Diagnosing Biliary Malignancy

Management of Malignant Biliary Obstruction

“…Recent studies have demonstrated a sensitivity of MRCP exceeding 96% and a specificity of 85% for distinguishing benign from malignant biliary obstruction. 3,4 The sensitivity and specificity of ERCP for the determination of benign versus malignant disease are increased further by the addition of endoscopic ultrasound (EUS) and the newer technique of intraductal ultrasound. 5 To further hone the diagnosis of malignant biliary obstruction, guidance of tissue sampling is the next goal.…”

“…While the reported sensitivity of brush cytology is typically at or below 50%, specificity is 95% 6 ; forceps or needle biopsy can augment brush cytology to further increase sensitivity and specificity to 70 and 100%, respectively. 4 Some interventional radiologists have used percutaneous transhepatic cholangioscopy to provide direct visualization of the lesion or stricture, increasing the reported sensitivity and specificity to greater than 95%. 7 The next step is determination of local and distal disease for staging.…”

Evaluation of indeterminate biliary strictures: Is it time to FISH or cut bait?

“…However, the numbers for FISH alone are quite variable and rarely approach the sensitivities of 60% to 70% one can achieve with multimodal sampling, including brush cytology and intraductal biopsy sampling. 5 The current study by Chaiteerakij et al 7 is yet another series reporting the performance of FISH using the Urovysion assay. The rationale for performing this study, which evaluated 101 Thai patients with "malignantappearing" biliary strictures, was based on the notion It has been over a decade since the first report of measuring DNA content of potential oncogenic genes on brush cytology samples obtained at ERCP to assist in the diagnosis of cholangiocarcinoma.…”

“…The serum tumor markers CEA and CA19-9, radiologic criteria applied to CT or magnetic resonance imaging, cholangioscopy with visual scoring, intraductal US, and confocal endomicroscopy applied directly to the biliary epithelium have all shown promise to improve diagnoses, but increases in sensitivity have come with decreases in specificity, and we still are far from achieving an ideal diagnostic algorithm. 5 Moving beyond microscopic morphologic inspection of cytology or tissue biopsy samples of indeterminate strictures obtained at ERCP, using molecular probes designed to detect genetic alterations in cholangiocarcinoma has been explored and is being added to the armamentarium of physicians caring for these patients.…”

Brush Cytology Performance for the Assessment of Biliopancreatic Strictures

“…Even though it has a high specificity to diagnose malignancy, the sensitivity is low and limits the utility of brush cytology, with patients frequently having to undergo multiple procedures to obtain a final diagnosis. The emergence of novel diagnostic modalities, such as fluorescence in situ hybridization, peroral cholangioscopy, intraductal endoscopic ultrasound, and confocal laser endomicroscopy, may improve the sensitivity of ERCP in the diagnosis of malignancy [10,11]. Ongoing trials are evaluating the role of these new technologies in the diagnostic algorithm of suspected pancreaticobiliary neoplasia.…”