdissected cells and in formalin-fixed paraffin-embedded (FFPE) samples of 87 pancreatic cancers by quantitative reverse transcription-polymerase chain reaction.

RESULTS

IDC cells expressed higher levels of S100A4 than IPMN cells (P = 0.002) and normal ductal cells (P < 0.001), although the difference between IPMN cells and normal ductal cells was not statistically significant (P = 0.070). Analysis of FFPE samples revealed that high S100A4 expression was significantly associated with a shorter overall survival (P = 0.023). In immunohistochemical analysis, the extent of S100A4 mRNA expression was significantly correlated with the expression of S100A4 protein (P = 0.028).

CONCLUSION

S100A4 could be a marker for malignancy in pancreatic tumors and for poor prognosis in patients with pancreatic cancer.

A multivariable model using advanced cytologic methods for the evaluation of indeterminate pancreatobiliary strictures

BACKGROUND & AIMS

Ancillary cytologic tests including digital image analysis (DIA) and fluorescence in situ hybridization (FISH) have been developed to improve the sensitivity of routine cytology (RC) for the diagnosis of malignancy in pancreatobiliary strictures. The goal of this study was to retrospectively compare the performance of RC, DIA, and FISH on clinical brushing specimens.

METHODS

Endoscopic retrograde cholangiopancreatography brushings were obtained from 498 consecutive patients with pancreatobiliary strictures and analyzed by RC, DIA, and FISH as per standard practice. RC diagnostic categories included negative, atypical, suspicious, or positive. Aneuploid/tetraploid histograms were considered positive for DIA. FISH was performed using UroVysion (Abbott Molecular, Inc, Des Plaines, IL) and classified as negative, trisomy, tetrasomy, or polysomy.

RESULTS

The sensitivity of polysomy FISH (42.9%) was significantly higher than RC (20.1%) when equivocal RC results were considered negative (P < .001) with identical specificity (99.6%). There was a significant difference in time for diagnosis of carcinoma between FISH diagnostic categories (P < .001) and between RC diagnostic categories (P < .001). Logistic regression analysis revealed that polysomy FISH, trisomy FISH, suspicious cytology, primary sclerosing cholangitis status, and age were associated with carcinoma (P < .05).

CONCLUSIONS

Polysomy FISH had high sensitivity without compromise to specificity. DIA was not a significant independent predictor of malignancy. Multivariable modeling using RC, FISH, age, and primary sclerosing cholangitis status can be used to estimate the probability of carcinoma for an individual patient. We recommend including FISH as a routine test where available, along with RC, in the evaluation of indeterminate pancreatobiliary strictures.

Pancreatic cytopathology: a practical approach and review

CONTEXT

Pancreatic cytopathology plays an important role in the diagnosis and management of patients with solid and cystic lesions of the pancreas.

OBJECTIVE

To serve as a practical guide to pancreatic cytopathology for the practicing pathologist. Data Sources.-A comprehensive assessment of the medical literature was performed.

CONCLUSIONS

We review pancreatic cytopathology, with specific discussions of its role in patient management, specimen types and specimen processing, specific diagnostic criteria, and the use of ancillary testing and advanced techniques.

Differential diagnosis of pancreatic tumors by molecular analysis of clinical specimens

OBJECTIVE

To describe the capabilities and limitations of the current state of the art in pancreatic cancer diagnostics and to discuss recent progress in the development of novel, highly accurate molecular diagnostic approaches.

RESULTS

Molecular analyses currently under evaluation as novel diagnostic tests include detection of point mutations, genomic imbalances, aberrant methylation patterns and gene expression changes on the mRNA and protein levels in pancreatic juice, fine needle aspiration biopsies and brush cytologies.

CONCLUSIONS

In exploratory studies, several candidate molecular markers show great potential to serve as general indicators of malignancy, but need to be validated in large, controlled, prospective studies. Multiplexing of diagnostic tests, e.g. in the form of specialized DNA microarrays, may provide more differentiated diagnoses such as the distinction of various tumor types or prognostic information for individual patients. The MolDiag-Paca consortium is strongly engaged in advancing these developments on a European level.

Diagnosis of biliary tract lesions by histological sectioning of brush bristles as alternative to cytological smearing

AIM

To increase the diagnostic potential of endoscopic biliary tract brushing, we devised an approach alternative to cytological smearing, leading to the preoperative histological examination of the collected material.

