1
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Alali A, Moris M, Martel M, Streutker C, Cirocco M, Mosko J, Kortan P, Barkun A, May GR. Predictors of Malignancy in Patients With Indeterminate Biliary Strictures and Atypical Biliary Cytology: Results From Retrospective Cohort Study. J Can Assoc Gastroenterol 2021; 4:222-228. [PMID: 34617004 PMCID: PMC8489527 DOI: 10.1093/jcag/gwaa043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 03/15/2021] [Indexed: 11/12/2022] Open
Abstract
Background Atypical cellular features are commonly encountered in patients with indeterminate biliary strictures, which are nondiagnostic of malignancy yet cannot rule it out. This study aims to identify clinical features that could discriminate patients with indeterminate biliary strictures and atypical biliary cytology who may harbor underlying malignancy. Methods All patients with an indeterminate biliary stricture and an atypical brush cytology obtained during endoscopic brushings were identified in a large tertiary-care center. Demographical information, clinical data and the final pathological diagnosis were collected. The study cohort was divided based on the final diagnosis into benign and malignant groups. Descriptive and multivariable analyses were performed. Results A total of 151 patients were included in the analysis. Of these, 62.9% were males with mean age of 61.7 ± 16.4 years. Overall, there was an almost equal distribution of patients in the benign and malignant groups. Older age (≥65 years), jaundice, weight loss, intrahepatic biliary and pancreatic duct dilation, double-duct sign and presence of a mass were associated with malignancy in the univariate analysis. However, only older age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.00 to 1.03), jaundice (OR 3.33, 95% CI 1.11 to 9.98) and presence of a mass (OR 12.10, 95% CI 4.94 to 29.67) were significantly associated with malignancy in the multivariate analysis. High CA19-9 was associated with malignancy only in patients with primary sclerosing cholangitis. Conclusion In patients with indeterminate biliary stricture and atypical brush cytology, older age, jaundice and presence of a mass are significant predictors of malignancy. Patients with such characteristics need prompt evaluation to rule out underlying malignancy.
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Affiliation(s)
- Ali Alali
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Haya Al-Habeeb Gastroenterology and Hepatology Center, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | - Maria Moris
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Digestive Disease Department, Marqués de Valdecilla University Hospital, Cantabria University, Santander, Spain
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Catherine Streutker
- Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maria Cirocco
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey Mosko
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul Kortan
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Gary R May
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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2
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Huynh R, Owers C, Pinto C, Nguyen TM, Kwok T. Endoscopic Evaluation of Biliary Strictures: Current and Emerging Techniques. Clin Endosc 2021; 54:825-832. [PMID: 34038998 PMCID: PMC8652159 DOI: 10.5946/ce.2021.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/17/2021] [Indexed: 11/25/2022] Open
Abstract
The diagnosis of biliary strictures in clinical practice can be challenging. Discriminating between benign and malignant biliary strictures is important to prevent the morbidity and mortality associated with incorrect diagnoses. Missing a malignant biliary stricture may delay surgery, resulting in poor prognostic outcomes. Conversely, it has been demonstrated that approximately 20% of patients who undergo surgery for suspected biliary malignancies have a benign etiology on histopathology. Traditional tissue sampling using endoscopic retrograde cholangiography does not always produce a definitive diagnosis, with a considerable proportion of cases remaining as indeterminate biliary strictures. Recent advances in endoscopic techniques have the potential to improve the diagnostic and prognostic accuracy of biliary strictures.
