OJGas  Vol.2 No.2 , May 2012
EUS guided fine needle aspiration is useful in diagnostic evaluation of indeterminate proximal biliary strictures
ABSTRACT
Background and Aim: Determination of the etiology of proximal biliary strictures (PBS) still remains a challenge. Even though EUS-FNA is potentially useful, its role in diagnostic evaluation of PBS is still not established due to a lack of sufficient data. We sought to determine the performance characteristics of EUS-FNA in patients with obstructive jaundice (ObJ) and PBS. Patients and Methods: This is a retrospective analysis and included patients with ObJ and PBS with non-diagnostic brush cytology, who underwent EUS-FNA in our university based practice from March 2002 to February 2009. We evaluated the final diagnoses in study patients and the performance characteristics of EUS-FNA for identifying malignant PBS. Final diagnosis was based on surgical pathology or clinical follow-up of at least 12 months. Results: The study included 28 patients (17 male, 11 female) with mean age of 62.4 ± 14.9 years. The strictures ranged from 10 - 70 mm in length. CT scan identified a hilar mass in 9 patients. EUS-FNA identified malignancy in 12 patients. 18 patients were finally diagnosed to have a malignant stricture and 10 patients had a benign stricture. There were 6 false negative diagnoses. The accuracy of EUS-FNA for diagnosis of cholangiocarcinoma was 78.6%, with 66.6% sensitivity, 100% specificity, 62.5% NPV and 100% PPV. Conclusions: EUS-FNA can diagnose malignancy in 66.6% of jaundiced patients with PBS and non-diagnostic brush cytology and may have a role in their further diagnostic evaluation.

Cite this paper
Krishna, N. , Tummala, P. , Labundy, J. and Agarwal, B. (2012) EUS guided fine needle aspiration is useful in diagnostic evaluation of indeterminate proximal biliary strictures. Open Journal of Gastroenterology, 2, 33-39. doi: 10.4236/ojgas.2012.22008.
References
[1]   DeWitt, J., Misra, V.L., Leblanc, J.K., et al. (2006) EUS-guided FNA of proximal biliary strictures after negative ERCP brush cytology results. Gastrointestinal Endoscopy, 64, 325-333. doi:10.1016/j.gie.2005.11.064

[2]   Fritscher-Ravens, A., Broering, D.C., Knoefel, W.T., et al. (2004) EUS-guided fine-needle aspiration of suspected hilar cholangiocarcinoma in potentially operable patients with negative brush cytology. The American Journal of Gastroenterology, 99, 45-51. doi:10.1046/j.1572-0241.2003.04006.x

[3]   Fritscher-Ravens, A., Broering, D.C., Sriram, P.V., et al. (2000) EUS-guided fine-needle aspiration cytodiagnosis of hilar cholangiocarcinoma: A case series. Gastrointestinal Endoscopy, 52, 534-540. doi:10.1067/mge.2000.109589

[4]   R?sch, T., Hofrichter, K., Frimberger, E., et al. (2004) ERCP or EUS for tissue diagnosis of biliary strictures? A prospective comparative study. Gastrointestinal Endos- copy, 60, 390-396. doi:10.1016/S0016-5107(04)01732-8

[5]   Eloubeidi, M.A., Chen, V.K., Jhala, N.C., et al. (2004) Endoscopic ultrasound-guided fine needle aspiration biopsy of suspected cholangiocarcinoma. Clinical Gastroenterology Hepatology, 2, 209-213. doi:10.1016/S1542-3565(04)00005-9

[6]   Glasbrenner, B., Ardan, M., Boeck, W., et al. (1999) Prospective evaluation of brush cytology of biliary strictures during endoscopic retrograde cholangiopancreatography. Endoscopy, 31, 712-717. doi:10.1055/s-1999-73

[7]   Lin, F. and Staerkel, G. (2003) Cytologic criteria for well differentiated adenocarcinoma of the pancreas in fine-needle aspiration biopsy specimens. Cancer, 99, 44-50. doi:10.1002/cncr.11012

[8]   Chahal, P. and Baron, T.H. (2006) Endoscopic palliation of cholangiocarcinoma. Current Opinion in Gastroenterology, 22, 551-560. doi:10.1097/01.mog.0000239872.12081.a4

