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Orzan RI, Bolboacă SD, Pojoga C, Hagiu C, Mosteanu O, Rusu I, Rednic V, Seicean R, Al Hajjar N, Agoston R, Seicean A. Contrast-enhanced vs. standard endoscopic ultrasound fine-needle aspiration for diagnosing malignant biliary tumors: Randomized controlled trial. Endosc Int Open 2025; 13:a25698969. [PMID: 40376025 PMCID: PMC12080515 DOI: 10.1055/a-2569-8969] [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: 12/31/2024] [Accepted: 02/24/2025] [Indexed: 05/18/2025] Open
Abstract
Background and study aims Contrast-enhanced endoscopic ultrasound (CH-EUS) is superior to standard EUS for staging biliary duct tumors (BDTs), but its role in guiding EUS-guided fine needle aspiration (EUS-FNA) remains unclear. We compared diagnostic accuracy of CH-EUS-fine needle aspiration (CH-EUS-FNA) and standard EUS-FNA in patients with suspected malignant biliary stenosis. Patients and methods A parallel randomized controlled trial was conducted in a tertiary medical center and included jaundiced patients with suspected malignant biliary stenosis on computed tomography. The patients were assigned randomly to EUS-FNA or CH-EUS-FNA groups. Final diagnosis was determined based on EUS-FNA, surgical specimen results, endoscopic retrograde cholangiopancreatography (ERCP), or 12-month follow-up. Results Sixty-one patients were included in the study, 31 in the EUS-FNA group and 30 in the CH-EUS-FNA group. Mean age of participants was 74 ± 11.04 years and mean tumor size was 20.39 ± 9.17 mm, with 43 tumors in the distal bile duct. Final diagnoses were cholangiocarcinoma (37 cases), pancreatic ductal carcinoma (12 cases), other malignancies (3 cases), and benign lesion (9 cases). Diagnostic sensitivity, specificity, and accuracy were 83.3%, 100%, and 87.1% for EUS-FNA, and 82.1%, 100%, and 83.3% for CH-EUS-FNA. Plastic biliary stent placement and tumor location did not influence results. Hyperenhancement in the CH-EUS with rapid washout was observed in 90.9% of cholangiocarcinoma cases. Conclusions Standard EUS-FNA and CH-EUS-FNA demonstrated comparable diagnostic accuracy in evaluation of extrahepatic bile duct tumors, but with better slightly efficiency and inaccuracy indices than standard EUS-FNA.
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Affiliation(s)
- Rares Ilie Orzan
- Gastroenterology, Regional Institute of Gastroenterology and Hepatology Prof Dr Octavian Fodor, Cluj-Napoca, Romania
| | - Sorana D. Bolboacă
- Medical Informatics and Biostatistics, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Cristina Pojoga
- Clinical Psychology and Psychotherapy, Babeș-Bolyai University, Cluj-Napoca, Romania
| | - Claudia Hagiu
- 3rd Department of Internal Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ofelia Mosteanu
- 3rd Medical Clinic, University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
| | - Ioana Rusu
- 3rd Department of Internal Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Voicu Rednic
- Regional Institute of Gastroenterology and Hepatology Prof Dr Octavian Fodor, Cluj-Napoca, Romania
| | - Radu Seicean
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Nadim Al Hajjar
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Renata Agoston
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andrada Seicean
- Regional Institute of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Neuzillet C, Decraecker M, Larrue H, Ntanda-Nwandji LC, Barbier L, Barge S, Belle A, Chagneau C, Edeline J, Guettier C, Huguet F, Jacques J, Le Bail B, Leblanc S, Lewin M, Malka D, Ronot M, Vendrely V, Vibert É, Bureau C, Bourliere M, Ganne-Carrie N, Blanc JF. Management of intrahepatic and perihilar cholangiocarcinomas: Guidelines of the French Association for the Study of the Liver (AFEF). Liver Int 2024; 44:2517-2537. [PMID: 38967424 DOI: 10.1111/liv.15948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/13/2024] [Accepted: 04/11/2024] [Indexed: 07/06/2024]
Abstract
Intrahepatic cholangiocarcinoma (iCCA) is the second most common malignant primary liver cancer. iCCA may develop on an underlying chronic liver disease and its incidence is growing in relation with the epidemics of obesity and metabolic diseases. In contrast, perihilar cholangiocarcinoma (pCCA) may follow a history of chronic inflammatory diseases of the biliary tract. The initial management of CCAs is often complex and requires multidisciplinary expertise. The French Association for the Study of the Liver wished to organize guidelines in order to summarize the best evidence available about several key points in iCCA and pCCA. These guidelines have been elaborated based on the level of evidence available in the literature and each recommendation has been analysed, discussed and voted by the panel of experts. They describe the epidemiology of CCA as well as how patients with iCCA or pCCA should be managed from diagnosis to treatment. The most recent developments of personalized medicine and use of targeted therapies are also highlighted.
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Affiliation(s)
- Cindy Neuzillet
- GI Oncology, Medical Oncology Department, Institut Curie, Versailles Saint-Quentin University, Paris Saclay University, Saint-Cloud, France
| | - Marie Decraecker
- Oncology Digestive Unit, INSERM U1312, University Hospital of Bordeaux, Bordeaux, France
| | - Hélène Larrue
- Department of Hepatology, University Hospital, Toulouse III-Paul Sabatier University, Toulouse, France
| | | | - Louise Barbier
- New Zealand Liver Transplant Unit and HPB Surgery, Te Toka Tumai, University of Auckland, Auckland, New Zealand
| | - Sandrine Barge
- Centre Hospitalier Intercommunal Créteil-CHI Créteil, Créteil, France
| | - Arthur Belle
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Julien Edeline
- Department of Medical Oncology, CLCC Eugène Marquis, COSS-UMR S1242, INSERM, Univ Rennes, Rennes, France
| | - Catherine Guettier
- Department of Pathology, APHP University Paris Saclay, Hôpital Bicetre, Paris, France
| | - Florence Huguet
- Radiation Oncology Department, Tenon Hospital, APHP-Sorbonne University, Paris, France
| | | | - Brigitte Le Bail
- Pathology Department, University Hospital of Bordeaux, Bordeaux, France
| | - Sarah Leblanc
- Gastroenterology Department, Private Hospital Jean Mermoz, Ramsay Santé, Lyon, France
| | - Maïté Lewin
- Service de Radiologie, AP-HP-Université Paris Saclay Hôpital Paul Brousse, Villejuif, France
| | - David Malka
- Medical Oncology Department, Institut Mutualiste Monsouris, Paris, France
| | - Maxime Ronot
- Department of Radiology, Beaujon Hospital, APHP Nord Clichy, University Paris Cité, CRI UMR, Paris, France
| | | | - Éric Vibert
- Centre Hepato-Biliaire, AP-HP-Université Paris Saclay Hôpital Paul Brousse, Villejuif, France
| | - Christophe Bureau
- Department of Hepatology, University Hospital, Toulouse III-Paul Sabatier University, Toulouse, France
| | | | | | - Jean-Frédéric Blanc
- Oncology Digestive Unit, INSERM U1312, University Hospital of Bordeaux, Bordeaux, France
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Affarah L, Berry P, Kotha S. Still elusive: Developments in the accurate diagnosis of indeterminate biliary strictures. World J Gastrointest Endosc 2024; 16:297-304. [PMID: 38946851 PMCID: PMC11212512 DOI: 10.4253/wjge.v16.i6.297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/09/2024] [Accepted: 05/07/2024] [Indexed: 06/13/2024] Open
Abstract
Indeterminate biliary strictures pose a significant diagnostic dilemma for gastroenterologists. Despite advances in endoscopic techniques and instruments, it is difficult to differentiate between benign and malignant pathology. A positive histological diagnosis is always preferred prior to high risk hepatobiliary surgery, or to inform other types of therapy. Endoscopic retrograde cholangiopancreatography with brushings has low sensitivity and despite significant improvements in instruments there is still an unacceptably high false negative rate. Other methods such as endoscopic ultrasound and cholangioscopy have improved diagnostic quality. In this review we explore the techniques available to aid accurate diagnosis of indeterminate biliary strictures and obtain accurate histology to facilitate clinical management.
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Affiliation(s)
- Lynn Affarah
- Department of Hepatology, Guy's and St Thomas' Hospital, London SE1 7EH, United Kingdom
| | - Philip Berry
- Department of Hepatology, Guy's and St Thomas' Hospital, London SE1 7EH, United Kingdom
| | - Sreelakshmi Kotha
- Department of Hepatology, Guy's and St Thomas' Hospital, London SE1 7EH, United Kingdom
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Ohno E, Kuzuya T, Kawabe N, Nakaoka K, Tanaka H, Nakano T, Miyachi Y, Hashimoto S, Hirooka Y. Contributions of endoscopic ultrasonography-guided tissue acquisition (EUS-TA) to the diagnostics of biliary stricture and gallbladder lesions. J Med Ultrason (2001) 2024; 51:227-233. [PMID: 38700561 DOI: 10.1007/s10396-024-01458-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/04/2024] [Indexed: 05/21/2024]
Abstract
Endoscopic ultrasonography (EUS) provides high spatial resolution and more detailed images than other diagnostic modalities. Furthermore, EUS-guided tissue acquisition (EUS-TA), such as EUS-guided fine needle aspiration or biopsy (EUS-FNA/FNB), is an indispensable tool in pancreaticobiliary disease diagnostics, supporting a conclusive pathological diagnosis. In this review, we evaluate the current status and the usefulness of EUS-TA for the diagnostics of the following biliary tract diseases: (A) biliary stricture diagnostics, (B) biliary tract cancer (BTC) itself, and (C) staging of advanced BTC. Previous reports have shown that EUS-FNA for biliary lesions is a safe procedure that is useful in differentiating biliary cancer from benign lesions and in the staging of BTC. On the other hand, the diagnostic performance of EUS-TA for bile duct lesions is reported to be similar to that of transpapillary biopsy. Overall, EUS-TA for biliary lesions may be a safe and effective method, but it should be performed with an understanding of the risk of serious adverse events such as bile leakage and peritoneal dissemination of cancer. It is recommended for distal biliary stricture lesions for which endoscopic retrograde cholangiopancreatography cannot confirm the diagnosis or gallbladder lesions if they do not require the needle to pass through the biliary lumen.
