Bile Duct Brushing Cytology Research Articles

A case of primary sclerosing cholangitis in which the critical diagnostic role of bile duct brush cytology obtained by ERCP was revealed

A case of primary sclerosing cholangitis in which the critical diagnostic role of bile duct brush cytology obtained by ERCP was revealed

Pancreatic ductal adenocarcinoma arising from the pancreatic parenchyma compressed by a huge pancreatic lipoma: a case report

BackgroundPancreatic lipomas (PLs) arising from the adipose tissue in the pancreatic parenchyma are rare among pancreatic tumors. Coexisting pancreatic ductal adenocarcinoma (PDAC) and PLs have not been previously reported. Herein, we report a case of PDAC arising from the pancreatic parenchyma with chronic pancreatitis compressed by a large PL.Case presentationThe patient was a 69-year-old male. He had been diagnosed with a PL using computed tomography (CT) 12 years previously. The tumor had been slowly growing and was followed up carefully because of the possibility of well-differentiated liposarcoma. During follow-up, laboratory data revealed liver damage and slightly elevated levels of inflammatory markers. Contrast-enhanced CT revealed the previously diagnosed 12 cm pancreatic head tumor and an irregular isodensity mass at the upper margin of the tumor that invaded and obstructed the distal common bile duct. Magnetic resonance cholangiopancreatography demonstrated no specific findings in the main pancreatic duct. Based on these imaging findings, the patient underwent endoscopic retrograde biliary drainage and bile duct brushing cytology, which revealed indeterminate findings. The differential diagnosis of the tumor at that time was as follows: (1) pancreatic liposarcoma (focal change from well-differentiated to dedifferentiated, not lipoma), (2) distal cholangiocarcinoma, and (3) pancreatic cancer. After the cholangitis improved, a pancreatoduodenectomy was performed. Histologically, hematoxylin–eosin staining revealed moderately differentiated PDAC compressed by proliferating adipose tissue. The adipose lesion showed homogeneous adipose tissue with no evidence of sarcoma, which led to a diagnosis of lipoma. Additionally, extensive fibrosis of the pancreatic parenchyma and atrophy of the acinar cells around the lipoma was suggestive of chronic pancreatitis. The pathological diagnosis was PDAC (pT2N0M0 pStage Ib) with chronic pancreatitis and PL. The postoperative course was uneventful, and the patient was discharged on the 15th day after surgery. The patient received adjuvant chemotherapy and has remained recurrence-free for more than 6 months.ConclusionsPL may be associated with the development of PDAC in the surrounding inflammatory microenvironment of chronic pancreatitis. In cases of growing lipomas, careful radiologic surveillance may be needed not only for the possibility of liposarcoma but also for the coincidental occurrence of PDAC.

The Role of Fluorescence In Situ Hybridization in Pancreatobiliary Brushing Cytology: A Large Retrospective Review with Histologic Correlation.

(1) Background: Although the specificity of brush cytology for the detection of malignant pancreaticobiliary strictures is high, its sensitivity is low. Fluorescence in situ hybridization (FISH) can be used to detect chromosomal aneuploidy in biliary brushing specimens, and when used as an adjunct to routine cytology, it significantly improves diagnostic sensitivity. (2) Methods: We searched our laboratory information system to identify all bile duct brush cytology cases with follow-up surgical pathology between January 2001 and September 2019. Cytologic diagnoses were classified as negative, atypical, suspicious, or malignant. Correlated surgical pathological diagnoses were classified as benign or malignant. FISH test results were obtained for a subset of cytology cases with concurrent FISH testing, and the sensitivity, specificity, positive predictive value, and negative predictive value in identifying malignancy for cytology alone, FISH alone, and combined cytology and FISH were calculated. (3) Results: A total of 1017 brushing cytology cases with histologic correlation were identified. A total of 193 FISH tests were performed concurrently with cytological specimens. Malignant diagnoses were identified in 623 of 1017 patients, while 394 patients had benign strictures. The sensitivity, specificity, positive predictive, and negative predictive rate were 65%, 78%, 83%, and 49% for cytology alone; 72%, 67%, 63%, and 68% for FISH alone; and 85%, 42%, 60%, and 74% for combined cytology and FISH, respectively. Among FISH-positive cases, the risk of malignancy for polysomy was 82% and 32% for trisomy. (4) Conclusions: FISH improves the sensitivity and negative predictive rate of bile duct brush cytology. The combination of cytology and FISH has increased the sensitivity from 65% to 85% and the negative predictive rate from 49% to 74% when compared to cytology alone. A patient with a polysomy FISH result had a significantly higher risk of malignancy than a patient with a trisomy 7 result (82% vs. 32%, p < 0.00001).