METHODS

One hundred twelve consecutive biliary brush specimens were included. All patients presented a stricture of the biliary tract, leading to a diagnostic procedure by brushing. Immediately following brushing, the endoscopist immersed the brush into methanol and sent it to the pathology laboratory. The brush was introduced into a cassette for paraffin embedding and sections parallel to the long axis of brush were cut until the metal wire was almost reached, then the block was rotated and new sections were obtained from the opposite side. Samples of the mucosa, inflammatory cell aggregates, small fragments of carcinomas, or isolated cells were observed, and displayed an optimal fixation, allowing a definite diagnosis that proved mandatory for therapy in the vast majority of cases (99.1%).

RESULTS

The results obtained in 112 consecutive cases using such technique compared with final histological diagnosis proved: 91% sensitivity, 100% specificity, 100% positive predictive value (PPV), and 87% negative predictive value (NPV) (P < 0.001). In nonoperated patients, the clinical diagnosis after at least 6 months of follow-up showed: 95.5% sensitivity, 100% specificity, 100% PPV, and 88.2% NPV (P < 0.001).

CONCLUSION

Such novel approach to the preoperative diagnosis of biliary tract lesions proved to be highly sensitive and specific, limiting the inadequate preoperative diagnoses to less than 1%.

Correlating routine cytology, quantitative nuclear morphometry by digital image analysis, and genetic alterations by fluorescence in situ hybridization to assess the sensitivity of cytology for detecting pancreatobiliary tract malignancy

Routine cytologic (RC), fluorescence in situ hybridization (FISH), digital image analysis (DIA), and quantifiable morphometric results from 284 pancreatobiliary stricture brushings were compared. We chose specific DIA nuclear features assessed by pathologists in evaluating RC specimens, such as area and shape. A visual nuclear morphometric score (VNMS) was calculated. There was a difference (P < .001) in the mean VNMS when RC results were classified as negative (11.5), atypical (12.5), suspicious (13.8), and positive (16.5). The mean VNMS of specimens diagnosed as disomy (11.3), trisomy 7 (12.1), and polysomy (14.7) by FISH was also different (P < .001). There was no difference in the VNMS of false-negative and true-negative cytologic specimens (P = .225). Our findings substantiate the relationship between cell nuclear visual alterations and genetic FISH abnormalities. The low sensitivity of cytologic examination for pancreatobiliary carcinoma is due to an absence of tumor cells or the presence of well-differentiated tumor lacking recognizable nuclear atypia.

Analysis of loss of heterozygosity in atypical and negative bile duct brushing cytology specimens with malignant outcome: are "false-negative" cytologic findings a representation of morphologically subtle molecular alterations?

CONTEXT

Conventional cytologic evaluation of bile duct brushings for neoplasia has high specificity but relatively low sensitivity.

OBJECTIVE

The aim of this pilot study was to examine whether K-ras mutations and loss of heterozygosity for multiple microsatellite markers in bile duct brushings would contribute to the detection of malignancy in cases initially reported as "negative" or "atypical."

DESIGN

Bile duct brushing specimens with a negative or an atypical cytologic result (9 cases) had a benign result on the surgical pathology specimen, and 9 additional negative or atypical cases demonstrated adenocarcinoma on the resected surgical specimen. Cells from representative cytopathology and histology slides were microdissected and analyzed for K-ras mutations and for loss of heterozygosity with a panel of 15 polymorphic markers on chromosomes 1p, 3p, 5q, 9p, 9q, 10q, 17p, and 22q.

RESULTS

Among cytology cases with malignant outcome, loss of heterozygosity or K-ras mutation was detected in 8 (88.8%) of 9 cases. In the corresponding 9 surgical pathology specimens with adenocarcinoma, K-ras mutations and/or allelic losses were detected in all (100%). Loss of heterozygosity or K-ras mutation was not detected in cytology cases that had a benign surgical outcome. The fractional allelic loss of these 9 cytology specimens ranged from 0 to 0.25 (mean, 0.14). This compared with the fractional allelic loss ranging from 0.15 to 0.42 (mean, 0.27) for the corresponding surgical specimens.

CONCLUSIONS

This pilot study suggests that low-level fractional allelic loss or K-ras mutation in the negative/atypical cytology samples with malignant outcome is a representation of morphologically subtle molecular alterations.