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Affiliation(s)
- Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan.
| | - Teiji Kuzuya
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Naoto Kawabe
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Kazunori Nakaoka
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Hiroyuki Tanaka
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Takuji Nakano
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Yohei Miyachi
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Senju Hashimoto
- Department of Gastroenterology and Hepatology, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Yoshiki Hirooka
- Department of Gastroenterology and Hepatology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
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Yadlapati S, Mulki R, Sánchez-Luna SA, Ahmed AM, Kyanam Kabir Baig KR, Peter S. Clinical approach to indeterminate biliary strictures: Clinical presentation, diagnosis, and workup. World J Gastroenterol 2023; 29:5198-5210. [PMID: 37901449 PMCID: PMC10600956 DOI: 10.3748/wjg.v29.i36.5198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/23/2023] [Accepted: 08/21/2023] [Indexed: 09/20/2023] Open
Abstract
Despite advances in cross-sectional imaging and endoscopic technology, bile duct strictures remain a challenging clinical entity. It is crucial to make an early determination of benign or malignant nature of biliary strictures. Early diagnosis not only helps with further management but also minimizes mortality and morbidity associated with delayed diagnosis. Conventional imaging and endoscopic techniques, particularly endoscopic retrograde cholangiopancreatography (ERCP) and tissue sampling techniques play a key in establishing a diagnosis. Indeterminate biliary strictures (IDBSs) have no definite mass on imaging or absolute histopathological diagnosis and often warrant utilization of multiple diagnostics to ascertain an etiology. In this review, we discuss possible etiologies, clinical presentation, diagnosis, and management of IDBSs. Based on available data and expert opinion, we depict an evidence based diagnostic algorithm for management of IDBSs. Areas of focus include use of traditional tissue sampling techniques such as ERCP with brush cytology, intraductal biopsies, fluorescence in situ hybridization and flow cytometry. We also describe the role of endoscopic ultrasound (EUS)-guided fine needle aspiration and biopsies, cholangioscopy, confocal laser endomicroscopy, and intraductal EUS in management of IDBSs.
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Affiliation(s)
- Sujani Yadlapati
- Department of Gastroenterology and Hepatology, Indiana University Hospital, Indianapolis, IN 46202, USA
| | - Ramzi Mulki
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Sergio A Sánchez-Luna
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Ali M Ahmed
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | | | - Shajan Peter
- Department of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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6
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Orzan RI, Pojoga C, Agoston R, Seicean R, Seicean A. Endoscopic Ultrasound in the Diagnosis of Extrahepatic Cholangiocarcinoma: What Do We Know in 2023? Diagnostics (Basel) 2023; 13:1023. [PMID: 36980331 PMCID: PMC10047764 DOI: 10.3390/diagnostics13061023] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 03/30/2023] Open
Abstract
Extrahepatic cholangiocarcinoma (CCA) is a rare and aggressive type of cancer, presenting as a mass or as a biliary stricture. This review summarizes the utility of endoscopic ultrasound (EUS) in the detection, staging, and determination of the differential diagnosis, especially when no cause of bile duct dilatation is revealed by cross-sectional imaging. The EUS detection rate for distal CCAs is higher than that for the proximal CCAs. The accuracy of T staging varies between 60 and 80%, and vascular involvement is correctly assessed by conventional EUS. EUS-tissue acquisition from the primary tumors is reserved for unresectable or metastatic CCA, especially in distal strictures or mass CCAs. For proximal lesions, EUS could be performed as an adjunctive to ERCP sampling when the latter is inconclusive. EUS is not appropriate for assessing the malignant features of lymph nodes in CCAs. Lymph node EUS-tissue acquisition should be performed only if it changes the surgical decision. Perhaps the development of EUS-fine needle biopsy and the detection of molecular genetic alteration will increase the diagnostic yield in CCAs.
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Affiliation(s)
- Rares Ilie Orzan
- Department of Internal Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, 400347 Cluj-Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, 400162 Cluj-Napoca, Romania
| | - Cristina Pojoga
- Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, 400162 Cluj-Napoca, Romania
- UBB Med, Babes-Bolyai University, 400347 Cluj-Napoca, Romania
| | - Renata Agoston
- Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400347 Cluj-Napoca, Romania
| | - Radu Seicean
- First Department of Surgery, Iuliu Hațieganu University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania
| | - Andrada Seicean
- Department of Internal Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, 400347 Cluj-Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, 400162 Cluj-Napoca, Romania
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7
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Diagnosis of Cholangiocarcinoma. Diagnostics (Basel) 2023; 13:diagnostics13020233. [PMID: 36673043 PMCID: PMC9858255 DOI: 10.3390/diagnostics13020233] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/03/2023] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Cholangiocarcinoma (CCA), a tumor of the bile duct epithelium, is increasing in incidence. CCA remains a highly fatal malignancy because early diagnosis is difficult. Based on its anatomical location, CCA can be categorized into the following three groups: perihilar, intrahepatic, and extrahepatic. Patients with CCA complain of asymptomatic jaundice, weight loss, and right upper quadrant abdominal discomfort. Imaging modalities, including transabdominal ultrasound, computed tomography, and magnetic resonance imaging, play an important role in detecting tumors as well as guiding biopsy procedures and staging workups in CCA. Characteristically, extrahepatic CCA shows abrupt changes in ductal diameter with upstream ductal dilation. Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are recommended as the next step in the evaluation of extrahepatic CCA. Tissue is obtained through EUS-FNA or ERCP (biopsy, brush cytology), and therapeutic intervention (such as stent insertion) is performed with ERCP. Moreover, several serum tumor markers (carbohydrate antigen 19-9 and carcinoembryonic antigen) can be useful in diagnosing CCA in some patients.
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Han C, Ling X, Sheng L, Yang M, Lin R, Ding Z. Distal extrahepatic cholangiocarcinoma mimicking groove pancreatitis: A case report and literature review. Front Oncol 2022; 12:948799. [PMID: 36237325 PMCID: PMC9553287 DOI: 10.3389/fonc.2022.948799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe differential diagnosis between cholangiocarcinoma and groove pancreatitis is quite challenging. Groove pancreatitis is commonly misdiagnosed as periampullary tumors. We reported a case of distal extrahepatic cholangiocarcinoma mimicking groove pancreatitis.Case reportA 57-year-old male patient was transferred to our hospital after endoscopic retrograde cholangiopancreatography (ERCP) with stent placement in the common bile duct due to obstructive jaundice at a local hospital. Groove pancreatitis was considered based on the clinical manifestations and multiple examinations [including computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and endoscopic ultrasonography (EUS)]. The patient’s symptoms and laboratory results almost returned to normal after conservative treatments. Interestingly, his symptoms and laboratory results worsened after the stent was removed. We performed a second EUS process and found a lesion in the lower common bile duct. Finally, the patient underwent pancreatoduodenectomy, and the diagnosis was confirmed as moderately differentiated adenocarcinoma of the common bile duct.ConclusionOur case highlights the fact that distal extrahepatic cholangiocarcinoma, which is a malignant disease, can mimic a benign condition like groove pancreatitis. Our case also raises the concern that performing stent placement through ERCP to relieve jaundice without a clear diagnosis could interfere with further evaluation of the disease.
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Affiliation(s)
- Chaoqun Han
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Ling
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liping Sheng
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ming Yang
- Division of Pathology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rong Lin
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Zhen Ding, ; Rong Lin,
| | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Zhen Ding, ; Rong Lin,
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Schepis T, Boškoski I, Tringali A, Costamagna G. Role of ERCP in Benign Biliary Strictures. Gastrointest Endosc Clin N Am 2022; 32:455-475. [PMID: 35691691 DOI: 10.1016/j.giec.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Benign biliary strictures (BBS) can be associated with several causes, with postoperative and inflammatory strictures representing the most common ones. Endoscopy represents nowadays the first-line treatment in the management of BBS. Endoscopic balloon dilatation, plastic stents placement, fully covered metal stent placement, and magnetic compression anastomosis are the endoscopic techniques available for the treatment of BBS. The aim of this study is to perform a review of the literature to assess the role of endoscopy in the management of BBS and to evaluate the application of the different procedures in the different clinical settings.
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Affiliation(s)
- Tommaso Schepis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Italy.
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Italy
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10
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Yoon SB, Moon SH, Ko SW, Lim H, Kang HS, Kim JH. Brush Cytology, Forceps Biopsy, or Endoscopic Ultrasound-Guided Sampling for Diagnosis of Bile Duct Cancer: A Meta-Analysis. Dig Dis Sci 2022; 67:3284-3297. [PMID: 34263382 DOI: 10.1007/s10620-021-07138-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 06/25/2021] [Indexed: 12/11/2022]
Abstract
Endoscopic sampling is essential for tissue diagnosis of cholangiocarcinoma (CCA). To evaluate and compare the diagnostic sensitivities of endoscopic retrograde cholangiopancreatography-guided brush cytology biopsy, and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in patients with CCA. A comprehensive literature search through multiple databases was conducted for articles published between January 1995 and August 2020. The pooled rates of sensitivity for the diagnosis of CCA and of adverse events were compared among brushing, biopsy, brushing & biopsy, and EUS-FNA. In total, 1123 patients with CCA (32 studies), 719 patients (20 studies), 358 patients (13 studies), and 422 patients (17 studies) were tested by brushing, biopsy, brushing & biopsy, and EUS-FNA, respectively. The pooled diagnostic sensitivity was 56.0% (95% confidence interval (CI) 48.8-63.1%, I2 = 83.0%) with brushing, 67.0% (95% CI 60.2-73.5%, I2 = 72.5%) with biopsy, 70.7% (95% CI 64.1-76.8%, I2 = 42.7%) with brushing & biopsy, and 73.6% (95% CI 64.7-81.5%, I2 = 74.7%) with EUS-FNA. The diagnostic sensitivity was significantly lower for brushing than for biopsy, brushing & biopsy, or EUS-FNA. No significant difference was noted in diagnostic sensitivities among biopsy, brushing & biopsy, and EUS-FNA. Adverse events were comparable between the groups. Intraductal biopsy, brushing & biopsy, and EUS-FNA had comparable efficacy and safety for the diagnosis of CCA. Brushing was the least sensitive diagnostic tool compared with intraductal biopsy or EUS-FNA. Given the modest diagnostic sensitivities of intraductal biopsy and EUS-FNA in the diagnosis of CCA, further studies for complementing these techniques with biomarkers may be needed.
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Affiliation(s)
- Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang, Gyeonggi-do, 14068, South Korea.
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea.
| | - Sung Woo Ko
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hyun Lim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang, Gyeonggi-do, 14068, South Korea
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea
| | - Ho Suk Kang
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang, Gyeonggi-do, 14068, South Korea
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea
| | - Jong Hyeok Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang, Gyeonggi-do, 14068, South Korea
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, South Korea
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Abstract
Bile duct stenosis continues to present a diagnostic dilemma for clinicians. It is important to establish the benign or malignant nature of the stricture early in order to avoid any unnecessary delay in medical treatment or surgery. Tissue acquisition for histological diagnosis is particularly crucial when the initial diagnostic work up is inconclusive. The diagnostic yield from the conventional endoscopic retrograde cholangiopancreatography (ERCP) with brushing and biopsy is suboptimal. Patients with indeterminate biliary strictures (IDBSs) often require a multi-disciplinary diagnostic approach and additional endoscopic evaluation, including cholangioscopy and endoscopic ultrasound, before a final diagnosis can be reached. In this article, we discuss the recent endoscopic advancements in the diagnosis of biliary stricture with a focus on the roles of cholangioscopy and endoscopic ultrasound (EUS).