Identification Of Liver Fluke Eggs In Bile Duct Brush Cytology In An 82 Year Old Man With A Hepatic Mass: Report Of A Case

Abstract Introduction/Objective Clonorchis sinensis infects the liver, gallbladder, and bile ducts in humans. It is acquired via consumption of raw/undercooked fish, crabs, or crayfish in endemic areas. Though majority are asymptomatic, long lasting infections may cause severe disease. Without treatment, human infections may persist for the parasite lifespan (25–30 years). Diagnosis in cytology is challenging with a potentially acellular sample with miniscule eggs that can be overlooked as an artifact. Here we reported a rare case of liver fluke eggs diagnosed in bile duct brush cytology. Methods An 82 year old man who emigrated from China 20 years prior presented to the hospital with worsening jaundice for 2 weeks. Abdominal CT revealed a 4.8 x 2.9 cm central right hepatic lobe mass extending to the hilum, obstructing the bile ducts, resulting in severe intrahepatic ductal dilatation and stricture and focal occlusion of the right anterior portal vein. His CBC revealed eosinophilia. Bile duct brushing was submitted for cytology. Results ThinPrep and cell block showed oval-shaped parasite eggs measuring 10-24 µm. There was no other cellular matter. Eggs had a convex operculum resting on “shoulders” at the smaller end of the egg. At the opposite (abopercular) end, a small knob or hook-like protrusion was often visible. Wet mounts revealed visible miracidium inside the eggs. These findings were compatible with liver fluke eggs. Conclusion Cytologic microbiologic features of fluke eggs confirmed the findings. The most important features are the shape and size of the eggs; The seated operculum with its prominent “shoulders”, a small knob at the abopercular end, which can distinguish them from acellular artifact or a human cell. The cytologic and microbiologic features combined with the travel history and clinical presentation can aid in achieving the diagnosis.

Efficacy of digital single-operator cholangioscopy and factors affecting its accuracy in the evaluation of indeterminate biliary stricture

Indeterminate biliary stricture remains a significant diagnostic challenge. The current method of ERCP with bile duct brush cytology has substantial room for improvement. We aimed to determine the efficacy of a digital single-operator cholangioscopy (DSOC) in evaluation of indeterminate biliary stricture. An observational cohort study was conducted among the patients who underwent DSOC for the indication of indeterminate biliary stricture at a tertiary academic medical center. The outcomes of interests were the accuracy of DSOC in visual interpretation and bile duct sample and identification of any factor(s) that could influence its effectiveness. One hundred five patients were included. The overall accuracy of DSOC in visual interpretation was 89.5%, whereas the accuracy of bile duct sample was 83.2%. The sensitivities of visual impression and bile duct sample were 89.1% and 69.8% and their specificities were 90% and 97.9%, respectively. The degree of endoscopists' experience with fewer than 25 cases and the severity of hyperbilirubinemia negatively impacted the accuracy of DSOC. Among 55 patients with definitive diagnosis of malignant stricture, the sensitivity of combined intraductal forceps biopsy sampling and brush cytology was 80.6%, whereas the sensitivity of brush cytology alone was 47.1%. DSOC augments ERCP in evaluating indeterminate biliary stricture. The acquisition of intraductal forceps biopsy samples should be a requisite in evaluation of indeterminate biliary stricture with DSOC. Discovery of modifiable factors such as the degree of endoscopists' expertise and the severity of hyperbilirubinemia, which can influence the accuracy of DSOC, warrants further studies on patient preprocedure optimization and an endoscopic training program that will cultivate procedural competency.

Mixed adenoendocrine carcinoma in the extrahepatic biliary tract: A case report and literature review.

