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Pugliese V, Antonelli G, Vincenti M, Gatteschi B. Endoductal Tissue Sampling of Biliary Strictures through Endoscopic Retrograde Cholangiopan Creatography (ERCP). TUMORI JOURNAL 2018; 83:698-702. [PMID: 9267491 DOI: 10.1177/030089169708300314] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aim and background Pathological proof of malignant in biliary strictures is useful in the preoperative setting as it helps define therapeutic planning and prognosis, and reduces the length of the subsequent surgical intervention. However, it is difficult to obtain. The aim of this study was to evaluate the yield of histological and cytological examination of endobiliary samples obtained during endoscopic retrograde cholangiopancreatography (ERCP). Methods Endobiliary forceps biopsy and brush cytology were performed during ERCP examination in 52 consecutive patients, 36 with malignant and 16 with benign strictures. Results Histology and cytology turned out to have the same sensitivity (53%). The gain in sensitivity achieved by combining the two techniques was limited, reaching a value of 61%. The specificity, however, was 100% for both methods. Most of the few complications observed were due to sphincterotomy and subsided spontaneously or with medical treatment. However, one patient experienced a serious complication and chose to be treated by surgical intervention. The complication was caused by forceps biopsy. Conclusions This study shows that 1) sampling of biliary strictures during ERCP is the primary approach to tissue diagnosis; 2) brush cytology alone is sufficient in clinical practice; 3) forceps biopsy must always be used to sample intra-ampullary strictures but should be considered as a secondary step to sample strictures located more proximally, in the bile ducts, if previous cytology was negative.
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Affiliation(s)
- V Pugliese
- Dipartimento di Oncologia, Università degli Studi, Genova, Italy
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Affiliation(s)
- Paul Korc
- Indiana University Medical Center, University Hospital, Indianapolis, Indiana, USA; Hoag-USC Digestive Disease Center, Newport Beach, California, USA
| | - Stuart Sherman
- Indiana University Medical Center, University Hospital, Indianapolis, Indiana, USA
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Nanda A, Brown JM, Berger SH, Lewis MM, Barr Fritcher EG, Gores GJ, Keilin SA, Woods KE, Cai Q, Willingham FF. Triple modality testing by endoscopic retrograde cholangiopancreatography for the diagnosis of cholangiocarcinoma. Therap Adv Gastroenterol 2015; 8:56-65. [PMID: 25729431 PMCID: PMC4314305 DOI: 10.1177/1756283x14564674] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Arjun Nanda
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jason M. Brown
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Stephen H. Berger
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Melinda M. Lewis
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - Emily G. Barr Fritcher
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Gregory J. Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Steven A. Keilin
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Kevin E. Woods
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Qiang Cai
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
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Tsuchiya T, Yokoyama Y, Ebata T, Igami T, Sugawara G, Kato K, Shimoyama Y, Nagino M. Randomized controlled trial on timing and number of sampling for bile aspiration cytology. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:433-8. [PMID: 24353113 DOI: 10.1002/jhbp.61] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The issue on timing and number of bile sampling for exfoliative bile cytology is still unsettled. METHODS A total of 100 patients with cholangiocarcinoma undergoing resection after external biliary drainage were randomized into two groups: a 2-day group where bile was sampled five times per day for 2 days; and a 10-day group where bile was sampled once per day for 10 days (registered University Hospital Medical Information Network/ID 000005983). The outcome of 87 patients who underwent laparotomy was analyzed, 44 in the 2-day group and 43 in the 10-day group. RESULTS There were no significant differences in patient characteristics between the two groups. Positivity after one sampling session was significantly lower in the 2-day group than in the 10-day group (17.0 ± 3.7% vs. 20.7 ± 3.5%, P = 0.034). However, cumulative positivity curves were similar and overlapped each other between both groups. The final cumulative positivity by the 10th sampling session was 52.3% in the 2-day group and 51.2% in the 10-day group. We observed a small increase in cumulative positivity after the 5th or 6th session in both groups. CONCLUSIONS Bile cytology positivity is unlikely to be affected by sample time.
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Affiliation(s)
- Tomonori Tsuchiya
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
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Syms RRA, Young IR, Wadsworth CA, Taylor-Robinson SD, Rea M. Magnetic Resonance Imaging Duodenoscope. IEEE Trans Biomed Eng 2013; 60:3458-67. [PMID: 23807423 DOI: 10.1109/tbme.2013.2271045] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A side-viewing duodenoscope capable of both optical and magnetic resonance imaging (MRI) is described. The instrument is constructed from MR-compatible materials and combines a coherent fiber bundle for optical imaging, an irrigation channel and a side-opening biopsy channel for the passage of catheter tools with a tip saddle coil for radio-frequency signal reception. The receiver coil is magnetically coupled to an internal pickup coil to provide intrinsic safety. Impedance matching is achieved using a mechanically variable mutual inductance, and active decoupling by PIN-diode switching. (1)H MRI of phantoms and ex vivo porcine liver specimens was carried out at 1.5 T. An MRI field-of-view appropriate for use during endoscopic retrograde cholangiopancreatography (ERCP) was obtained, with limited artefacts, and a signal-to-noise ratio advantage over a surface array coil was demonstrated.
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Dumonceau JM. Sampling at ERCP for cyto- and histopathologicical examination. Gastrointest Endosc Clin N Am 2012; 22:461-77. [PMID: 22748243 DOI: 10.1016/j.giec.2012.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Sampling at ERCP may be performed at the level of the papilla or of the biliopancreatic ducts. Samples collected at the level of the biliopancreatic ducts allow for diagnosing malignancy with a specificity close to 100% but present a moderate sensitivity in most studies. In this article, the different aspects of sampling at ERCP are discussed, and a special focus is placed on the means that are routinely available to the endoscopist for obtaining a high sensitivity for the diagnosis of malignancy.
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Affiliation(s)
- Jean-Marc Dumonceau
- Division of Gastroenterology and Hepatology, Geneva University Hospitals, Geneva, Switzerland.
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Chin MW, Byrne MF. Update of cholangioscopy and biliary strictures. World J Gastroenterol 2011; 17:3864-9. [PMID: 22025874 PMCID: PMC3198015 DOI: 10.3748/wjg.v17.i34.3864] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 01/15/2011] [Accepted: 01/22/2011] [Indexed: 02/06/2023] Open
Abstract
Cholangioscopy remains another modality in the investigation of biliary strictures. At cholangioscopy, the “tumour vessel” sign is considered a specific sign for malignancy. Through its ability to not only visualise mucosa, but to take targeted biopsies, it has a greater accuracy, sensitivity and specificity for malignant strictures than endoscopic retrograde cholangiopancreatography guided cytopathological acquisition. Cholangioscopy however, is time consuming and costly, requires greater technical expertise, and should be reserved for the investigation of undifferentiated strictures after standard investigations have failed.
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Tamada K, Ushio J, Sugano K. Endoscopic diagnosis of extrahepatic bile duct carcinoma: Advances and current limitations. World J Clin Oncol 2011; 2:203-16. [PMID: 21611097 PMCID: PMC3100496 DOI: 10.5306/wjco.v2.i5.203] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 09/16/2010] [Accepted: 09/23/2010] [Indexed: 02/06/2023] Open
Abstract
The accurate diagnosis of extrahepatic bile duct carcinoma is difficult, even now. When ultrasonography (US) shows dilatation of the bile duct, magnetic resonance cholangiopancreatography followed by endoscopic US (EUS) is the next step. When US or EUS shows localized bile duct wall thickening, endoscopic retrograde cholangiopancreatography should be conducted with intraductal US (IDUS) and forceps biopsy. Fluorescence in situ hybridization increases the sensitivity of brush cytology with similar specificity. In patients with papillary type bile duct carcinoma, three biopsies are sufficient. In patients with nodular or infiltrating-type bile duct carcinoma, multiple biopsies are warranted, and IDUS can compensate for the limitations of biopsies. In preoperative staging, the combination of dynamic multi-detector low computed tomography (MDCT) and IDUS is useful for evaluating vascular invasion and cancer depth infiltration. However, assessment of lymph nodes metastases is difficult. In resectable cases, assessment of longitudinal cancer spread is important. The combination of IDUS and MDCT is useful for revealing submucosal cancer extension, which is common in hilar cholangiocarcinoma. To estimate the mucosal extension, which is common in extrahepatic bile duct carcinoma, the combination of IDUS and cholangioscopy is required. The utility of current peroral cholangioscopy is limited by the maneuverability of the “baby scope”. A new baby scope (10 Fr), called “SpyGlass” has potential, if the image quality can be improved. Since extrahepatic bile duct carcinoma is common in the Far East, many researchers in Japan and Korea contributed these studies, especially, in the evaluation of longitudinal cancer extension.
