Diagnostic value of brush cytology in the diagnosis of bile duct carcinoma: A study in 65 patients with bile duct strictures

Abstract

Malignant strictures of the extrahepatic bile ducts are difficult to distinguish from benign strictures, particularly in patients with primary sclerosing cholangitis. Because attempts at diagnosing small cancers with fine-needle aspiration biopsy are not possible in the absence of an aesociated mass lesion and because the sensitivity of exfoliative biliary cytology is controversial, brush cytology has been used as a potential means of establishing a specific diagnosis of bile duct carcinoma. Herein we report our experience with this technique when performed on 65 patients over a 5-yr period. Each had at least one brushing. Thirty-seven were found to have bile duct carcinoma and 28 were found to have benign strictures. Of these 37, the first brushing was positive for malignancy in 15 (40%), whereas four (11%) had cells suspected but not diagnostic of malignancy. Thirteen patients with bile duct carcinoma whose initial brushings were negative for malignancy had second brushings. Of these, five (38%) had malignant cells, whereas three (24%) yielded suspicious cells. Three of the eight whose first two brushings were negative for malignancy were found to have malignant cells on the third brushing. In contrast, of the 28 patients with benign strictures, malignant cells were never found. However, in two patients, suspicious cells were reported with the h t but not the second brushing. A single negative or suspicious cytological &ding decreased the probability of bile duct carcinoma to 43%. Two and three sequential negative tests reduced the probability to 32% and 0%, respectively. When suspicious cytological findings were excluded from the negative results, the probability of having bile duct carcinoma was further reduced to 41%, 20% and 0%, respectively.Using these results, we conclude that (a) a single cytological brushing of a bile duct stricture has a low yield, (b) the sensitivity of the test increases with repeated attempts, (c) the probability of having bile duct carcinoma after three sequential negative cyto-

Diagnostic Value of Brush Cytology in the Diagnosis of Duodenal, Biliary, and Ampullary Neoplasms

“…In one recent study, however, the sensitivity of the test seemed to increase with repeated attempts, and the probability of having bile duct carcinoma after three sequential negative cytologic brushings was less than 6%. 5 In cases of malignant lesions located distally in the pancreaticobiliary ductal system, theoretically exfoliative cytology may be highly sensitive for cholangiocarcinoma. 6 However, inaccessible anatomic sites, poor visualization, a high degree of tumor differentiation, extensive fibrosis, and the presence of benign epithelium overlying the malignant stricture without significant ulceration or exfoliation may be seen in some cases and may account for the relatively low diagnostic sensitivity of brushings.…”

Reporting the Presence of Signi.cant Epithelial Atypia in Pancreaticobiliary Brush Cytology Specimens Lacking Evidence of Obvious Carcinoma

“…In the context of inconclusive cytologic results or even negative cytodiagnoses not consistent with suspicious clinical and/or radiologic findings, performing repeat brushing is a reasonable alternative likely to enhance diagnostic accuracy on EBC specimens from the biliary 15 and pancreatic ducts. In our current experience, performing repeat brushing confirmed the correct cytologic diagnosis in 13 (72%) of 18 patients.…”

Role of Biliary Brush Cytology in Primary Sclerosing Cholangitis

“…These results are in keeping with a study by Rabinovitz et al in which 26 of 28 cases with benign strictures had no malignant cells on brush cytology. 17 The remaining 2 patients had suspicious cells reported on the first but not the second bile duct brushing specimen. 17 In this study, the diagnosis "atypical not otherwise specified" correlated with histologically identified dysplasia of the bile duct epithelium in 2 of 2 patients, thereby enabling transplantation to be performed prior to the development of cholangiocarcinoma.…”