Neuroendocrine neoplasm (NEN) comprises a group of tumors that exhibit neuroendocrine phenotypes. NEN is subclassified into neuroendocrine tumor (NET), neuroendocrine carcinoma (NEC) and mixed adenoendocrine carcinoma (MANEC), based on histopathological parameters. NEN in the extrahepatic biliary tract (EHBT) is uncommon. Little is known about its clinicopathological features and prognostic indicators. The present study presented a case of MANEC in the distal common bile duct (CBD) and reviewed previous cases of NENs in the EHBT to characterize the clinical settings of this disease entity and to identify influencing factors of survival outcomes. A 64-year-old Chinese woman presented with abdominal pain and jaundice. Imaging studies demonstrated malignant stenosis in the distal CBD. Bile duct brush cytology revealed small clusters of atypical cells. Following an initial diagnosis of distal cholangiocarcinoma (CCA), the patient underwent pancreaticoduodenectomy. Histological analysis combined with immunohistochemical investigation of the resected specimen revealed a collision tumor that was composed of poorly differentiated adenocarcinoma and NEC. Each histological component accounted for >30% of the tumor. The definitive diagnosis was a MANEC in the distal CBD. Multiple intrahepatic and pulmonary metastases were observed postoperatively over 8 months. The patient succumbed to the disease 12 months after surgery. In conclusion, NEN occurs infrequently in the EHBT, with NET being the predominant type. NEN in the EHBT is extremely challenging to diagnose preoperatively due to its tendency to mimic CCA. Patients with NEN in the EHBT exhibited extremely distinct oncology outcomes according to pathological types. Additionally, old age (>60 years) and the presence of tumor recurrence were associated with decreased survival of patients with NEN.

Cytologic diagnosis of adenocarcinoma on bile duct brushings in the presence of stent associated changes: A retrospective analysis

Bile duct brushing (BDB) cytology, for the characterization of bile duct strictures, can be challenging to interpret when associated with a stent. Our study aims to identify the cytologic criteria for the diagnosis of adenocarcinoma in BDBs in the presence of a stent. A database search (January 2010-December 2015) identified three groups of BDBs-negative with stent, malignant with stent, malignant without stent. All malignant cases had histologic and/or cytologic evidence of malignancy within 1 month of the brushing sample. All reactive cases had ≥6 months of benign clinical follow-up. ThinPrep slides were reviewed by two cytopathologists and cytologic features were recorded. Statistical analysis was performed using Fisher's exact test. The study cohort included 12 reactive cases with stent, 17 malignant cases with stent and 32 malignant cases without stent. Among the stented cases, the cytologic features that reached statistical significance were 3D architecture, anisonucleosis to the extent of ≥1:6, coarse chromatin distribution and the presence of single atypical cells in the malignant group in contrast to the benign group. Cases that were diagnosed malignant in the presence of a stent revealed a spectrum of cell populations more frequently as compared with the malignant cases without stent (76% vs 16%). Our findings reveal that the cytologic features of malignancy in non-stented BDBs mostly hold true for stented specimens as well. Application of these criteria in the presence of a stent can improve diagnostic accuracy and thereby patient care.

Investigation of Factors Affecting the Sensitivity of Bile Duct Brush Cytology.

Objectives While bile duct brush cytology during endoscopic retrograde cholangiopancreatography (ERCP) is a well-established procedure for detecting malignant biliary stricture, its sensitivity is reportedly low. We aimed to determine the pre-ERCP factors affecting brush cytology sensitivity.Methods We retrospectively analyzed 185 patients who underwent brush cytology during the first ERCP for undiagnosed biliary stricture at our institution between January 2014 and December 2016. We analyzed the relationship of age, sex, final diagnosis, stricture location, tumor size, stricture length, total bilirubin level, white blood cell count, and C-reactive protein level with brush cytology sensitivity.Results The following conditions were established as final diagnoses: benign disease, 19 cases (10.3%); intrahepatic cholangiocarcinoma, 10 cases (5.4%); hilar cholangiocarcinoma, 38 cases (20.5%); extrahepatic cholangiocarcinoma, 44 cases (23.8%); pancreatic cancer, 55 cases (29.7%); other malignant tumors, 19 cases (10.3%). The sensitivity and specificity of brush cytology were 60.8% and 94.7%, respectively. The stricture length, total bilirubin level, and white blood cell count in true-positive cases were significantly higher than those in false-negative cases. Furthermore, a stratified analysis of the bilirubin levels demonstrated that sensitivity was highest in patients with moderate jaundice (80% for a total bilirubin level of 10-20 mg/dL), but significantly lower in patients with severe jaundice (total bilirubin level ≥20 mg/dL).Conclusion While the sensitivity of brush cytology increases with bilirubin levels of up to 20 mg/dL, severe jaundice has a negative effect on sensitivity, warranting additional pathological examinations according to the pre-ERCP bilirubin level.

