Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis

doi:10.1016/j.gie.2014.09.017

Gastrointestinal Endoscopy

Volume 81, Issue 1, January 2015, Pages 168-176

https://doi.org/10.1016/j.gie.2014.09.017 Get rights and content

Background

Evaluation of indeterminate biliary strictures typically involves collection and analysis of tissue or cells. Brush cytology and intraductal biopsies that are routinely performed during ERCP to assess malignant-appearing biliary strictures are limited by relatively low sensitivity.

Objective

To study the comparative effectiveness of brushings for cytology and intraductal biopsies in the etiology of biliary strictures.

Design

Meta-analysis.

Setting

Referral center.

Patients

PUBMED and Embase databases were reviewed for studies published to April 2014 where diagnostic correlation of histology was available.

Intervention

Database and review of study findings.

Main Outcome Measurements

Sensitivity and specificity.

Results

The pooled sensitivity and specificity of brushings for the diagnosis of malignant biliary strictures was 45% (95% confidence interval [CI], 40%-50%) and 99% (95% CI, 98%-100%), respectively. The pooled diagnostic odds ratio to detect malignant biliary strictures was 33.43 (95% CI, 14.29-78.24). For intraductal biopsies, the pooled sensitivity and specificity were 48.1% (95% CI, 42.8%-53.4%) and 99.2% (95% CI, 97.6%-99.8%), respectively. The pooled diagnostic odds ratio to detect malignant biliary strictures was 43.18 (95% CI, 19.39-95.83). A combination of both modalities only modestly increased the sensitivity (59.4%; 95% CI, 53.7%-64.8%) with a specificity of 100% (95% CI, 98.8%-100.0%). The Begg-Mazumdar and Egger tests indicated a low potential for publication bias.

Limitations

Inclusion of low-quality studies.

Conclusion

Our study suggests that both brushings and biopsy are comparable and have limited sensitivity for the diagnosis of malignant biliary strictures. A combination of both only modestly increases the sensitivity.

Section snippets

Medical literature search

A comprehensive search of the medical literature was performed to identify peer-reviewed articles that examined the diagnostic accuracy of endoscopic retrograde biliary brush cytology and intraductal biopsies to detect malignancy as the etiology of biliary strictures. We systematically searched the PUBMED and Embase databases for studies published from January 1980 to April 2014 by using the following search terms: “ERCP brush cytology and forceps biopsy,” “bile duct brush cytology,” and

Eligible studies and quality assessment

An initial medical literature search yielded 1121 articles. After excluding irrelevant studies, 42 potential studies were reviewed in detail. Of these, 9 studies (n = 730 patients) met the inclusion criteria and were included in the analysis.16, 17, 18, 19, 20, 21, 22, 23, 24 The reported pooled estimates were calculated by the random-effects model. Figure 1 shows the flow diagram for studies identified for the systematic review. Table 1 lists the various studies included in the meta-analysis.

Discussion

Pancreatic cancer and CCA usually manifest as biliary strictures that are difficult to differentiate from strictures caused by bile duct stones, chronic pancreatitis, or other benign conditions. Cytological or histological diagnosis of the strictures alters the management plan significantly in terms of aggressive treatment of confirmed malignancies and avoiding unnecessary surgery in benign conditions. ERCP-based tissue diagnosis of suspicious biliary strictures can be achieved with brush

References (40)

K.N. Lazaridis et al.
Cholangiocarcinoma
Gastroenterology
(2005)
M.D. Bellin et al.
Total pancreatectomy and islet autotransplantation in chronic pancreatitis: recommendations from PancreasFest
Pancreatology
(2014)
A.S. Burnett et al.
Sensitivity of endoscopic retrograde cholangiopancreatography standard cytology: 10-y review of the literature
J Surg Res
(2013)
G. Trikudanathan et al.
Diagnostic yield of bile duct brushings for cholangiocarcinoma in primary sclerosing cholangitis-a systematic review and meta-analysis
Gastrointest Endosc
(2014)
D.A. Howell et al.
Complete tissue sampling of biliary strictures at ERCP using a new device
Gastrointest Endosc
(1996)
J. Jailwala et al.
Triple-tissue sampling at ERCP in malignant biliary obstruction
Gastrointest Endosc
(2000)
T. Ponchon et al.
Value of endobiliary brush cytology and biopsies for the diagnosis of malignant bile duct stenosis: results of a prospective study
Gastrointest Endosc
(1995)
V. Pugliese et al.
Endoscopic retrograde forceps biopsy and brush cytology of biliary strictures: a prospective study
Gastrointest Endosc
(1995)
T. Rösch et al.
ERCP or EUS for tissue diagnosis of biliary strictures? A prospective comparative study
Gastrointest Endosc
(2004)
K.M. Mohandas et al.
Diagnosis of malignant obstructive jaundice by bile cytology: results improved by dilating the bile duct strictures
Gastrointest Endosc
(1994)

R.J. Farrell et al.

