Original Articles
Triple-tissue sampling at ERCP in malignant biliary obstruction☆

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Abstract

Background: Procurement of cytologic samples by brushing is common practice at endoscopic retrograde cholangiopancreatography (ERCP) but has low sensitivity for cancer detection. Limited data are available on other techniques, including endoluminal fine-needle aspiration and forceps biopsy. This series reviews the yield of these three stricture sampling methods. Methods: In this prospective study, patients with biliary obstruction with a clinical suspicion of malignancy underwent triple-tissue sampling at one ERCP session. Final cancer diagnosis was based on all sampling methods plus surgery, autopsy, and clinical follow-up. Tissue specimens were reported as normal, atypia, or malignant. Results: A total of 133 patients were evaluated: 104 had cancer and 29 had benign strictures. Tissue sampling sensitivity varied according to the type of cancer; the highest yield was seen in ampullary cancers (62% to 85%). The cumulative sensitivity of triple-tissue sampling in the cancer patients was as follows: sensitivity was 52% if atypia was considered benign and 77% if it was considered malignant. The addition of a second or third technique increased sensitivity rates in most instances. No serious complications occurred from the tissue sampling methods. Conclusions: Tissue sampling sensitivity varied according to the type of cancer. Combining a second or third method increased sensitivity; general use of at least two sampling methods is therefore recommended. (Gastrointest Endosc 2000;51:383-90.)

Section snippets

PATIENTS AND METHODS

From 1991 to 1995, selected (nonconsecutive) patients with biliary obstruction presenting to the ERCP service of our medical center with jaundice, in whom there was clinical suspicion of malignancy but without histologic confirmation from other sources, underwent simultaneous tissue sampling by brushing, forceps biopsy, and fine-needle aspiration cytology at one ERCP session. We consider tissue sampling part of the standard of care when a biliary stricture is encountered at ERCP. Approval for

RESULTS

A total of 137 patients were evaluated by triple-tissue sampling. However, four patients were excluded due to lack of adequate follow-up and no histopathologic evidence of malignancy. One-hundred thirty-three patients were therefore available for analysis, of which 104 had cancer and 29 had benign disease based on the above criteria. Forty-six patients had pancreatic cancer, 30 had cholangiocarcinoma, 13 had ampullary carcinoma, and 15 had metastatic cancer. Among patients with metastases, the

DISCUSSION

Aspiration of bile or pancreatic juice is the easiest method of obtaining cellular material when evaluating biliary strictures for malignancy. Unfortunately, the results have been largely disappointing, with cancer sensitivities in the 6% to 32% range1, 7, 11, 12 and frequent acellular specimens. The desmoplastic nature of certain tumors or failure of the neoplasm to invade the ductal epithelium is likely responsible for these results.13 It has been suggested that endoscopic manipulation of the

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Reprint requests: Evan Fogel, MD, Division of Gastroenterology and Hepatology, Indiana University Hospital, 550 N. University Blvd., Suite 2300, Indianapolis, IN 46202.

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Copyright © 2000 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.