Bile Duct Brushing Cytology Research Articles

Beyond cytomorphology: Expanding the diagnostic potential for biliary cytology

Malignancy of the extrahepatic biliary tract is a difficult and crucial diagnosis, both clinically and pathologically. Cytologic evaluation of brushings obtained endoscopically from the biliary tree is currently the standard of care in most institutions. However, bile duct brushing cytology has been plagued by low sensitivity and interpretative difficulties in differentiating reactive from malignant cytology. This review outlines both the difficulties presented by cytomorphology and the potential of new diagnostic techniques that promise to increase sensitivity without sacrificing the high specificity of cytomorphology.

Diagnostic value of K‐ras mutation analysis for pancreaticobiliary cytology specimens with indeterminate diagnosis

Fine-needle aspiration and bile duct brushing cytology have been traditionally used for early detection of pancreaticobiliary malignancy. Quite frequently, the cytological interpretations of these specimens are indeterminate. In this retrospective study, we evaluated the diagnostic value of detecting K-ras (v-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog) mutation in pancreaticobiliary cytology specimens that had equivocal cytological diagnoses. A total of 129 cases that had indeterminate cytology diagnoses, K-ras mutational analysis, and histopathological follow-up were retrieved. The cytological interpretations, histopathological diagnoses, and K-ras mutation results were reviewed and analyzed. Overall, the sensitivity and specificity of K-ras mutation for detection of pancreaticobiliary malignancy including adenocarcinoma, intraductal papillary mucinous neoplasm, and mucinous cystic neoplasm were 57% and 94%, respectively. The positive and negative predictive values of K-ras mutation for the presence of pancreaticobiliary malignancy were 94% and 60%, respectively. The results demonstrate that K-ras mutation has a high predictive value for malignancy in patients with indeterminate pancreaticobiliary cytology and should be included as an important adjuvant diagnostic marker. It should be noted that a negative K-ras mutation result does not rule out malignancy, and K-ras mutation can be detected, although infrequently, in morphologically benign conditions.

Cholangiocarcinoma in a 17‐year‐old boy with primary sclerosing cholangitis and UroVysion™ fluorescent in situ hybridization

Primary sclerosing cholangitis (PSC) is uncommon in the younger age range and bile duct brushing cytology can present unique challenges. We describe the case of a 17-year-old boy with a new diagnosis of PSC who presented with cholangiocarcinoma. The clinical history, endoscopic features, cytomorphologic findings, and results of UroVysion™ fluorescent in situ hybridization (FISH) on the bile duct brush are described. UroVysion FISH on bile duct brushings is an ancillary study that can improve the diagnostic sensitivity for malignancy, specially in challenging cases where the cytomorphologic or clinical characteristics of the case are not typical. The occurrence of cholangiocarcinoma in young age group with PSC is uncommon, and the utilization of UroVysion FISH has been rarely described.

Usefulness of transpapillary bile duct brushing cytology and forceps biopsy for improved diagnosis in patients with biliary strictures

Transpapillary bile duct brushing cytology and/or forceps biopsy was performed in the presence of an indwelling guidewire in patients with biliary stricture, and the treatment time, overall diagnosis rate, diagnosis rate of each disease, complications, and influences on subsequent biliary drainage were investigated. After endoscopic retrograde cholangiography, brushing cytology was performed, followed by forceps biopsy. In patients with obstructive jaundice, endoscopic biliary drainage (EBD) was subsequently performed. To investigate the influences of bile duct brushing cytology and forceps biopsy on EBD, patients who underwent subsequent EBD by plastic stent were compared with patients who underwent EBD alone. The samples for cytology were collected successfully in all cases, and the sensitivity for malignancy/benignity, specificity, and accuracy were 71.6%, 100%, and 75.0%, respectively. The biopsy sampling was successful in 51 patients, and samples applicable to the evaluation were collected in all 51 patients. The sensitivity for malignancy/benignity, specificity, and accuracy were 65.2%, 100%, and 68.6%, respectively. Combination of the two procedures increased the sensitivity and accuracy to 73.5% and 76.6%, respectively. The time required for cytology and biopsy was 11.7 min, which is relatively short. Cytology and biopsy did not affect drainage. Regarding accidents, bile duct perforation occurred during biopsy in one patient (1.9%), but was rapidly improved by endoscopic biliary drainage. Transpapillary brushing cytology and forceps biopsy could be performed in a short time. The diagnosis rate was high, and the incidence of complication was low, having no influence on subsequent biliary drainage.