Relationship between mucin expression and preoperative bile juice cytology in biliary tract carcinoma

The present study evaluated correlations between preoperative bile juice cytology and mucin expression of surgical specimens in biliary tract carcinoma. Twenty-five patients with biliary tract carcinoma surgically treated at our hospital, whose bile juice cytology had been evaluated before operation, were allocated to this study. Biliary cytology was classified into three categories based on the Papanicolaou classification. Immunohistochemical staining of tissues was performed using MUC1 and MUC2 monoclonal antibodies. Lesions showing MUC1 expression of ++ or higher and MUC2 expression of - were classified as Group A, and the remaining lesions as Group B. According to the epithelial site, preoperative cytology was highly correlated in Group A, while it was negative in Group B (p<0.05). In the advanced site of carcinomas, preoperative cytology tended to highly be positive in Group A, while it tended to be negative in Group B (p<0.05). These results suggest that the bile juice cytology results are affected by characteristics of mucin expression in the tissue. Based on the possibility that mucin expression correlates with the prognosis of each carcinoma, a positive cytological result suggests a poor prognosis for the carcinoma, which may be informative for predicting the post-operative courses and choosing treatments.

Intérêt de l’association cytologie de la bile et brossage de la voie biliaire principale : étude comparative chez 115 patients

This study summarizes the results concerning 120 specimens of biliary cytology which were classified in 3 groups: bile cytology alone, bile duct brushing alone, combined bile cytology and bile duct brushing made during endoscopic retrograde cholangiopancreatography (ERCP) in patients with biliary tract stricture. Comparison of these three groups showed that the number of diagnoses of malignant disease was greater when bile cytology and bile duct brushing were combined. Thus we recommend the use of the combined bile and brush cytology in the event of presumed malignant non-operable stricture. Furthermore, the ERCP is less aggressive for the patient if bile and biliary brushings are collected without biopsy.

Pancreatic and bile duct brushing cytology in 1000 cases: review of findings and comparison of preparation methods

BACKGROUND

Duct brushing cytology is an important tool in evaluation of the extrahepatic biliary tract and large pancreatic ducts. The emergence of neoadjuvant therapies underscores the importance of accurate preoperative diagnosis by noninvasive means. Liquid-based preparation methods, such as ThinPrep, have become popular for nongynecologic cytology specimens.

METHODS

Findings from bile and pancreatic duct brushings were reviewed over the 10-year period of 1994-2003. Cytologic material, imaging reports, and clinical data were reviewed and pathologic and clinical follow-up data were obtained. The slides were prepared by direct smear only (18.8%), direct smear plus cytospin (14.4%), or direct smear plus ThinPrep (66.8%).

RESULTS

A total of 1118 specimens were identified (1008 bile duct, 110 pancreatic duct) from 864 patients. The cytologic findings were: 53.5% negative, 16.5% malignant, 18.2% suspicious for malignancy, 11% atypical/inconclusive, 0.8% inadequate. Follow-up in the form of either histology or at least 6 months clinical observation was available for 82.2% of cases (n = 971). Overall operating characteristics were: 52.6% sensitivity, 99.4% specificity, 98.9% positive predictive value, 67.1% negative predictive value, and 75.7% accuracy. Diagnostic agreement between cytology and follow-up was the main variable analyzed. Agreement was significantly affected by characteristics of the sampled lesion, with ductal narrowing having the lowest rate of malignancy. In addition, the ThinPrep method showed superior sensitivity and accuracy compared with other preparation methods (P = .02). Nonsignificant associations were noted for patient age and gender, site of lesion, and the presence of either stones or prior stent.

CONCLUSION

In a large dataset from a single institution, brushing cytology showed modest sensitivity and high specificity. Diagnostic agreement was considerably better for benign cases. The combination of direct smear and the ThinPrep method showed superior sensitivity and accuracy.

Utility of bile duct brushings for the early detection of cholangiocarcinoma in patients with primary sclerosing cholangitis

BACKGROUND

In patients with primary sclerosing cholangitis, there are no reliable markers or imaging modalities to detect malignant changes or early cholangiocarcinoma when curative interventions may still be possible.

METHODS

Clinical features and outcomes were evaluated for 47 patients who underwent 101 endoscopic retrograde cholangiopancreatography (ERCP) procedures with bile duct brushings and cytopathologic examination for the detection of malignant changes between January 2001 and 2004. Bile duct cytology was characterized as unsatisfactory, benign, atypical, or malignant.