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Affiliation(s)
- Roy Huynh
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Sydney, NSW, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Corinne Owers
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Christopher Pinto
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Thuy-My Nguyen
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Titus Kwok
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Sydney, NSW, Australia
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3
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Dumonceau JM, Delhaye M, Charette N, Farina A. Challenging biliary strictures: pathophysiological features, differential diagnosis, diagnostic algorithms, and new clinically relevant biomarkers - part 1. Therap Adv Gastroenterol 2020; 13:1756284820927292. [PMID: 32595761 PMCID: PMC7298429 DOI: 10.1177/1756284820927292] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 04/16/2020] [Indexed: 02/04/2023] Open
Abstract
It is frequently challenging to make the correct diagnosis in patients with biliary strictures. This is particularly important as errors may have disastrous consequences. Benign-appearing strictures treated with stents may later be revealed to be malignant and unnecessary surgery for benign strictures carries a high morbidity rate. In the first part of the review, the essential information that clinicians need to know about diseases responsible for biliary strictures is presented, with a focus on the most recent data. Then, the characteristics and pitfalls of the methods used to make the diagnosis are summarized. These include serum biomarkers, imaging studies, and endoscopic modalities. As tissue diagnosis is the only 100% specific tool, it is described in detail, including techniques for tissue acquisition and their yields, how to prepare samples, and what to expect from the pathologist. Tricks to increase diagnostic yields are described. Clues are then presented for the differential diagnosis between primary and secondary sclerosing cholangitis, IgG4-related sclerosing cholangitis, cholangiocarcinoma, pancreatic cancer, autoimmune pancreatitis, and less frequent diseases. Finally, algorithms that will help to achieve the correct diagnosis are proposed.
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Affiliation(s)
- Jean-Marc Dumonceau
- Department of Gastroenterology, Charleroi
University Hospitals, Chaussée de Bruxelles 140, Charleroi, 6042,
Belgium
| | - Myriam Delhaye
- Department of Gastroenterology,
Hepatopancreatology and GI Oncology, Erasme University Hospital, Brussels,
Belgium
| | - Nicolas Charette
- Department of Gastroenterology, Charleroi
University Hospitals, Charleroi, Belgium
| | - Annarita Farina
- Department of Medicine, Geneva University,
Geneva, Switzerland
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4
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Bhattarai S, Graham RP, Sigel CS, Shi J, Gonzalez RS, Xue Y, Krasinskas AM, HooKim K, Adsay V, Reid MD. Bile duct involvement by hepatocellular carcinoma: A rare occurrence and poor prognostic indicator in bile duct brushing samples. Cancer Cytopathol 2019; 127:691-699. [PMID: 31518056 DOI: 10.1002/cncy.22185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 08/26/2019] [Accepted: 08/26/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) rarely involves the biliary tree and may be inadvertently sampled on bile duct brushings (BDBs). METHODS The pathology archives of 5 institutions were searched for BDBs with HCC involvement. RESULTS A total of 17 BDBs from 14 patients were obtained. There was a male:female ratio of 6:1; the median age of the patients was 59.5 years (range, 22-80 years). The median hepatic tumor size was 6.2 cm (range, 2.2-13.0 cm). HCC risk factors included viral hepatitis (5 patients), cirrhosis (5 patients), hemochromatosis (1 patient), and alcoholic steatohepatitis (1 patient). Jaundice with elevated bilirubin, liver enzymes, and α-fetoprotein was common. Endoscopic retrograde cholangiopancreatography demonstrated bile duct dilatation, polypoid intraductal masses (5 samples), clots/debris (2 samples), or strictures (4 samples). All BDBs had single and clustered large cells with naked atypical nuclei, granular cytoplasm, high nuclear/cytoplasmic ratios, and nuclei with prominent macronucleoli. Less common findings included clear/microvesicular cytoplasm (35%), papillae (29%), and anisonucleosis (35%). Classic HCC features (widened trabeculae [35%], endothelial wrapping [24%], multinucleation [24%], and cytoplasmic bile pigment [35%]) were uncommon. A total of 11 BDBs were diagnosed as malignant (10 with HCC and 1 with cholangiocarcinoma), 2 were diagnosed as atypical, and 1 BDB was diagnosed as negative; approximately two-thirds were found to have polysomy on fluorescence in situ hybridization. Approximately 71% of patients died of disease at a median of 3.5 months. CONCLUSIONS HCC may extend into the intrahepatic and/or extrahepatic biliary tree, causing masses and/or strictures that may be sampled on BDB. Although cytologically malignant, the classic features of HCC are uncommon, which can cause misdiagnosis. Cytopathologists should be mindful of this differential when evaluating BDBs, particularly when concomitant liver masses and/or HCC risk factors are present. Because of the associated high mortality and rapid rate of death, its presence should be conveyed clearly in pathology reports.
