Original article
Endoscopic ultrasound-guided fine needle aspiration biopsy of suspected cholangiocarcinoma

Presented in part at Digestive Disease Week, May 17–22, 2003, Orlando, Florida.
https://doi.org/10.1016/S1542-3565(04)00005-9Get rights and content

Abstract

Background and Aims: Despite advances in endoscopic techniques for sampling bile duct strictures, the diagnosis of cholangiocarcinoma remains a challenge. The purpose of this study was to evaluate the yield of EUS-FNA and its impact on patient management for patients with suspected cholangiocarcinoma. Methods: All patients undergoing EUS for the evaluation of suspected malignant biliary strictures were prospectively evaluated over a 23-month period. A single gastroenterologist performed all EUS-FNAs in the presence of a cytopathologist. Reference standard for final diagnosis included surgery, death from disease, and clinical and/or imaging follow-up. Results: Twenty-eight patients (mean age 67 years [SD ± 11], 72% male) were evaluated. Most patients (91%) presented with obstructive jaundice, and all except 1 had nondiagnostic sampling of the biliary lesions either at ERCP (88%), percutaneous transhepatic cholangiogram (n = 2), and/or computed tomography-guided biopsy (n = 1). Sixty-seven percent (14/21) had no definitive mass seen on prior abdominal imaging studies. The mean tumor size by EUS was 19 mm × 16 mm with a median number of passes to diagnosis of 3 (range 1–7). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 86%, 100%, 100%, 57%, and 88%, respectively. EUS-FNA had a positive impact on patient management in 84% of patients: preventing surgery for tissue diagnosis in patients with inoperable disease (n = 10), facilitating surgery in patients with unidentifiable cancer by other modalities (n = 8), and avoiding surgery in benign disease (n = 4). Conclusions: Given the apparent accuracy and safety of EUS with FNA for imaging bile duct mass lesions and for obtaining a tissue diagnosis in patients with suspected cholangiocarcinoma, this technology may represent a new approach to diagnosis especially when other methods fail. The ability to obtain a definite diagnosis has a significant impact on patient management.

Section snippets

Patients and methods

Over a 23-month period, all patients (n = 28) undergoing EUS for evaluation of common bile duct strictures were prospectively identified. This study was given expedited approval by the Institutional Review Board of the University of Alabama at Birmingham.

Patients included in the study were strictly limited to those with suspected cholangiocarcinoma based on the clinical history, imaging studies including ERCP, percutaneous transhepatic cholangiogram (PTC), computed tomography (CT) and magnetic

Results

EUS detected a bile duct abnormality in (25/28) 89% of the patients evaluated. The mean age of the 25 patients was 67 years (SD ± 11), and there were 18 men and 7 women. Only 1 patient was known to have ulcerative colitis and primary sclerosing cholangitis. The majority of the patients (91%) presented with obstructive jaundice and had nondiagnostic bile duct brushings at ERCP (88%). Two additional patients had nondiagnostic brushings at percutaneous transhepatic cholangiogram (PTC) and 1 had a

Discussion

Despite advances in endoscopic techniques for sampling bile duct strictures, the diagnosis of cholangiocarcinoma remains elusive. As with any suspected neoplasm, a tissue diagnosis is essential to guide therapy. In a select cohort of patients with biliary strictures suspicious for carcinoma, all of whom had no diagnosis established by conventional nonoperative means, we were able to visualize the tumor by EUS in all but 3 patients with tumors in the extrahepatic bile duct, perihilar area, and

Acknowledgements

The authors thank Brenda McKenzie for her expert help with this manuscript.

References (31)

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