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Affiliation(s)
- Kiichi Tamada
- Kiichi Tamada, Jun Ushio, Kentaro Sugano, Department of Gastroenterology and Hepatology, Jichi Medical University, Yakushiji, Tochigi 329-0498, Japan
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Hattori M, Nagino M, Ebata T, Kato K, Okada K, Shimoyama Y. Prospective study of biliary cytology in suspected perihilar cholangiocarcinoma. Br J Surg 2011; 98:704-9. [PMID: 21290384 DOI: 10.1002/bjs.7412] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2010] [Indexed: 12/19/2022]
Abstract
BACKGROUND The diagnostic value of biliary cytology for hilar bile duct stricture is uncertain. This study prospectively examined three methods for the evaluation of biliary cytology in a consecutive group of patients. METHODS Preoperative bile sampling by aspiration through a drainage catheter (aspiration samples), saline flush through a drainage catheter (saline samples) or direct sampling from a drainage bag (bag samples) was performed in consecutive patients with suspected perihilar cholangiocarcinoma who underwent resection after endoscopic nasobiliary drainage or percutaneous transhepatic biliary drainage. All bile sampling was performed three times on separate days. The accuracy of cytology in the diagnosis of carcinoma was determined. RESULTS Of 100 consecutive patients with hilar strictures, 97 had histologically proven cholangiocarcinoma. The proportion of these 97 patients who had a positive finding on cytology in at least one of three sampling sessions was 55 per cent for aspiration samples, 48 per cent for bag samples and 38 per cent for saline samples (P = 0·021, aspiration versus saline). Tumour length correlated significantly with overall positivity. For aspiration samples, sensitivity was 55 per cent, specificity was 100 per cent and accuracy 56·0 per cent. CONCLUSION For biliary cytology, sampling by catheter aspiration is more effective than catheter flushing or sampling from a drainage bag. Repeated sampling increases sensitivity. Biliary cytology has modest diagnostic yield, but is easy to perform, highly specific, and can provide a definitive diagnosis.
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Affiliation(s)
- M Hattori
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Abstract
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.
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Kim YS, Kim HG, Han J, Hur CJ, Kim BS, Jung JT, Kwon JG, Kim EY, Cho CH, Sohn YK. The Significance of p53 and K-ras Immunocytochemical Staining in the Diagnosis of Malignant Biliary Obstruction by Brush Cytology during ERCP. Gut Liver 2010; 4:219-25. [PMID: 20559525 DOI: 10.5009/gnl.2010.4.2.219] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Accepted: 03/14/2010] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND/AIMS Brush cytology during ERCP can provide a pathologic diagnosis in malignant biliary obstruction. K-ras and p53 mutations are commonly found in biliary and pancreatic cancers. We evaluated the diagnostic yield of brush cytology and the changes obtained by adding p53 and K-ras staining. METHODS One hundred and forty patients with biliary obstruction who underwent ERCP with brush cytology during a 7-year period were included. The sensitivity and specificity of brush cytology only and with the addition of p53 and K-ras staining were obtained. RESULTS Malignant biliary obstruction was confirmed in 119 patients. The sensitivity and specificity of brush cytology were 78.2% and 90.5%, respectively. The sensitivity of cytology was 77.3% at the ampulla-distal common bile duct (CBD), 92.6% at the mid common hepatic duct (CHD), and 94.7% at the proximal CBD-CHD (p<0.05); these values did not differ with the degree or the length of the obstruction. In the 97 patients who received additional p53 and K-ras staining, the sensitivity of cytology plus p53 was 88.2%, cytology plus K-ras was 84.0%, and cytology plus p53 and K-ras was 88.2%. The sensitivity of cytology plus p53 was higher than that of brush cytology only (95% confidence interval: 83.69-92.78 vs 72.65-83.65) but not that of cytology plus K-ras. CONCLUSIONS Brush cytology for malignant biliary obstruction has a high diagnostic accuracy. Adding p53 staining can further improve the diagnostic yield, whereas K-ras staining does not.
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Affiliation(s)
- Young Sup Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
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Nguyen NQ, Binmoeller KF, Shah JN. Cholangioscopy and pancreatoscopy (with videos). Gastrointest Endosc 2009; 70:1200-10. [PMID: 19863954 DOI: 10.1016/j.gie.2009.07.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Accepted: 07/05/2009] [Indexed: 02/08/2023]
Affiliation(s)
- Nam Q Nguyen
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California 94115, USA
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Abstract
PURPOSE OF REVIEW The extremely poor outcome in patients with cholangiocarcinoma, in large part, reflects the late presentation of these tumors and the challenging nature of establishing a tissue diagnosis. Establishing a diagnosis of cholangiocarcinoma requires obtaining evidence of malignancy from sampling of the epithelium of the biliary tract, which has proven to be challenging. Although endoscopic ultrasound-guided fine needle aspiration performs slightly better than endoscopic retrograde cholangiopancreatography in diagnosing cholangiocarcinoma, both endoscopic approaches demonstrate disappointing performance characteristics. RECENT FINDINGS The limitations of cytologic analysis have recently led to the evaluation of new technologies such as digital image analysis and fluorescence in-situ hybridization to enhance diagnostic sensitivity. Both of these approaches carry the ability to identify malignant cells in samples of limited cellularity and thereby provide enhanced diagnostic sensitivity. SUMMARY Overall, recognizing the limited sensitivity of diagnostic approaches for tissue diagnosis of cholangiocarcinoma, it would appear prudent to pursue further tissue sampling when there is a strong clinical suspicion of malignancy despite a prior negative/nondiagnostic result.
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Affiliation(s)
- Gavin C Harewood
- Division of Gastroenterology and Hepatology, Beaumont Hospital, Dublin, Ireland.
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Abstract
PURPOSE OF REVIEW Biliary endoscopy offers both diagnostic and therapeutic value in complex clinical situations. This review addresses the latest advances over the past year in endoscopic approaches of biliary tract diseases. RECENT FINDINGS Specifically, we focus on the latest findings on endoscopic retrograde cholangiopancreatography for the evaluation of biliary strictures. In addition, key studies have demonstrated the enhanced role of cholangioscopy, photodynamic therapy in cholangiocarcinoma, and biliary stent technology. SUMMARY The following review focuses on the latest advancements in the field of biliary endoscopy. Pivotal studies were selected to highlight some of the current investigations in therapeutic endoscopic retrograde cholangiopancreatography as well as knowledge gaps for future research.
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Cholangiocarcinoma: natural history, treatment, and strategies for surveillance in high-risk patients. J Clin Gastroenterol 2008; 42:178-90. [PMID: 18209589 DOI: 10.1097/mcg.0b013e31806daf89] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cholangiocarcinoma is a primary malignancy of biliary epithelium. Risk factors for cholangiocarcinoma include primary sclerosing cholangitis and other conditions that produce chronic inflammation of the biliary tree. The diagnosis of cholangiocarcinoma can be elusive; it is often not made until advanced disease is present and at a stage when a curative surgical resection is not feasible. Currently used diagnostic modalities include serum and bile tumor markers, radiologic and endoscopic imaging, and pathologic analysis. Surveillance strategies to increase the chance of early diagnosis should be strongly considered in individuals at high risk for cholangiocarcinoma. Patients with long-standing primary sclerosing cholangitis would be the ideal candidates for a screening program.
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Larghi A, Waxman I. Differentiating benign from malignant idiopathic biliary strictures: are we there yet? Gastrointest Endosc 2007; 66:97-9. [PMID: 17591480 DOI: 10.1016/j.gie.2006.12.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2006] [Accepted: 12/23/2006] [Indexed: 01/16/2023]
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Papachristou GI, Smyrk TC, Baron TH. Endoscopic retrograde cholangiopancreatography tissue sampling: when and how? Clin Gastroenterol Hepatol 2007; 5:783-90. [PMID: 17628333 DOI: 10.1016/j.cgh.2007.04.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A 69-year-old man presented with obstructive jaundice. Endoscopic retrograde cholangiopancreatography was performed for biliary tree decompression and diagnostic tissue acquisition. Techniques, indications, methodologic considerations, and interpretation of tissue sampling at endoscopic retrograde cholangiopancreatography in patients with biliary/pancreatic strictures are discussed. This case-based educational presentation focuses on the importance of interdisciplinary communication between endoscopists and pathologists for optimal tissue sampling, interpretation, and diagnostic accuracy.