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Affiliation(s)
| | | | - Carlie S Sigel
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jiaqi Shi
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - Raul S Gonzalez
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Yue Xue
- Department of Pathology, Emory University Hospital, Atlanta, Georgia
| | | | - Kim HooKim
- Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Volkan Adsay
- Department of Pathology, Koç University, Istanbul, Turkey
| | - Michelle D Reid
- Department of Pathology, Emory University Hospital, Atlanta, Georgia
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5
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Hacihasanoglu E, Memis B, Pehlivanoglu B, Avadhani V, Freedman, AA, Goodman MM, Adsay NV, Reid MD. Factors Impacting the Performance Characteristics of Bile Duct Brushings: A Clinico-Cytopathologic Analysis of 253 Patients. Arch Pathol Lab Med 2018; 142:863-870. [DOI: 10.5858/arpa.2017-0150-oa] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Literature on factors impacting bile duct brushings (BDBs) performance characteristics remain limited.
Objective.—
To capture the current state of daily practice with BDB sign-out.
Design.—
Two hundred fifty-three of 444 BDBs signed out by more than 7 cytopathologists, with histopathologic and/or clinical follow-up of at least 18 months, were examined.
Results.—
One hundred thirty-five of 253 BDBs (53%) had histologically confirmed malignancies, 22 (9%) had cancer-related deaths, and 96 (38%) were benign. Cytologic diagnoses in the 444 BDBs were nondiagnostic (11 [2.5%]), negative (284 [64%]), atypical (62 [13.9%]), suspicious (34 [7.7%]), and malignant (53 [11.9%]). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of malignancy detection were 35%, 100%, 100%, 58%, and 66%, respectively. When atypical, suspicious, and malignant (ASM) categories were combined, sensitivity increased (58%), specificity and PPV dropped (97%), and accuracy increased (73%). Carcinoma type (bile-duct versus pancreatic-ductal) had no effect on accuracy (P = .60) or diagnostic class (P = .84), nor did time of performance (first 7.5 versus latter 7.5 years, P = .13). Interestingly, ThinPrep + cell block (n = 41) had higher sensitivity (61%) and lower specificity (80%) than ThinPrep only (versus 51% and 100%, respectively). Sensitivity and specificity were higher (47% and 100%) in nonstented than stented specimens (59% and 97%). Relative risk of malignancy for “suspicious” (2.30) and “atypical” (2.28) categories was lower but not very different from that of “malignant” category (2.41).
Conclusions.—
Bile duct brushings had fairly low sensitivity but high specificity and PPV with no false positives. Sensitivity almost doubled and specificity dipped minimally when ASM categories were combined, highlighting the need for better classification criteria for atypical/suspicious cases. Higher specificity, PPV, NPV, and accuracy but lower sensitivity in stented BDBs suggest that they be called malignant only when evidence is overwhelmingly convincing.
