The combined secretin and cytology test in the diagnosis of pancreatic and biliary tract cancer

Proximal bile duct stricture disguised as malignant neoplasm

BACKGROUND

Discrimination of malignant proximal bile duct (PBD) stricture from a benign lesion is difficult with nonsurgical methods; indeed, 8% to 13% of PBD strictures prove to be benign after histologic examination of the surgically resected specimen.

METHODS

In a 7-year period 178 patients with PBD stricture were admitted, and 99 of them underwent radical resection for presumably malignant lesions. In 14 of these patients the stenotic lesions were proved to be benign by postoperative histologic assessment. We reviewed these patients retrospectively by collecting data from their charts.

RESULTS

Preoperative radiologic findings including cholangiography and angiography were compatible with malignancy in all 14 patients. Preoperative histologic studies suggested malignancy in 2 of 8 examined. Findings at laparotomy could not allow differentiation between malignant and benign lesions in any of the patients and strongly suggested malignancy in 3. Histologic examination of the resected specimens revealed extensive fibrosis with inflammatory cellular infiltration in all patients. There was 1 episode of significant morbidity postoperatively (transient cholangitis) but no mortality.

CONCLUSION

Benign PBD strictures, although rare, are usually indistinguishable from malignant PBD strictures by preoperative or perioperative investigation. Given the minimal morbidity, all PBD strictures should be presumed malignant and managed accordingly, even at the risk of overtreating some benign cases.

Biliary stent replacement cytology

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

A prospective study of biliary cytology in 100 patients with bile duct strictures

In patients with obstructive jaundice due to biliary tract stricture a tissue diagnosis is essential because of the varied treatment options available. Radiological imaging of a biliary stricture may suggest that it is malignant, but only a tissue diagnosis can be conclusive. The difficulty of obtaining biopsy tissue has encouraged the use of cytology in this field. This study prospectively analyzed the diagnostic value of exfoliative bile and brush cytology methods. One hundred consecutive patients with biliary strictures diagnosed at endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography (60 men and 40 women; median age = 71 yr, range = 31 to 91 yr) underwent biliary cytology and were divided into two groups. Group 1 comprised the first 47 patients, who were studied by means of bile cytology alone; and group 2 comprised the subsequent 46 patients, who were studied by means of bile and brush cytology techniques. Seven patients were excluded from analysis because of inadequate follow-up information. A single experienced cytologist examined all samples to determine whether they were neoplastic. Eighty-one patients had malignant strictures and 12 had benign strictures. Combined bile and brush cytology (group 2) was more sensitive than bile cytology alone (group 1) (69% [27 of 39] vs. 33% [16 of 42], p < 0.01). In the patients studied by means of bile and brush cytology methods (group 2), cytologic study of brushings was more sensitive (69% vs. 26%, p < 0.01). No false-positive results were reported in either group (specificity = 100%).(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic value of cytology for biliary stricture

Over the past 20 years, bile aspiration at endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography has been developed for cytological diagnosis of biliary tract stricture. This safe and specific test has allowed a diagnosis to be reached before or without operation in about one-third of malignancies of the pancreas or biliary tree. The recent development of biliary brush cytology has produced better results. An endobiliary biopsy forceps is now available that may allow safe sampling of lesions causing extrinsic compression of the biliary tract. An endobiliary aspiration cytology needle has been produced that may permit non-ulcerating lesions to be diagnosed. A safe alternative to endobiliary methods is percutaneous fine-needle aspiration cytology; this yields a diagnosis in about half of patients presenting with obstructive jaundice and an imaged mass lesion.

Cytologic brushings of ductal lesions during ERCP

Cytologic brushings of ductal lesions noted at ERCP are a reliable method of diagnosing malignancy. However, prior studies have involved only small numbers of patients. This study presents the results of attempted brushings in 69 patients. A satisfactory specimen was obtained in 62 patients (90%). The overall sensitivity was 44% with 100% specificity. Common bile duct brushings had a higher sensitivity rate than did pancreatic brushings. Similarly, biliary tract cancer was more likely to be diagnosed than was pancreatic cancer by brushing. Markedly atypical cells were identified in 36% of patients with a false negative cytology result. These findings were not seen in patients with benign disease. Two patients developed mild pancreatitis and one developed cholangitis. It is unclear what role the act of brushing had on causing these complications.

