Endoscopic cytology of biliary and pancreatic lesions

Abstract

I read with great interest the article recently published in Gastrointestinal Endoscopy by Vandervoort et al.1Vandervoort J Soetilino RM Montes H Lichtenstein DR Van Dam J Ruymann FW et al.Accuracy and complication rate of brush cytology from bile duct versus pancreatic duct.Gastrointest Endosc. 1999; 49: 322-327Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar on endoscopic biliary and pancreatic cytology using the Geenen cytology system or Geenen brush passed through One Action Stent Insertion System (Wilson-Cook Medical, Inc., Winston-Salem, N.C.). I would like to bring to the attention of your readers an article published in Gastrointestinal Endoscopy on improved diagnosis of malignant biliary strictures using endoscopic bile cytology after dilating bile duct strictures before placement of a plastic endoprosthesis.2Mohandas KM Swaroop VS Gullar SU Dave UR Jagannath P DeSouza LJ Diagnosis of malignant obstructive jaundice by bile duct cytology: results improved by dilating the bile duct structures.Gastrointest Endosc. 1994; 40: 150-154Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar I was the senior investigator and personally performed more than 80% of the stent insertions in the 61 patients included in that study. Vandervoort et al. must have overlooked this report, while including 20 other references to studies dealing with the sensitivity of different endoscopic techniques for cytologic samplings from bile and pancreatic ducts, most of them describing the brush technique. Vandervoort et al. reported a 64.3% accuracy rate for biliary cytology in 101 patients using the brush with an 11% pancreatitis rate. The study in which I was involved had a similar accuracy rate of 63.3% for definite cancer; in an additional 12.2% of patients the results were “suggestive” of cancer. Pancreatitis occurred in 4% of the patients. Logically, dilating a malignant stricture and then collecting bile for cytology could cause more exfoliation of cells and thus a higher yield of positive diagnosis. However, Kurzawinski et al.,3Kurzawinski T Deery A Dooley JS Dick R Hobbs KE Davidson BR A prospective study of biliary cytology in 100 patients with bile duct strictures.Hepatology. 1993; 18: 1399-1403Crossref PubMed Scopus (118) Google Scholar using a somewhat similar technique, reported 26% rate of positive diagnoses with bile cytology while prospectively comparing it to brush technique which yielded a higher rate of 69%. I believe that bile aspiration after dilating a biliary stricture, before insertion of a prosthesis, is a simpler technique for obtaining cytology samples. It does not require additional accessory equipment or procedure time and should be compared in a prospective, randomized fashion with brush cytology. doi:10.1067/mge.2000.106106