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Affiliation(s)
- Georgios I Papachristou
- Department of Medicine, Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Pungpapong S, Noh KW, Wallace MB. Endoscopic ultrasonography in the diagnosis and management of cancer. Expert Rev Mol Diagn 2007; 5:585-97. [PMID: 16013976 DOI: 10.1586/14737159.5.4.585] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Since its development and introduction to clinical practice, endoscopic ultrasonography (EUS) has progressed rapidly from being a purely imaging modality with limited use in the detection of small pancreatic cancers to one that can provide a tissue diagnosis by fine-needle aspiration (FNA) and deliver therapy. EUS has now firmly established a place as the investigation of choice in the diagnosis, locoregional staging and management of a wide range of gastrointestinal cancers. With the increasing use of FNA, the accuracy of EUS has substantially improved and may become a stand-alone investigation in some situations. However, it is recommended that a combination of information obtained from other imaging modalities and EUS is needed to maximize the accuracy, in particular to complete staging beyond locoregional stage. In addition to well-established indications, newer applications of EUS are emerging and are no longer limited to the gastrointestinal system. In lung cancer, EUS combined with endobronchial ultrasonography is emerging as an accurate, minimally invasive, nonsurgical alternative to staging of the mediastinum. Furthermore, the ability of EUS to acquire tissue safely and conveniently results in a potential role of the molecular diagnostics to enhance the performance of EUS-guided FNA. Besides a diagnostic role of EUS, there continues to be technological advances in the field of interventional EUS, with many potential applications under investigation. This review focuses on the current and future roles of EUS in the diagnosis and management of cancers.
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Affiliation(s)
- Surakit Pungpapong
- Division of Gastroenterology & Hepatology, Mayo Clinic College of Medicine, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Serikawa M, Sasaki T, Fujimoto Y, Kuwahara K, Chayama K. Management of intraductal papillary-mucinous neoplasm of the pancreas: treatment strategy based on morphologic classification. J Clin Gastroenterol 2006; 40:856-62. [PMID: 17016145 DOI: 10.1097/01.mcg.0000225609.63975.6f] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
GOALS The aim of this study was to examine and clarify the preoperative markers that are useful for differentiating between benign and malignant lesions of intraductal papillary-mucinous neoplasms (IPMN) of the pancreas, grouped according to morphologic classification. BACKGROUND There are various stages of pathology in IPMN, ranging from benign to malignant lesions. Although the determination of appropriate treatment guidelines to deal with IPMN is a critical issue, no such guidelines have been established. PATIENTS AND METHODS One hundred twenty cases of IPMN were classified morphologically into either main or branch duct types. We compared the morphologic classification with histopathologic diagnosis using indicators of malignancy detected by imaging such as main duct diameter, the number and diameter of cysts, and the presence or absence of mural nodules. We also examined the usefulness of pancreatic juice cytology and measurement of telomerase activity as indicators of malignancy. Finally, we performed a survival analysis on the basis of morphologic classification to determine prognosis of IPMN. RESULTS Whereas a high incidence (64%) of malignant lesions was seen in main duct type IPMN, benign lesions were dominant (80.5%) in branch duct type IPMN. Survival analysis showed that the prognosis was significantly worse in main duct type than in branch duct type IPMN. The lesions were aggravated in all patients with main duct type who did not undergo resection, resulting in death due to progression of the pancreatic lesion. The incidence of mural nodules was a useful indicator in main duct type, whereas main duct diameter and incidence of mural nodules were useful indicators in branch duct type. Although pancreatic juice cytology showed a high accuracy rate with low sensitivity for determining malignancy, measurement of telomerase activity in this juice was very effective for differentiating between benign and malignant lesions. CONCLUSIONS The incidence of malignant lesions was extremely high in main duct type IPMN, indicating that surgery is required in all these patients. However, to determine whether surgery is indicated in branch duct type IPMN it is necessary to obtain an appropriate image diagnosis focusing on main duct diameter and mural nodules and also to carry out cytology and measurement of telomerase activity in samples of pancreatic juice.
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Affiliation(s)
- Masahiro Serikawa
- Department of Medicine and Molecular Science, Division of Frontier Medical Science, Programs for Biochemical Research, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
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DeWitt J, Misra VL, Leblanc JK, McHenry L, Sherman S. EUS-guided FNA of proximal biliary strictures after negative ERCP brush cytology results. Gastrointest Endosc 2006; 64:325-33. [PMID: 16923477 DOI: 10.1016/j.gie.2005.11.064] [Citation(s) in RCA: 180] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2005] [Accepted: 11/27/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND Accurate nonoperative diagnosis of proximal biliary strictures (PBSs) is often difficult. OBJECTIVE To report our experience with EUS-guided FNA (EUS-FNA) of PBSs following negative or unsuccessful results with brush cytology during ERCP. DESIGN Retrospective cohort study. SETTING Single, tertiary referral hospital in Indianapolis, Indiana. PATIENTS Consecutive subjects from January 2001 to November 2004 who underwent EUS-FNA of a PBS documented by ERCP. INTERVENTIONS EUS-FNA of PBS. MAIN OUTCOME MEASURES Performance of EUS-FNA, with the final diagnosis determined by surgical pathology study or the results of EUS-FNA and follow-up. RESULTS A total of 291 biliary strictures undergoing EUS were identified. Of these, 26 (9%) had PBSs and 2 were excluded. EUS-FNA was not attempted in 1 because no mass was visualized. The second had a PBS seen on magnetic resonance cholangiopancreatography, but no ERCP was performed. Twenty-four patients (14 men; mean age, 68 years) underwent EUS-FNA of a PBS following ERCP brush cytology studies that were either negative/nondiagnostic (20) or unable to be performed (4). EUS visualized a mass in 23 (96%) patients, including 13 in whom previous imaging detected no lesion. EUS-FNA (median, 4 passes; range, 1-11) demonstrated malignancy in 17 of 24 (71%) patients with findings showing adenocarcinoma (15), lymphoma (2), atypical cytology (3), or benign cells (4). No complications were noted. Pathology results from 8 of 24 (33%) patients who underwent surgery showed hilar cholangiocarcinoma (6), gallbladder cancer (1), and a benign, inflammatory stricture (1). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA were 77% (95% confidence interval [CI], 54%-92%), 100% (95% CI, 15%-100%), 100% (95% CI, 83%-100%), 29% (95% CI, 4%-71%), and 79% (95% CI, 58%-93%), respectively. LIMITATIONS Histopathologic correlation of EUS-FNA findings was limited to 8 of 24 (33%) patients who underwent surgery. CONCLUSIONS EUS-FNA is a sensitive method for the diagnosis of PBSs following negative results or unsuccessful ERCP brush cytology. The low negative predictive value does not permit reliable exclusion of malignancy following a negative biopsy.
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Affiliation(s)
- John DeWitt
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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Pavey DA, Gress FG. The role of EUS-guided FNA for the evaluation of biliary strictures. Gastrointest Endosc 2006; 64:334-7. [PMID: 16923478 DOI: 10.1016/j.gie.2006.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2006] [Accepted: 03/15/2006] [Indexed: 02/07/2023]
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Adamsen S, Olsen M, Jendresen MB, Holck S, Glenthøj A. Endobiliary brush biopsy: Intra- and interobserver variation in cytological evaluation of brushings from bile duct strictures. Scand J Gastroenterol 2006; 41:597-603. [PMID: 16638704 DOI: 10.1080/00365520500389099] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Obtaining cytological specimens by wire-guided endobiliary brushing at the time of endoscopic retrograde cholangiopancreatography (ERCP) is a convenient way to reach a diagnosis. Sensitivity for malignant disease is generally around 50% and specificity around 100%. The present study was designed to assess the reproducibility of the cytological examination. MATERIAL AND METHODS Samples were obtained from 55 consecutive patients with biliary duct strictures that eventually turned out to be caused by malignant disease in 41 patients (73%). The cytology specimens were evaluated twice in different random order with an interval of at least 4 months by two pathologists blinded to the final diagnoses. Suitability for diagnosis (suitable, suboptimal or unsuitable) and cytologic diagnosis (benign, atypical, suspicious for malignancy and malignant cells) were registered. Kappa analysis was applied. RESULTS Regarding suitability for diagnosis, the two observers reproduced their findings in 84% (kappa 0.76) and 87% (0.59) (p>0.05), while the interobserver variations on the two occasions were 76% and 78% (kappa 0.49 and 0.58, respectively) (p>0.05). Five percent of samples were rated as inadequate for diagnosis in at least one reading; 18% were suboptimal and 62-82% were suitable. The observers reproduced their cytological diagnosis in 77% and 71% (weighted kappa 0.83 and 0.75) (p>0.05), and agreed on the cytological diagnosis in 65% and 73% (weighted kappa 0.65 and 0.75) (p>0.05). CONCLUSIONS The intra- and interobserver agreement in cytological evaluation of endobiliary brushings from bile duct strictures is generally good. The rates of inadequate and suboptimal samples can probably be reduced by modifications of the brush design.
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Affiliation(s)
- Sven Adamsen
- Department of Gastrointestinal Surgery, Copenhagen University Hospital Herlev, Denmark.