Analysis of loss of heterozygosity in atypical and negative bile duct brushing cytology specimens with malignant outcome: are "false-negative" cytologic findings a representation of morphologically subtle molecular alterations?

Abstract Context.—Conventional cytologic evaluation of bile duct brushings for neoplasia has high specificity but relatively low sensitivity. Objective.—The aim of this pilot study was to examine whether K-ras mutations and loss of heterozygosity for multiple microsatellite markers in bile duct brushings would contribute to the detection of malignancy in cases initially reported as “negative” or “atypical.” Design.—Bile duct brushing specimens with a negative or an atypical cytologic result (9 cases) had a benign result on the surgical pathology specimen, and 9 additional negative or atypical cases demonstrated adenocarcinoma on the resected surgical specimen. Cells from representative cytopathology and histology slides were microdissected and analyzed for K-ras mutations and for loss of heterozygosity with a panel of 15 polymorphic markers on chromosomes 1p, 3p, 5q, 9p, 9q, 10q, 17p, and 22q. Results.—Among cytology cases with malignant outcome, loss of heterozygosity or K-ras mutation was detected in 8 ...

Analysis of Loss of Heterozygosity in Atypical and Negative Bile Duct Brushing Cytology Specimens With Malignant Outcome: Are “False-Negative” Cytologic Findings a Representation of Morphologically Subtle Molecular Alterations?

Conventional cytologic evaluation of bile duct brushings for neoplasia has high specificity but relatively low sensitivity. The aim of this pilot study was to examine whether K-ras mutations and loss of heterozygosity for multiple microsatellite markers in bile duct brushings would contribute to the detection of malignancy in cases initially reported as "negative" or "atypical." Bile duct brushing specimens with a negative or an atypical cytologic result (9 cases) had a benign result on the surgical pathology specimen, and 9 additional negative or atypical cases demonstrated adenocarcinoma on the resected surgical specimen. Cells from representative cytopathology and histology slides were microdissected and analyzed for K-ras mutations and for loss of heterozygosity with a panel of 15 polymorphic markers on chromosomes 1p, 3p, 5q, 9p, 9q, 10q, 17p, and 22q. Among cytology cases with malignant outcome, loss of heterozygosity or K-ras mutation was detected in 8 (88.8%) of 9 cases. In the corresponding 9 surgical pathology specimens with adenocarcinoma, K-ras mutations and/or allelic losses were detected in all (100%). Loss of heterozygosity or K-ras mutation was not detected in cytology cases that had a benign surgical outcome. The fractional allelic loss of these 9 cytology specimens ranged from 0 to 0.25 (mean, 0.14). This compared with the fractional allelic loss ranging from 0.15 to 0.42 (mean, 0.27) for the corresponding surgical specimens. This pilot study suggests that low-level fractional allelic loss or K-ras mutation in the negative/atypical cytology samples with malignant outcome is a representation of morphologically subtle molecular alterations.