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12
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Kuwatani M, Kawakubo K, Sakamoto N. Promising Genomic Testing for Biliary Tract Cancer Using Endoscopic Ultrasound-Guided Fine-Needle Aspiration/Biopsy Specimens. Diagnostics (Basel) 2022; 12:900. [PMID: 35453948 PMCID: PMC9030881 DOI: 10.3390/diagnostics12040900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/01/2022] [Accepted: 04/03/2022] [Indexed: 02/01/2023] Open
Abstract
The undesired prognosis of biliary tract cancer is mainly attributed to the difficult detection of cancer lesions, including intraepithelial neoplasia and no standard examination for screening. In addition, pathological diagnosis of biliary stricture, whether it is malignant or benign, is not so easy, because of difficult optimal sampling by forceps biopsy and brush cytology, although various devices and methods for pathological diagnosis have been reported. Furthermore, we have to be careful about post-endoscopic retrograde cholangiography pancreatitis when we approach the biliary tract lesion via a transpapillary route. In order to improve the diagnostic accuracy, there have been several studies that indicate the feasibility and efficacy of genomic analysis for accurate diagnosis of biliary tract cancer by using pathological specimens, including endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/FNB) samples. For efficient and precision medicine for patients with biliary tract cancer, future diagnosis and treatment should also be based on molecular and genetic analyses. In this article, we review and summarize the past knowledge and cutting edge of genomic testing for biliary tract cancer, using EUS-FNA/FNB specimens, and indicate some ingenuities in sample processing to promote effective clinical practice and future perspectives.
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Affiliation(s)
- Masaki Kuwatani
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, North 14, West 5, Kita-ku, Sapporo 060-8648, Japan; (K.K.); (N.S.)
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13
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Pausawasdi N, Hongsrisuwan P, Kamani L, Maipang K, Charatcharoenwitthaya P. The Diagnostic Value of Endoscopic Ultrasonography for Common Bile Duct Dilatation without Identifiable Etiology Detected from Cross-Sectional Imaging. Clin Endosc 2022; 55:122-127. [PMID: 34974680 PMCID: PMC8831402 DOI: 10.5946/ce.2021.122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/07/2021] [Indexed: 11/14/2022] Open
Abstract
Background/Aims Endoscopic ultrasonography (EUS) is warranted when cross-sectional imaging demonstrates common bile duct (CBD) dilatation without identifiable causes. This study aimed to assess the diagnostic performance of EUS in CBD dilatation of unknown etiology.
Methods Retrospective review of patients with dilated CBD without definite causes undergoing EUS between 2012 and 2017.
Results A total of 131 patients were recruited. The mean age was 63.2±14.1 years. The most common manifestation was abnormal liver chemistry (85.5%). The mean CBD diameter was 12.2±4.1 mm. The area under the receiver operating characteristic curve (AUROC) of EUS-identified pathologies, including malignancy, choledocholithiasis, and benign biliary stricture (BBS), was 0.98 (95% confidence interval [CI], 0.95-1.00). The AUROC of EUS for detecting malignancy, choledocholithiasis, and BBS was 0.91 (95% CI, 0.85-0.97), 1.00 (95% CI, 1.00-1.00), and 0.93 (95% CI, 0.87-0.99), respectively. Male sex, alanine aminotransferase ≥3× the upper limit of normal (ULN), alkaline phosphatase ≥3× the ULN, and intrahepatic duct dilatation were predictors for pathological obstruction, with odds ratios of 5.46 (95%CI, 1.74-17.1), 5.02 (95% CI, 1.48-17.0), 4.63 (95% CI, 1.1-19.6), and 4.03 (95% CI, 1.37-11.8), respectively.
Conclusions EUS provides excellent diagnostic value in identifying the etiology of CBD dilatation detected by cross-sectional imaging.
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Affiliation(s)
- Nonthalee Pausawasdi
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Penprapai Hongsrisuwan
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Lubna Kamani
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Liaquat National Hospital and Aga Khan University Hospital, Karachi, Pakistan
| | - Kotchakon Maipang
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phunchai Charatcharoenwitthaya
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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14
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Almuhaidb A, Olson D, Aadam AA. Advancements in Endoscopic Biliary Interventions by Gastroenterology. Semin Intervent Radiol 2021; 38:280-290. [PMID: 34393338 DOI: 10.1055/s-0041-1731266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic technique in which a specialized side-viewing endoscope is guided into the duodenum, allowing for instruments to access the biliary and pancreatic ducts. ERCP was initially developed as a diagnostic tool as computed tomography was in its infancy during that time. ERCP has evolved since its inception in the 1960s to becoming not only a valuable diagnostic resource but now an effective therapeutic intervention in the treatment of various biliary disorders. The most common biliary interventions performed by ERCP include the management of biliary obstructions for benign and malignant indications. Additionally, endoscopic ultrasound (EUS) has been increasingly utilized in diagnosing and intervening on pancreaticobiliary lesion. This article will discuss the various methods currently available for various endoscopic biliary interventions and future interventional techniques. For the management of biliary strictures, EUS can be utilized with fine need aspiration, while ERCP can be used for the placement of various stents and diagnostic modalities. Another example is radiofrequency ablation, which can be used for the treatment of hilar strictures. Achieving bile duct access can be challenging in patients with complicated clinical scenarios; other techniques that can be used for bile duct access include EUS-guided rendezvous approach, transluminal approach, Choleodochoduodenostomy, and hepatogastrostomy, along with gaining access in complicated anatomy such as in patients with Rou-en-Y anatomy. Another useful endoscopic tool is nonsurgical drainage of the gallbladder, which can be a suitable option when patients are not optimal surgical candidates. There has also been an increase in outpatient utilization of ERCP, which was previously seen as a predominantly inpatient procedure in the past. Possible future evolutions of biliary interventions include robotic manipulation of a duodenoscope and direct infusion of chemotherapeutic or immunomodulatory agents into the pancreaticobiliary tree. These advancements will depend on parallel advancements in other imaging and laboratory as well as breakthrough technology or techniques by other disciplines including interventional radiology and minimally invasive surgery.
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Affiliation(s)
- Aymen Almuhaidb
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dylan Olson
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - A Aziz Aadam
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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15
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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: 1.8] [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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16
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Ikezawa K, Shigekawa M, Yamai T, Suda T, Kegasawa T, Yoshioka T, Sakamori R, Tatsumi T, Takehara T. Endoscopic biliary stenting as the risk factor for cholangitis after endoscopic ultrasound in patients with biliary strictures. J Gastroenterol Hepatol 2021; 36:1263-1266. [PMID: 32955726 DOI: 10.1111/jgh.15264] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 08/14/2020] [Accepted: 09/14/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration (FNA) are established as efficient and safe diagnostic modalities. However, the risk of cholangitis after EUS/EUS-FNA (post-EUS cholangitis) in patients who have biliary strictures has not been fully examined. METHODS We retrospectively reviewed 136 consecutive inpatients with biliary strictures who received EUS/EUS-FNA at our hospital from April 2012 to September 2017 and evaluated complications that occurred by the next day after EUS/EUS-FNA. Patients with percutaneous biliary drainage, those in whom it was difficult to reach the duodenum, and those receiving concurrent endoscopic retrograde cholangiopancreatography were excluded. RESULTS We included 121 patients (147 cases); 90 patients were malignant. Endoscopic biliary stenting (EBS) with plastic stents had already been performed in 86 cases. Post-EUS cholangitis was observed in 4.1% (6/147). No other EUS-related complications were observed. The incidence of cholangitis with EBS was significantly higher than that in the cases without EBS (7.0% [6/86] vs 0% [0/61], P = 0.042). Biliary enzyme elevation was also identified as a risk factor of cholangitis. CONCLUSION Endoscopic biliary stenting was identified as a risk factor associated with post-EUS cholangitis in patients with biliary strictures. Endoscopists should pay attention to post-EUS cholangitis, especially in cases with EBS and biliary enzyme elevation.
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Affiliation(s)
- Kenji Ikezawa
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.,Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Minoru Shigekawa
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takuo Yamai
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takahiro Suda
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tadashi Kegasawa
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Teppei Yoshioka
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Ryotaro Sakamori
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomohide Tatsumi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
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17
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Diagnosis of Pancreatic Solid Lesions, Subepithelial Lesions, and Lymph Nodes Using Endoscopic Ultrasound. J Clin Med 2021; 10:jcm10051076. [PMID: 33807558 PMCID: PMC7961381 DOI: 10.3390/jcm10051076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Currently, endoscopic ultrasound (EUS) has become widely accepted and has considerable advantages over computed tomography (CT) and other imaging modalities, given that it enables echostructure assessment in lesions with <1 cm diameter and permits high resolution imaging. EUS-guided tissue acquisition (EUS-TA) provides consistent results under ultrasound guidance and has been considered more effective compared to CT- or ultrasound-guided lesion biopsy. Moreover, complication rates, including pancreatitis and bleeding, have been extremely low, with <1% morbidity and mortality rates, thereby suggesting the exceptional overall safety of EUS-TA. The aggressive use of EUS for various lesions has been key in facilitating early diagnosis and therapy. This review summarizes the diagnostic ability of EUS for pancreatic solid lesions, subepithelial lesions, and lymph nodes where it is mainly used. EUS has played an important role in diagnosing these lesions and planning treatment strategies. Future developments in EUS imaging technology, such as producing images close to histopathological findings, are expected to further improve its diagnostic ability. Moreover, tissue acquisition via EUS is expected to be used for precision medicine, which facilitates the selection of an appropriate therapeutic agent by increasing the amount of tissue collected and improving genetic analysis.
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18
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Raine T, Thomas JP, Brais R, Godfrey E, Carroll NR, Metz AJ. Test performance and predictors of accuracy of endoscopic ultrasound-guided fine-needle aspiration for diagnosing biliary strictures or masses. Endosc Int Open 2020; 8:E1537-E1544. [PMID: 33140008 PMCID: PMC7577792 DOI: 10.1055/a-1231-4948] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 06/05/2020] [Indexed: 12/11/2022] Open
Abstract
Background and study aims Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has emerged as an important method for obtaining a preoperative tissue diagnosis for suspected cholangiocarcinoma. However, doubts remain about test sensitivity. This study assessed the value and limitations of EUS-FNA in clinical practice. Patients and methods Patients undergoing EUS-FNA for biliary strictures/masses at a UK tertiary referral center from 2005 to 2014 were prospectively enrolled. Data on EUS-FNA findings, histology, and endoscopy and patient outcomes were collected to evaluate test performance and identify factors predictive of an inaccurate diagnostic result. Results Ninety-seven patients underwent a total of 112 EUS-FNA procedures. Overall test sensitivity for an initial EUS-FNA for suspected cholangiocarcinoma was 75 % (95 % CI 64 %-84 %), with specificity 100 % (95 % CI 85 %-100 %) and negative predictive value 0.62 (95 % CI 0.47-0.75). Hilar lesions, the presence of a biliary stent, and a diagnosis of PSC were significantly independently associated with an inaccurate result. For the most difficult cases, repeat sampling and use of the Papanicolaou cytopathology grading scale led to an increase in test sensitivity from 17 % to 100 % ( P = 0.015) with no loss of specificity. Conclusions EUS-FNA was found to be a useful method for obtaining a preoperative tissue diagnosis for patients with suspected cholangiocarcinoma. This study identified markers that can reduce test accuracy and measures that can improve test performance of EUS-FNA.