[9]   Simmons, D.T., Baron, T.H., Petersen, B.T., et al. (2006) A novel endoscopic approach to brachytherapy in the management of Hilar cholangiocarcinoma. The American Journal of Gastroenterology, 101, 1792-1796. doi:10.1111/j.1572-0241.2006.00700.x

[10]   Malhi, H. and Gores, G.J. (2006) Review article: The modern diagnosis and therapy of cholangiocarcinoma. Alimentary Pharmacology & Therapeutics, 23, 1287-1296. doi:10.1111/j.1365-2036.2006.02900.x

[11]   Nagino, M., Kamiya, J., Nishio, H., et al. (2006) Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: Surgical outcome and long-term follow-up. Annals of Surgery, 243, 364-372. doi:10.1097/01.sla.0000201482.11876.14

[12]   Arnagin, W.R., Zager, J.S., Hezel, M., et al. (2006) Treatment of cholangiocarcinoma with oncolytic herpes simplex virus combined with external beam radiation therapy. Cancer Gene Therapy, 13, 326-334.

[13]   Rea, D.J., Heimbach, J.K., Rosen, C.B., et al. (2005) Liver transplantation with neoadjuvant chemoradiation is more effective than resection for hilar cholangiocarcinoma. Annals of Surgery, 242, 451-458.

[14]   Ortner, M.E., Caca, K., Berr, F., et al. (2003) Successful photodynamic therapy for nonresectable cholangiocarcinoma: A randomized prospective study. Gastroenterology, 125, 1355-1363. doi:10.1016/j.gastro.2003.07.015

[15]   Mansfield, J.C., Griffin, S.M., Wadehra, V., et al. (1997) A prospective evaluation of cytology from biliary strictures. Gut, 40, 671-677.

[16]   Harewood, G.C., Baron, T.H., Stadheim, L.M., et al. (2004) Prospective, blinded assessment of factors influencing the accuracy of biliary cytology interpretation. The American Journal of Gastroenterology, 99, 1464- 1469. doi:10.1111/j.1572-0241.2004.30845.x

[17]   De Bellis, M., Fogel, E.L., Sherman, S., et al. (2003) Influence of stricture dilation and repeat brushing on the cancer detection rate of brush cytology in the evaluation of malignant biliary obstruction. Gastrointestinal Endoscopy, 58, 176-182. doi:10.1067/mge.2003.345

[18]   Farrell, R.J., Jain, A.K., Brandwein, S.L., et al. (2001) The combination of stricture dilation, endoscopic needle aspiration, and biliary brushings significantly improves diagnostic yield from malignant bile duct strictures. Gastrointestinal Endoscopy, 54, 587-594. doi:10.1067/mge.2001.118715

[19]   Venu, R.P., Geenen, J.E., Kini, M., et al. (1990) Endoscopic retrograde brush cytology. A new technique. Gastroenterology, 99, 1475-1479.

[20]   Van Heek, N.T., Clayton, S.J., Sturm, P.D., et al. (2005) Comparison of the novel quantitative ARMS assay and an enriched PCR-ASO assay for K-ras mutations with conventional cytology on endobiliary brush cytology from 312 consecutive extrahepatic biliary stenoses. Journal of Clinical Pathology, 58, 1315-1320. doi:10.1136/jcp.2004.022707

[21]   Khalid, A., Pal, R., Sasatomi, E., et al. (2004) Use of microsatellite marker loss of heterozygosity in accurate diagnosis of pancreaticobiliary malignancy from brush cytology samples. Gut, 53, 1860-1865. doi:10.1136/gut.2004.039784

[22]   Kipp, B.R., Stadheim, L.M., Halling, S.A., et al. (2004) A comparison of routine cytology and fluorescence in situ hybridization for the detection of malignant bile duct strictures. The American Journal of Gastroenterology, 99, 1675-1681. doi:10.1111/j.1572-0241.2004.30281.x