UroVysion Multi-Target Fluorescence in situ Hybridization Assay for the Detection of Malignant Bile Duct Brushing Specimens: A Comparison with Routine Cytology

Objective: Routine bile duct brushing cytology is an important diagnostic tool in the evaluation of bile duct stricture. The purpose of this study was to evaluate the performance of the UroVysion fluorescence in situ hybridization (FISH) assay for the detection of malignant bile duct brushing specimens. Study Design: Thirty-five bile duct brushing specimens were included in the study. The FISH assay utilized the commercially available UroVysion probes. The indeterminate cytology results were considered as negative for statistical analysis. Results: Twenty-two of 35 patients were diagnosed as having malignancy based on tissue diagnosis or clinical progression of disease by image assessment. The sensitivity of routine cytology and FISH for the detection of malignancy was 14% (3/22) and 55% (12/22), respectively (p = 0.003). The specificity of routine cytology and FISH was 100% (13/13) and 62% (8/13), respectively (p = 0.025). The false-positive rate for routine cytology and FISH was 0% (0/13) and 38% (5/13), respectively. Conclusions: Our study shows that FISH is significantly more sensitive than routine cytology for the detection of malignancy in bile duct brushing specimens. However, in our study, the specificity of FISH was poor compared to the excellent specificity of routine cytology. The compromised specificity of FISH may limit its utility in the detection of malignant bile duct brushing specimens.

A328 FACTORS PREDICTIVE OF MALIGNANCY IN PATIENTS WITH BILIARY BRUSHINGS OBTAINED BY ERCP

Abstract Aims Biliary brushings for cytology obtained during endoscopic retrograde cholangiopancreatography (ERCP) are the most commonly used method of evaluating patients with biliary strictures for potential underlying malignancy. Patients generally proceed to a pancreatoduodenectomy if there is concern for pancreatic or peripancreatic neoplasm and the patient is an operable candidate. Some patients undergo pancreatoduodenectomy for what is eventually determined to be benign disease. We sought to analyze ERCP brushings to determine predictive factors for malignancy at our centre and whether brushing results influenced decision for pancreatoduodenectomy. Methods Retrospective review was conducted on adult patients who underwent ERCP with biliary duct brushings for cytology at the QEII Health Sciences Centre in Halifax, NS, from 2013–2014. Bile duct brushing cytology reports were identified by electronic search of hospital pathology archives (Cerner Millenium, Cerner, Kansas City, MO). Information on gender, age, symptoms, biliary stricture location and endoscopic impression, presence of pancreatic mass, cytologic impression of brushings, CA 19-9 level, CEA level, surgical intervention and clinical outcome was collected. Abnormal cytology was defined as samples reported as suggestive of malignancy or positive for malignant cells. Basic descriptive statistics and qualitative analysis were performed. Results A total of 185 ERCP patients had biliary brushings for cytology during the study time period. Patients who received biliary brushings were more likely to be between ages 60 to 79 (56%) with a mean age of 66. Presenting symptoms included elevated liver enzymes (82%), jaundice (75%) and pain (48%). Location of biliary stricture, age and gender were not associated with abnormal cytology results. Endoscopic impression of the biliary stricture was malignant in 53% of cases and associated with increased likelihood of abnormal cytology (39/92; p &amp;lt; 0.001). Pancreatic mass on imaging, seen in 38%, was associated with abnormal cytology (25/69, p = 0.001). Elevated CEA, but not CA 19-9, was associated with abnormal cytology (13/23; p = 0.008). Patients who received a pancreatoduodenectomy were not more likely to have abnormal cytology (5/18, p = 0.051). Patients eventually diagnosed with malignancy were more likely to have abnormal cytology on biliary brushing (49/120, p &amp;lt; 0.001). Conclusions Age, gender, location of stricture and elevated CA 19-9 were not associated with abnormal cytology suggestive of malignancy. The presence of a pancreatic mass, elevated CEA and eventual diagnosis of cancer were associated with abnormal cytology. Patients who received a pancreatoduodenectomy were not more likely to have abnormal cytology, which may reflect the scarcity of surgical candidates due to advanced disease at diagnosis. Funding Agencies None

False negative and false positive rates in common bile duct brushing cytology, a single center experience.