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Affiliation(s)
- Tim Raine
- Division of Gastroenterology, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - John P. Thomas
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Rebecca Brais
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Edmund Godfrey
- Department of Endoscopy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Nicholas R. Carroll
- Department of Endoscopy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew J. Metz
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Australia
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19
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Pörner D, Kaczmarek DJ, Heling D, Hausen A, Mohr R, Hüneburg R, Matthaei H, Glowka TR, Manekeller S, Fischer HP, Toma M, Nattermann J, Strassburg CP, Gonzalez-Carmona MA, Weismüller TJ. Transpapillary tissue sampling of biliary strictures: balloon dilatation prior to forceps biopsy improves sensitivity and accuracy. Sci Rep 2020; 10:17423. [PMID: 33060723 PMCID: PMC7566456 DOI: 10.1038/s41598-020-74451-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/29/2020] [Indexed: 12/11/2022] Open
Abstract
The early and definitive diagnosis of malignant bile duct stenoses is essential for a timely and adequate therapy. However, tissue sampling with transpapillary brush cytology (BC) or forceps biopsy (FB) remains challenging. With this study, we aimed to compare the effectiveness and safety of different tissue sampling modalities (BC, FB without/after previous balloon dilatation). Standardized database research identified all patients, who underwent endoscopic retrograde cholangiography with BC and/or FB for indeterminate bile duct stenosis between January 2010 and April 2018 and with a definitive diagnosis. 218 patients were enrolled (149 cases with malignant and 69 with benign disease). FB had a significant higher sensitivity than BC (43% vs. 16%, p < 0.01). Prior balloon dilatation of the stenosis improved the sensitivity of FB from 41 to 71% (p = 0.03), the NPV from 36 to 81% (p < 0.01) and the accuracy from 55 to 87% (p < 0.01). The complication rates did not differ significantly between the modalities. In our center FB turned out to be the diagnostically more effective procedure. Balloon dilatation of the stenosis before FB had a significant diagnostic benefit and was not associated with a higher complication rate.
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Affiliation(s)
- Daniel Pörner
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Dominik J Kaczmarek
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Dominik Heling
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Annekristin Hausen
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Raphael Mohr
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Robert Hüneburg
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Hanno Matthaei
- Department of Surgery, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Tim R Glowka
- Department of Surgery, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Steffen Manekeller
- Department of Surgery, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Hans-Peter Fischer
- Institute of Pathology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Marieta Toma
- Institute of Pathology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jacob Nattermann
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Christian P Strassburg
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Maria A Gonzalez-Carmona
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Tobias J Weismüller
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
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20
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Current Status of Needles in the Optimization of Endoscopic Ultrasound-Guided Procedures. Diagnostics (Basel) 2020; 10:diagnostics10070463. [PMID: 32650628 PMCID: PMC7400280 DOI: 10.3390/diagnostics10070463] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 07/05/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022] Open
Abstract
Endoscopic ultrasound (EUS) is among the most important tools for the evaluation of gastrointestinal tumors and affected areas around the gastrointestinal tract. It enables the acquisition of material from abnormal lesions via the gastrointestinal wall for tissue confirmation via endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). EUS-FNA has played a vital role in oncological care and has become the standard method for tissue sampling. The choice of needle type is an important factor determining tissue acquisition and has been evaluated by many researchers. New needles are introduced into the market almost every year, and opinions vary regarding proper needle selection. While there are diverse opinions but no definitive recommendations about the use of one particular device, fine-needle biopsy needles may provide detailed information on a tissue’s architecture based on greater sample yields. This permits additional analyses, including genetic sequencing and phenotyping, thereby enabling the provision of more personalized treatment plans. Furthermore, other EUS-guided procedures have been developed, including interventional EUS and through-the-needle devices. Given the continued attempts to improve the diagnostic ability and therapeutic techniques, we review in detail the available types of puncture needles to provide guidance on the selection of the appropriate needle types.
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21
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Singhi AD, Nikiforova MN, Chennat J, Papachristou GI, Khalid A, Rabinovitz M, Das R, Sarkaria S, Ayasso MS, Wald AI, Monaco SE, Nalesnik M, Ohori NP, Geller D, Tsung A, Zureikat AH, Zeh H, Marsh JW, Hogg M, Lee K, Bartlett DL, Pingpank JF, Humar A, Bahary N, Dasyam AK, Brand R, Fasanella KE, McGrath K, Slivka A. Integrating next-generation sequencing to endoscopic retrograde cholangiopancreatography (ERCP)-obtained biliary specimens improves the detection and management of patients with malignant bile duct strictures. Gut 2020; 69:52-61. [PMID: 30971436 PMCID: PMC6943248 DOI: 10.1136/gutjnl-2018-317817] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Despite improvements in imaging, serum CA19-9 and pathological evaluation, differentiating between benign and malignant bile duct strictures remains a diagnostic conundrum. Recent developments in next-generation sequencing (NGS) have opened new opportunities for early detection and management of cancers but, to date, have not been rigorously applied to biliary specimens. DESIGN We prospectively evaluated a 28-gene NGS panel (BiliSeq) using endoscopic retrograde cholangiopancreatography-obtained biliary specimens from patients with bile duct strictures. The diagnostic performance of serum CA19-9, pathological evaluation and BiliSeq was assessed on 252 patients (57 trainings and 195 validations) with 346 biliary specimens. RESULTS The sensitivity and specificity of BiliSeq for malignant strictures was 73% and 100%, respectively. In comparison, an elevated serum CA19-9 and pathological evaluation had sensitivities of 76% and 48%, and specificities of 69% and 99%, respectively. The combination of BiliSeq and pathological evaluation increased the sensitivity to 83% and maintained a specificity of 99%. BiliSeq improved the sensitivity of pathological evaluation for malignancy from 35% to 77% for biliary brushings and from 52% to 83% for biliary biopsies. Among patients with primary sclerosing cholangitis (PSC), BiliSeq had an 83% sensitivity as compared with pathological evaluation with an 8% sensitivity. Therapeutically relevant genomic alterations were identified in 20 (8%) patients. Two patients with ERBB2-amplified cholangiocarcinoma received a trastuzumab-based regimen and had measurable clinicoradiographic response. CONCLUSIONS The combination of BiliSeq and pathological evaluation of biliary specimens increased the detection of malignant strictures, particularly in patients with PSC. Additionally, BiliSeq identified alterations that may stratify patients for specific anticancer therapies.
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Affiliation(s)
- Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Marina N Nikiforova
- Department of Pathology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Jennifer Chennat
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Asif Khalid
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Rohit Das
- Department of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Savreet Sarkaria
- Department of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - M Samir Ayasso
- Department of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Abigail I Wald
- Department of Pathology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Sara E Monaco
- Department of Pathology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Michael Nalesnik
- Department of Pathology, Division of Transplant Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - N Paul Ohori
- Department of Pathology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - David Geller
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Herbert Zeh
- Department of Clinical Sciences, Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - J Wallis Marsh
- Department of Surgery, West Virginia University Health Sciences Center, Morgantown, West Virginia, USA
| | - Melissa Hogg
- Department of Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Kenneth Lee
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David L Bartlett
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James F Pingpank
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Abhinav Humar
- Department of Transplant, Thomas E Starzl Transplant Instiute University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nathan Bahary
- Division of Hematology and Oncology, UPMC Cancer Centers, Pittsburgh, Pennsylvania, USA
| | - Anil K Dasyam
- Department of Radiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Randall Brand
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kenneth E Fasanella
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kevin McGrath
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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22
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Fung BM, Tabibian JH. Biliary endoscopy in the management of primary sclerosing cholangitis and its complications. LIVER RESEARCH (BEIJING, CHINA) 2019; 3:106-117. [PMID: 31341699 PMCID: PMC6656407 DOI: 10.1016/j.livres.2019.03.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic, idiopathic, cholestatic liver disease characterized by inflammation and fibrosis of the intrahepatic and/or extrahepatic bile ducts. It can affect individuals of all age groups and gender, has no established pharmacotherapy, and is associated with a variety of neoplastic (e.g. cholangiocarcinoma) and non-neoplastic (e.g. dominant strictures) hepatobiliary complications. Given these considerations, endoscopy plays a major role in the care of patients with PSC. In this review, we discuss and provide updates regarding endoscopic considerations in the management of hepatobiliary manifestations and complications of PSC. Where evidence is limited, we suggest pragmatic approaches based on currently available data and expert opinion.
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Affiliation(s)
- Brian M. Fung
- University of California Los Angeles-Olive View Internal Medicine Residency Program, Sylmar, CA, USA
| | - James H. Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-University of California Los Angeles Medical Center, Sylmar, CA, USA
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23
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Abstract
Benign and malignant biliary strictures are common indications for endoscopic retrograde cholangiopancreatography. Diagnosis involves high-quality cross-sectional imaging and cholangiography with various endoscopic sampling techniques. Treatment options include placement of plastic biliary stents and self-expanding metal stents, which differ in patency duration and cost effectiveness. Whether the etiology is benign or malignant, a multidisciplinary strategy should be implemented. This article will discuss general principles of biliary stenting in both benign and malignant conditions.
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Affiliation(s)
- Jason G Bill
- Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA
| | - Daniel K Mullady
- Interventional Endoscopy, Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Campus Box 8124, St Louis, MO 63110, USA.
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Onoyama T, Matsumoto K, Takeda Y, Kawata S, Kurumi H, Koda H, Yamashita T, Takata T, Isomoto H. Endoscopic Ultrasonography-Guided Fine Needle Aspiration for Extrahepatic Cholangiocarcinoma: A Safe Tissue Sampling Modality. J Clin Med 2019; 8:jcm8040417. [PMID: 30934706 PMCID: PMC6518173 DOI: 10.3390/jcm8040417] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 03/15/2019] [Accepted: 03/25/2019] [Indexed: 12/15/2022] Open
Abstract
Few studies have compared the diagnostic utility of endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) and endoscopic retrograde cholangiopancreatography (ERCP) tissue sampling for extrahepatic cholangiocarcinoma (ECC). We evaluated the efficacy and safety of EUS-FNA for diagnosing ECC compared with ERCP tissue sampling. Patients who underwent EUS-FNA or ERCP tissue sampling to differentiate ECC from benign biliary disease were enrolled retrospectively between October 2011 and March 2017. We evaluated diagnostic performances of EUS-FNA and ERCP tissue sampling based on pathological evaluation. We compared adverse events in EUS-FNA and ERCP tissue sampling. We enrolled 73 patients with biliary disease and performed EUS-FNA and ERCP in 19 and 54 patients, respectively. Sensitivity, specificity, and accuracy of ERCP tissue sampling were 76.0%, 100%, and 88.9%, respectively, and for EUS-FNA these were 81.8%, 87.5%, and 84.2%, respectively. Statistical values of ERCP tissue sampling and EUS-FNA were not significantly different. The adverse event frequency of EUS-FNA was significantly lower than that of ERCP tissue sampling (0% vs. 25.9%, p = 0.033). The diagnostic ability of EUS-FNA for ECC is similar to that of ERCP tissue sampling. EUS-FNA is a safer tissue sampling modality than ERCP for evaluating biliary disease.
