Differentiation of malignant and benign proximal bile duct strictures: The diagnostic dilemma

Abstract

AIM:To identify the criteria for the differentiation of hilar cholangiocarcinoma (HCCA) from benign strictures. METHODS: A total of 68 patients underwent resection of lesions suspicious for HCCA between 1998 and 2006. The results of laboratory investigations, imaging studies and brush cytology were collected. These findings were analyzed to obtain the final diagnosis. RESULTS: Histological examination of the resected specimens confirmed HCCA in 58 patients (85%, group Ⅰ) whereas 10 patients (15%, group Ⅱ) were diagnosed to have benign strictures. The most common presenting symptom was obstructive jaundice in 77% patients (79% group Ⅰ vs 60% group Ⅱ, P = 0.23). Laboratory findings showed greater elevation of transaminase levels in group Ⅰ compared to group Ⅱ. The various imaging modalities showed vascular involvement exclusively in the malignant group (36%, P < 0.05). Brush cytology was positive for malignant cells in only 50% patients in group Ⅰ whereas none in group Ⅱ showed malignant cells. CONCLUSION: Despite improvements in imaging techniques, 10 patients (15%) with a presumptive diagnosis of HCCA were ultimately found to have benign strictures. Except for vascular involvement which was associated significantly with malignancy, there were no conclusive features of malignancy on regular imaging modalities. This uncertainty should be taken into account when patients with a suspicious lesion at the liver hilum are considered for resection.

FDG-positron emission tomography/computed tomography and standardized uptake value in the primary diagnosis and staging of hilar cholangiocarcinoma

“…In addition, the differentiation of HCCA from benign lesions that mimic malignancies has proven a difficult diagnostic problem. Several institutional reports have found 10–15% of patients suspected for HCCA to have been misdiagnosed on microscopic examination of the resection specimen 6,7 …”

Benign Tumours and Pseudotumours Within the Porta Hepatis Masquerading as Perihilar Cholangiocarcinoma

“…Notwithstand ing this, a 25% rate of false dia gnosis especially in complicated case of hilar obstruction is significantly high, higher than most would have expected and higher than most would have considered as occasional. In fact, accord ing to the results of a recent large series of patients with hilar strictures, approximately 16% of patients with hilar strictures and a preoperative dia gnosis of HC proved to have a benign dis ease [9,10,[13][14][15][16][17]. This rate of false dia gnosis cannot be overlooked, especially when misdia gnosis leads to unnecessary, high-risk surgical procedures.…”

“…On the other hand, these methods can be applied for biliary drainage as well as for material sampling for brush cytology and forceps biopsy or molecular analysis, which may accomplish a definitive dia gnosis. However, both cytology and bio psy have a low sensitivity for HC rang ing between 41 and 50% for brush cytology [16,44], and 53% for forceps bio psy [44], since cancerous tissue is mainly located in the fibrous stroma surround ing the bile ducts [45].…”

Benign hilar bile duct strictures resected as perihilar cholangiocarcinoma

“…Since Hadjis and colleagues first reported ‘malignant masquerade’ at the hepatic hilum in 1985, several authors have reported the clinical and pathological features of benign hilar strictures operated under the preoperative diagnosis of presumed malignancy. Most of these studies were published more than 10 years ago. Some studies did not report the actual number of patients who underwent resection and others included gallbladder cancer involving the hepatic hilum.…”