Cancer of the pancreas: diagnostic accuracy and survival statistics

We have reviewed the natural history, reliability of diagnosis, and survivorship of 100 patients with adenocarcinoma of the pancreas, in the context of a thorough review of the literature on survival after therapy for adenocarcinoma of the pancreas. There is 40--62.5% error in the histologic confirmation of the diagnosis of pancreatic cancer. The error by inspection and palpation alone at the time of surgery may be as great as 25%. The absolute 5 year survival rate calculated from 61 clinical studies representing approximately 15,000 patients is 0.4%. The best series in the current literature has only 3% 5 year rate based upon the total population of pancreatic cancer patients. 12.3% of 5 year survivors from the world literature did not have curative surgery. This study shows the necessity for standardization of reporting methods. The same patients and survivors should not be used repeatedly in different reports. Some authors who claim the most effective palliation by pancreatic resection have the highest mortality rates.

Preoperative diagnosis of pancreatic carcinoma by percutaneous aspiration biopsy

Carcinoma of the pancreas and chronic pancreatitis may be extremely difficult to differentiate by standard diagnostic methods preoperatively as well as at the operating table. Operative pancreatic biopsy may have a high morbidity, rare mortality, and can be misleading. Percutaneous aspiration biopsy may be of great potential benefit. It provides additional histological material not usually available, and an accurate diagnosis of malignancy can be made. In select patients a needless laparotomy may be avoided. It appears to be a safe procedure that should be considered in the evaluation of the patient with suspected pancreatic malignancy in which a mass lesion is demonstrated by ultrasonography, computerized tomography, angiography, or retrograde pancreatography.

Assessment of endoscopic aspiration cytology and endoscopic retrograde cholangio-pancreatography in patients with cancer of the hepato-biliary tract. Part II

Aspiration cytology and ERCP were evaluated in 66 patients with cancer of the hepato-biliary tract. Cytology was diagnostic in 100% of ampullary cancer, 83% of cancer of extrahepatic bile duct, 0% of cancer of intrahepatic bile duct, 25% of cancer of gall bladder and 0% of cancer of liver. ERCP was diagnostic in 65% of ampullary cancer, 90% of cancer of extrahepatic bile duct, 100% of cancer of intrahepatic bile duct, 25% of cancer of gall bladder and 25% of cancer of liver. Endoscopic findings was diagnostic in 77% of cancer of ampullary region. By combining these approaches, a diagnostic result was obtained in 100% of ampullary cancer, 96.5% of cancer of extrahepatic bile duct, 100% of cancer of intrahepatic bile duct, 50% of cancer of gall bladder and 25% of cancer of liver. It is concluded that the combined diagnostic approach has enhanced the diagnostic accuracy of malignant lesions of the hepato-biliary tract and that it has not yet led to an improvement in resectability and mortality.

Cancer of the bile duct: the occult malignancy

Primary malignant lesions of the bile duct system are almost always discovered at a late stage, and largely because of this, the prognosis with this disease is poor. Despite this bleak prognosis, many of these lesions are well differentiated and relatively slow growing. In contrast to periampullary lesions, which may be polypoid or papillary with a relatively good prognosis, bile duct cancers are almost always of the infiltrative type and are often scirrhous. Metastases to lymph nodes occur in the majoirty of patients, about half have liver metastases, direct invasion of the liver occurs frequently, extension into the wall of the bile duct often occurs early, periductal involvement often precludes resection, and perineural invasion frequently extends far beyond the limits of resection. The early periductal spread of these lesions along with the anatomic barriers, that is, the portal vasculature, often prevents wide excision of tumors in the supraduodenal portions of the bile ducts. These lesions are difficult to detect accurately and, because of this, often are nonresectable when definitive diagnosis is established. To detect these tumors more frequently during exploration of the extrahepatic biliary system, especially during cholecystectomy, biopsy specimens of any indurated area should be taken. The discovery of white bile in the common duct is highly suggestive of malignant disease, scrapings of indurated areas may establish the diagnosis, and perhaps the interior of the ductal system should be visualized directly with the optical instruments currently available. However, since most intraductal malignant lesions resemble fibrous strictures, direct visualization may not allow distinction between the two; moreover, biopsy may not establish the diagnosis of malignant disease since often the lesions are extensively fibrotic. Retrograde cholangiography with the duodenoscope probably will be used increasingly in the study of various problems in the bile ducts, including malignant disease. It is unlikely, however, that this method will contribute to the discovery of lesions confined to the mucosa, since carcinoma at this stage seldom produces symptoms and duodenoscopy would rarely be carried out in a patient without significant biliary symptoms.

Cytologic diagnosis of pancreatic cancer by ductal aspiration

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