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Affiliation(s)
- Takumi Onoyama
- Division of Medicine and Clinical Science, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan.
| | - Kazuya Matsumoto
- Division of Medicine and Clinical Science, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan.
| | - Yohei Takeda
- Division of Medicine and Clinical Science, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan.
| | - Soichiro Kawata
- Division of Medicine and Clinical Science, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan.
| | - Hiroki Kurumi
- Division of Medicine and Clinical Science, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan.
| | - Hiroki Koda
- Division of Medicine and Clinical Science, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan.
| | - Taro Yamashita
- Division of Medicine and Clinical Science, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan.
| | - Tomoaki Takata
- Division of Medicine and Clinical Science, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan.
| | - Hajime Isomoto
- Division of Medicine and Clinical Science, Faculty of Medicine, Tottori University, Yonago, Tottori 683-8504, Japan.
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Takagi T, Sugimoto M, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Watanabe K, Nakamura J, Kikuchi H, Takasumi M, Hashimoto M, Hikichi T, Ohira H. Appropriate number of biliary biopsies and endoscopic retrograde cholangiopancreatography sessions for diagnosing biliary tract cancer. World J Gastrointest Endosc 2019; 11:231-238. [PMID: 30918588 PMCID: PMC6425282 DOI: 10.4253/wjge.v11.i3.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 02/28/2019] [Accepted: 03/11/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Biliary ductal cancer (BDC) is a lethal disease; however, diagnosing BDC is challenging. Biliary biopsies are performed to pathologically diagnose BDC, but the appropriate parameters for biliary biopsy [number of biliary biopsies, number of endoscopic retrograde cholangiopancreatography (ERCP) sessions, etc.] are unknown. AIM To clarify what constitutes an adequate method for biliary biopsy. METHODS In total, 95 patients who underwent endoscopic biliary biopsy without choledochoscopy and who were pathologically diagnosed with BDC were enrolled in this study. The patients were divided into two groups. Seventy-six patients who were diagnosed by biliary biopsy were defined as the positive group (P group), and nineteen patients who were not diagnosed by biliary biopsy were defined as the negative group (N group). The patient characteristics and ERCP-related procedures were compared between the P and N groups. RESULTS The numbers of ERCP sessions and biliary biopsies were significantly different between the two groups [ERCP sessions (one/two), P group 72/4 vs N group 15/4, P value = 0.048; number of biliary biopsies, P group 2 (1-6) vs N group 2 (1-7), P value = 0.039]. In a multivariate analysis, fewer than 2 ERCP sessions was an independent factor influencing the positivity of the biliary biopsies. CONCLUSION This study clarified that ERCP and biliary ductal biopsy should only be performed once. If biliary cancer is not pathologically diagnosed after the first ERCP session, other methods (Endoscopic ultrasonography-guided fine needle aspiration or choledochoscopy-guided biliary ductal biopsy) should be employed.
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Affiliation(s)
- Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Naoki Konno
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Yuki Sato
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Hiroki Irie
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Ko Watanabe
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Jun Nakamura
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Hitomi Kikuchi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | - Mika Takasumi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
| | - Minami Hashimoto
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1247, Japan
| | | | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 960-1247, Japan
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Liu Y, Cheng C, Bai L, Yao F, Shi S, Zhang Y. Value of bile soluble B7H3 for the diagnosis of malignant biliary strictures: Results of a retrospective study. Surg Oncol 2019; 28:195-200. [PMID: 30851900 DOI: 10.1016/j.suronc.2019.01.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 12/28/2018] [Accepted: 01/27/2019] [Indexed: 02/03/2023]
Abstract
AIMS Increasing evidence has demonstrated that serum soluble B7H3(sB7-H3) is a useful tumor marker for cancer diagnosis and prognostic evaluations. Whether sB7-H3 expressed in the bile is related to the progression of malignant biliary strictures must be clarified. METHODS Bile sB7-H3 was obtained via endoscopic retrograde cholangiopancreatography (ERCP) from 323 patients suspected to have malignant biliary strictures and was detected using a B7H3 ELISA kit. Diagnostic value was compared among bile sB7-H3, CA19-9, CA12-5, and CEA and ERCP-based cytological/tissue examination. Additionally, the correlations between the bile sB7-H3 concentration and the clinical characteristics of malignant biliary strictures were studied. RESULTS The bile sB7-H3 levels of patients with malignant biliary strictures were significantly higher than those in patients with benign biliary strictures (P < 0.001). The AUC values of the receiver operating characteristic(ROC) curves for CA19-9, CA12-5 and CEA were 0.764, 0.475 and 0.399, respectively, which were significantly lower than that of sB7-H3 (0.878); the sensitivities of ERCP-based cytological and tissue examinations were 55.7% and 66.4%, respectively, which were far lower than that of bile sB7-H3(81.2%). A high level of sB7-H3 in patients with malignant biliary strictures was found to be correlated with vascular invasion(P < 0.001), lymph node metastasis(P < 0.001), distant metastasis (P < 0.001) and tumor-node-metastasis (TNM) stage(P = 0.01). The overall survival rate of the patients in the high sB7-H3 group was significantly lower than that of the patients in the low sB7-H3 group(P = 0.014). CONCLUSIONS Bile sB7-H3 could serve as a valuable biomarker for patients with malignant biliary strictures and high levels of bile sB7-H3 were associated with poor clinical outcomes.
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Affiliation(s)
- Yang Liu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Chao Cheng
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Lan Bai
- Department of Oncology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, 430014, China
| | - Feng Yao
- Hepato Pancreat Obiliary & Spteen Surgery Dept Wuhan PuAi Hospital，, Tongji Medical College, Huazhong University of Science and Technology, Wuhanm, 430000, China
| | - Shenchao Shi
- Department of General Surgery, The Third People's Hospital of Hubei Province, Wuhan, 430033, China
| | - Yu Zhang
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Periampullary Metastases from Breast Cancer: A Case Report and Literature Review. Case Rep Oncol Med 2019; 2019:3479568. [PMID: 30729053 PMCID: PMC6343154 DOI: 10.1155/2019/3479568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/10/2018] [Indexed: 12/25/2022] Open
Abstract
We presented a metastatic breast cancer case who was afflicted with obstructive jaundice caused by an ampullary neoplasm. Since jaundice due to periampullary metastasis from breast cancer was a rare entity, a literature review of similar cases through the PubMed database was done. A total of 23 additional cases were found. Among these 24 cases, 5 presented with periampullary metastasis synchronously with the diagnosis of breast cancer, while 19 had metachronous periampullary metastasis with an interval ranging between 1.3 and 23 years from the initial diagnosis of breast cancer to the emergence of jaundice. It is intriguing to establish a differential diagnosis for common bile tract stricture prior to tissue biopsy, even with diagnostic workups including serum tumor markers, MRI plus MRCP, ERCP with intraductal brushing, and endoscopic ultrasound, in that the clinical, radiological, and endoscopic findings of metastatic lesions overlapped extensively with those found with primary periampullary malignancies. An immunohistochemical portfolio including cytokeratin7/20 (CK7/20), homeobox protein CDX2, human epidermal growth factor receptor 2 (HER2/neu), estrogen receptor alfa (ERα), progesterone receptor (PgR), mammaglobin, gross cystic disease fluid protein-15 (GCDFP-15), and transacting T-cell-specific transcription factor (GATA-3) was helpful for differential diagnosis among cases with ambiguous microscopic features.
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28
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Chapman CG, Lodhia NA, Manzano M, Waxman I. Endoscopic Evaluation and Management of Pancreaticobiliary Disease. SHACKELFORD'S SURGERY OF THE ALIMENTARY TRACT, 2 VOLUME SET 2019:1300-1322. [DOI: 10.1016/b978-0-323-40232-3.00111-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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29
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Sun B, Moon JH, Cai Q, Rerknimitr R, Ma S, Lakhtakia S, Ryozawa S, Kutsumi H, Yasuda I, Shiomi H, Li X, Li W, Zhang X, Itoi T, Wang HP, Qian D, Wong Lau JY, Yang Z, Ji M, Hu B. Review article: Asia-Pacific consensus recommendations on endoscopic tissue acquisition for biliary strictures. Aliment Pharmacol Ther 2018; 48:138-151. [PMID: 29876948 DOI: 10.1111/apt.14811] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 03/23/2018] [Accepted: 04/26/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pre-operative tissue diagnosis for suspected malignant biliary strictures remains challenging. AIM To develop evidence-based consensus statements on endoscopic tissue acquisition for biliary strictures. METHODS The initial draft of statements was prepared following a systematic literature review. A committee of 20 experts from Asia-Pacific region then reviewed, discussed, and modified the statements. Two rounds of independent voting were conducted to reach a final version. Consensus was considered to be achieved when 80% or more of voting members voted "agree completely" or "agree with some reservation." RESULTS Eleven statements achieved consensus. The choice of tissue sampling modalities for biliary strictures depends on the clinical setting, the location of lesion, and availability of expertise. Detailed radiological and endoscopic evaluation is useful to guide the selection of appropriate tissue acquisition technique. Standard intraductal biliary brushing and/or forceps biopsy is the first option when endoscopic biliary drainage is required with an overall (range) sensitivity and specificity of 45% (26%-72%) and 99% (98%-100%), and 48% (15%-100%) and 99% (97%-100%), respectively, in diagnosing malignant biliary strictures. Probe-based confocal laser endomicroscopy and fluorescence in situ hybridisation using 4 fluorescent-labelled probes targeting chromosomes 3, 7, 17 and 9p21 locus may be added to improve the diagnostic yield. Cholangioscopy-guided biopsy and EUS-guided tissue acquisition can be considered after prior negative conventional tissue sampling with an overall (range) sensitivity and specificity of 60% (38%-88%) and 98% (83%-100%), and 80% (46%-100%) and 97% (92%-100%), respectively, in diagnosing malignant biliary strictures. CONCLUSION These consensus statements provide evidence-based recommendations for endoscopic tissue acquisition of biliary strictures.
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30
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Wang AY, Yachimski PS. Endoscopic Management of Pancreatobiliary Neoplasms. Gastroenterology 2018; 154:1947-1963. [PMID: 29458151 DOI: 10.1053/j.gastro.2017.11.295] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/16/2017] [Accepted: 11/17/2017] [Indexed: 12/14/2022]
Abstract
Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are the mainstays of interventional endoscopic practice. EUS occupies a central role in the diagnosis of pancreatobiliary neoplasms and offers a platform for a wide range of direct tumor therapies. Initial steps have demonstrated the feasibility of such applications in animal models and pilot studies. Larger clinical trials and incorporation of EUS-based therapies into cooperative cancer studies might demonstrate an impact in the clinical prognosis of patients with pancreatic cancer. ERCP plays an important role in elucidating indeterminate biliary strictures and in treating patients with malignant biliary obstruction who are symptomatic or have borderline-resectable or unresectable disease. ERCP-directed ablative therapies enable neoadjuvant and palliative intervention in patients with malignant biliary obstruction, in particular perihilar cholangiocarcinoma. Additional comparative, multicenter studies are needed to better understand the safety and efficacy of endobiliary brachytherapy, photodynamic therapy, and radiofrequency ablation in patients with pancreatobiliary malignancies.