Pancreatic and bile duct brushing cytology in 1000 cases

Duct brushing cytology is an important tool in evaluation of the extrahepatic biliary tract and large pancreatic ducts. The emergence of neoadjuvant therapies underscores the importance of accurate preoperative diagnosis by noninvasive means. Liquid-based preparation methods, such as ThinPrep, have become popular for nongynecologic cytology specimens. Findings from bile and pancreatic duct brushings were reviewed over the 10-year period of 1994-2003. Cytologic material, imaging reports, and clinical data were reviewed and pathologic and clinical follow-up data were obtained. The slides were prepared by direct smear only (18.8%), direct smear plus cytospin (14.4%), or direct smear plus ThinPrep (66.8%). A total of 1118 specimens were identified (1008 bile duct, 110 pancreatic duct) from 864 patients. The cytologic findings were: 53.5% negative, 16.5% malignant, 18.2% suspicious for malignancy, 11% atypical/inconclusive, 0.8% inadequate. Follow-up in the form of either histology or at least 6 months clinical observation was available for 82.2% of cases (n = 971). Overall operating characteristics were: 52.6% sensitivity, 99.4% specificity, 98.9% positive predictive value, 67.1% negative predictive value, and 75.7% accuracy. Diagnostic agreement between cytology and follow-up was the main variable analyzed. Agreement was significantly affected by characteristics of the sampled lesion, with ductal narrowing having the lowest rate of malignancy. In addition, the ThinPrep method showed superior sensitivity and accuracy compared with other preparation methods (P = .02). Nonsignificant associations were noted for patient age and gender, site of lesion, and the presence of either stones or prior stent. In a large dataset from a single institution, brushing cytology showed modest sensitivity and high specificity. Diagnostic agreement was considerably better for benign cases. The combination of direct smear and the ThinPrep method showed superior sensitivity and accuracy.

Determination of sequential mutation accumulation in pancreas and bile duct brushing cytology

Neoplastic progression is characterized by clonal expansion of tumor cells associated with accumulation of mutational damage. The timing of mutation acquisition could be of value in distinguishing preneoplastic conditions from early and advanced cancer as well as characterizing tumor aggressiveness and treatment response. Using quantitative methods applied to microdissected cell clusters selected according to cytomorphologic features, we sought to demonstrate the feasibility and efficacy for determining the time and course of mutation accumulation in pancreatobiliary cytology specimens. In all, 40 pancreatic duct and 21 biliary brushing cytology specimens were retrieved from the cytology database. Xylene-resistant markings were placed on the slide underside and coverslips removed. Clusters of benign, atypical and malignant cells were manually microdissected and DNA extracted. Mutations (allelic imbalance) (loss of heterozygosity) were quantitatively determined for a broad panel of 15 markers (1p, 3p, 5q, 9p, 10q, 17p, 17q, 21q, 22q) as well as point mutation in K-ras-2 using PCR/capillary electrophoresis. Time course was based on earlier mutations having a higher proportion of mutant DNA for a particular marker. The descending frequency of detectable mutational involvement in pancreatic cytology was K-ras-2 point mutation (58%), 3p25–26 and 17q21 (35%), 5q23 (33%), 1p36 (28%), followed by the remaining molecular markers. The descending frequency of mutational content in bile duct cytology was 17p13, 1p36, 3p25–26, and 5q23 followed by remaining molecular markers. K-ras-2 point mutation was not seen in bile duct specimens. While there was overlap in the spectrum of mutational markers in pancreatic duct and biliary brushing cytology, the temporal profile was significantly different (P<0.001). Pancreatic and biliary neoplasia progression involves distinct subset of accumulated defined mutations. Determination of timing of the mutational damage in cytologic material could be incorporated in the work-up and help in making a more definitive diagnosis of malignancy in pancreatobiliary cytology specimens.

Primary sclerosing cholangitis as a cause of false positive bile duct brushing cytology: Report of two cases.

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease of unknown etiology characterized by ongoing inflammation, destruction, and fibrosis of intrahepatic and extrahepatic bile ducts. Irregular narrowing and dilation of the biliary duct system produces the characteristic beaded pattern seen on cholangiogram. Malignant degeneration resulting in cholangiocarcinoma is a well-recognized sequela of PSC. Bile duct brushing cytology is the primary screening technique for cholangiocarcinoma. It is associated with a relatively low sensitivity but high specificity. Few false positive bile duct brushings have been reported in the literature, with the majority of these having occurred in a background of PSC. We report two patients with PSC in whom bile duct brush cytologies were falsely positive for carcinoma.

A Prospective Study of the Yield of Endoscopic Ultrasound-Guided Fine-Needle Aspiration in Patients with Malignant-Appearing Biliary Strictures with Negative ERCP Bile Duct Brush Cytology

The yield of ERCP brush cytology in suspected malignant biliary strictures is low. Patients with negative brush cytology may represent a subset of malignancies difficult to diagnose with endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Aim: To determine the yield of EUS-FNA in patients with negative brush cytology at initial ERCP. Methods: Between 11/01-7/03, a prospective study was performed to evaluate the yield of a novel Cytolong brush compared to the Geenen brush to detect malignancy in patients with biliary strictures. Patients with negative brush cytology who subsequently underwent EUS were identified. The location of the bile duct stricture (proximal, mid or distal bile duct) and the malignant tissue of origin was recorded. Results: 50 patients (26 M, mean age: 65 yrs, range: 27-83 yrs)with a malignant appearing bile duct stricture and negative ERCP brush cytology underwent EUS and form the basis for analysis. At EUS-FNA, a positive cancer diagnosis was made in 37 patients and negative in 13 patients. Of the 37 patients with positive EUS-FNA, 25 had pancreas adenocarcinoma, 7 hilar adenocarcinoma, 2 lymphoma, 1 cholangiocarcinoma, 1 metastatic breast carcinoma, and 1 neuroendocrine carcinoma. Of the 13 patients with negative EUS-FNA, 9 patients had a malignant diagnosis (7 pancreas adenocarcinoma, 1 lymphoma, 1 neuroendocrine carcinoma) and 4 patients had benign diagnosis (chronic pancreatitis) at time of surgery. Location of the bile duct strictures did not differ between the two groups: Positive EUS-FNA (65%distal, 22% proximal bile duct) as compared to Negative EUS-FNA (69% distal, 23% proximal). Sensitivity of EUS-FNA in patients with ERCP negative brush cytology was 80% (37/46), and the specificity was 100% (4/4) with a diagnostic accuracy of 82% (41/50). Conclusions: In patients with malignant-appearing bile duct strictures with negative brush cytology at ERCP, EUS-FNA is highly accurate in detecting malignancy. Location of the bile duct stricture did not influence accuracy of EUS-FNA.

Comparison of ThinPrep and conventional smears in detecting carcinoma in bile duct brushings

Bile duct brushing cytology is a common procedure for the exclusion of adenocarcinoma in the bile duct. The authors evaluated the use of ThinPrep (TP) to determine whether the information obtained is equivalent to that found with conventional smear cytology (CS). Thirty-eight prospectively collected endoscope retrograde cholangiopancreatography-guided bile duct brushing samples were split in the following manner. First, two to four CS were prepared and immediately spray-fixed or wet-fixed. Second, the remaining sample was rinsed in PreservCyt (Cytyc Corp., Boxborough, MA). In the laboratory, one TP slide was prepared from each sample. TP and CS were stained by routine Papanicolaou stain. For the current study, TP and CS were reviewed independently by two cytopathologists. The diagnoses made by the two methods were compared with the final histology. The cytologic diagnoses for both TP and CS were categorized into five main groups: 1) unsatisfactory, 2) negative, 3) reactive, 4) suspicious for malignancy, and 5) malignant. The diagnoses on the 38 TP bile duct brushings and CS were categorized as follows: 1) unsatisfactory-2, 4; 2) negative-7, 4; 3) reactive-10, 14; 4) suspicious for malignancy-9, 9; and 5) malignant-10, 7, respectively. Histologic follow-up was available in 14 cases (reactive-4, suspicious for malignancy-1, and malignant-9). The sensitivity was 77% for TP and 66% for CS. The specificity was 100% for both methods. The two methods described in the current study detected equivalent disease on bile duct brushings. TP was found to provide better preservation and cytologic detail. However, the diagnostic criteria may require modification.

Hepatocellular carcinoma with obstructive jaundice: diagnosis, treatment and prognosis.

Obstructive jaundice as the main clinical feature is uncommon in patients with hepatocellular carcinoma (HCC). Only 1-12 % of HCC patients manifest obstructive jaundice as the initial complaint. Such cases are clinically classified as "icteric type hepatoma", or "cholestatic type of HCC". Identification of this group of patients is important, because surgical treatment may be beneficial. HCC may involve the biliary tract in several different ways: tumor thrombosis, hemobilia, tumor compression, and diffuse tumor infiltration. Bile duct thrombosis (BDT) is one of the main causes for obstructive jaundice, and the previously reported incidence is 1.2-9 %. BDT might be benign, malignant, or a combination of both. Benign thrombi could be blood clots, pus, or sludge. Malignant thrombi could be primary intrabiliary malignant tumors, HCC with invasion to bile ducts, or metastatic cancer with bile duct invasion. The common clinical features of this type of HCC include: high level of serum AFP; history of cholangitis with dilation of intrahepatic bile duct; aggravating jaundice and rapidly developing into liver dysfunction. It is usually difficult to make diagnosis before operation, because of the low incidence rate, ignorant of this disease, and the difficulty for the imaging diagnosis to find the BDT preoperatively. Despite recent remarkable improvements in the imaging tools for diagnosis of HCC, such cases are still incorrectly diagnosed as cholangiocarcinoma or choledocholithiases. Ultrasonography (US) and CT are helpful in showing hepatic tumors and dilated intrahepatic and /or extrahepatic ducts containing dense material corresponding to tumor debris. Direct cholangiography including percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiopancreatography (ERCP) remains the standard procedure to delineate the presence and level of biliary obstruction. Magnetic resonance cholangiopancreatography (MRCP) is superior to ERCP in interpreting the cause and depicting the anatomical extent of the perihilar obstructive jaundice, and is particularly distinctive in cases associated with tight biliary stenosis and along segmental biliary stricture. Choledochoscopy and bile duct brushing cytology could be alternative useful techniques in the differentiating obstructions due to intraluminal mass, infiltrating ductal lesions or extrinsic mass compression applicable before and after duct exploration. Jaundice is not necessarily a contraindication for surgery. Most patients will have satisfactory palliation and occasional cure if appropriate procedures are selected and carried out safely, which can result in long-term resolution of symptoms and occasional long-term survival. However, the prognosis of icteric type HCC is generally dismal, but is better than those HCC patients who have jaundice caused by hepatic insufficiency.

4555 Diagnosis of malignancy in pancreatobiliary lesions: is fnab better than brush cytology?

Pancreatobiliary lesions can be evaluated by bile duct (BB) and pancreatic duct (PB) brush cytology during ERCP or fine needle aspiration biopsy (FNAB) during endoscopic ultrasonography (EUS). These techniques can be combined when the diagnosis of malignancy remains uncertain. Methods: between January 1997 and November 1999, 142 BB and 136 PB and/or FNAB were performed in our institution. All specimens were methanol fixed smears and cytocentrifuged cell suspensions stained with Papanicoalaou method. 26 patients (8 F and 19M, mean age: 59 y) had both BB or/and PB and FNAB performed. 16 patients had BB/PB and FNAB performed during the same general anesthesia, 10 had FNAB performed later (under sedation with midazolam 2-8mg) because of negative findings on former brush cytology. 7 pts had a total of 3 procedures (2 BB/PP and 1 FNAB); 1 pt had 4 (2 BB and 2FNAB) and 2 pts had 6 (3BB/PB and 3 FNAB) before final diagnosis, which was adenocarcinoma in 17 and benign disease in 9. Final diagnosis was obtained in all patients by surgery (12)or follow-up (24),mean 17,2 ± 1,6 m. Mean lesion size was 21.9 ± 1.2 mm. There was no procedure related adverse event. Results: are shown in table. Accuracy of BB was 65%, PP 66.7%, FNAB 73.1%, and of all methods 92.3%. There was no false positive result, false negative rate was 7.7% (2 pts in the early experience of FNAB (1997-1998). FNAB was the only positive method in 4 pts, PB/BP were positive in 5 FNAB negative patients. From the cytologist point of view, FNAB are much easier to analyse than brush cytology, especially in well-differentiated lesions because of absence of contamination by normal bilio-pancreatic duct epithelium. Conclusion: combination of brush cytology and FNAB should be used and if necessary repeated in cases of clinical, radiological or cytologic suspicion of malignancy, until final diagnosis. ERCP with brush cytology and EUS with FNAB can be performed safely during the same session.

