Tissue acquisition for diagnosis of biliary strictures using peroral cholangioscopy or endoscopic ultrasound-guided fine-needle aspiration

Abstract

Background Although endoscopic retrograde cholangiopancreatography (ERCP) is a first-line diagnostic modality for suspected malignant biliary stricture (MBS), the diagnostic yield of ERCP-based tissue sampling is insufficient. Peroral cholangioscopy-guided forceps biopsy (POC-FB) and endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) are evolving as reliable diagnostic procedures for inconclusive MBS. This study aimed to evaluate the usefulness of a diagnostic approach using POC-FB or EUS-FNAB according to the stricture location in patients with suspected MBS. Methods Consecutive patients diagnosed with suspected MBS with obstructive jaundice and/or cholangitis were enrolled prospectively. ERCP with transpapillary forceps biopsy (TPB) was performed initially. When malignancy was not confirmed by TPB, POC-FB using a SpyGlass direct visualization system or direct POC using an ultraslim endoscope was performed for proximal strictures, and EUS-FNAB was performed for distal strictures as a follow-up biopsy. Results Among a total of 181 patients, initial TPB showed malignancy in 122 patients, and the diagnostic accuracy of initial TPB was 71.8 % (95 % confidence interval [CI] 65.3 % – 78.4 %]. Of the 59 patients in whom TPB was negative for malignancy, 32 had proximal biliary strictures and underwent successful POC. The remaining 27 patients had distal strictures and underwent successful EUS-FNAB. The accuracy of malignancy detection using POC-FB for proximal biliary strictures and EUS-FNAB for distal biliary strictures was 93.6 % (95 %CI 84.9 %−100 %) and 96.3 % (95 %CI 89.2 %−100 %), respectively. The overall diagnostic accuracy for the combination of TPB with either POC-FB for proximal strictures and EUS-FNAB for distal strictures was 98.3 % (95 %CI 95.9 %−100 %) and 98.4 % (95 %CI 95.3 %−100 %), respectively. Conclusions An approach using POC-FB or EUS-FNAB according to the stricture location may be useful in the diagnosis of suspected MBS.

Bimodal ERCP, a new way of seeing things

“…Diagnostic and surveillance challenges posed by indeterminate biliary strictures, especially in PSC patients, are well known [18,19]. In the current study, bimodal ERCP unveiled a dominant segmental stricture in a patient with PSC, not otherwise seen on conventional fluoroscopy.…”

Endoscopic ultrasound in chronic liver disease

“…EUS sensitivity is dependent on the location of the stricture (higher sensitivity for more distal strictures) and the underlying etiology (higher sensitivity for pancreatic cancer compared to CCA, for example)[ 56 , 57 ]. Thus, it has been proposed that stricture-location should be considered when deciding which diagnostic modality to use; when EUS is used for distal biliary strictures, irrespective of underlying PSC, its accuracy for malignancy detection has been reported to be as high as 96%[ 58 ].…”

Pathologic interpretation of endoscopic ultrasound–guided fine needle aspiration cytology/biopsy for pancreatic lesions

“…Aspirated material usually demonstrates atypical cells with or without a necrotic background. The cellularity of the cytologic smear depends on many parameters, including tumor size, location, cellularity, type of aspiration needle, and endoscopist technique [7][8][9]. A pathologist is more likely to encounter a paucicellular smear than a highly cellular smear.…”