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Affiliation(s)
- Daniel Wolfson
- Department of Medicine, George Washington University Medical Center, Washington, DC, USA
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25
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Ornellas LC, Santos GDC, Libera ED, Cury MDS, Ferrari AP. [Survival of patients with malignant biliary stricture based on endoscopic brushing and on bilirubinemia]. ARQUIVOS DE GASTROENTEROLOGIA 2005; 41:167-72. [PMID: 15678201 DOI: 10.1590/s0004-28032004000300006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Pancreatic cancer and cholangiocarcinoma are the main causes of malignant biliary stricture. Both types of cancers have dismal survival rates, and treatment has little or no effect on prolonging the patients lives. Prognostic definition at initial endoscopic retrograde cholangiopancreatography is important to choose the most suitable management. AIM To analyse endoscopic brushing and bilirubinemia importance in determination of the survival of patients with malignant biliary stricture. METHODS Patients with biliary strictures diagnosed during endoscopic retrograde cholangiopancreatography were submitted to double brushing cytology. Serum samples were taken from all patients for bilirubinemia assay. Patients were followed to determine the final diagnosis and survival rates. RESULTS A total of 50 patients with biliary stricture underwent endoscopic retrograde cholangiopancreatography (40 ultimately found to have a final diagnosis of malignant disease). Hyperbilirubinemia or cytology brushing positive for malignancy was related to a shorter survival rate. CONCLUSION This research data demonstrate the possibility of determining the prognosis of patients with malignant biliary stricture using endoscopic brushing results and bilirubinemia levels.
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Affiliation(s)
- Laura Cotta Ornellas
- Departamento de Medicina, Universidade Federal de São Paulo (UNESP), São Paulo, SP.
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Chen VK, Arguedas MR, Kilgore ML, Eloubeidi MA. A cost-minimization analysis of alternative strategies in diagnosing pancreatic cancer. Am J Gastroenterol 2004; 99:2223-34. [PMID: 15555006 DOI: 10.1111/j.1572-0241.2004.40042.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Several modalities currently exist for tissue confirmation of suspected pancreatic cancer prior to therapy. Since there is a paucity of cost-minimization studies comparing these different biopsy modalities, we analyzed costs and examined effectiveness of four alternative strategies for diagnosing pancreatic cancer. METHODS A decision analysis model of patients with suspected pancreatic cancer was constructed. We analyzed costs, failure rate, testing characteristics, and complication rates of four commonly employed diagnostic modalities: 1) computerized tomography or ultrasound-guided fine-needle aspiration (CT/US-FNA), 2) endoscopic retrograde cholangiopancreatography with brushings (ERCP-B), 3) Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA), and 4) laparoscopic surgical biopsy. If the first attempt with a particular modality failed, a different modality was employed to identify the most preferable secondary biopsy strategy. RESULTS This analysis identifies EUS-FNA as the preferred initial modality for the diagnosis of pancreatic cancer. Resultant expected costs and strategies in decreasing optimality include: 1) EUS-FNA (1,405 dollars), 2) ERCP-B (1,432 dollars), 3) CT/US-FNA (3,682 dollars), and 4) surgery (17,711 dollars). If a patient presents with obstructive jaundice, decision analysis modeling resulted in a total expected costs of 1,970 dollars if ERCP-B is successful at the time of biliary stent placement. Additional analyses to identify the preferred follow-up modality after a failed alternative method showed that EUS-FNA is the preferred secondary modality if any of the other three modalities failed first, in both the setting of and absence of obstructive jaundice. One- and two-way sensitivity analysis of the variables shows unchanged results over an acceptable range. CONCLUSIONS This cost-minimization study illustrates that EUS-FNA is the best initial and the preferred secondary alternative method for the diagnosis of suspected pancreatic cancer. In addition to local expertise and availability, costs and diagnostic yield should be considered when choosing an optimal diagnostic strategy.
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Affiliation(s)
- Victor K Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama 35294-0007, USA
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Kipp BR, Stadheim LM, Halling SA, Pochron NL, Harmsen S, Nagorney DM, Sebo TJ, Therneau TM, Gores GJ, de Groen PC, Baron TH, Levy MJ, Halling KC, Roberts LR. A comparison of routine cytology and fluorescence in situ hybridization for the detection of malignant bile duct strictures. Am J Gastroenterol 2004; 99:1675-81. [PMID: 15330900 DOI: 10.1111/j.1572-0241.2004.30281.x] [Citation(s) in RCA: 237] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM The aim of this study was to assess the relative sensitivities and specificities of fluorescence in situ hybridization (FISH) and routine cytology for the detection of malignancy in biliary tract strictures. METHODS Bile duct brushing and aspirate specimens were collected from 131 patients being evaluated for possible malignant bile duct strictures. Both specimen types were assessed by FISH but only brushing specimens were assessed by cytology. The FISH assay used a mixture of fluorescently-labeled probes to the centromeres of chromosomes 3, 7, and 17 and chromosomal band 9p21 (Vysis UroVysion) to identify cells having chromosomal abnormalities. A case was considered positive for malignancy if five or more cells exhibited polysomy. RESULTS Sixty-six of the 131 patients had surgical pathologic and/or clinical evidence of malignancy. Thirty-nine patients had cholangiocarcinoma, 19 had pancreatic carcinoma, and 8 had other types of malignancy. The sensitivity of cytology and FISH for the detection of malignancy in bile duct brushing specimens in these patients was 15% and 34% (p < 0.01), respectively. The sensitivity of FISH for the bile aspirate specimens was 23%, and the combined sensitivity of FISH for aspirate and brushing specimens was 35%. The specificity of FISH and cytology brushings were 91% and 98% (p= 0.06), respectively. CONCLUSIONS FISH is significantly more sensitive than and nearly as specific as conventional cytology for the detection of malignant biliary strictures in biliary brushing specimens. FISH may improve the clinical management of patients who are being evaluated for malignancy in bile duct strictures.
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Affiliation(s)
- Benjamin R Kipp
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Harewood GC, Baron TH, Stadheim LM, Kipp BR, Sebo TJ, Salomao DR. Prospective, blinded assessment of factors influencing the accuracy of biliary cytology interpretation. Am J Gastroenterol 2004; 99:1464-9. [PMID: 15307861 DOI: 10.1111/j.1572-0241.2004.30845.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES There is little published data assessing factors that influence the accuracy of biliary cytology. The aim of this study was to (a) prospectively compare interobserver variability among two blinded pathologists interpreting biliary cytology specimens, (b) to describe the predictors of interpathologist agreement, and (c) to characterize the predictors of accurate cytology interpretation. METHODS In total, 113 consecutive patients undergoing endoscopic retrograde cholangiopancreatography with brushing of suspicious biliary tract strictures were prospectively enrolled to assess routine cytology (RC) accuracy. The initial RC interpretation was performed by the pathologist on duty with the benefit of the patient's clinical information. Subsequent interpretation was performed by two independent pathologists blinded to the patients' clinical details. RESULTS Of the 113 patients, 67 had malignant strictures and 46 had benign strictures. The sensitivity of RC varied from 9% to 24% (p= 0.02), while the specificity varied from 61% to 100% (p < 0.001). Accuracy varied from 43% to 51% (p= n.s.). The rate of equivocal readings was lowest for the initial interpretation (1.7%), p < 0.0001 versus pathologist 1, p= 0.002 versus pathologist 2. Overall correlation of the blinded pathologists' interpretations was moderate, k= 0.66. Neither cytology accuracy nor interpathologist agreement improved with increasing specimen cellularity. CONCLUSIONS There is a high rate of interpathologist variation for the biliary cytology interpretation. The knowledge of the patient's clinical information appears to clarify cytology interpretation resulting in fewer equivocal results. We did not detect any reliable predictors of cytology accuracy.
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Affiliation(s)
- Gavin C Harewood
- Division of Gastroenterology and Hepatology, Department of Pathology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Abstract
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.
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Affiliation(s)
- S M Selvaggi
- University of Wisconsin Medical School and University of Wisconsin Hospital and Clinics, Madison, WI 53792-2472, USA.