In this study we tried to find out the accuracy of biliary tract brushing cytology in our center as the largest referral center in the south of Iran. Common bile duct brushing cytology has been introduced as the method of choice for the diagnosis of pancreaticobiliary malignancies. However, there have been controversial reports about the sensitivity, specificity and overall accuracy of this method in the English literature. During the study period (2012-2016) there has been 166 cases of common bile duct brushing cytology taken during endoscopic retrograde cholangiopancreatography (ERCP). One case has been excluded because of inadequate number of cells in the cytology smear. All the smears have been stained by routine cytologic stains and screened by cytotechnologists and diagnosed by expert cytopathologist. Final diagnosis by biopsy has been considered as the gold standard. According to the final histologic diagnosis as the gold standard, there were 22 false negative and 7 false positive cases. All of the false positive cases have been suspected cases in the background of primary sclerosing cholangitis. The most common final diagnosis of false negative cytologic diagnoses has been intrahepatic cholangiocarcinoma in which no malignant cell has been identified in the presence of adequate number of normal ductal epithelial cells. Common bile duct brushing cytology is the method of choice for the diagnosis of pancreaticobiliary tract malignancies; however, having high specificity (90%), the sensitivity is low (56%). Cytologic diagnosis of biliary tract malignancies should be made with caution in the patients with primary sclerosing cholangitis. Also it is important to know that high false negative rate is present in common bile duct brushing cytology especially in the cases of intrahepatic cholangiocarcinoma without extension into extrahepatic ducts.

Bile Duct Brush Cytology - Challenges, Limitations and Ancillary Studies

Bile Duct Brush Cytology - Challenges, Limitations and Ancillary Studies

The role of bile duct brush cytology in distinguishing malignant from benign biliary obstruction in patients stratified by clinical parameters for risk of malignancy, a retrospective review

The role of bile duct brush cytology in distinguishing malignant from benign biliary obstruction in patients stratified by clinical parameters for risk of malignancy, a retrospective review

Retrospective Comparison of Concordance of Diagnosis of Bile Duct Brushing Cytology with Concurrent Biopsy and/or Surgical Resection Specimens in a Tertiary Care Setting

Retrospective Comparison of Concordance of Diagnosis of Bile Duct Brushing Cytology with Concurrent Biopsy and/or Surgical Resection Specimens in a Tertiary Care Setting

ERCP tissue sampling

ERCP tissue sampling

Bile duct brushing cytology: Cytohistologic/fine-needle aspiration correlation and diagnostic pitfalls

Bile duct brushings are a mainstay in the work-up of patients who present with clinical findings of pancreaticobiliary disease. This study presents the University of Wisconsin Hospital and Clinics Cytopathology Laboratory's experience over a 10.5-year period with histologic and fine-needle aspiration (FNA) correlation. From January 1, 2005, through June 30, 2015, 676 bile duct brushings were processed, of which 408 (60%) were negative, 84 (12%) were atypical, 65 (10%) were suspicious, and 119 (18%) were malignant. Histologic and FNA follow-up was available in 285 (42%) of the cases and forms the basis of this study. There were 59 (21%) positive, 38 (13%) suspicious, 54 (19%) atypical, and 134 (47%) negative bile duct brushings with follow-up. Of the 59 positive cases, 57 (97%) were malignant and 2 (3%) were negative on histologic/FNA follow-up. Thirty-three (87%) of the suspicious brushing were malignant on follow-up and 5 (13%) were negative; 43 (80%) of the atypical brushings were malignant and 11 (20%) were negative; and 94 (70%) of the negative brushings were malignant and 40 (30%) were negative on histologic/FNA follow-up. The sensitivity was 38%; specificity, 95%; positive predictive value, 97%; negative predictive value, 30%. Bile duct brushing cytology is highly specific in the detection of malignant pancreatobiliary lesions with few false positives, but has low sensitivity with many false negatives.

The outcomes of "atypical" and "suspicious" bile duct brushings in the identification of pancreaticobiliary tumors: Follow-up analysis of surgical resection specimens.