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Affiliation(s)
| | | | | | | | | | | | | | - Michelle D. Reid
- From the Department of Pathology, Emory University School of Medicine, Atlanta, Georgia (Drs Hacihasanoglu, Memis, Pehlivanoglu, Avadhani, and Reid); the Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia (Ms Freedman and Dr Goodman); and the Department of Pathology, Medical College of Wisconsin, Milwaukee (Dr Adsay)
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6
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Papanicolaou Society of Cytopathology new guidelines have a greater ability of risk stratification for pancreatic endoscopic ultrasound-guided fine-needle aspiration specimens. Oncotarget 2018; 8:8154-8161. [PMID: 28042957 PMCID: PMC5352390 DOI: 10.18632/oncotarget.14105] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 11/23/2016] [Indexed: 02/06/2023] Open
Abstract
The Papanicolaou Society of Cytopathology has recently proposed a standardized terminology and nomenclature guidelines for pancreatic cytology. However the risk of malignancy associated with the new guidelines has been scarcely studied. In this study, a series of pancreatic cytology cases obtained by endoscopic ultrasound-guided fine-needle aspiration from 294 Chinese patients were retrospectively re-categorized into six categories according the new guidelines. The risks of malignancy were 18.1% for “negative,” 20.0% for “neoplastic,” 57.1% for “nondiagnostic,” 69.2% for “atypical,” 87.5% for “suspicious,” and 100.0% for “positive” respectively. The area under the receiver operating characteristic curve was 0.93 (95% Confidence Interval, 0.90-0.96), which was significantly higher than that associated with old classification system (0.82; 95% Confidence Interval, 0.77-0.87) conventionally used in China. Our investigation demonstrated that the new guidelines have a greater ability of risk stratification than the old classification system conventionally used in China. This may be helpful in giving better predictions of malignancy, thus leading to more personalized treatment strategies.
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7
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Choi WT, Swanson PE, Grieco VS, Wang D, Westerhoff M. The outcomes of “atypical” and “suspicious” bile duct brushings in the identification of pancreaticobiliary tumors: Follow-up analysis of surgical resection specimens. Diagn Cytopathol 2015. [DOI: 10.1002/dc.23323] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Won-Tak Choi
- Department of Pathology; University of Washington School of Medicine; Seattle Washington
| | - Paul E. Swanson
- Department of Pathology; University of Washington School of Medicine; Seattle Washington
| | - Verena S. Grieco
- Department of Pathology; University of Washington School of Medicine; Seattle Washington
| | - Dongliang Wang
- Department of Public Health and Preventive Medicine; SUNY Upstate Medical University; Syracuse New York
| | - Maria Westerhoff
- Department of Pathology; University of Washington School of Medicine; Seattle Washington
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8
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Jo YG, Lee TH, Cho HD, Park SH, Park JM, Cho YS, Jung Y, Chung IK, Choi HJ, Moon JH, Cha SW, Cho YD, Kim SJ. Diagnostic Accuracy of Brush Cytology with Direct Smear and Cell-block Techniques according to Preparation Order and Tumor Characteristics in Biliary Strictures. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2014; 63:223-30. [DOI: 10.4166/kjg.2014.63.4.223] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Yeong Geol Jo
- Department of Internal Medicine, Soonchunhyang University Hospital Cheonan, Korea
| | - Tae Hoon Lee
- Department of Internal Medicine, Soonchunhyang University Hospital Cheonan, Korea
| | - Hyun-Deuk Cho
- Department of Internal Medicine and Pathology, Soonchunhyang University Hospital Cheonan, Korea
| | - Sang-Heum Park
- Department of Internal Medicine, Soonchunhyang University Hospital Cheonan, Korea
| | - Jae Man Park
- Department of Internal Medicine, Soonchunhyang University Hospital Cheonan, Korea
| | - Young Sin Cho
- Department of Internal Medicine, Soonchunhyang University Hospital Cheonan, Korea
| | - Yunho Jung