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Baron TH, Harewood GC, Rumalla A, Pochron NL, Stadheim LM, Gores GJ, Therneau TM, De Groen PC, Sebo TJ, Salomao DR, Kipp BR. A prospective comparison of digital image analysis and routine cytology for the identification of malignancy in biliary tract strictures. Clin Gastroenterol Hepatol 2004; 2:214-9. [PMID: 15017605 DOI: 10.1016/s1542-3565(04)00006-0] [Citation(s) in RCA: 164] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Digital image analysis (DIA) allows quantification of nuclear DNA content and may help distinguish benign and malignant strictures of the biliary tract. METHODS One hundred ten consecutive patients undergoing endoscopic retrograde cholangiography for suspicious biliary tract strictures were enrolled in a prospective study comparing the accuracy of DIA and routine cytology (RC). Standard brush cytology sampling was performed twice by using 2 cytology brushes per patient. Both brushes were fixed in a single-specimen vial. Each specimen was formed into 1 pellet, and the sample was equally divided for evaluation by DIA and RC. DNA histograms were generated for ploidy analysis. The DIA criterion for malignancy was demonstration of aneuploidy. RESULTS Two patients had inadequate samples obtained for DIA analysis, 7 benign patients were excluded because of inadequate follow-up of less than 75 days, and 1 patient was lost to follow-up to clarify malignant versus benign disease. Of the remaining 100 patients, 56 strictures were malignant and 44 were benign. The sensitivities of DIA and RC were 39.3% and 17.9%, respectively (P = 0.014). The specificities of DIA and RC were 77.3% and 97.7%, respectively (P = 0.003). The accuracy of DIA (56.0%) was equivalent to RC (53.0%). CONCLUSIONS DIA is a valuable adjunct to RC for detecting malignant strictures of the biliary tract.
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Affiliation(s)
- Todd H Baron
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Eloubeidi MA, Chen VK, Jhala NC, Eltoum IE, Jhala D, Chhieng DC, Syed SA, Vickers SM, Mel Wilcox C. Endoscopic ultrasound-guided fine needle aspiration biopsy of suspected cholangiocarcinoma. Clin Gastroenterol Hepatol 2004; 2:209-13. [PMID: 15017604 DOI: 10.1016/s1542-3565(04)00005-9] [Citation(s) in RCA: 177] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Despite advances in endoscopic techniques for sampling bile duct strictures, the diagnosis of cholangiocarcinoma remains a challenge. The purpose of this study was to evaluate the yield of EUS-FNA and its impact on patient management for patients with suspected cholangiocarcinoma. METHODS All patients undergoing EUS for the evaluation of suspected malignant biliary strictures were prospectively evaluated over a 23-month period. A single gastroenterologist performed all EUS-FNAs in the presence of a cytopathologist. Reference standard for final diagnosis included surgery, death from disease, and clinical and/or imaging follow-up. RESULTS Twenty-eight patients (mean age 67 years [SD +/- 11], 72% male) were evaluated. Most patients (91%) presented with obstructive jaundice, and all except 1 had nondiagnostic sampling of the biliary lesions either at ERCP (88%), percutaneous transhepatic cholangiogram (n = 2), and/or computed tomography-guided biopsy (n = 1). Sixty-seven percent (14/21) had no definitive mass seen on prior abdominal imaging studies. The mean tumor size by EUS was 19 mm x 16 mm with a median number of passes to diagnosis of 3 (range 1-7). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 86%, 100%, 100%, 57%, and 88%, respectively. EUS-FNA had a positive impact on patient management in 84% of patients: preventing surgery for tissue diagnosis in patients with inoperable disease (n = 10), facilitating surgery in patients with unidentifiable cancer by other modalities (n = 8), and avoiding surgery in benign disease (n = 4). CONCLUSIONS Given the apparent accuracy and safety of EUS with FNA for imaging bile duct mass lesions and for obtaining a tissue diagnosis in patients with suspected cholangiocarcinoma, this technology may represent a new approach to diagnosis especially when other methods fail. The ability to obtain a definite diagnosis has a significant impact on patient management.
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Affiliation(s)
- Mohamad A Eloubeidi
- Departments of Gastroenterology and Hepatology, University of Alabama at Birmingham, Alabama 35294-0007, USA.
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Abstract
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.
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Affiliation(s)
- DL Clarke
- Department of General Surgery, Nelson R Mandela School of Medicine, University of NatalDurbanSouth Africa
| | - BA Clarke
- Department of Anatomical Pathology, Nelson R Mandela School of Medicine, University of NatalDurbanSouth Africa
| | - SR Thomson
- Department of General Surgery, Nelson R Mandela School of Medicine, University of NatalDurbanSouth Africa
| | - OJ Garden
- Department of Clinical and Surgical Sciences, Royal Infirmary of EdinburghEdinburghUK
| | - NG Lazarus
- Department of Anatomical Pathology, Nelson R Mandela School of Medicine, University of NatalDurbanSouth Africa
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de Bellis M, Fogel EL, Sherman S, Watkins JL, Chappo J, Younger C, Cramer H, Lehman GA. Influence of stricture dilation and repeat brushing on the cancer detection rate of brush cytology in the evaluation of malignant biliary obstruction. Gastrointest Endosc 2003; 58:176-82. [PMID: 12872082 DOI: 10.1067/mge.2003.345] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The sensitivity for cancer detection of brush cytology at ERCP is relatively low. Manipulation of the stricture and repeated tissue sampling may increase the yield. This study compared the cancer detection rate of brush cytology before and after biliary stricture dilation. METHODS In patients with a biliary stricture at ERCP of suspected malignant origin, the stricture was sampled with a cytology brush and then dilated with either a graduated dilating catheter or a dilating balloon (4-8 mm). Brushing was then repeated in all patients. Specimens were interpreted as normal, atypical (benign), highly atypical (suspicious for cancer), and malignant. Final diagnoses were based on cytology plus surgery, EUS, percutaneous biopsy, autopsy, or clinical follow-up. RESULTS A total of 139 patients with suspected malignant obstructive jaundice underwent 143 ERCPs (116 ultimately found to have malignant obstruction, and 27 benign disease). Dilation was performed with a catheter in 68 cases, balloon in 73, and both in 2. Brush cytology had a sensitivity of 34.5% (40/116) before dilation and 31% (36/116) after dilation (p = NS). However, sensitivity with predilation and postdilation brushing specimens combined was 44% (51/116), which was higher than that for either the predilation or postdilation brush cytology (p = 0.001). Cancer detection rates were 34.7% (17/49) after dilation with the catheter and 27.7% (18/65) after balloon dilation (p = NS). CONCLUSIONS Stricture dilation does not improve the sensitivity of brush cytology for the detection of cancer, which remains relatively low. However, repeat brushing increases the diagnostic yield and should be performed when sampling biliary strictures with a cytology brush at ERCP.
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Affiliation(s)
- Mario de Bellis
- Division of Gastroenterology/Hepatology, Department of Pathology and Laboratory Medicine, Indiana University Medical Center, Indianapolis, Indiana, USA
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Devereaux BM, Fogel EL, Bucksot L, Shelly LA, Lehman GA, Sherman S. Clinical utility of stent cytology for the diagnosis of pancreaticobiliary neoplasms. Am J Gastroenterol 2003; 98:1028-31. [PMID: 12809824 DOI: 10.1111/j.1572-0241.2003.07428.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE ERCP is frequently the technique of choice for the diagnosis and palliative treatment of pancreaticobiliary neoplasms. The sensitivity of tissue sampling techniques has been disappointing. Two small series have reported a high diagnostic yield from cytological examination of cellular debris from removed biliary stents. The aim of this study was to determine the clinical utility of stent cytology for the diagnosis of biliary and pancreatic neoplasia. METHODS Patients who had biliary or pancreatic stents removed at ERCP and evaluated cytologically were the subjects of this study. Stents were scraped and washed, and the cellular debris was examined cytologically and recorded as positive, atypical, or negative. Patient demographics, ductal stricture, and stent characteristics were recorded. RESULTS Between January, 1994 and January, 2001 a total of 126 biliary stents from 101 patients (61 male, 40 female, mean age 62 yr) and 29 pancreatic stents from 19 patients (seven male, 12 female, mean age 58 yr) were examined. The sensitivity, specificity, positive predictive value, and negative predictive value of biliary and pancreatic stents for the diagnosis of neoplasia were: 11%, 100%, 100%, 53%, and 25%, 100%, 100%, 77.8%, respectively. The sensitivity improved slightly if all degrees of atypia were considered positive for neoplasia. The mean duration of stent placement was 93.6 days for biliary stents and 43.5 days for pancreatic stents. CONCLUSIONS Biliary and pancreatic stent cytology has limited clinical utility in the diagnosis of pancreaticobiliary neoplasia, owing to poor sensitivity. In addition, the time lag between stent placement and removal for cytologic examination further limits its contribution to patient management.