Bile duct brushing cytology is frequently used to investigate suspected pancreaticobiliary tumors, but it is associated with low diagnostic sensitivity. As recently proposed by the Papanicolaou Society of Cytopathology in its new classification scheme for pancreaticobiliary cytology, the use of "atypical" and "suspicious (for malignancy)" categories may give a better prediction of malignancy and improve patient management. A series of 65 "atypical" and "suspicious" results initially diagnosed at the University of Washington and Harborview Medical Centers between 2005 and 2012 were analyzed to determine outcomes based on the review of subsequent surgical resection specimens. Seven of 15 (47%) "atypical" cases demonstrated malignant outcomes, whereas 49 of 50 (98%) "suspicious" cases showed documented malignancy within a mean follow-up of 4 months (P < 0.0001 from Pearson's chi-squared test). The analysis of surgical resection specimens demonstrates that 59% of "atypical" and "suspicious" bile duct brushings with malignant outcomes were pancreatic adenocarcinoma (95% confidence interval (CI): 46-71%), 97% of pancreatic adenocarcinomas caused strictures in the head of the pancreas (95% CI: 86-100%), and that 86% of pancreatic adenocarcinomas were moderate to poorly differentiated (95% CI: 73-99%). Fifty-three of the 60 (88%) patients in the presence of prior stenting had a histologically confirmed malignancy. The use of "atypical" and "suspicious" categories may allow more accurate surveillance and/or more rapid surgical exploration of pancreaticobiliary tumors.

Adenomyomatous Hyperplasia of the Ampulla of Vater Masquerading as Malignancy: A Case Series

Introduction: Adenomyomas are benign lesions rarely seen in the ampulla of Vater, composed of heterotopic pancreatic tissue. Patients may present with biliary obstructive, abnormal liver tests, and/or imaging abnormalities, but may be found incidentally. Endoscopic sampling of the papilla may show epithelial cell atypia suggesting dysplasia. Patients often undergo invasive surgical resection for presumed malignancy. In this case series 2 patients underwent pancreaticoduodenectomy for distal common bile duct (CBD) brush cytology adequate for adenocarcinoma with ultimate surgical pathology diagnosis revealing benign adenomyomatous hyperplasia (AH). Case 1: A 74-year-old female with a history of cholecystectomy presents with recent colonic surgery complicated by an intra-abdominal abscess. Computed tomography (CT) imaging showed new significant dilatation of the CBD without pancreatic mass. The patient underwent endoscopic ultrasound (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) to further investigate dilatation. Gross dilatation of the CBD to 18 mm down to the ampulla and pancreatic duct prominence of 3.5 mm was confirmed with EUS. Cholangiogram showed significant upstream CBD dilation and a 1-cm stricture of the distal CBD. She underwent sphincterotomy, cytology brushings of the distal CBD, and biliary stenting. Cytology was positive for malignant adenocarcinoma. A pancreaticoduodenectomy was performed. Surgical pathology showed AH of the ampulla of Vater and incidental focal low-grade pancreatic intraepithelial neoplasia. Her postoperative course has been uneventful and she is doing well. Case 2: A 73-year-old female with a history of cervical carcinoma, chronic kidney disease, and cholecystectomy presents with epigastric pain, back pain, dark urine, and weight loss. MRCP showed CBD dilatation to 20 mm. EUS revealed prominent pancreatic duct (3 mm) and CBD dilatation to 20 mm (10 mm in the distal CBD). Cholangiogram showed a shelf with abrupt tapering in the distal CBD. She underwent sphincterotomy, cytology brushings of the distal CBD, and biliary stenting. Cytology showed distal CBD high-grade biliary intraepithelial neoplasia; could not exclude adenocarcinoma. After pancreaticoduodenectomy, surgical pathology specimens of the ampulla of Vater showed features of AH without carcinoma. Her course has been uneventful after postoperative recovery. Discussion: Although uncommon, AH should be considered in the differential of CBD dilatation. Brush cytology may be highly suggestive of dysplasia and lead to surgical resection. Gastroenterologists should be aware of AH of the ampulla of Vater as a rare benign clinical entity which may mimic a pancreaticobiliary malignancy. Disclosure - Dr. Shah - Speaker’s Bureau: US Endoscopy.