- Department of Internal Medicine, Soonchunhyang University Hospital Cheonan, Korea
| | - Il-Kwun Chung
- Department of Internal Medicine, Soonchunhyang University Hospital Cheonan, Korea
| | - Hyun Jong Choi
- Department of Internal Medicine, Soonchunhyang University Hospital Bucheon, Soonchunhyang University College of Medicine, Korea
| | - Jong Ho Moon
- Department of Internal Medicine, Soonchunhyang University Hospital Bucheon, Soonchunhyang University College of Medicine, Korea
| | - Sang Woo Cha
- Department of Internal Medicine, Hospital Seoul, Soonchunhyang University College of Medicine, Korea
| | - Young Deok Cho
- Department of Internal Medicine, Hospital Seoul, Soonchunhyang University College of Medicine, Korea
| | - Sun-Joo Kim
- Department of Internal Medicine, Soonchunhyang University Hospital Cheonan, Korea
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9
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Chadwick BE, Layfield LJ, Witt BL, Schmidt RL, Cox RNK, Adler DG. Significance of atypia in pancreatic and bile duct brushings: Follow-Up analysis of the categories atypical and suspicious for malignancy. Diagn Cytopathol 2013; 42:285-91. [DOI: 10.1002/dc.23035] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 08/21/2013] [Indexed: 01/27/2023]
Affiliation(s)
- Barbara E. Chadwick
- Department of Pathology; University of Utah School of Medicine and ARUP Laboratories; Salt Lake City Utah
| | - Lester J. Layfield
- Department of Pathology and Anatomical Sciences; University of Missouri; Columbia Missouri
| | - Benjamin L. Witt
- Department of Pathology; University of Utah School of Medicine and ARUP Laboratories; Salt Lake City Utah
| | - Robert L. Schmidt
- Department of Pathology; University of Utah School of Medicine and ARUP Laboratories; Salt Lake City Utah
| | - R. N. Kristin Cox
- Department of Internal Medicine; University of Utah School of Medicine and ARUP Laboratories; Salt Lake City Utah
- Division of Gastroenterology and Hepatology; Department of Internal Medicine; University of Utah School of Medicine; Salt Lake City Utah
| | - Douglas G. Adler
- Department of Internal Medicine; University of Utah School of Medicine and ARUP Laboratories; Salt Lake City Utah
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10
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Witt BL, Kristen Hilden RN, Scaife C, Chadwick B, Layfield L, Cory Johnston W, Safaee M, Siddiqui A, Adler DG. Identification of factors predictive of malignancy in patients with atypical biliary brushing results obtained via ERCP. Diagn Cytopathol 2012; 41:682-8. [PMID: 23008113 DOI: 10.1002/dc.22924] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 08/09/2012] [Indexed: 12/16/2022]
Abstract
Biliary brushings obtained during ERCP can have one of three cellular interpretations: benign, malignant, or "atypical." Atypical interpretations usually result in further testing, and may cause controversy over management and increases in cost. We evaluated a large cohort of patients with atypical biliary brushings for analysis and risk stratification. All biliary brushing specimens collected between January 1, 2001 and December 31, 2010 that had an atypical result were included. Hospital electronic records were reviewed for these patients to include: demographics, indication for ERCP, endoscopist/pathologist impressions, serologic testing, stricture site, and information relating to the final clinical diagnosis. Eighty-six patients were included. Totally, 60/86 patients (70%) had malignancies while 26/86 (30%) had no evidence of malignancy during long term follow up. Univariate analysis showed that the risk of malignant outcomes was significantly associated with older age, suspicious/malignant endoscopic impression, pancreatic mass, indications including jaundice and/or dilated bile ducts, stricture location within the common bile duct, PSC, and CA 19-9 levels >300 U/mL. We created a novel scoring system for prediction of malignancy based on clinical and endoscopic factors. We identified parameters that are typically available to the clinician to categorize patients with an "atypical" bile duct brushing results into "high risk" and "lower risk" classifications. Our proposed scoring system would allow such risk stratification to take place.