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Affiliation(s)
- Benedict M Devereaux
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana 46260, USA
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Klump B, Hsieh CJ, Nehls O, Dette S, Holzmann K, Kiesslich R, Jung M, Sinn U, Ortner M, Porschen R, Gregor M. Methylation status of p14ARF and p16INK4a as detected in pancreatic secretions. Br J Cancer 2003; 88:217-22. [PMID: 12610506 PMCID: PMC2377051 DOI: 10.1038/sj.bjc.6600734] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The clinical management of pancreatic disease is often hampered by a lack of tissue diagnosis. Endoscopic pancreatography offers the opportunity to investigate exfoliated cells. However, the significance of mere cytological investigation is compromised by an insufficient sensitivity. The evaluation of the molecular background of carcinogenesis hopefully is capable of providing more sensitive diagnostic markers. The p16INK4a-/retinoblastoma tumour-suppressive pathway has been shown to be involved in the development of near to all pancreatic neoplasms. p14ARF is another tumour suppressor located in the immediate neighbourhood of p16INK4a. Promoter methylation has been demonstrated to be a major inactivating mechanism of both genes. We sought to further evaluate the role of the gene locus INK4a methylation status in the endoscopic differentiation of chronic inflammatory and neoplastic pancreatic disease. Pancreatic fluid specimens of 61 patients with either pancreatic carcinoma (PCA: 39), chronic pancreatitis (CP: 16) or a normal pancreatogram (NAD: 6) were retrieved. In order to detect methylation of either the p14ARF or the p16INK4a promoter a methylation-specific PCR protocol was applied. While 19 out of 39 patients with PCA showed p16 promoter methylation (49%), none of the 16 patients with CP revealed p16 promoter methylation. p14ARF methylation was found in a lower percentage of PCA specimens and in none of the samples of patients with CP. These results suggest a specific significance of INK4a for the development of malignant pancreatic disease. Our data further indicate a potential role for INK4a methylation as a diagnostic marker in the endoscopic differentiation of benign and malignant pancreatic disease.
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Affiliation(s)
- B Klump
- Department of Internal Medicine I, University Hospital Tübingen, Germany.
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Ylagan LR, Edmundowicz S, Kasal K, Walsh D, Lu DW. Endoscopic ultrasound guided fine-needle aspiration cytology of pancreatic carcinoma: a 3-year experience and review of the literature. Cancer 2002; 96:362-9. [PMID: 12478684 DOI: 10.1002/cncr.10759] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) of small pancreatic lesions that are undetectable by computed tomography has gained wide acceptance for the procurement of cells for diagnostic purposes. However, this technique is not without difficulty. The authors examined the sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively) of this technique in the evaluation of patients with pancreatic biliary duct strictures/masses. The authors were interested in reviewing their cases of pancreatic adenocarcinoma of ductal type and finding the sources of their false-negative cases. METHODS A computer search was performed between January 1998 and July 2001. For the last 3 years, a total of 80 cases of suspected ductal adenocarcinoma of the pancreas was identified. Thirty-four patients (42%) underwent a subsequent Whipple procedure or biopsy. Cytologic and histologic correlation was performed in these cases. The rest of the 23 patients (29%) considered to be positive and the 23 patients (29%) considered to be negative underwent no subsequent biopsy and were followed clinically. Cases termed "suspicious" on cytology were considered positive and those termed "atypical cytology" were considered negative in the authors' final calculation. The causes of the false-negative diagnoses were evaluated carefully. RESULTS Of the 34 cases followed with subsequent tissue biopsy or surgery; 12 were confirmed to be positive, 12 were confirmed to be negative, and 10 were considered to be false-negative. Previously identified cytomorphologic features of malignancy were used to review all cases. These features were: loss of the honeycomb pattern (100%), anisonucleosis (100%), nuclear contour irregularity (100%), a high nuclear/cytoplasmic ratio (100%), paranuclear chromatin clearing (77%), and the presence of prominent nucleoli in the absence of inflammatory cells (77%). The causes of the 10 false-negative cases were technical difficulty of procuring material in 6 cases, the nature of the lesion in 2 cases, and the scarcity of lesional tissue in 2 cases. CONCLUSIONS Using strict cytoarchitectural and cytomorphologic criteria of malignancy for ductal pancreatic lesions previously described in the literature, the sensitivity of this technique at the study institution was 78% with a specificity of 100%. The PPV and NPV of this technique were 100% and 78%, respectively. The most common causes of the false-negative results in descending order were the technical aspect of the procedure, the size and nature of the lesion, and the scarcity of lesional tissue.
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Affiliation(s)
- Lourdes R Ylagan
- Division of Cytopathology, The Lauren V. Ackerman Laboratory of Surgical Pathology, Washington University Medical School, St. Louis, Missouri 63110, USA.
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de Bellis M, Sherman S, Fogel EL, Cramer H, Chappo J, McHenry L, Watkins JL, Lehman GA. Tissue sampling at ERCP in suspected malignant biliary strictures (Part 2). Gastrointest Endosc 2002. [PMID: 12397282 DOI: 10.1016/s0016-5107(02)70123-5] [Citation(s) in RCA: 127] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Mario de Bellis
- Division of Gastroenterology/Hepatology, Department of Pathology and Laboratory Medicine, Indiana University Medical Center, Indianapolis 46202, USA
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Govil H, Reddy V, Kluskens L, Treaba D, Massarani-Wafai R, Selvaggi S, Gattuso P. Brush cytology of the biliary tract: retrospective study of 278 cases with histopathologic correlation. Diagn Cytopathol 2002; 26:273-7. [PMID: 11992366 DOI: 10.1002/dc.10098] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Bile aspiration during endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography has been used as a diagnostic tool in the evaluations of pancreatic and biliary tree strictures for the last two decades. However, recently biliary tract brush cytology has become the method of choice in evaluating pancreatic/biliary tract abnormalities. The aim of this study was to evaluate the accuracy of pancreatobiliary lesions by an endobiliary cytotechnique. From 1993-1999, 278 pancreatobiliary brushings were performed at our institutions. Cytologic material was air-dried for Diff-Quik stain or fixed in ethanol for Papanicolaou staining. The cytologic diagnoses were classified in three categories: 1) benign, 2) atypical/suspicious, or 3) malignant. Subsequent surgical biopsy was available in 87 (31%) patients. There were 150 males and 128 females with a mean age of 63 yr (range 22-97); 167 (60%) were benign cases. Follow-up surgical material was available in 39 cases, seven of which showed adenocarcinoma; 67 of all cases (24%) were atypical/suspicious cases. Follow-up surgical material was available in 31 cases, 17 (55%) of which showed adenocarcinoma; 32 cases (12%) were malignant cases. Follow-up surgical material was available in 15 cases. All 15 cases were in agreement with the cytologic diagnosis. Twelve (4%) cases were unsatisfactory for cytologic examination. Follow-up surgical material was available in two cases. One case showed mucinous cystadenoma of the pancreas. The other case showed benign duct epithelium. Our study shows a sensitivity of 68% and a specificity of 100%. Of the atypical cases, 55% were malignant on follow-up biopsy. Brush cytology of pancreatobiliary strictures is the most widely used technique in the diagnosis of carcinoma, with a high degree of specificity.
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Affiliation(s)
- Hema Govil
- Department of Pathology, Rush-Presbyterian St. Luke's Medical Center, 1653 West Congress Parkway, Chicago, IL 60612, USA
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Kodama T, Koshitani T, Sato H, Imamura Y, Kato K, Abe M, Wakabayashi N, Tatsumi Y, Horii Y, Yamane Y, Yamagishi H. Electronic pancreatoscopy for the diagnosis of pancreatic diseases. Am J Gastroenterol 2002; 97:617-22. [PMID: 11922556 DOI: 10.1111/j.1572-0241.2002.05539.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Diagnostic pancreatoscopy was performed in 56 patients using the newly developed peroral electronic pancreatoscope (PEPS). The diagnostic value of the PEPS for pancreatic diseases was evaluated. METHODS The PEPS (external diameter = 2.1 mm, bidirectional tip deflection) was developed with a minute 50,000-pixel interline charge-coupled device. Pancreatoscopy was performed by means of an endoscopic retrograde approach without sphincterotomy. The cases examined were normal (three), chronic pancreatitis (32), pancreatic cancer (eight), and intraductal papillary mucinous tumors (13). RESULTS Of the 56 cases, 42 (75%) were adequately seen. In normal cases, fine capillary vessels were clearly visualized on the smooth whitish-pink mucosa. Findings in chronic pancreatitis included protein plugs, calcified stones, rough whitish mucosa, scar formation, edema, erythema, and indistinct capillary appearance. All the stenoses of chronic pancreatitis could be differentiated from those of pancreatic cancer with the PEPS. In the pancreatic cancer cases, all patients had stenoses or duct cutoffs; most cases had friable mucosa with erythema and erosive changes, and a single patient had a compressed pancreatic duct wall covered with normal epithelium. In the cases of intraductal papillary mucinous tumors, papillary tumors were visualized with extreme clarity. In the case of adenocarcinoma, the PEPS revealed oval-shaped tumors with spotty redness or villous tumors with dilation of capillary vessels. Moderate acute pancreatitis was recognized after pancreatoscopy in one of the 56 cases (1.8%). CONCLUSIONS Electronic pancreatoscopy with the PEPS is feasible in most patients and technically safe, and improves diagnostic yield over conventional pancreatoscopy.