The combination of stricture dilation, endoscopic needle aspiration, and biliary brushings significantly improves diagnostic yield from malignant bile duct strictures

Gastrointest Endosc

(2001)

V.K. Parasher et al.

Endoscopic retrograde wire-guided cytology of malignant biliary strictures using a novel scraping brush

Gastrointest Endosc

(1998)

M. de Bellis et al.

Influence of stricture dilation and repeat brushing on the cancer detection rate of brush cytology in the evaluation of malignant biliary obstruction

Gastrointest Endosc

(2003)

F. Weilert et al.

EUS-FNA is superior to ERCP-based tissue sampling in suspected malignant biliary obstruction: results of a prospective, single-blind, comparative study

Gastrointest Endosc

(2014)

M.A. Khashab et al.

Utility of EUS in patients with indeterminate biliary strictures and suspected extrahepaticcholangiocarcinoma (with videos)

Gastrointest Endosc

(2012)

J.K. Heimbach et al.

Trans-peritoneal fine needle aspiration biopsy of hilar cholangiocarcinoma is associated with disease dissemination

HPB (Oxford)

(2011)

S. Friman

Cholangiocarcinoma–current treatment options

Scand J Surg

(2011)

M.W. Saif

Pancreatic neoplasm in 2011: an update

JOP

(2011)

E.G. Brown et al.

Outcomes of pancreaticoduodenectomy: where should we focus our efforts on improving outcomes?

JAMA Surg

(2014)

A.Y. Chok et al.

A systematic review and meta-analysis comparing pancreaticoduodenectomy versus limited resection for duodenal gastrointestinal stromal tumors

Ann Surg Oncol

(2014)

Cited by (349)