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Affiliation(s)
- Benjamin L Witt
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah 84132, USA
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11
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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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12
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Waugh MS, Guy CD, Maygarden SJ, Livasy CA, Jones CK, Volmar KE. Use of the ThinPrep method in bile duct brushings: analysis of morphologic parameters associated with malignancy and determination of interobserver reliability. Diagn Cytopathol 2008; 36:651-6. [PMID: 18677761 DOI: 10.1002/dc.20855] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Recent work suggests the ThinPrep method can improve diagnostic sensitivity and accuracy in bile duct brushings. However, the proportion of atypical and suspicious diagnoses remains high. The aim of this study was to identify the most useful morphologic features in ThinPrep bile duct cytology and evaluate interobserver reliability. We evaluated 100 bile duct brushings prepared by ThinPrep, all with either histology or long term clinical follow-up (55 malignant, 45 benign). Morphologic features were evaluated by four experienced cytopathologists blind to clinical information and follow-up diagnoses. These features included cellularity, blood or diathesis, mitoses, inflammation, three-dimensional groups, discohesive atypical cells, macronucleoli, well-defined cytoplasmic borders, and nuclear features of malignancy (nuclear membrance irregularity, chromatin clumping). The data were analyzed by intraclass correlation (ICC) and stepwise multiple logistic regression. Reviewers showed unanimous agreement in 29% of cases, one degree of disagreement in 58% of cases, and full disagreement in 13% of cases. Of benign cases, 38% were thought to be diagnostic of malignancy by at least one of the four reviewers. Sensitivity for the morphologic parameters varied from 18 to 67%; the highest sensitivity was for discohesive atypical cells, well-defined cytoplasmic borders, nuclear features of malignancy, and cellularity (67, 62, 51 and 46%, respectively). Specificity of parameters varied from 16 to 100%; the highest specificity was for mitoses, three-dimensional groups, nuclear features of malignancy, and macronucleoli (100, 98, 93, and 93%, respectively). Interobserver reliability (ICC) was very good for specimen cellularity (0.72) and nuclear features of malignancy (0.60). In logistic regression analysis, only nuclear features of malignancy and increasing patient age separated benign from malignant. On ThinPrep bile duct brushings, nuclear features of malignancy are most useful in distinguishing benign from malignant, and interobserver reliability for this parameter is very good. Discohesive atypical cells show moderate sensitivity and specificity, while three dimensional clusters and macronucleoli are specific but not sensitive for malignancy, and are not significant in multivariate logistic regression models. The relatively high proportion of benign cases thought to be diagnostic of malignancy by at least one reviewer argues for a consensus approach to this diagnosis.
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Affiliation(s)
- Michael S Waugh
- Department of Pathology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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13
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Asioli S, Accinelli G, Pacchioni D, Bussolati G. Diagnosis of biliary tract lesions by histological sectioning of brush bristles as alternative to cytological smearing. Am J Gastroenterol 2008; 103:1274-81. [PMID: 18177458 DOI: 10.1111/j.1572-0241.2007.01698.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM To increase the diagnostic potential of endoscopic biliary tract brushing, we devised an approach alternative to cytological smearing, leading to the preoperative histological examination of the collected material. METHODS One hundred twelve consecutive biliary brush specimens were included. All patients presented a stricture of the biliary tract, leading to a diagnostic procedure by brushing. Immediately following brushing, the endoscopist immersed the brush into methanol and sent it to the pathology laboratory. The brush was introduced into a cassette for paraffin embedding and sections parallel to the long axis of brush were cut until the metal wire was almost reached, then the block was rotated and new sections were obtained from the opposite side. Samples of the mucosa, inflammatory cell aggregates, small fragments of carcinomas, or isolated cells were observed, and displayed an optimal fixation, allowing a definite diagnosis that proved mandatory for therapy in the vast majority of cases (99.1%). RESULTS The results obtained in 112 consecutive cases using such technique compared with final histological diagnosis proved: 91% sensitivity, 100% specificity, 100% positive predictive value (PPV), and 87% negative predictive value (NPV) (P < 0.001). In nonoperated patients, the clinical diagnosis after at least 6 months of follow-up showed: 95.5% sensitivity, 100% specificity, 100% PPV, and 88.2% NPV (P < 0.001). CONCLUSION Such novel approach to the preoperative diagnosis of biliary tract lesions proved to be highly sensitive and specific, limiting the inadequate preoperative diagnoses to less than 1%.