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Affiliation(s)
- Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia.
| | - Patrick S Yachimski
- Division of Gastroenterology, Hepatology & Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
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31
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Cazacu IM, Luzuriaga Chavez AA, Saftoiu A, Vilmann P, Bhutani MS. A quarter century of EUS-FNA: Progress, milestones, and future directions. Endosc Ultrasound 2018; 7:141-160. [PMID: 29941723 PMCID: PMC6032705 DOI: 10.4103/eus.eus_19_18] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 03/21/2018] [Indexed: 12/11/2022] Open
Abstract
Tissue acquisition using EUS has considerably evolved since the first EUS-FNA was reported 25 years ago. Its introduction was an important breakthrough in the endoscopic field. EUS-FNA has now become a part of the diagnostic and staging algorithm for the evaluation of benign and malignant diseases of the gastrointestinal tract and of the organs in its proximity, including lung diseases. This review aims to present the history of EUS-FNA development and to provide a perspective on the recent developments in procedural techniques and needle technologies that have significantly extended the role of EUS and its clinical applications. There is a bright future ahead for EUS-FNA in the years to come as extensive research is conducted in this field and various technologies are continuously implemented into clinical practice.
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Affiliation(s)
- Irina Mihaela Cazacu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Craiova, Romania
- Department of Gastroenterology, Hepatology, and Nutrition, University of Texas – MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Adrian Saftoiu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Craiova, Romania
| | - Peter Vilmann
- Gastrounit, Division of Surgery, Copenhagen University Hospital Herlev, Copenhagen, Denmark
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology, and Nutrition, University of Texas – MD Anderson Cancer Center, Houston, Texas, USA
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32
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Rassam F, Roos E, van Lienden KP, van Hooft JE, Klümpen HJ, van Tienhoven G, Bennink RJ, Engelbrecht MR, Schoorlemmer A, Beuers UHW, Verheij J, Besselink MG, Busch OR, van Gulik TM. Modern work-up and extended resection in perihilar cholangiocarcinoma: the AMC experience. Langenbecks Arch Surg 2018; 403:289-307. [PMID: 29350267 PMCID: PMC5986829 DOI: 10.1007/s00423-018-1649-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/15/2017] [Indexed: 12/12/2022]
Abstract
AIM Perihilar cholangiocarcinoma (PHC) is a challenging disease and requires aggressive surgical treatment in order to achieve curation. The assessment and work-up of patients with presumed PHC is multidisciplinary, complex and requires extensive experience. The aim of this paper is to review current aspects of diagnosis, preoperative work-up and extended resection in patients with PHC from the perspective of our own institutional experience with this complex tumor. METHODS We provided a review of applied modalities in the diagnosis and work-up of PHC according to current literature. All patients with presumed PHC in our center between 2000 and 2016 were identified and described. The types of resection, surgical techniques and outcomes were analyzed. RESULTS AND CONCLUSION Upcoming diagnostic modalities such as Spyglass and combinations of serum biomarkers and molecular markers have potential to decrease the rate of misdiagnosis of benign, inflammatory disease. Assessment of liver function with hepatobiliary scintigraphy provides better information on the future remnant liver (FRL) than volume alone. The selective use of staging laparoscopy is advisable to avoid futile laparotomies. In patients requiring extended resection, selective preoperative biliary drainage is mandatory in cholangitis and when FRL is small (< 50%). Preoperative portal vein embolization (PVE) is used when FRL volume is less than 40% and optionally includes the left portal vein branches to segment 4. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as alternative to PVE is not recommended in PHC. N2 positive lymph nodes preclude long-term survival. The benefit of unconditional en bloc resection of the portal vein bifurcation is uncertain. Along these lines, an aggressive surgical approach encompassing extended liver resection including segment 1, regional lymphadenectomy and conditional portal venous resection translates into favorable long-term survival.
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Affiliation(s)
- F Rassam
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
| | - E Roos
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - K P van Lienden
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - J E van Hooft
- Department of Gastroenterology & Hepatology and Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands
| | - H J Klümpen
- Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - G van Tienhoven
- Department of Radiotherapy, Academic Medical Center, Amsterdam, The Netherlands
| | - R J Bennink
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - M R Engelbrecht
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - A Schoorlemmer
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - U H W Beuers
- Department of Gastroenterology & Hepatology and Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands
| | - J Verheij
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - M G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - O R Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - T M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Rizvi S, Eaton J, Yang JD, Chandrasekhara V, Gores GJ. Emerging Technologies for the Diagnosis of Perihilar Cholangiocarcinoma. Semin Liver Dis 2018; 38:160-169. [PMID: 29871021 PMCID: PMC6463495 DOI: 10.1055/s-0038-1655775] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The diagnosis of malignant biliary strictures remains problematic, especially in the perihilar region and in primary sclerosing cholangitis (PSC). Conventional cytology obtained during endoscopic retrograde cholangiography (ERC)-guided brushings of biliary strictures is suboptimal due to limited sensitivity, albeit it remains the gold standard with a high specificity. Emerging technologies are being developed and validated to address this pressing unmet patient need. Such technologies include enhanced visualization of the biliary tree by cholangioscopy, intraductal ultrasound, and confocal laser endomicroscopy. Conventional cytology can be aided by employing complementary and advanced cytologic techniques such as fluorescent in situ hybridization (FISH), and this technique should be widely adapted. Interrogation of bile and serum by examining extracellular vesicle number and cargo, and exploiting next-generation sequencing and proteomic technologies, is also being explored. Examination of circulating cell-free deoxyribonucleic acid (cfDNA) for differentially methylated regions is a promising test which is being rigorously validated. The special expertise required for these analyses has to date hampered their validation and adaptation. Herein, we will review these emerging technologies to inform the reader of the progress made and encourage further studies, as well as adaptation of validated approaches.
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Affiliation(s)
- Sumera Rizvi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - John Eaton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Ju Dong Yang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Gregory J. Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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34
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Affiliation(s)
- Emad S. Aljahdli
- Consultant, Division of Gastroenterology, Department of Internal Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Saudi Arabia
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35
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Xie C, Aloreidi K, Patel B, Ridgway T, Thambi-Pillai T, Timmerman G, Khan A, Atiq M. Indeterminate biliary strictures: a simplified approach. Expert Rev Gastroenterol Hepatol 2018; 12:189-199. [PMID: 29034764 DOI: 10.1080/17474124.2018.1391090] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Pre-operative evaluation of biliary strictures remains challenging. The dilemma that exists is how to balance the risk of failing to detect malignancy and the potential morbidity caused by unnecessary surgery in patients with benign etiologies. With emerging novel diagnostic modalities, this study aims to assess the efficacy of diagnostic techniques and facilitate a clinical approach to indeterminate biliary strictures. Areas covered: Conventional imaging modalities are crucial in identifying the location of a stricture and are helpful for choosing further diagnostic modalities. Utilization of endoscopic techniques, including endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS), is key in establishing a diagnosis. The emergence of novel diagnostic modalities, such as fluorescence in-situ hybridization (FISH), peroral cholangioscopy (POC), intraductal endoscopic ultrasound (IDUS) and confocal laser endomicroscopy (CLE), enhance the diagnostic yield in the evaluation of indeterminate biliary strictures. Expert commentary: More reliable and validated visual criteria for differentiating malignancy from benign biliary conditions, utilizing advanced imaging modalities such as POC and CLE, need to be established. It is of significance to further evaluate these novel diagnostic modalities through ongoing trials and to develop a diagnostic algorithm that reconciles cost-effectiveness with diagnostic accuracy.
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Affiliation(s)
- Chencheng Xie
- a Internal Medicine , University of South Dakota Sanford School of Medicine , Sioux Falls , SD , USA
| | - Khalil Aloreidi
- a Internal Medicine , University of South Dakota Sanford School of Medicine , Sioux Falls , SD , USA
| | - Bhavesh Patel
- b Surgery , University of South Dakota Sanford School of Medicine , Sioux Falls , SD , USA
| | - Timothy Ridgway
- b Surgery , University of South Dakota Sanford School of Medicine , Sioux Falls , SD , USA
| | - Thavam Thambi-Pillai
- a Internal Medicine , University of South Dakota Sanford School of Medicine , Sioux Falls , SD , USA
| | - Gary Timmerman
- a Internal Medicine , University of South Dakota Sanford School of Medicine , Sioux Falls , SD , USA
| | - Adeel Khan
- c Surgery , Washington University in St. Louis , St. Louis , MO , USA
| | - Muslim Atiq
- b Surgery , University of South Dakota Sanford School of Medicine , Sioux Falls , SD , USA
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Moutinho-Ribeiro P, Peixoto A, Macedo G. Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound: To Be One Traveler in Converging Roads. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2017; 25:138-145. [PMID: 29761150 DOI: 10.1159/000481537] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 09/14/2017] [Indexed: 12/28/2022]
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were initially introduced into the world of gastroenterology as purely diagnostic procedures. With progressive evolution of intervention, both these techniques conquered fields in the treatment of many conditions that had once been exclusively surgical domains. Nowadays, more and more clinical situations have an indication to perform both EUS and ERCP, and these two techniques are frequently required at the same time for the same patient. More than competitors, ERCP and EUS are truly complementary, with great ability for mutual aid. They share their main indications, equipment, accessories, and main technical gestures. Objectives and Methods We review the major indications to perform both techniques, sequentially or complementarily, describe the common things that these two techniques essentially share, and discuss the ERCP-EUS single session. Also, the issues of learning curves and education of upcoming biliopancreatic endoscopists are highlighted. Conclusion In recent years the complementation between ECRP and EUS has been growing both from a diagnostic and a therapeutic point of view, allowing optimization of the use of these techniques and the creation of a more systematized approach of patients with biliopancreatic pathology. Endoscopists with experience in both techniques will be increasingly important, suggesting a parallel formation in the training plans of future endoscopists with interest in the area.
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Affiliation(s)
- Pedro Moutinho-Ribeiro
- Gastroenterology Department, Centro Hospitalar São João, and Porto World Gastroenterology Organization Training Center, University of Porto Medical School, Porto, Portugal
| | - Armando Peixoto
- Gastroenterology Department, Centro Hospitalar São João, and Porto World Gastroenterology Organization Training Center, University of Porto Medical School, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar São João, and Porto World Gastroenterology Organization Training Center, University of Porto Medical School, Porto, Portugal
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Abstract
Endoscopic ultrasound (EUS)-guided tissue acquisition has greatly evolved since the first EUS-guided fine-needle aspiration was reported nearly 25 years ago. EUS-guided tissue acquisition has become the procedure of choice for sampling of the pancreas, subepithelial lesions, and other structures adjacent to the gastrointestinal tract. This review focuses on recent developments in procedural techniques and needle technologies for EUS-guided tissue acquisition.
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Papafragkakis C, Lee J. Comprehensive management of cholangiocarcinoma: Part I. Diagnosis. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii1500341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Charilaos Papafragkakis
- epartment of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Lee
- epartment of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lee YN, Moon JH, Choi HJ, Kim HK, Choi SY, Choi MH, Lee TH, Lee TH, Cha SW, Park SH. Diagnostic approach using ERCP-guided transpapillary forceps biopsy or EUS-guided fine-needle aspiration biopsy according to the nature of stricture segment for patients with suspected malignant biliary stricture. Cancer Med 2017; 6:582-590. [PMID: 28220692 PMCID: PMC5345615 DOI: 10.1002/cam4.1034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/02/2017] [Accepted: 01/17/2017] [Indexed: 12/21/2022] Open
Abstract
In malignant biliary stricture (MBS), the diagnostic accuracy of ERCP‐based tissue sampling is insufficient. EUS‐guided fine needle aspiration biopsy (EUS‐FNAB) is emerging as a reliable diagnostic procedure. This study aimed to evaluate the usefulness of a diagnostic approach using ERCP‐guided transpapillary forceps biopsy (TPB) or EUS‐FNAB according to the characteristics of suspected MBS. Consecutive patients diagnosed with suspected MBS with obstructive jaundice and/or cholangitis were enrolled prospectively. ERCP with intraductal ultrasonography (IDUS) and TPB were performed as initial diagnostic procedures. Based on the results of imaging studies and IDUS, all MBS were classified as extrinsic or intrinsic type. If the malignancy was not confirmed by TPB, EUS‐FNAB for extrinsic type or second TPB for intrinsic type was performed. Among a total of 178 patients, intrinsic and extrinsic types were detected in 88 and 90 patients, respectively. The diagnostic accuracy of first TPB was significantly higher in the intrinsic than in the extrinsic type (81.8% vs. 67.8, P = 0.023). In 33 patients with extrinsic type and negative for malignancy on first TPB, the diagnostic accuracy of EUS‐FNAB was 90.9%. In 19 patients with intrinsic type and negative for malignancy on first TPB, the diagnostic accuracy of second TPB was 84.2%. The diagnostic accuracies of the combination of initial TPB with EUS‐FNAB and second TPB were 96.7% and 96.6%, respectively. A diagnostic approach using EUS‐FNAB or TPB according to the origin of MBS is considered effective to improve the diagnostic accuracy of MBS with negative for malignancy on first TPB. (Clinical trial registration number: UMIN000016886).
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Affiliation(s)
- Yun Nah Lee
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon and Seoul, Korea
| | - Jong Ho Moon
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon and Seoul, Korea
| | - Hyun Jong Choi
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon and Seoul, Korea
| | - Hee Kyung Kim
- Department of Pathology, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Seo-Youn Choi
- Department of Radiology, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Moon Han Choi
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon and Seoul, Korea
| | - Tae Hee Lee
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon and Seoul, Korea
| | - Tae Hoon Lee
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon and Seoul, Korea
| | - Sang-Woo Cha
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon and Seoul, Korea
| | - Sang-Heum Park
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon and Seoul, Korea
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40
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Gornals JB, Esteban JM, Guarner-Argente C, Marra-Lopez C, Repiso A, Sendino O, Loras C. Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography: Can they be successfully combined? GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:627-642. [PMID: 26920225 DOI: 10.1016/j.gastrohep.2015.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 12/01/2015] [Accepted: 12/04/2015] [Indexed: 02/07/2023]
Abstract
Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) have much in common, including their main indications (biliopancreatic disorders), powerful therapeutic capacities and a steep learning curve. Over the years they have evolved from novel diagnostic procedures to interventional therapeutic techniques, but along different paths (different scopes or devices and endoscopists specializing exclusively in one or the other technique). However, EUS has gradually developed into a therapeutic technique that requires skills in the use of ERCP devices and stents, leading some ERCP specialists to explore the therapeutic potential of EUS. The corresponding literature, which has grown exponentially, includes recent experiments on combining the two techniques, which have gradually come to be used in routine care in a number of centers, with positive technical, clinical and financial outcomes. We review EUS and ERCP as individual or combined procedures for managing biliopancreatic disorders.
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Affiliation(s)
- Joan B Gornals
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain.
| | - José Miguel Esteban
- Endoscopy Unit, Department of Digestive Diseases, Hospital Clinic San Carlos, Madrid, Spain
| | - Carlos Guarner-Argente
- Endoscopy Unit, Department of Digestive Diseases, Hospital Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Carlos Marra-Lopez
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitario Araba sede Txagorritxu, Alava, Spain
| | - Alejandro Repiso
- Endoscopy Unit, Department of Digestive Diseases, Hospital Virgen de la Salud, Toledo, Spain
| | - Oriol Sendino
- Endoscopy Unit, Department of Digestive Diseases, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Carme Loras
- Endoscopy Unit, Department of Digestive Diseases, Hospital Mútua Terrassa, CIBEREHD, Terrassa, Catalonia, Spain
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41
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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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42
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Chen WM, Wei KL, Chen YS, Chang PJ, Tung SY, Chang TS, Huang HC, Shen CH, Hsieh YY, Wu CS. Transpapillary biliary biopsy for malignant biliary strictures: comparison between cholangiocarcinoma and pancreatic cancer. World J Surg Oncol 2016; 14:140. [PMID: 27142076 PMCID: PMC4855757 DOI: 10.1186/s12957-016-0883-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 04/21/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Tissue sampling for biliary stricture is important for differential diagnosis and further treatment. This study aims to assess the differences of transpapillary biliary biopsy for malignant biliary strictures between cholangiocarcinoma and pancreatic cancer. METHODS From January 2010 to December 2013, we retrospectively studied 79 patients who suffered from biliary strictures and received transpapillary forceps biopsy after sphincterotomy for tissue sampling. The diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of forceps biopsy were calculated in all cases for both cholangiocarcinoma and pancreatic cancer patients. Possible factors that distinguish malignant strictures from benign strictures and which could affect the accuracy of tissue sampling were analyzed. RESULTS There are 65 malignant and 14 benign biliary stricture patients enrolled. The malignant group has a significantly higher serum bilirubin level than the benign group, but age, clinical presentation, level of serum carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9, and alkaline phosphatase are not. The sensitivity, specificity, PPV, and NPV of forceps biopsy for biliary stricture are 53.85, 100, 100, and 31.82%, respectively. The cholangiocarcinoma group has a higher sensitivity (73.53 versus 29.17%, p < 0.001), older age, lower CA 19-9 level, and more common hepatic duct strictures than the pancreatic group. The age, serum CEA, CA 19-9 and the alkaline phosphatase level, serum bilirubin level >10 mg/dL, tissue sampling ≧3 are not significant factors affecting diagnostic accuracy in forceps biopsy for pancreatobiliary strictures. There is neither major bleeding nor perforation in our study. CONCLUSIONS Transpapillary forceps biopsy of biliary strictures after sphincterotomy for tissue sampling is safe and a significantly higher sensitive method in cholangiocarcinoma but not in pancreatic cancer.
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Affiliation(s)
- Wei-Ming Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chang Gung Memorial Hospital, 6 Section West, Chia-Po Road, Putz City, Chiayi, 613, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuo-Liang Wei
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chang Gung Memorial Hospital, 6 Section West, Chia-Po Road, Putz City, Chiayi, 613, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Yi-Shing Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chang Gung Memorial Hospital, 6 Section West, Chia-Po Road, Putz City, Chiayi, 613, Taiwan
| | - Pey-Jium Chang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shui-Yi Tung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chang Gung Memorial Hospital, 6 Section West, Chia-Po Road, Putz City, Chiayi, 613, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Te-Sheng Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chang Gung Memorial Hospital, 6 Section West, Chia-Po Road, Putz City, Chiayi, 613, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hao-Chun Huang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chang Gung Memorial Hospital, 6 Section West, Chia-Po Road, Putz City, Chiayi, 613, Taiwan
| | - Chein-Heng Shen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chang Gung Memorial Hospital, 6 Section West, Chia-Po Road, Putz City, Chiayi, 613, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Yu Hsieh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chang Gung Memorial Hospital, 6 Section West, Chia-Po Road, Putz City, Chiayi, 613, Taiwan
| | - Cheng-Shyong Wu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chang Gung Memorial Hospital, 6 Section West, Chia-Po Road, Putz City, Chiayi, 613, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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43
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Onda S, Ogura T, Kurisu Y, Masuda D, Sano T, Takagi W, Fukunishi S, Higuchi K. EUS-guided FNA for biliary disease as first-line modality to obtain histological evidence. Therap Adv Gastroenterol 2016; 9:302-12. [PMID: 27134660 PMCID: PMC4830098 DOI: 10.1177/1756283x15625584] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Few reports have described endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) for biliary lesions. In addition, adverse events were not completely examined in previous reports, due to the inclusion of cases in which biliary stents had already been placed. The present study aimed to investigate the diagnostic yield and adverse events of EUS-FNA for biliary lesions as the first-line diagnostic modality for consecutive prospectively registered patients. METHODS Inclusion criteria were as follows: (1) patients with suspected cholangiocarcinoma (CCA) based on computed tomography or other imaging modalities; (2) patients who had not previously undergone endoscopic retrograde cholangiopancreatography or EUS-FNA; (3) absence of surgically altered anatomy, such as Roux-en-Y anastomosis or duodenal obstruction caused by tumor invasion, through which an endoscope could not pass; and (4) provision of written informed consent to all procedures associated with the study. RESULTS A total of 47 consecutive patients with suspected CCA were registered to this study. Sensitivity and accuracy were 89% and 87%, respectively. On multivariate analysis, puncture site was the only factor associated with reduced diagnostic yield (hazard ration, 6.879; 95% confidence interval, 1.172-40.374; P = 0.033). Remarkably, no adverse events such as bleeding or bile leakage were associated with EUS-FNA in any of the 47 patients. CONCLUSIONS Our results suggest that EUS-FNA can be safely performed for biliary disease without biliary stenting. Furthermore, this procedure may warrant use as the first-line diagnostic method, although our results need to be validated in future prospective studies.