Biliary tract cancers: French national clinical practice guidelines for diagnosis, treatments and follow-up (TNCD, SNFGE, FFCD, UNICANCER, GERCOR, SFCD, SFED, AFEF, SFRO, SFP, SFR, ACABi, ACHBPT)
2024, European Journal of Cancer
This document is a summary of the French intergroup guidelines of the management of biliary tract cancers (BTC) (intrahepatic, perihilar and distal cholangiocarcinomas, and gallbladder carcinomas) published in September 2023, available on the website of the French Society of Gastroenterology (SNFGE) (www.tncd.org).
This collaborative work was conducted under the auspices of French medical and surgical societies involved in the management of BTC. Recommendations were graded in three categories (A, B and C) according to the level of scientific evidence until August 2023.
BTC diagnosis and staging is mainly based on enhanced computed tomography, magnetic resonance imaging and (endoscopic) ultrasound-guided biopsy. Treatment strategy depends on BTC subtype and disease stage. Surgery followed by adjuvant capecitabine is recommended for localised disease. No neoadjuvant treatment is validated to date. Cisplatin-gemcitabine chemotherapy combined to the anti-PD-L1 inhibitor durvalumab is the first-line standard of care for advanced disease. Early systematic tumour molecular profiling is recommended to screen for actionable alterations (IDH1 mutations, FGFR2 rearrangements, HER2 amplification, BRAF^V600E mutation, MSI/dMMR status, etc.) and guide subsequent lines of treatment. In the absence of actionable alterations, FOLFOX chemotherapy is the only second-line standard-of-care. No third-line chemotherapy standard is validated to date.
These guidelines are intended to provide a personalised therapeutic strategy for daily clinical practice. Each individual BTC case should be discussed by a multidisciplinary team.
Diagnostic accuracy and interobserver agreement of cholangioscopy for indeterminate biliary strictures: A single-center experience
2024, Digestive and Liver Disease
Characterization of indeterminate biliary strictures (IDBS) still represents a major challenge. Digital single-operator cholangioscopy (DSOC) could potentially overcome limits of conventional biopsy and brush sampling. The aim of this study was to compare diagnostic accuracy of visual evaluation and DSOC-guided biopsies to conventional trans-papillary sampling techniques and to evaluate the inter-observer agreement (IOA) on visual diagnosis.
All consecutive patients undergoing DSOC-guided biopsy after conventional sampling techniques for IDBS during a six—year period were retrospectively evaluated. Final diagnosis was based on histological evaluation of the surgical specimen if available or a clinical follow-up of at least 6 months. For IOA, 20-second DSOC clips were retrospectively reviewed by 6 experts and 6 trainees and classified according to the Monaco Classification.
Thirty-five patients underwent DSOC for IDBS in the study period; 14 patients (F = 9) with a median age of 64 years (range 53–76) met the study aim. After DSOC, strictures location was changed in three patients (additional yield of 21.4 %). Intraductal DSOC-guided biopsy were technically successful in all cases, with an adequacy of 92.8 %. No adverse events were recorded. Final diagnosis was benign disease in five cases and cholangiocarcinoma in the others. For IOA, 29 videos were evaluated with almost perfect agreement for final diagnosis (kappa 0.871; agreement 93.1, p <0.001), although overall accuracy of DSOC visual finding was 73.6 % and 64.4 % for experts and trainees, respectively.
DSOC could improve diagnostic accuracy for IDBS, since it showed high sensitivity for visual finding and high specificity for DSOC guided-biopsy. Visual diagnosis seems reliable for diagnosis using the Monaco Classification.
Combining brushing cytology with simultaneous vacuum aspiration in suspicious biliopancreatic malignancies: A multicenter propensity score-matched study (with video)
2024, Digestive and Liver Disease
Brush cytology during endoscopic retrograde cholangiopancreatography (ERCP) is a standard approach in diagnosing biliopancreatic strictures, with yet unsatisfying sensitivity.
We brought additional simultaneous vacuum aspiration to brushing process and re-evaluate the diagnostic performance.
This multi-centered retrospective study was conducted in three tertiary centers. Consecutive patients with biliopancreatic strictures were identified. The patients were divided into two arms: the conventional arm (CA) receiving general brushing approach, and the modified arm (MA) being treated with additional vacuum aspiration when performing bushing. The 1:1 propensity-score matching was implemented to tackle the selective biases.
A total of 555 patients were identified and 200 patient pairs (193 males, 207 females, with a mean age of 68.1 ± 13.1 years.) fell into the ultimate evaluation. A final diagnosis of malignant stricture was established in 243 patients. The diagnostic yield of the MA group was substantially better than that of the CA group, whether "suspicious malignancies" were considered malignancies or not. The rates of sensitivity, specificity and accuracy were 46.2%, 100%, 68.0% in the MA group, and 15.3%, 98.7%, and 47.0% in the CA group respectively.
Brushing accompanied by simultaneous vacuum aspiration at ERCP improves the diagnostic yield in suspicious biliopancreatic malignancies.
Cholangiocarcinoma Surveillance Recommendations in Patients with Primary Sclerosing Cholangitis
2024, Clinics in Liver Disease
Development of a molecular barcode detection system for pancreaticobiliary malignancies and comparison with next-generation sequencing
2024, Cancer Genetics
Obtaining sufficient tumor tissue for genomic profiling is challenging in pancreaticobiliary cancer (PBCA). We determined the utility of molecular barcoding (MB) of liquid biopsies (bile, duodenal fluid, and plasma) for highly sensitive genomic diagnosis and detection of druggable mutations for PBCA.
Two in-house panels of 60 genes (non-MB panel) and 21 genes using MB (MB panel) were used for the genomic analysis of 112 DNA samples from 20 PBCA patients. We measured the yield of DNA and compared the genomic profiles of liquid samples obtained using the non-MB panel and the MB panel. The utility of the panels in detecting druggable mutations was investigated.
A significantly greater amount of DNA was obtained from bile supernatants and precipitates compared to tumor samples (P < 0.001 and P = 0.001, respectively). The number of mutations per patient was significantly higher using the MB panel than using the non-MB panel (2.8 vs. 1.3, P = 0.002). Tumor-derived mutations were detected more frequently using the MB panel than the non-MB panel (P = 0.023). Five drug-matched mutations were detected in liquid samples.
Liquid biopsy with MB may have utility in providing genomic information for the prognosis of patients with PBCA.
Endoscopic Diagnosis of Extra-Luminal Cancers
2024, Gastrointestinal Endoscopy Clinics of North America

View all citing articles on Scopus

: DISCLOSURE: Dr Vargo is a consultant for Olympus, Boston Scientific, Ethicon Endosurgery, and Cook Endoscopy. Dr Parsi is a consultant for Boston Scientific. All other authors disclosed no financial relationships relevant to this article.

: If you would like to chat with an author of this article, you may contact Dr Navaneethan at [email protected].

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Original articleClinical endoscopyComparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis

Background

Objective

Design

Setting

Patients

Intervention

Main Outcome Measurements

Results

Limitations

Conclusion

Section snippets

Medical literature search

Eligible studies and quality assessment

Discussion

Gastroenterology

Pancreatology

J Surg Res

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

HPB (Oxford)

Cholangiocarcinoma–current treatment options

Scand J Surg

Pancreatic neoplasm in 2011: an update

JOP

Outcomes of pancreaticoduodenectomy: where should we focus our efforts on improving outcomes?

JAMA Surg

A systematic review and meta-analysis comparing pancreaticoduodenectomy versus limited resection for duodenal gastrointestinal stromal tumors

Ann Surg Oncol

Original article
Clinical endoscopy
Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis