Malignant Gallbladder Research Articles

Metastasis to the gallbladder: A single-center experience of 20 cases in South Korea

To evaluate the clinicopathologic characteristics of patients with metastases to the gallbladder (MGBs). We performed a single-center retrospective study of 20 patients with MGBs diagnosed pathologically from 1999 to 2007. Among 417 gallbladder (GB) malignancies, 20 (4.8%) were MGBs. The primary malignancies originated from the stomach (n = 8), colorectum (n = 3), liver (n = 2), kidney (n = 2), skin (n = 2), extrahepatic bile duct (n = 1), uterine cervix (n = 1), and appendix (n = 1). Twelve patients were diagnosed metachronously, presenting with cholecystitis (n = 4), abdominal pain (n = 2), jaundice (n = 1), weight loss (n = 1), and serum CA 19-9 elevation (n = 1); five patients were asymptomatic. The median survival after the diagnosis of MGB was 8.7 mo. On Cox regression analysis, R0 resection was the only factor associated with a prolonged survival [hazard ratio (HR): 0.01, P = 0.002]; presentation with cholecystitis was associated with poor survival (HR: 463.27, P = 0.006). MGBs accounted for 4.8% of all pathologically diagnosed GB malignancies. The most common origin was the stomach. The median survival of MGB was 8.7 mo.

Asymptomatic Gallstones: What We Should Do?

Cholelithiasis is common (10-25%) in the general population, with the majority (70-80%) being asymptomatic at the time of diagnosis, and only few (10-20%) produce symptoms or complications in life time. Cholecystectomy, either open or laparoscopic, is straight forward for symptomatic gallstones, unlike the controversies in asymptomatic or silent gallstones. Stones with true biliary ‘colic’ (and not the vague dyspeptic symptoms) are considered symptomatic. Patients on long-term parental nutrition and liver cirrhosis have high prevalence of asymptomatic stone formation. Transient gallbladder sludge or stone formation is common in children treated with high doses of ceftriaxone or in pregnancy. Diabetic patients with asymptomatic stones are no longer considered at being at high risk of developing symptoms or complications. In case of an asymptomatic gallstone together with a common bile duct stone, endoscopic treatment of the ductal stone is sufficient, leaving the gallbladder in situ. Most of the transplant patients with asymptomatic gallstones can safely undergo cholecystectomy when their asymptomatic stone turns symptomatic. On the other hand, good risk patients undergoing abdominal surgery may undergo concomitant cholecystectomy for asymptomatic gallstones. Certain geographical areas with high incidence of cholelithiasis and gallbladder malignancy may have a relaxed policy for cholecystectomy. Except in high-risk groups, most of the studies favor a ‘wait and watch’ policy for asymptomatic gallstones. Aim of this comprehensive review is to analyze the available evidence to help both clinician and patients to make a decision in case of asymptomatic or silent gallstones.

Hepatobiliary and pancreatic: Malignant gallbladder polyp

Hepatobiliary and pancreatic: Malignant gallbladder polyp

Management Strategies for Gallbladder Polyps: Is It Possible to Predict Malignant Gallbladder Polyps?

Gallbladder (GB) polyps are commonly encountered in clinical practice, and are found more frequently as the number of medical screening examinations increases. The aim of this study was to determine optimal practice guideline for surgical treatment and follow-up of GB polyps. Data from healthy subjects of Seoul National University Hospital (SNUH) Health Care System of Gangnam Center were used to investigate the true prevalence of GB polyps. We also enrolled 689 patients with GB polyps diagnosed at SNUH from May 1(st), 1988 to April 30(th), 2006. The GB polyp prevalence was 6.1% (7.1% in males and 4.8% in females). The median follow-up duration in the 689 study patients was 60 months, and 139 (20%) of them had polyps >/=10 mm in size. Twenty-five of the 180 patients who underwent cholecystectomy had adenocarcinomas. The chi(2) test was used to identify which of the following were risk factors of malignancy: age, sex, symptoms, size, rate of growth, multiplicity, accompanying stones, and shape. Age (>/=57 years), presence of symptoms, size (>/=10 mm), and shape (sessile) were found to be statistically significant risk factors by univariate analysis. However, multivariate analysis identified only age (>/=57 years) and size (>/=10 mm) as independent predictors of malignancy. The present study shows that GB polyps >/=10 mm in size in patients aged >/=57 years are the independent factors predicting malignancy of the GB.

Analysis of Enhancement Pattern of Flat Gallbladder Wall Thickening on MDCT to Differentiate Gallbladder Cancer from Cholecystitis

The objective of our study was to determine the diagnostic value of analyzing the pattern of gallbladder wall enhancement on MDCT to characterize diffuse gallbladder wall thickening as benign or malignant. MDCT scans obtained during the portal venous phase in 78 patients with gallbladder wall thickening caused by various pathologic conditions were retrospectively reviewed by two blinded observers. The CT features of benign and malignant gallbladder wall thickening were compared by means of univariate and multivariate analyses. The study cases were then divided into five patterns according to enhancement pattern. Using these five patterns, two radiologists reviewed the MDCT images and recorded their diagnostic confidence for differentiating benign versus malignant cause on a 5-point scale. The diagnostic performance of CT was evaluated by each observer using a receiver operating characteristic curve analysis. The thicknesses of the inner and outer layers ("thick" enhancing inner layer > or = 2.6 mm, "thin" outer layer < or = 3.4 mm), strong enhancement of the inner wall, and irregular contour of the affected wall were significant predictors for a malignant cause of gallbladder wall thickening (p < 0.001). The two-layer pattern with a strongly enhancing thick inner layer and weakly enhancing or nonenhancing outer layer and the one-layer pattern with a heterogeneously enhancing thick layer were patterns that were significantly associated with gallbladder cancer (p < 0.05). When we consider those two enhancing patterns as a sign of malignancy, the diagnostic accuracy of MDCT was 89.1% and 87.6% for the two observers, respectively. Analyzing the enhancement pattern of a thickened gallbladder wall on MDCT is helpful in differentiating gallbladder cancer from benign inflammatory diseases.

Acute Hemobilia and Hemocholecyst in 2 Dogs with Gallbladder Carcinoid

Acute Hemobilia and Hemocholecyst in 2 Dogs with Gallbladder Carcinoid

Incidental carcinoma gall bladder during laparoscopic cholecystectomy for symptomatic gall stone disease

Carcinoma gall bladder (CaGB) is a disease with high mortality and is usually diagnosed as an incidental case among patients undergoing laparoscopic cholecystectomy (LC) for symptomatic gall stone disease. A total of 3205 LC done between January 2004 and August 2007 for symptomatic gall stone disease were retrospectively searched for incidental CaGB (detected on histopathology). None of these cases had preoperative suspicion of malignancy and their whole data was analyzed with special attention to preoperative and intraoperative findings which could raise suspicion of CaGB. In November 2007, patients were followed up telephonically about their present status of health. Nineteen patients (14 female and 5 male) with incidental CaGB (incidence 0.59%) were detected. Mean age of the patients was 56 years. Only two of these patients had clinical jaundice and both had common bile duct (CBD) stones. The majority of the patients were in early pathological stages (pT) and none was in pT3 and pT4 stage. Seventeen patients could be followed up telephonically in November 2007 and of those 14 patients were alive at a mean follow-up duration of 21.2 months, with one of them having evidence of metastatic disease. Gall bladder (GB) malignancy may be curable if diagnosed in early stages as an incidental finding and LC may not worsen the prognosis in such cases. In our series, incidental CaGB was detected in 0.59% patients undergoing LC. No association could be found between preoperative and intraoperative findings that could raise a suspicion of malignancy of gall bladder and so use of retrieval bag as a routine measure in cases with bile spillage may reduce the incidence of port-site metastasis.

Simultaneous gallbladder and bile duct cancers: revisiting the pathological possibilities

The pathogenesis of gallbladder cancer presenting synchronously with malignancy of the bile duct has not been clearly understood. The possible causes for the simultaneous presence of these tumors could be due to local spread, metastases, de novo multifocal origin, or as part of a field change in the extrahepatic biliary apparatus. In this article, we discuss the cases of four patients with simultaneous gallbladder and bile duct malignancies and analyze their individual pathologies to provide an explanation into the mechanisms that may play a role in such conditions.

Pre-operative predictive factors for gallbladder cholesterol polyps using conventional diagnostic imaging

To determine the clinical data that might be useful for differentiating benign from malignant gallbladder (GB) polyps by comparing radiological methods, including abdominal ultrasonography (US) and computed tomography (CT) scanning, with postoperative pathology findings. Fifty-nine patients underwent laparoscopic cholecystectomy for a GB polyp of around 10 mm. They were divided into two groups, one with cholesterol polyps and the other with non-cholesterol polyps. Clinical features such as gender, age, symptoms, size and number of polyps, the presence of a GB stone, the radiologically measured maximum diameter of the polyp by US and CT scanning, and the measurements of diameter from postoperative pathology were recorded for comparative analysis. Fifteen of the 41 cases with cholesterol polyps (36.6%) were detected with US but not CT scanning, whereas all 18 non-cholesterol polyps were observed using both methods. In the cholesterol polyp group, the maximum measured diameter of the polyp was smaller by CT scan than by US. Consequently, the discrepancy between those two scanning measurements was greater than for the non-cholesterol polyp group. The clinical signs indicative of a cholesterol polyp include: (1) a polyp observed by US but not observable by CT scanning, (2) a smaller diameter on the CT scan compared to US, and (3) a discrepancy in its maximum diameter between US and CT measurements. In addition, US and the CT scan had low accuracy in predicting the polyp diameter compared to that determined by postoperative pathology.

Mirizzi syndrome

Mirizzi syndrome is an important complication of gallstone disease. If not recognized preoperatively, it can result in significant morbidity and mortality. Preoperative diagnosis may be difficult despite the availability of multiple imaging modalities. Ultrasonography (US), CT, and magnetic resonance cholangiopancreatography (MRCP) are common initial tests for suspected Mirizzi syndrome. Typical findings on US suggestive of Mirizzi syndrome are a shrunken gallbladder, impacted stone(s) in the cystic duct, a dilated intrahepatic tree, and common hepatic duct with a normal-sized common bile duct. The main role of CT is to differentiate Mirizzi syndrome from a malignancy in the area of porta hepatis or in the liver. MRI and MRCP are increasingly playing an important role and have the additional advantage of showing the extent of inflammation around the gallbladder that can help in the differentiation of Mirizzi syndrome from other gallbladder pathologies such as gallbladder malignancy. Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in the diagnosis of Mirizzi syndrome. It delineates the cause, level, and extent of biliary obstruction, as well as ductal abnormalities, including fistula. ERCP also offers a variety of therapeutic options, such as stone extraction and biliary stent placement. Percutaneous cholangiogram can provide information similar to ERCP; however, ERCP has an additional advantage of identifying a low-lying cystic duct that may be missed on percutaneous cholangiogram. Wire-guided intraductal US can provide high-resolution images of the biliary tract and adjacent structures. Treatment is primarily surgical. Open surgery is the current standard for managing patients with Mirizzi syndrome. Good short- and long-term results with low mortality and morbidity have been reported with open surgical management. Laparoscopic management is contraindicated in many patients because of the increased risk of morbidity and mortality associated with this approach. Endoscopic treatment may serve as an alternative in patients who are poor surgical candidates, such as elderly patients or those with multiple comorbidities. Endoscopic treatment also can serve as a temporizing measure to provide biliary drainage in preparation for an elective surgery.

Occult pancreaticobiliary reflux in gallbladder cancer and benign gallbladder diseases

It was proposed that occult pancreaticobiliary reflux (OPBR) was associated with precancerous mucosal changes in the gallbladder, hence the importance of this disorder. There are no published reports investigating the incidence of OPBR in patients operated on for the entire spectrum of benign gallbladder diseases and gallbladder cancer. Our aim was to determine the incidence of OPBR and measure the levels of active pancreatic enzymes (amylase and lipase) in gallbladder bile of patients undergoing cholecystectomy for benign and malignant gallbladder diseases. One hundred eight patients with normal pancreaticobiliary junction evidenced by operative cholangiography were included in the study. According to gallbladder bile amylase and lipase levels, 84.2% and 89% patients respectively had OPBR. OPBR was present in all gallbladder cancer patients; in these patients the biliary levels of amylase and lipase were significantly higher than the levels found in patients with benign gallbladder pathology (P < 0.0001). OPBR could lead to inflammatory changes of the biliary epithelium and progress towards the development of precancerous mucosal changes and gallbladder cancer. The reason why such high levels of pancreatic enzymes are regurgitated into the biliary tree of patients with gallbladder cancer should be clarified.

Adenosquamous/squamous cell carcinoma of the gallbladder

Adenosquamous/squamous cell carcinoma is a rare histopathologic subtype of gallbladder malignancy. Its clinical features have rarely been described, and its differences from the major histopathologic subtype, adenocarcinoma, remain uncertain. All patients with gallbladder carcinoma were retrospectively reviewed. Patients with a histopathologic subtype of either adenosquamous (n = 12) or squamous cell (n = 2) carcinoma were categorized to group I, and patients with adenocarcinoma were categorized to group II. The clinical characteristics and outcomes of these two groups were compared. The two groups were generally no different in clinical features. However, tumor stages of group I patients were significantly advanced (P = 0.048) and included liver involvement (P = 0.008). The outcomes of advanced-stage patients in group II were not different from group I (P = 0.413). Nevertheless, patients in both groups with advanced stage pT who had undergone curative resection showed significantly better survival curves than patients who had undergone non-curative resection (P = 0.003). Patients with adenosquamous/squamous cell carcinoma of the gallbladder were generally similar to those with adenocarcinoma in clinical characteristics, but had a tendency for liver infiltration. Although the two histopathologic subtypes of the gallbladder carcinoma had similar poor outcomes, better survival could be obtained by performing curative resection for these patients.

Is intra-operative cholangiography necessary during laparoscopic cholecystectomy? A multicentre rural experience from a developing world country

To evaluate the feasibility and safety of performing laparoscopic cholecystectomy (LC) in non-teaching rural hospitals of a developing country without intra-operative cholangiography (IOC). To evaluate the possibility of reduction of costs and hospital stay for patients undergoing LC. A prospective analysis of patients with symptomatic benign diseases of gall bladder undergoing LC in three non-teaching rural hospitals of Kashmir Valley from Jan 2001 to Jan 2007. The cohort represented a sample of patients requiring LC, aged 13 to 78 (mean 47.2) years. Main outcome parameters included mortality, complications, re-operation, conversion to open procedure without resorting to IOC, reduction in costs borne by the hospital, and the duration of hospital stay. Twelve hundred and sixty-seven patients (976 females/291 males) underwent laparoscopic cholecystectomy. Twenty-three cases were converted to open procedures; 12 patients developed port site infection, nobody died because of the procedure. One patient had common bile duct (CBD) injury, 4 patients had biliary leak, and 4 patients had subcutaneous emphysema. One cholecystohepatic duct was detected and managed intraoperatively, 1 patient had retained CBD stones, while 1 patient had retained cystic duct stones. Incidental gallbladder malignancy was detected in 2 cases. No long-term complications were detected up to now. LC can be performed safely even in non-teaching rural hospitals of a developing country provided proper equipment is available and the surgeons and other team members are well trained in the procedure. It is stressed that IOC is not essential to prevent biliary tract injuries and missed CBD stones. The costs to the patient and the hospital can be minimized by using reusable instruments, intracorporeal sutures, and condoms instead of titanium clips and endobags.

Distinguishing benign from malignant gallbladder wall thickening using FDG-PET

Because thickening of the gallbladder wall is observed not only in patients with gallbladder cancer but also in those with benign diseases such as chronic cholecystitis and gallbladder adenomyosis, it is difficult to distinguish between benign and malignant gallbladder wall thickening by conventional techniques of diagnostic imaging such as computed tomography (CT), magnetic resonance imaging (MRI), and abdominal ultrasonography (US). In the present study, we attempted to distinguish between benign and malignant gallbladder wall thickening by means of fluorine-18-fluorodeoxyglucose (FDG)-Positron emission tomography (PET). FDG-PET was performed in 12 patients with gallbladder wall thickening detected by CT or US, to determine whether it was benign or malignant. Emission scans were taken, beginning 45 minutes after intravenous administration of FDG, and SUV was calculated as an indicator of glucose metabolism. Of the 12 patients, 4 showed positive uptake of FDG in the gallbladder wall. Of these 4 patients, 3 had gallbladder cancer. The remaining one, who had chronic cholecystitis, had false-positive findings. The other 8 patients had negative uptake of FDG in the gallbladder wall. Two of these 8 underwent surgical resection, which yielded a diagnosis of chronic cholecystitis. The other 6 patients exhibited no sign of gallbladder malignancy and have been followed without active treatment. FDG-PET appears able to distinguish between benign and malignant gallbladder wall thickening.

ACUTE BILIARY PANCREATITIS IN CHOLECYSTECTOMIZED PATIENTS

Background: Gallstone is the major cause of acute pancreatitis in most countries. Bile duct stone is prevalent in oriental society. ERCP with ES and stone retraction is the best therapy for common bile duct stones in patients of pancreatitis after cholecystectomy. However, most bile duct stone dropped out from gallbladder can pass out spontaneously as time pass by in acute pancreatitis with gallbladder in situ. The situation in post-cholecystectomy is not clear. We conduct this study to explore which parameter can predict stones in bile duct in cholecystectomized patient present with pancreatitis. Methods: Consequent 3 and half years medical records from our Therapeutic Endoscopic Center were reviewed. Those patients who presented with acute pancreatitis and received ERCP study were reviewed. In these patients, eighty patients had cholecystectomy before ERCP due to symptomatic or complicated gallstone, gallbladder malignancy, or miscellaneous indications. We excluded those patients with history of ethanol use, hypertriglyceridemia, hypercalcemia, biliary or pancreatic malignancy and frank intrahepatic bile duct stones by image study. There are forty-two patients left. Patients' symptom, demographic data, biochemistry data, image study and results of ERCP study were reviewed and analyzed according the results of ERCP study. Results: Most patients (97%) presented with epigastralgia. Significant differences are found in the serum levels of alkaline phosphatase (250.3 +/− 28.67 vs 151.9 +/− 18.97 IU/L, p < 0.01) and gamma-glutamyl transferase (260.6 +/− 40.59 vs 144.8 +/− 2.68 IU/L, p = 0.0322) between patients with or without bile duct stones. The sensitivity, specificity, positive and negative predictive values of alkaline phosphatase and gamma glutamyl transferase are (90.9%, 33.3%, 62.5%, 75%) and (100%, 0%, 41.2%, 0%). There are no differences in serum levels of AST, ALT, bilirubin between patients with or without stones. Echography is not sensitive (36.8%) to detect the presence of bile duct stones. In demographic data, the days between symptom begin and ERCP study in patients with or without stones (3.409 +/− 0.5166 vs 8.143 +/− 1.199 Days, p < 0.001) is significantly different. All patients presented with bile duct stones if ERCP is done within 3 days but decreased to 33.3% if ERCP is done after 3 days. Conclusion: In our study, bile duct stones may pass out spontaneously as time pass by in cholecystectomized patients presented with biliary pancreatitis. Serum levels of alkaline phosphatase and gamma glutamyl transferase are good to predict the residual stones in bile duct.

Laparoscopic cholecystectomy for early gallbladder carcinoma: long-term outcome in comparison with conventional open cholecystectomy

The role of laparoscopic surgery for malignant gallbladder tumors remains uncertain. This study compared the surgical results of laparoscopic versus conventional open cholecystectomy for patients with early-stage gallbladder carcinoma and examined the role of laparoscopic surgery for early gallbladder carcinomas. Data for the treatment of gallbladder carcinomas were gathered from Chang Gung Memorial Hospital (Linkou, Taiwan). A retrospective analysis of 40 patients with either stage 0 or stage 1 gallbladder carcinoma was performed. The patients were categorized into two groups on the basis of cholecystectomy procedures. The long-term outcomes for the two groups were compared. During the follow-up period, which ranged from 6.5 to 197.6 months, four patients in the conventional open cholecystectomy group encountered tumor recurrence, and one patient in the laparoscopic cholecystectomy group experienced distant tumor recurrence (p = 0.216). No local port-site tumor recurrence was identified in patients who underwent laparoscopic cholecystectomy. The overall 5-year survival rate in this series was 87.1%. A comparison of survival rates between the two groups demonstrated no significant difference (p = 0.340). The laparoscopic cholecystectomy procedure did not adversely influence the prognosis of patients with early-stage gallbladder carcinomas. Furthermore, meticulous removal of gallbladders during laparoscopic surgery, in which early gallbladder carcinoma can be managed successfully using laparoscopic cholecystectomy, achieved a satisfactory surgical result and a low port-site tumor recurrence rate.

Unusual Malignant Tumors of the Gallbladder

The purpose of this pictorial essay is to review the spectrum of unusual malignant tumors of the gallbladder and to illustrate their radiologic features. Radiologic findings of unusual malignant gallbladder tumors are varied and overlap with those of ordinary gallbladder carcinoma. Despite their rarity, being familiar with the wide spectrum of radiologic findings of these unusual tumors is helpful to improve diagnostic accuracy.

CA 125: A potential tumor marker for gallbladder cancer

CA 125 is a glycoprotein and a commonly used tumor marker in ovarian carcinoma. Its use in gallbladder carcinoma (GBC) has not yet been reported. We have henceforth examined for the first time the diagnostic utility of CA 125 in patients with gallbladder diseases. Serum CA 125 was measured in 64 patients with GBC, 47 Gallstone disease (GSD) and 23 healthy volunteers by ELISA. CA 125 level was compared between different cohorts by non-parametric test (Kruskal Wallis and Mann-Whitney test). Receiver operating characteristic curve (ROC) was constructed to see the diagnostic utility of CA 125. Its level was also correlated with age, sex and clinico-pathological parameters of the patients included in the study. Mean value of CA 125 in patients with GBC, GSD and healthy volunteers was 77.44 +/- 141.31 U/ml, 7.85 +/- 5.40 U/ml, and 8.08 +/- 3.26 U/ml respectively and showed a statistically significant difference (P < 0.001). CA 125 at cut off value of 11 U/ml yielded 64% sensitivity and 90% specificity in differentiating benign from malignant gallbladder disease. CA 125 level increased with stage and grade of the GBC though this was not statistically significant. A higher level of CA 125 was found in presence of gallbladder mass, weight loss, ascites and loss of appetite compared to patients with GSD. No association of CA 125 was apparent with either age or sex of the patients. CA 125 has a diagnostic potential for GBC and can differentiate GBC from GSD in light of other clinical details.

Preoperative Diagnosis and Management of Thick-Walled Gallbladder Based On the Results of Bile Cytology Using an Endoscopic Transpapillary Gallbladder Drainage Tube

Objective: The objective of the present study was to evaluate retrospectively the usefulness of bile cytology to distinguish benign and malignant disease in patients with thickened gallbladder walls using endoscopic transpapillary gallbladder drainage (ETGD) in comparison with computed tomography (CT). Patients and Methods: We reviewed gallbladder diseases in 85 patients visited in our hospital. Twenty-seven cases of gallbladder cancer (GBC) and 58 benign gallbladder diseases were obtained. A pig-tail-type nasobilliary drainage tube was left indwelling in the gallbladder, and washing cytology was performed using this tube. Results: ETGD was performed in 71 of the 85 patients with lesions in thick-walled gallbladders (83.5%) including 22 of the 27 patients with GBC (81.5%) and 49 of the 58 patients with benign gallbladder diseases (84.5%). There were no significant differences in the success rate of ETGD between patients with GBC and those with benign gallbladder diseases CT and cytology using an ETGD tube had 81% and 81% sensitivity, 91% and 83% specificity, and 88% and 82% accuracy, respectively (P > 0.05). Looking only at the 71 successful ETGD cases, CT and ETGD cytology had 82% and 100% sensitivity, 92% and 98% specificity, and 89% and 99% accuracy, respectively. There is statistically significant in the sensitivity and accuracy (P = 0.036 and 0.025, respectively). Four patients with GBC, in whom CT showed benign findings, underwent open cholecystectomy because ETGD cytology revealed malignant findings. In contrast, 4 patients with benign diseases, in whom CT suggested malignant finding, underwent LC because the findings of ETGD cytology suggested benign disease. Positive cytology for GBC in the first, second, third and fourth examination was seen at 50% (11/22), 72% (13/18), 60% (6/10), and 100% (1/1). Accumulative positive rate was 50%, 92%, and 100% in the first, second, and third examination, respectively. Conclusions: ETGD cytology can be conducted following ERC and is useful in differentiating benign and malignant gallbladder diseases. Although success rate of ETGD procedure is limited now, the present study strongly suggests that ETGD cytology is useful in detecting not only lesions that can be discovered by ordinary image diagnosis but also those that are difficult to discover by conventional diagnostic methods.

Endoscopic ultrasound‐guided FNA biopsy of bile duct and gallbladder: analysis of 53 cases

Endoscopic retrograde cholangiopancreaticography (ERCP)-guided brushing has been the standard of practice for surveillance and detection of carcinoma in the biliary tree. Few studies have evaluated the role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in diagnosing clinically suspected cholangiocarcinoma. The role of this method in diagnosing clinically suspected gallbladder malignancies has not been extensively evaluated in the USA. This study investigates the role of EUS-FNA in the diagnosis of clinically suspected biliary tree and gallbladder malignancies in a large patient series. EUS-FNAs were obtained from 46 bile duct and seven gallbladder lesions. On-site rapid interpretation was provided using air-dried Diff Quik stained smears. In addition, alcohol fixed Papanicoloau stained smears and Thin Prep preparations (Cytye Corp., Marlborough, MA, USA) were evaluated before providing a final cytological diagnosis. Tissue biopsies and/or clinical follow-up were used as the standards to determine operating characteristics for EUS-FNA. The mean ages for bile duct and gallbladder lesions were 66 years (range: 37-84 years), and 69 years (range 49-86 years), respectively. All cases diagnosed as suspicious/malignant on preliminary evaluation were confirmed on final cytological interpretation (27/27). The operating characteristics show that EUS-FNA is highly specific (100%) with sensitivity rates of 87% and 80% from clinically suspected malignancies of biliary tract and gallbladder, respectively. Sampling error in three cases and associated acute inflammation in two cases resulted in false-negative diagnoses. EUS-FNA of biliary tree and gallbladder carcinoma is highly specific and should be considered for evaluation of clinically suspicious lesions. Marked inflammation may result in false-negative diagnoses.