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Affiliation(s)
- Sofia Asioli
- Department of Biomedical Sciences and Human Oncology, Molinette Hospital, University of Turin, Turin, Italy
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14
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Volmar KE, Vollmer RT, Routbort MJ, Creager AJ. Pancreatic and bile duct brushing cytology in 1000 cases: review of findings and comparison of preparation methods. Cancer 2006; 108:231-8. [PMID: 16541448 DOI: 10.1002/cncr.21842] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Duct brushing cytology is an important tool in evaluation of the extrahepatic biliary tract and large pancreatic ducts. The emergence of neoadjuvant therapies underscores the importance of accurate preoperative diagnosis by noninvasive means. Liquid-based preparation methods, such as ThinPrep, have become popular for nongynecologic cytology specimens. METHODS Findings from bile and pancreatic duct brushings were reviewed over the 10-year period of 1994-2003. Cytologic material, imaging reports, and clinical data were reviewed and pathologic and clinical follow-up data were obtained. The slides were prepared by direct smear only (18.8%), direct smear plus cytospin (14.4%), or direct smear plus ThinPrep (66.8%). RESULTS A total of 1118 specimens were identified (1008 bile duct, 110 pancreatic duct) from 864 patients. The cytologic findings were: 53.5% negative, 16.5% malignant, 18.2% suspicious for malignancy, 11% atypical/inconclusive, 0.8% inadequate. Follow-up in the form of either histology or at least 6 months clinical observation was available for 82.2% of cases (n = 971). Overall operating characteristics were: 52.6% sensitivity, 99.4% specificity, 98.9% positive predictive value, 67.1% negative predictive value, and 75.7% accuracy. Diagnostic agreement between cytology and follow-up was the main variable analyzed. Agreement was significantly affected by characteristics of the sampled lesion, with ductal narrowing having the lowest rate of malignancy. In addition, the ThinPrep method showed superior sensitivity and accuracy compared with other preparation methods (P = .02). Nonsignificant associations were noted for patient age and gender, site of lesion, and the presence of either stones or prior stent. CONCLUSION In a large dataset from a single institution, brushing cytology showed modest sensitivity and high specificity. Diagnostic agreement was considerably better for benign cases. The combination of direct smear and the ThinPrep method showed superior sensitivity and accuracy.
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Affiliation(s)
- Keith E Volmar
- Department of Pathology, University of North Carolina, Chapel Hill, North Carolina, USA.
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Moff SL, Clark DP, Maitra A, Pandey A, Thuluvath PJ. Utility of bile duct brushings for the early detection of cholangiocarcinoma in patients with primary sclerosing cholangitis. J Clin Gastroenterol 2006; 40:336-41. [PMID: 16633106 DOI: 10.1097/01.mcg.0000210102.82241.de] [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: 12/26/2022]
Abstract
BACKGROUND In patients with primary sclerosing cholangitis, there are no reliable markers or imaging modalities to detect malignant changes or early cholangiocarcinoma when curative interventions may still be possible. METHODS Clinical features and outcomes were evaluated for 47 patients who underwent 101 endoscopic retrograde cholangiopancreatography (ERCP) procedures with bile duct brushings and cytopathologic examination for the detection of malignant changes between January 2001 and 2004. Bile duct cytology was characterized as unsatisfactory, benign, atypical, or malignant. RESULTS Fifteen patients had at least one sample that was abnormal. Patients with abnormal findings were older (P = 0.03); otherwise the groups were similar. Three of six patients with marked atypia have undergone transplantation for these abnormal findings, and of these, two had cholangiocarcinoma and one had no cancer detected in the explant. Of the nine patients with focal atypia, seven are doing well, one underwent transplantation for marked atypia seen on brushings at another hospital, and the other underwent transplantation for decompensated cirrhosis. Two patients with benign findings developed cholangiocarcinoma, whereas 29 others have not. CONCLUSION Cytopathologic examination of bile duct brushings taken at ERCP may be useful for the early detection of malignant changes in patients with primary sclerosing cholangitis. However, long-term prospective studies are needed to confirm the utility of surveillance ERCP and brushings.