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Affiliation(s)
- Tadashi Kodama
- Department of Gastroenterology, Otsu Municipal Hospital, Shiga, Japan
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40
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Fritscher-Ravens A, Bohuslavizki KH, Broering DC, Jenicke L, Schäfer H, Buchert R, Rogiers X, Clausen M. FDG PET in the diagnosis of hilar cholangiocarcinoma. Nucl Med Commun 2001; 22:1277-85. [PMID: 11711897 DOI: 10.1097/00006231-200112000-00002] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Resectional surgery offers a curative intent and a survival benefit for patients with hilar cholangiocarcinoma, but is associated with high morbidity. Since morphological imaging cannot solve differential diagnosis preoperatively, in order to exclude patients inappropriate to this aggressive surgery, we evaluated the impact of functional imaging using fluorodeoxyglucose positron emission tomography (FDG PET) in the detection of cholangiocarcinoma and its usefulness in the differentiation from benign Klatskin tumour-mimicking lesions. Fifteen consecutive patients aged 47-78 years underwent standardized whole-body FDG PET with attenuation correction before potentially curative surgery using a conventional full-ring PET scanner with an axial field-of-view of 16.2 cm. FDG PET was evaluated visually and semiquantitatively using tumour-to-background ratios (T/B) ratios. All lesions were evaluated histopathologically. FDG PET presumed to be indicative for carcinoma was positive in 12 of 15 patients, true positive in 10 (T/B ratio, 3.2+/-1.9) and false positive in two of them (T/B ratios, 2.1 and 2.8) with Klatskin tumour-mimicking lesions. While all true positive PET results were seen in the tubular type of cholangiocarcinoma with a high amount of tumour cells and only low production of mucus, a false negative FDG PET in three patients was observed in mucinous adenocarcinoma. Additionally, FDG PET detected locoregional lymph nodes in two patients and distant metastases in a further three patients. Due to false positive results FDG PET does not allow the differentiation of benign from malignant lesions, and FDG PET should be avoided in patients with mucinous cholangiocarcinoma. However, FDG PET may have significant influence on the treatment strategy in as much as 20% of the patients, since it may detect distant metastases.
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Affiliation(s)
- A Fritscher-Ravens
- Department of Interdisciplinary Endoscopy, University Hospital Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany
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Pugliese V, Pujic N, Saccomanno S, Gatteschi B, Pera C, Aste H, Ferrara GB, Nicolò G. Pancreatic intraductal sampling during ERCP in patients with chronic pancreatitis and pancreatic cancer: cytologic studies and k-ras-2 codon 12 molecular analysis in 47 cases. Gastrointest Endosc 2001; 54:595-9. [PMID: 11677475 DOI: 10.1067/mge.2001.119220] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND A preoperative tissue diagnosis of pancreatic cancer is desirable but difficult to obtain. METHODS Pancreatic brush cytology, salvage cytology, and collection of pancreatic juice were attempted prospectively during ERCP in 34 patients with pancreatic cancer and 11 with chronic pancreatitis. K-ras-2 codon 12 was analyzed for presence and type of point mutations. RESULTS Brush cytology coupled with salvage cytology had a sensitivity of 74%. The addition of cytologic analysis of pancreatic juice did not substantially improve sensitivity (76%). K-ras-2 was mutated in both cancer (87%) and pancreatitis (40%). The specificity for cytology was 100% and for K-ras-2 mutations 60%. Combining cytology with mutation analysis increased sensitivity to 93% but reduced the positive predictive value. The negative predictive value never exceeded 75%. None of the patients with chronic pancreatitis had cancer develop (median follow-up 60 months). CONCLUSIONS Pancreatic ductal brushing with salvage cytology is useful in the diagnosis of cancer, whereas cytologic analysis of pancreatic juice can be abandoned. At present, K-ras-2 mutation is not useful for differentiating pancreatic cancer from chronic pancreatitis or the identification of patients with chronic pancreatitis at risk for malignant transformation.
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Affiliation(s)
- V Pugliese
- Center for Gastrointestinal Endoscopy, the Department of Oncology, University of Genoa, Italy
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Abstract
Acute recurrent pancreatitis (ARP) results most commonly from alcohol abuse or gallstone disease. Initial evaluation fails to detect the cause of ARP in 10-30% of patients, and as a result the diagnosis of "idiopathic" ARP is given. In these patients, a more extensive evaluation including specialized labs, ERCP, endoscopic ultrasound, or magnetic resonance cholangiopancreatography typically leads to a diagnosis of microlithiasis, sphincter of Oddi dysfunction, or pancreas divisum. Less commonly, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatobiliary tumors, or chronic pancreatitis are diagnosed. Determining the etiology is important, as it helps to direct therapy, limits further unnecessary evaluation, and may improve a patient's long term prognosis.
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Affiliation(s)
- M J Levy
- The Mayo Clinic, Rochester, Minnesota 55905, USA
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Rumalla A, Baron TH, Leontovich O, Burgart LJ, Yacavone RF, Therneau TM, de Groen PC, Sebo TJ. Improved diagnostic yield of endoscopic biliary brush cytology by digital image analysis. Mayo Clin Proc 2001; 76:29-33. [PMID: 11155409 DOI: 10.4065/76.1.29] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the accuracy of digital image analysis (DIA) for distinguishing between benign and malignant strictures of the biliary tract. PATIENTS AND METHODS Our pathology databank was used to identify all biliary brush cytology specimens obtained during endoscopic retrograde cholangiopancreatography between June 1997 and June 1999. Corresponding medical records were reviewed to determine whether patients had benign or malignant strictures. Strictures were further classified into benign strictures with negative routine cytology, malignant strictures with negative routine cytology, and malignant strictures with positive routine cytology. Papanicolaou-stained smears of available brush cytology specimens were destained and then restained with Feulgen dye. Nuclear images were quantified for DNA content without knowledge of stricture type. DNA histograms were generated and ploidy results compared with the class of stricture. RESULTS We analyzed 27 specimens from 69 confirmed benign or malignant strictures. Assuming that the presence of any aneuploid cells indicated malignancy, the sensitivity of DIA was 85%. Furthermore, aneuploid cells were detected by DIA in 13 of 16 specimens in which routine cytology was unrevealing. CONCLUSION Ploidy assessment by DIA has potential to enhance the sensitivity of diagnosing malignant strictures compared with routine cytology alone.
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Affiliation(s)
- A Rumalla
- Division of Gastroenterology and Hepatology and Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Inoue H, Tsuchida A, Kawasaki Y, Fujimoto Y, Yamasaki S, Kajiyama G. Preoperative diagnosis of intraductal papillary-mucinous tumors of the pancreas with attention to telomerase activity. Cancer 2001; 91:35-41. [PMID: 11148557 DOI: 10.1002/1097-0142(20010101)91:1<35::aid-cncr5>3.0.co;2-a] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND It has been reported that, in patients with intraductal papillary-mucinous tumor (IPMT) of the pancreas, it is difficult to distinguish adenoma from carcinoma preoperatively. Recently, it has also been reported that telomerase activity was detected in many patients with carcinoma. In this report, the authors used the method of telomerase repeat amplification protocol (TRAP) assay on pancreatic juice retrieved by endoscopic retrograde pancreatic juice aspiration (ERP aspiration). METHODS Pancreatic juice was collected from 28 patients (13 with intraductal carcinoma and 15 with adenoma) using ERP aspiration at either Hiroshima University Hospital or its affiliated hospitals. Two samples of pancreatic juice were collected from each patient. Each sample was examined by cytology for Papanicolaou staining and TRAP assay. RESULTS Four of 13 IPMT patients (31%) with intraductal carcinoma were diagnosed accurately by cytology. Seven of nine patients who were classified with benign tumors by cytologic assessment had tumors that expressed telomerase activity. Overall, 11 of 13 IPMT patients (85%) with intraductal carcinoma were diagnosed correctly by cytology associated with telomerase activity. All of the IPMT patients with adenoma were classified with benign tumors by cytologic assessment, and telomerase activity was not expressed. CONCLUSIONS In this study, the authors found that telomerase activity was expressed with a comparatively high probability in intraductal carcinoma. These results suggest that telomerase activity in pancreatic juices may be used as an adjunct to cytologic diagnosis and may aid further in distinguishing between benign IPMT and malignant IPMT of the pancreas preoperatively.