Metastatic Transitional Cell Carcinoma Masquerading as Cholangiocarcinoma

Introduction: An 85-year old female presented with a 3-week history of RUQ pain radiating to the back. She reports intermittent nausea, nonbilious/nonbloody vomitus, anorexia, weight loss, and was found to have abnormal liver function tests. Her past medical history was significant for a stage II urothelial tumor of the left ureter treated with a left nephrectomy 1 year prior. On exam she was noted to have icterus, mild jaundice, and tenderness to palpation of the RUQ. No masses palpated and no organomegaly was noted. Laboratory findings showed elevated total bilirubin, alkaline phosphatase, AST, and ALT. Sonogram suggested acute cholecystitis and biliary ductal dilatation, and HIDA scan confirmed cystic duct obstruction. An MRI/MRCP was performed that suggested a malignant obstructive process in the RUQ, consistent with a cholangiocarcinoma. The patient underwent ERCP, which revealed a long smooth common bile duct stricture and brush cytology was obtained. A plastic stent was placed across the stricture with biliary drainage. EUS suggested gallbladder carcinoma without evidence of vascular invasion. She then underwent laparascopic investigation with intent to resect the tumor but was found to have encasement of the hepatic artery. An open cholecystectomy was performed and biopsy results were consistent with transitional cell origin (IHC was diffusely positive for GATA-3, p63 and focally positive for uroplakin-2). This was an unexpected finding of metastatic disease from her previous left renal pelvis tumor. More than 90% of ureter and renal pelvis tumors are of urothelial origin. Histologically these represent transitional cell carcinoma (TCC) of the bladder. In the United States and Western Europe, approximately 90% of bladder cancers are TCC. Much less commonly, urothelial cancers can arise in the renal pelvis, ureter, or urethra. TCC rarely spreads to distant sites and this occurs in less than 5% of cases. The most common sites of TCC metastasis are lymph nodes, bone, lung, liver, and peritoneum. Metastasis causing biliary obstruction is extremely rare; there has been only 1 report which described bile duct wall metastasis due to TCC mimicking primary hilar cholangiocarcinoma and 1 case in which TCC metastasized to the gallbladder. Furthermore, to our knowledge, there has not been a case in which TCC not only caused biliary obstruction but also cystic duct obstruction. This is the first case in which a TCC caused common bile duct and cystic duct obstruction. This is an extremely uncommon scenario in the literature. Therefore, physicians should consider, in the appropriate setting, metastatic TCC causing biliary obstruction. The patient in this case was successfully palliated with a cholecystectomy and CBD SEMS placement. She was planned to begin outpatient chemotherapy.

Diagnostic yield of bile duct brushings for cholangiocarcinoma in primary sclerosing cholangitis: a systematic review and meta-analysis

The most ominous adverse event of primary sclerosing cholangitis (PSC) is development of cholangiocarcinoma (CCA). There is a wide variation in the reported diagnostic yield of bile duct brush cytology in PSC strictures. To determine the diagnostic utility of biliary brush cytology for CCA detection in patients with PSC. Meta-analysis. Systematic search of PubMed, EMBASE, Web of Science, and the Cochrane Library for relevant studies published up to December 2012. Meta-analysis of diagnostic parameters. A total of 747 patients in studies (both retrospective and prospective) in which histopathologic correlation of CCA was available. Meta-analysis. Construction of 2 × 2 contingency data. Sensitivity, specificity, likelihood ratio, and pooled diagnostic odds ratio. The search yielded 54 studies of which 11, involving 747 patients, were included in our meta-analysis. The pooled sensitivity and specificity of bile duct brushings for a diagnosis of CCA in patients with PSC were 43% (95% confidence interval [CI], 35%-52%) and 97% (95% CI, 95%-98%), respectively. The pooled diagnostic odds ratio to detect CCA was 20.23 (95% CI, 8.75-46.79). The heterogeneity indices of χ(2) statistics, I(2) measure of inconsistency, and the Cochran Q test were 0.156, 14.4, and 30.5%, respectively. Visual inspection of the funnel plot showed low potential for publication bias. Inclusion of low-quality studies, study heterogeneity. Our study suggests that bile duct brushing is a simple and highly specific technique for detection of CCA in patients with PSC. However, the modest sensitivity from bile duct brushing precludes its utility as a diagnostic tool for early detection of CCA in patients with PSC.