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Affiliation(s)
- Stephen L Moff
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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Elek G, Gyökeres T, Schäfer E, Burai M, Pintér F, Pap A. Early diagnosis of pancreatobiliary duct malignancies by brush cytology and biopsy. Pathol Oncol Res 2005; 11:145-55. [PMID: 16195768 DOI: 10.1007/bf02893391] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2005] [Accepted: 08/01/2005] [Indexed: 10/21/2022]
Abstract
Two hundred and five preoperative intraductal samplings (brushing and biopsy) were evaluated from 113 patients with biliary or Wirsung duct strictures. One hundred and three strictures could be specified by histology of the operative specimens, autopsy, or by the patients' clinical course. Preoperative diagnostic efficacy depended on the tumor location (it was the best for ampullary and para-papillary tumors), but the average quantitative indices for sensitivity, absolute sensitivity, specificity, positive and negative predictive values, diagnostic accuracy of cytology were 53%, 20%, 100%, 100%, 25%, 59%, respectively. The same values for biopsy were 43%, 34%, 100%, 100%, 36% and 56%. These figures improved after simultaneous cytology and biopsy. Close cooperation with the endoscopist was necessary in cases of negative, inconclusive and dysplastic (27%) samples. Repetition of sampling improved the results by 8%. Among the 26 preoperative false negative cases, sampling-, technical- and interpretative errors occurred in 84%, 4% and 12%, respectively. Revision of samples revealed 4 malignant cases among the false negative cytologic brushings. Reclassification of specimens considering the latest criteria - primary and secondary malignant features, pancreatic intraepithelial neoplasia (PanINs), etc. - resulted in improvement of the diagnostic efficiency.
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Affiliation(s)
- Gábor Elek
- Department of Pathology, Central Railway Hospital and Polyclinic, Budapest, Hungary
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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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Duggan MA, Brasher P, Medlicott SA. ERCP-directed brush cytology prepared by the ThinprepR method: test performance and morphology of 149 cases. Cytopathology 2004; 15:80-6. [PMID: 15056167 DOI: 10.1111/j.1365-2303.2004.00129.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Conventionally prepared endobiliary brushings are moderately (42%) sensitive and highly (98%) specific in detecting malignancy. The performance and morphological features of brushings prepared by Thinprep, a liquid-based method are mostly unknown. All brushings were retrieved from the laboratory files. Disease was classified as benign or malignant by linkage with the provincial cancer registry and sensitivity, specificity, positive (PPV) and negative predictive values (NPV) calculated. True positives and negatives were reviewed and predictive morphological features analysed by regression tree analysis. Out of 149 brushings, 55 (37%) were positive and 94 (63%) negative. Malignancy was identified in 86 (58%) and benign disease in 63 (42%) of the cases. The sensitivity was 51%, specificity 83%, PPV 80% and NPV 55%. Absolute discriminants of positive and negative brushings were not found, but nuclear cytoplasmic ratio was a useful feature. The performance of Thinprep-prepared brushings from this anatomical site was comparable with conventional preparations.
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Affiliation(s)
- M A Duggan
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada.
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Minamiguchi S, McEvoy R, Fraig M, Lewin DN, Wallace MB, Hoda RS. Bile duct brushings on ThinPrep®: Experience with 68 specimens. Diagn Cytopathol 2004; 30:292-3. [PMID: 15048971 DOI: 10.1002/dc.10414] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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