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Affiliation(s)
- Saori Onda
- Second Department of Internal Medicine, Osaka Medical College, Japan
| | | | | | - Daisuke Masuda
- Second Department of Internal Medicine, Osaka Medical College, Japan
| | - Tatsushi Sano
- Second Department of Internal Medicine, Osaka Medical College, Japan
| | - Wataru Takagi
- Second Department of Internal Medicine, Osaka Medical College, Japan
| | - Shinya Fukunishi
- Second Department of Internal Medicine, Osaka Medical College, Japan
| | - Kazuhide Higuchi
- Second Department of Internal Medicine, Osaka Medical College, Japan
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Banales JM, Cardinale V, Carpino G, Marzioni M, Andersen JB, Invernizzi P, Lind GE, Folseraas T, Forbes SJ, Fouassier L, Geier A, Calvisi DF, Mertens JC, Trauner M, Benedetti A, Maroni L, Vaquero J, Macias RIR, Raggi C, Perugorria MJ, Gaudio E, Boberg KM, Marin JJG, Alvaro D. Expert consensus document: Cholangiocarcinoma: current knowledge and future perspectives consensus statement from the European Network for the Study of Cholangiocarcinoma (ENS-CCA). Nat Rev Gastroenterol Hepatol 2016; 13:261-80. [PMID: 27095655 DOI: 10.1038/nrgastro.2016.51] [Citation(s) in RCA: 948] [Impact Index Per Article: 105.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cholangiocarcinoma (CCA) is a heterogeneous group of malignancies with features of biliary tract differentiation. CCA is the second most common primary liver tumour and the incidence is increasing worldwide. CCA has high mortality owing to its aggressiveness, late diagnosis and refractory nature. In May 2015, the "European Network for the Study of Cholangiocarcinoma" (ENS-CCA: www.enscca.org or www.cholangiocarcinoma.eu) was created to promote and boost international research collaboration on the study of CCA at basic, translational and clinical level. In this Consensus Statement, we aim to provide valuable information on classifications, pathological features, risk factors, cells of origin, genetic and epigenetic modifications and current therapies available for this cancer. Moreover, future directions on basic and clinical investigations and plans for the ENS-CCA are highlighted.
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Affiliation(s)
- Jesus M Banales
- Department of Liver and Gastrointestinal Diseases, Biodonostia Health Research Institute - Donostia University Hospital, Ikerbasque, CIBERehd, Paseo del Dr. Begiristain s/n, E-20014, San Sebastian, Spain
| | - Vincenzo Cardinale
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Viale dell'Università 37, 00185, Rome, Italy
| | - Guido Carpino
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Piazza Lauro De Bosis 6, 00135, Rome, Italy
| | - Marco Marzioni
- Department of Clinic and Molecular Sciences, Polytechnic University of Marche, Via Tronto 10, 60020, Ancona, Italy
| | - Jesper B Andersen
- Biotech Research and Innovation Centre, University of Copenhagen, Ole Maaløes Vej 5, DK-2200, Copenhagen N, Denmark
| | - Pietro Invernizzi
- Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, 20089, Milan, Italy
- Program for Autoimmune Liver Diseases, International Center for Digestive Health, Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, 20900, Monza, Italy
| | - Guro E Lind
- Department of Molecular Oncology, Institute for Cancer Research, Oslo University Hospital, The Norwegian Radium Hospital, Montebello, 0310, Oslo, Norway
| | - Trine Folseraas
- Department of Transplantation Medicine, Division of Cancer Medicine, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Pb. 4950 Nydalen, N-0424, Oslo, Norway
| | - Stuart J Forbes
- MRC Centre for Regenerative Medicine, University of Edinburgh, 49 Little France Crescent, EH16 4SB, Edinburgh, United Kingdom
| | - Laura Fouassier
- INSERM UMR S938, Centre de Recherche Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris cedex 12, Fondation ARC, 9 rue Guy Môquet 94803 Villejuif, France
| | - Andreas Geier
- Department of Internal Medicine II, University Hospital Würzburg, Oberdürrbacherstrasse 6, D-97080, Würzburg, Germany
| | - Diego F Calvisi
- Institute of Pathology, Universitätsmedizin Greifswald, Friedrich-Löffler-Strasse 23e, 17489, Greifswald, Germany
| | - Joachim C Mertens
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Rämistrasse 100, 8091, Zürich, Switzerland
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Antonio Benedetti
- Department of Clinic and Molecular Sciences, Polytechnic University of Marche, Via Tronto 10, 60020, Ancona, Italy
| | - Luca Maroni
- Department of Clinic and Molecular Sciences, Polytechnic University of Marche, Via Tronto 10, 60020, Ancona, Italy
| | - Javier Vaquero
- INSERM UMR S938, Centre de Recherche Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris cedex 12, Fondation ARC, 9 rue Guy Môquet 94803 Villejuif, France
| | - Rocio I R Macias
- Department of Physiology and Pharmacology, Experimental Hepatology and Drug Targeting (HEVEFARM), Campus Miguel de Unamuno, E.I.D. S-09, University of Salamanca, IBSAL, CIBERehd, 37007, Salamanca, Spain
| | - Chiara Raggi
- Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Maria J Perugorria
- Department of Liver and Gastrointestinal Diseases, Biodonostia Health Research Institute - Donostia University Hospital, Ikerbasque, CIBERehd, Paseo del Dr. Begiristain s/n, E-20014, San Sebastian, Spain
| | - Eugenio Gaudio
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Via Alfonso Borelli 50, 00161, Rome, Italy
| | - Kirsten M Boberg
- Department of Transplantation Medicine, Division of Cancer Medicine, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Pb. 4950 Nydalen, N-0424, Oslo, Norway
| | - Jose J G Marin
- Department of Physiology and Pharmacology, Experimental Hepatology and Drug Targeting (HEVEFARM), Campus Miguel de Unamuno, E.I.D. S-09, University of Salamanca, IBSAL, CIBERehd, 37007, Salamanca, Spain
| | - Domenico Alvaro
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Viale dell'Università 37, 00185, Rome, Italy
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Gulati A, Thakkar P, Thakkar S. Endoscopic management of hilar stricture. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2016; 18:67-74. [DOI: 10.1016/j.tgie.2016.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
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Brijbassie A, Yeaton P. Approach to the patient with a biliary stricture. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2016. [DOI: 10.1016/j.tgie.2016.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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El-Haddad HM, Kassem MI, Shehata GM, Afifi AH. Predictors of success of treatment of distal two thirds common bile duct strictures: A retrospective Cohort study over two years. Int J Surg 2016; 28:106-11. [DOI: 10.1016/j.ijsu.2016.02.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/22/2016] [Accepted: 02/10/2016] [Indexed: 10/22/2022]
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48
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Diagnostic yield of EUS-guided FNA for malignant biliary stricture: a systematic review and meta-analysis. Gastrointest Endosc 2016; 83:290-8.e1. [PMID: 26422979 DOI: 10.1016/j.gie.2015.09.024] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 09/17/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS EUS-guided FNA (EUS-FNA) is increasingly being used for tissue diagnosis of extrahepatic biliary strictures. The aim of this study was to determine the diagnostic yield of EUS-FNA in malignant biliary strictures. METHODS A comprehensive literature review was carried out by 2 reviewers for studies evaluating the accuracy of EUS-FNA in biliary stricture. A meta-analysis was performed to determine the pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio for EUS-FNA of extrahepatic biliary stricture. A Quality Assessment of Diagnostic Accuracy Studies questionnaire was used to assess the quality of the selected studies. Several sensitivity analyses were performed to assess the effect of the quality of the studies on the accuracy of the final results of the meta-analysis. RESULTS Twenty studies involving 957 patients met inclusion criteria and were included in the meta-analysis. The pooled sensitivity and specificity of EUS-FNA for diagnosis of malignant biliary stricture were 80% (95% confidence interval [CI], 74%-86%), and 97% (95% CI, 94%-99%), respectively. The pooled positive likelihood ratio was 12.35 (95% CI, 7.37-20.72), and the negative likelihood ratio was 0.26 (95% CI, 0.18-0.38). The pooled diagnostic odds ratio for diagnosing a malignant biliary stricture was 70.53 (95% CI, 38.62-128.82). The area under the receiver-operating characteristic curve was 0.97. Sensitivity analyses showed that the quality of the included studies did not affect the accuracy of the final results of the meta-analysis. CONCLUSION This meta-analysis demonstrates that EUS-FNA is sensitive and highly specific for diagnosing malignancy in biliary strictures. Further studies are needed to compare EUS--FNA with emerging methods including cholangioscopy-guided biopsy and laser endomicroscopy.
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Abstract
Biliary strictures frequently present a diagnostic challenge during pre-operative evaluation to determine their benign or malignant nature. A variety of benign conditions, such as primary sclerosing cholangitis (PSC) and IgG4-related sclerosing cholangitis, frequently mimic malignancies. In addition, PSC and other chronic biliary diseases increase the risk of cholangiocarcinoma and so require ongoing vigilance. Although traditional methods of evaluation including imaging, detection of circulating tumour markers, and sampling by endoscopic ultrasound and endoscopic retrograde cholangiopancreatography have a high specificity, they suffer from low sensitivity. Currently, up to 20% of biliary strictures remain indeterminate after pre-operative evaluation and necessitate surgical intervention for a definitive diagnosis. The discovery of novel biomarkers, new imaging modalities and advanced endoscopic techniques suggests that a multimodality approach might lead to better diagnostic accuracy.
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Fior-Gozlan M, Giovannini D, Rabeyrin M, Mc Leer-Florin A, Laverrière MH, Bichard P. Monocentric study of bile aspiration associated with biliary brushing performed during endoscopic retrograde cholangiopancreatography in 239 patients with symptomatic biliary stricture. Cancer Cytopathol 2015; 124:330-9. [PMID: 26700399 DOI: 10.1002/cncy.21667] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 11/16/2015] [Accepted: 11/17/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND The cytologic diagnosis obtained by brushing or biopsy in malignant biliary strictures is considered to be highly specific but poorly sensitive. The diagnostic association of biliary brushing and bile exfoliate cytology has been suggested but is rarely performed in clinical practice. The objective of this study was to assess the diagnostic performance of bile aspiration associated with biliary brushing during therapeutic endoscopic retrograde cholangiopancreatography (ERCP). METHODS From 2004 to 2009, 239 consecutive patients who underwent ERCP were included in the study. The biliary strictures were considered clinically benign in 26% of patients, uncertain in 25%, and malignant in 49%. The 298 cytologic samples collected were divided in 3 groups: bile aspiration alone (26%), biliary brushing alone (20%), and bile aspiration combined with brushing (54%). The definitive diagnosis of malignancy was obtained by biopsy, surgery, and fine-needle aspiration or was determined by an unfavorable disease course. RESULTS The cytologic diagnoses were as follows: 149 samples were benign (50%), 114 were malignant (38%), 34 had atypia (12%), and 1 had no diagnostic value. The procedure output values were as follows: for bile aspiration alone, sensitivity was 56.4%, specificity was 93.9%, the positive predictive value (PPV) was 91.7%, and the negative predictive value (NPV) was 64.6%; for brushing alone, sensitivity was 62.5%, both specificity and the PPV were 100%, and the NPV was 73%; and, for bile aspiration and brushing combined, sensitivity was 81%, both specificity and the PPV were 100%, and the NPV was 75%. CONCLUSIONS For patients who have symptomatic biliary stricture, bile aspiration during ERCP is a simple and safe procedure. Bile aspiration combined with brushing significantly increases the yield of cytology for malignant biliary tumors (sensitivity, 81%), particularly in cholangiocarcinomas. Cancer Cytopathol 2016;124:330-9. © 2015 American Cancer Society.
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Affiliation(s)
| | - Diane Giovannini
- Pathology Department, Grenoble University Hospital, Grenoble, France
| | - Maud Rabeyrin
- Pathology Department, Edouard Herriot Hospital, Lyon, France
| | | | | | - Philippe Bichard
- Endoscopy Department, Grenoble University Hospital, Grenoble, France
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