[23]   Baron, T.H., Harewood, G.C., Rumalla, A., et al. (2004) A prospective comparison of digital image analysis and routine cytology for the identification of malignancy in biliary tract strictures. Clinical Gastroenterology and Hepatology, 2, 214-219. doi:10.1016/S1542-3565(04)00006-0

[24]   Tascilar, M., Sturm, P.D., Caspers, E., et al. (1999) Diagnostic p53 immunostaining of endobiliary brush cytology: preoperative cytology compared with the surgical specimen. Cancer, 87, 306-311. doi:10.1002/(SICI)1097-0142(19991025)87:5<306::AID-CNCR11>3.0.CO;2-Y

[25]   Agarwal, B., Abu-Hamda, E., Molke, K.L., et al. (2004) Endoscopic ultrasound-guided fine needle aspiration and multidetector spiral CT in the diagnosis of pancreatic cancer. The American Journal of Gastroenterology, 99, 844-850. doi:10.1111/j.1572-0241.2004.04177.x

[26]   Chang, K.J., Nguyen, P., Erickson, R.A., et al. (1997) The clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of pancreatic carcinoma. Gastrointestinal Endoscopy, 45, 387-393. doi:10.1016/S0016-5107(97)70149-4

[27]   Giovannini, M., Seitz, J.F., Monges, G., et al. (1995) Fine-needle aspiration cytology guided by endoscopic ultrasonography: results in 141 patients. Endoscopy, 27, 171-177. doi:10.1055/s-2007-1005657

[28]   Wiersema, M.J., Vilmann, P., Giovannini, M., et al. (1997) Endosonography-guided fine-needle aspiration bi- opsy: Diagnostic accuracy and complication assessment. Gastroenterology, 112, 1087-1095. doi:10.1016/S0016-5085(97)70164-1

[29]   Faigel, D.O., Ginsberg, G.G., Bentz, J.S., et al. (1997) Endoscopic ultrasound-guided real-time fine-needle aspiration biopsy of the pancreas in cancer patients with pancreatic lesions. Journal of Clinical Oncology, 15, 1439-1443.

[30]   Williams, D.B., Sahai, A.V., Aabakken, L., et al. (1999) Endoscopic ultrasound guided fine needle aspiration biopsy: A large single centre experience. Gut, 44, 720-726. doi:10.1136/gut.44.5.720

[31]   Fritscher-Ravens, A., Izbicki, J.R., Sriram, P.V., et al. (2000) Endosonography-guided, fine-needle aspiration cytology extending the indication for organ-preserving pancreatic surgery. The American Journal of Gastroenterology, 95, 2255-2260. doi:10.1111/j.1572-0241.2000.02311.x

[32]   Tio, T.L. and Tytgat, G.N. (1986) Endoscopic ultrasonography of bile duct malignancy and the preoperative assessment of local resectability. Scandinavian Journal of Gastroenterology, 123, 151-157. doi:10.3109/00365528609091877

[33]   Vilmann, P. (1998) Endoscopic ultrasound-guided fineneedle biopsy in Europe. Endoscopy, 30, 161-162. doi:10.1055/s-2007-1001506

[34]   Corvera, C.U., Blumgart, L.H., Darvishian, F., et al. (2005) Clinical and pathologic features of proximal biliary strictures masquerading as hilar cholangiocarcinoma. Journal of the American College of Surgeons, 201, 862- 869. doi:10.1016/j.jamcollsurg.2005.07.011

[35]   Krishna, N.B., Saripalli, S., Safdar, R., et al. (2007) Intraductal US in evaluation of biliary strictures without a mass lesion on CT scan or magnetic resonance imaging: Significance of focal wall thickening and extrinsic compression at the stricture site. Gastrointestinal Endoscopy, 66, 90-96. doi:10.1016/j.gie.2006.10.020

[36]   Tamada, K. and Sugano, K. (2000) Diagnosis and non-surgical treatment of bile duct carcinoma: Developments in the past decade. Journal of Gastroenterology, 35, 319-325. doi:10.1007/s005350050355

[37]   Tamada, K., Tomiyama. T., Wada, S., et al. (1999) Detection of bile duct cancer in an early stage by intraductal ultrasonography (in Japanese with English abstract). Endoscopy, 11, 1164-1172.

 
 
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