RESULTS

Fifteen patients had at least one sample that was abnormal. Patients with abnormal findings were older (P = 0.03); otherwise the groups were similar. Three of six patients with marked atypia have undergone transplantation for these abnormal findings, and of these, two had cholangiocarcinoma and one had no cancer detected in the explant. Of the nine patients with focal atypia, seven are doing well, one underwent transplantation for marked atypia seen on brushings at another hospital, and the other underwent transplantation for decompensated cirrhosis. Two patients with benign findings developed cholangiocarcinoma, whereas 29 others have not.

CONCLUSION

Cytopathologic examination of bile duct brushings taken at ERCP may be useful for the early detection of malignant changes in patients with primary sclerosing cholangitis. However, long-term prospective studies are needed to confirm the utility of surveillance ERCP and brushings.

Palliative management of hilar cholangiocarcinoma

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

Primary sclerosing cholangitis as a cause of false positive bile duct brushing cytology: Report of two cases

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease of unknown etiology characterized by ongoing inflammation, destruction, and fibrosis of intrahepatic and extrahepatic bile ducts. Irregular narrowing and dilation of the biliary duct system produces the characteristic beaded pattern seen on cholangiogram. Malignant degeneration resulting in cholangiocarcinoma is a well-recognized sequela of PSC. Bile duct brushing cytology is the primary screening technique for cholangiocarcinoma. It is associated with a relatively low sensitivity but high specificity. Few false positive bile duct brushings have been reported in the literature, with the majority of these having occurred in a background of PSC. We report two patients with PSC in whom bile duct brush cytologies were falsely positive for carcinoma.

Biliary brushing cytology

Biliary tract brush specimens are fast becoming the method of choice in the evaluation of patients who present with biliary tract strictures. Although the specificity is high, sensitivity rates for the detection of malignancy are generally low on cytological sampling. New liquid-based preparations and ancillary tests have emerged with the intent of addressing this issue. This review focuses on the current schemata used in the diagnosis of biliary tract lesions and the current available modalities which aid in the diagnosis of cholangiocarcinoma.

The role of preoperative biopsy in pancreatic cancer

BACKGROUND

Cyto-histological diagnosis of pancreatic pathology in the management of suspected pancreatic malignancy is re-evaluated in the light of evolving trends in management and tissue sampling.

METHODS

The literature on cyto-histological diagnosis of pancreatic pathology was reviewed over the period 1977-2003.

RESULTS AND CONCLUSION

Endoluminal techniques of tissue sampling carry less risk of tumour seeding and are the sampling methods of choice for potentially resectable lesions if a tissue diagnosis will alter therapy. Endosonar-guided biopsy in expert hands appears to be the most reliable tissue sampling technique. Transcoelomic sampling methods should be reserved for those with un-resectable disease. All methods of cyto-histological diagnosis have high specificity but have a low negative predictive value. Therefore, potentially resectable lesions that are highly suspicious for malignancy should be explored even if pre-operative histology or cytology is negative.

Comparative molecular analysis of loss of heterozygosity in adenocarcinoma in bile duct brushings and corresponding surgical pathology specimens

BACKGROUND

Bile duct brushing is the procedure of choice for the assessment of neoplasia of the biliary and pancreatic ducts. Conventional cytopathologic evaluation has been reported to have high specificity but relatively low sensitivity. Although a number of molecular studies regarding biliary tract tissue specimens have been performed, to the authors' knowledge their precise applicability to cytopathology specimens has not been critically analyzed.

METHODS

Bile duct brushing specimens with the cytopathologic diagnosis of "suspicious" or "positive for malignant cells" along with corresponding surgical pathology specimens demonstrating adenocarcinoma were searched for in the files of UPMC-Presbyterian Hospital for the years 1990-1996. Tumor cells from representative cytopathology and histology slides were microdissected and analyzed for loss of heterozygosity (LOH) in a panel of microsatellite markers. The results obtained from cytopathologic and surgical pathology specimens were compared.

RESULTS

Eight paired surgical and cytopathology cases of adenocarcinoma involving the biliary tract were identified. The fractional allelic loss (FAL) for the surgical specimens (FAL-S) ranged from 12.5-71.4% and the FAL for the cytopathology specimens (FAL-C) ranged from 25-71.4%. However, when evaluating the actual loci of LOH, the concordance rate of the surgical and cytopathology specimens ranged from 71.4-100% (mean, 88.6%). Only 3 of the 8 cases (37.5%) were found to have identical matching of the LOH loci.

CONCLUSIONS

Although the overall concordance rate of LOH in biliary cytology and surgical specimens by molecular analysis is relatively high, the issue of molecular tumoral heterogeneity must be considered if clinical decisions are to be based exclusively on cytopathologic analysis.