Bile duct brushing cytology: statistical analysis of proposed diagnostic criteria.

Recent studies based on multivariate analysis have identified cytologic features that may be of value in the diagnosis of malignancy in bile duct brushings. We sought to assess the reproducibility and accuracy of these criteria. Three different observers used 4 sets of criteria that included 9 cytologic features to review 165 bile duct brushing specimens with available follow-up data. An overall assessment of malignancy and evaluation for the presence of chromatin clumping had excellent reproducibility (3-way kappa values of 0.708 and 0.629, respectively). Evaluation for the presence of enlarged nuclei, increased nuclear:cytoplasmic ratio, nuclear molding, and loss of honeycombing showed moderate reproducibility. An overall assessment of malignancy was a better predictor of the presence of malignancy than any other criteria, with a sensitivity of 36.2% and a specificity of 95%. Retrospective analysis demonstrated that the criteria of chromatin clumping, increased nuclear:cytoplasmic ratio, and either nuclear molding or loss of honeycombing had similar sensitivity and specificity as the overall assessment of malignancy (sensitivity = 35.2%, specificity = 95%). An overall assessment of malignancy or the criteria of chromatin clumping, increased nuclear:cytoplasmic ratio, and either nuclear molding or loss of honeycombing are reproducible cytologic criteria that accurately predict malignancy in bile duct brushings.

Hepatocellular carcinoma diagnosis in bile duct brush cytology

Hepatocellular carcinoma diagnosis in bile duct brush cytology

Biliary stricture due to hepatocellular carcinoma: diagnosis by bile duct brushing cytology.

Bile duct brushing cytology is a useful technique in the diagnosis of malignant biliary strictures. Adenocarcinoma is the usual type of carcinoma diagnosed in these brushing specimens. This report details the bile duct brushing cytology findings in an unusual case of hepatocellular carcinoma which presented with obstructive jaundice due to invasion of the biliary tract. A striking feature of the brushing was the prominent capillary vascular pattern associated with the tumor cells. This is a cytologic feature which has been noted in fine-needle aspirates of hepatocellular carcinoma as well, and is distinct from the expected findings in adenocarcinoma.

Biliary stricture due to hepatocellular carcinoma: Diagnosis by bile duct brushing cytology

Biliary stricture due to hepatocellular carcinoma: Diagnosis by bile duct brushing cytology

An in vitro, randomized, prospective study to maximize cellular yield during bile duct brush cytology

Endoscopic retrograde brush cytology is useful for the evaluation of biliary strictures. Access across a stricture can be maintained by removing the cytology brush while leaving the sheath in the bile duct. We examined the potential for loss of diagnostic cellular material in this setting using the canine biliary system. Twenty consecutive samples were randomly collected by (1) pushing the brush from the end of the sheath or (2) pulling the brush through the length of the sheath. Slides prepared from cell suspensions were scored by a cytopathologist blinded to the collection method. Pulling the brush resulted in a significant loss of cellular material ( p < 0.001). In a second phase, 23 consecutive samples were randomly obtained in the same fashion. Combining salvage cytology of material from the sheath with cytology of the pulled-brush specimens produced cellular yields similar to those of specimens obtained by pushing the brush from the sheath. If the brush is pulled from the sheath during bile duct brush cytology, we suggest that salvage cytology be performed in order to maximize the diagnostic sensitivity. (Gastrointest Endosc 1994;40:146-9.)