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MESH Headings
- Adenocarcinoma, Mucinous/diagnosis
- Adenocarcinoma, Mucinous/enzymology
- Adenocarcinoma, Mucinous/pathology
- Biomarkers, Tumor/analysis
- Biomarkers, Tumor/metabolism
- Carcinoma, Pancreatic Ductal/diagnosis
- Carcinoma, Pancreatic Ductal/enzymology
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Papillary/diagnosis
- Carcinoma, Papillary/enzymology
- Carcinoma, Papillary/pathology
- Diagnosis, Differential
- Female
- Humans
- Male
- Middle Aged
- Nucleic Acid Amplification Techniques
- Pancreatic Juice/chemistry
- Pancreatic Neoplasms/diagnosis
- Pancreatic Neoplasms/enzymology
- Pancreatic Neoplasms/pathology
- Preoperative Care
- Telomerase/analysis
- Telomerase/metabolism
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Affiliation(s)
- H Inoue
- First Department of Internal Medicine, Hiroshima University School of Medicine, Hiroshima, Japan.
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Fritscher-Ravens A, Broering DC, Sriram PV, Topalidis T, Jaeckle S, Thonke F, Soehendra N. EUS-guided fine-needle aspiration cytodiagnosis of hilar cholangiocarcinoma: a case series. Gastrointest Endosc 2000; 52:534-40. [PMID: 11023576 DOI: 10.1067/mge.2000.109589] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Improved methods of tissue diagnosis for obstruction at the hilum of the liver (porta hepatis) have contributed substantially to the preoperative diagnosis of cholangiocarcinoma. Endoscopic brushing during endoscopic retrograde cholangiopancreatography (ERCP), with sensitivity of 20% to 100%, is the preferred technique for obtaining accurate pathologic results. Extensive hepatic resection with curative intent as well as modern approaches to palliative treatment are based on definitive diagnosis. This is a study involving endosonography-guided, fine-needle aspiration (EUS-FNA) for cytodiagnosis of potentially operable hilar cholangiocarcinoma when brush cytology was negative or unavailable. METHODS Ten consecutive patients (7 men, 3 women; age 47 to 78 years, median 59 years) with bile duct strictures at the hepatic hilum, diagnosed by CT and/or ERCP, underwent EUS-FNA using linear echoendoscopes and 22-gauge needles. RESULTS Adequate material was obtained in nine patients. Cytology revealed cholangiocarcinoma in seven and hepatocellular carcinoma in one. One benign inflammatory lesion identified on cytology proved to be a false-negative finding by frozen section. Metastatic locoregional hilar lymph nodes were detected in two patients, and in one patient the celiac and para-aortic lymph nodes were aspirated to obtain tissue proof of distant metastasis. There were no complications. CONCLUSIONS When standard methods of tissue diagnosis are inconclusive, EUS-guided FNA may have a potential role in the diagnosis of primary cholangiocarcinoma of the hepatic hilum. As a new, minimally invasive approach, it proved to be technically feasible without significant risks.
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Affiliation(s)
- A Fritscher-Ravens
- Department of Interdisciplinary Endoscopy, Department of Hepatobiliary Surgery, University Hospital, Eppendorf, Hamburg, Germany.
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Jailwala J, Fogel EL, Sherman S, Gottlieb K, Flueckiger J, Bucksot LG, Lehman GA. Triple-tissue sampling at ERCP in malignant biliary obstruction. Gastrointest Endosc 2000; 51:383-90. [PMID: 10744806 DOI: 10.1016/s0016-5107(00)70435-4] [Citation(s) in RCA: 220] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Procurement of cytologic samples by brushing is common practice at endoscopic retrograde cholangiopancreatography (ERCP) but has low sensitivity for cancer detection. Limited data are available on other techniques, including endoluminal fine-needle aspiration and forceps biopsy. This series reviews the yield of these three stricture sampling methods. METHODS In this prospective study, patients with biliary obstruction with a clinical suspicion of malignancy underwent triple-tissue sampling at one ERCP session. Final cancer diagnosis was based on all sampling methods plus surgery, autopsy, and clinical follow-up. Tissue specimens were reported as normal, atypia, or malignant. RESULTS A total of 133 patients were evaluated: 104 had cancer and 29 had benign strictures. Tissue sampling sensitivity varied according to the type of cancer; the highest yield was seen in ampullary cancers (62% to 85%). The cumulative sensitivity of triple-tissue sampling in the cancer patients was as follows: sensitivity was 52% if atypia was considered benign and 77% if it was considered malignant. The addition of a second or third technique increased sensitivity rates in most instances. No serious complications occurred from the tissue sampling methods. CONCLUSIONS Tissue sampling sensitivity varied according to the type of cancer. Combining a second or third method increased sensitivity; general use of at least two sampling methods is therefore recommended.
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Affiliation(s)
- J Jailwala
- Indiana University Medical Center, Indianapolis, Indiana 46202, USA
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47
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Vandervoort J, Soetikno RM, Montes H, Lichtenstein DR, Van Dam J, Ruymann FW, Cibas ES, Carr-Locke DL. Accuracy and complication rate of brush cytology from bile duct versus pancreatic duct. Gastrointest Endosc 1999; 49:322-7. [PMID: 10049415 DOI: 10.1016/s0016-5107(99)70008-8] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The accuracy and complication rates of brush cytology obtained from pancreaticobiliary strictures have not been fully defined. In this study we compared the accuracy and complications of brush cytology obtained from bile versus pancreatic ducts. METHODS We identified 148 consecutive patients for whom brush cytology was done during an ERCP from a database with prospectively collected data. We compared cytology results with the final diagnosis as determined by surgical pathologic examination or long-term clinical follow-up. We followed all patients and recorded ERCP-related complications. RESULTS Forty-two pancreatic brush cytology samples and 101 biliary brush cytology samples were obtained. The accuracy rate of biliary cytology was 65 of 101 (64.3%) and the accuracy rate of pancreatic cytology was 30 of 42 (71.4%). Overall sensitivity was 50% for biliary cytology and 58.3% for pancreatic cytology. Of 67 patients with pancreatic adenocarcinoma, sensitivity for biliary cytology was 50% versus 66% for pancreatic cytology. Concurrent pancreatic and biliary cytology during the same procedure increased the sensitivity in only 1 of 10 (10%) patients. Pancreatitis occurred in 11 (11%) patients (9 mild cases, 2 moderate cases) after biliary cytology and in 9 (21%) patients (6 mild cases, 3 moderate cases) after pancreatic cytology (p = 0.22). In 10 patients who had pancreatic brush cytology, a pancreatic stent was placed. None of these patients developed pancreatitis versus 9 of 32 (28%) patients in whom a stent was not placed (p = 0.08). Pancreatic cytology samples obtained from the head of the pancreas were correct in 13 of 18 (72%) cases, from the genu in 7 of 7 (100%) cases, from the body in 5 of 9 (55%) cases, and from the tail in 4 of 7 (57%) cases. CONCLUSION The accuracy of biliary brush cytology is similar to the accuracy of pancreatic brush cytology. The yield of the latter for pancreatic adenocarcinoma is similar to that of the former. Complication rates for pancreatic cytology are not significantly higher than the rates for biliary cytology. The placement of a pancreatic stent after pancreatic brushing appears to reduce the risk of postprocedure pancreatitis.
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Affiliation(s)
- J Vandervoort
- Divisions of Gastroenterology and Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Sackmann M, Beuers U, Helmberger T. Biliary imaging: magnetic resonance cholangiography versus endoscopic retrograde cholangiography. J Hepatol 1999; 30:334-8. [PMID: 10068117 DOI: 10.1016/s0168-8278(99)80083-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- M Sackmann
- Department of Medicine II, Klinikum Grosshadern, Ludwig-Maximilian's University, Munich, Germany.
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49
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Technology Assessment Status Evaluation. Gastroenterol Nurs 1998. [DOI: 10.1097/00001610-199809000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Parasher VK, Huibregtse K. Endoscopic retrograde wire-guided cytology of malignant biliary strictures using a novel scraping brush. Gastrointest Endosc 1998; 48:288-90. [PMID: 9744607 DOI: 10.1016/s0016-5107(98)70193-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Tissue sampling to differentiate benign from malignant pancreatobiliary strictures remains problematic despite the availability of several new sampling methods. A new device is described which attempts to correct some of the drawbacks. METHODS The device consists of a 10F dilator which has an attached pad of Velcro. The Velcro has semi-rigid, mushroom-shaped bristles. A cytologic sample is obtained by the abrasive action of the brush when it is passed through the stricture. Fifteen patients with obstructive jaundice underwent brushing of the bile duct using this device. RESULTS Cytologic samples obtained with this device were positive for malignancy in all 15 patients. Diagnostic confirmation was obtained by assessment of clinical course, radiologic findings, and during surgery. CONCLUSION Preliminary experience indicates that this new device enhances the yield of tissue sampling from malignant bile duct strictures.
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Affiliation(s)
- V K Parasher
- Department of Medicine, Beebe Medical Center, Lewes, Delaware 19958, USA
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