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Diagnostic Yield of Endoscopic Retrograde Cholangiography and of EUS-Guided fine Needle Aspiration Sampling in Gallbladder Carcinomas

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Diagnostic Yield of Endoscopic Retrograde Cholangiography and of EUS-Guided fine Needle Aspiration Sampling in Gallbladder Carcinomas J Hepatobiliary Pancreat Sci (2012) 19:650–655 DOI 10.1007/s00534-011-0482-6 ORIGINAL ARTICLE Diagnostic yield of endoscopic retrograde cholangiography and of EUS-guided fine needle aspiration sampling in gallbladder carcinomas Susumu Hijioka • Kazuo Hara • Nobumasa Mizuno • Hiroshi Imaoka • Takeshi Ogura • Shin Haba • Mohamed A. Mekky • Vikram Bhatia • Waki Hosoda • Yasushi Yatabe • Yasuhiro Shimizu • Yasumasa Niwa • Masahiro Tajika • Shinya Kondo • Tsutomu Tanaka • Kiichi Tamada • Kenji Yamao Published online: 30 November 2011 Ó Japanese Society of Hepato-Biliary-Pancreatic Surgery and Springer 2011 Abstract GBC was obtained through either ERC cytopathologic Background Obtaining histological evidence of gall- sampling (n = 33), EUS-FNA (n = 24) or both (n = 26). bladder carcinoma (GBC) is difficult due to its extraductal Results Among the 83 patients, 59 (71.0%) with biliary nature, and pathological confirmation remains challenging. obstruction were sampled using ERC with 47.4% (28/59) We compared the diagnostic value and safety of endo- sensitivity. In 19 of the remaining 31 cases, EUS-FNA scopic ultrasound-guided fine-needle aspiration (EUS- sampling had 100% diagnostic sensitivity. Likewise, 50 FNA) with endoscopic retrograde cholangiography (ERC) (60.2%) of the 83 patients with suspected GBC underwent in patients with suspected GBC. EUS-FNA of regional lymph nodes or the gallbladder (GB) Patients Eighty-three patients with GBC were evaluated. mass itself with 94.8% sensitivity. The overall diagnostic Prior to definitive management, pathological evidence of sensitivity rates of ERC and EUS-FNA were 47.4 and 96%, respectively (P \ 0.001). Post-procedural complications were seen in 6.7% of the ERC group (4/59, all were mild & S. Hijioka ( ) Á K. Hara Á N. Mizuno Á H. Imaoka Á T. Ogura Á pancreatitis), and in none of the EUS-FNA group S. Haba Á K. Yamao Department of Gastroenterology, Aichi Cancer Center Hospital, (P = 0.10). 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi 464-8681, Japan Conclusions Gallbladder carcinoma sampling using ERC e-mail: [email protected] and EUS-FNA should be incorporated into the diagnostic workup of GB lesions as complementary tools, and EUS- M. A. Mekky Department of Tropical Medicine and Gastroenterology, FNA should be applied in the setting of failed or not Assiut University Hospital, Assiut, Egypt indicated ERC. V. Bhatia Keywords Gallbladder carcinoma (GBC) Á Endoscopic Department of Medical Hepatology, Institute of Liver and Biliary Sciences (ILBS), Delhi, India retrograde cholangiography (ERC) Á Endoscopic ultrasound (EUS) Á EUS-guided fine-needle aspiration (EUS-FNA) W. Hosoda Á Y. Yatabe Department of Pathology and Molecular Diagnostics, Aichi Cancer Center Hospital, Nagoya, Japan Introduction Y. Shimizu Department of Surgery, Aichi Cancer Center Hospital, Obtaining pathological evidence of gallbladder carcinoma Nagoya, Japan (GBC) is medically and ethically necessary for both Y. Niwa Á M. Tajika Á S. Kondo Á T. Tanaka operable and non-operable cases, prior to resection and Department of Endoscopy, Aichi Cancer Center Hospital, chemotherapy, respectively. In the pre-endoscopic ultra- Nagoya, Japan sound (EUS) era, endoscopic retrograde cholangiography (ERC) drainage with cytologic sampling was the initial K. Tamada Department of Gastroenterology, Jichi Medical University, investigation of choice to prove malignancy, especially in Tochigi, Japan cases with biliary obstruction. ERC-guided sampling has a 123 J Hepatobiliary Pancreat Sci (2012) 19:650–655 651 specificity approaching 100%, and has a sensitivity of 15– 83 patients (M:F 41:42, mean age 64.8 ± 9.5 years) 65% for pancreatic cancer, and 44–82% for bile duct car- were recruited and were treated either by surgery (n = 8), cinoma [1–4]. There are no published figures for diagnostic chemotherapy (n = 65) or best supportive care (n = 10). yield of ERC for strictures due to GBC. EUS-guided fine GBC were categorized according to the TNM classification needle aspiration (FNA) sampling has replaced ERC in of Union for International Cancer Control, as follows: stage cases with pancreatic [5, 6] and bile duct carcinoma [7–10], IIB(n = 1), stage III (n = 46), stage IV (n = 36). Path- when ERC-guided sampling has failed, or is not indicated ological evidence of GBC was obtained through ERC- because of a non-obstructing tumor. However, there are sampling (n = 33), EUS-FNA (n = 24) or both (n = 26) only a few published reports of use of EUS-FNA in GBC (Fig. 1). [11–14]. All the patients provided written informed consent as a The present study evaluates the diagnostic sensitivity of routine part of their management. The Institutional Review ERC cytopathology in GBC with bile duct strictures, and of Board of Aichi Cancer Center approved the study. EUS-FNA in settings where ERC has failed and/or is not indicated, and compares the sensitivity and safety of EUS- Methods FNA with those of ERC. ERC-sampling Materials and methods Endoscopic retrograde cholangiography-brush cytology was performed by passing a brush within a catheter sheath, Patients into the biliary tree over a guidewire, with fluoroscopy guidance. The brush was advanced from the catheter to a This retrospective, single-center study included all con- point proximal to the stricture, withdrawn slightly, and secutive patients who were admitted for management of moved to and fro across the stricture more than 10 times. GBC at Aichi Cancer Center Hospital, from March 2001 to Both the brush and catheter were simultaneously removed April 2010. The inclusion criteria comprised (1) previous to improve the diagnostic yield compared with using brush ERC in an attempt to obtain a cytopathological sample alone [15]. The ERC biopsies were performed after using bile aspirate, brushing and/or forceps biopsy when sphincterotomy and the forceps were passed through the GBC with obstructive jaundice was suspected, (2) previous endoscope into the bile duct under fluoroscopic guidance, EUS-FNA for a suspected GBC, when ERC cytopathology opened, and then closed to grasp tissue from the distal rim was interpreted as non-diagnostic or negative for malig- of the stricture. The maneuver was repeated to obtain a nancy. Figure 1 shows details of the patients selection minimum of three specimens. algorithm and the exclusion criteria. EUS-FNA Fifty (60.2%) of the 83 patients underwent EUS-FNA using a convex array echoendoscope (GF-UCT240; Olympus Optical Corp. Ltd., Tokyo, Japan), connected to an ultra- sound scanning system (SSD 5500 or Prosounda10; Aloka, Tokyo, Japan). The FNA procedures involved either 22-gauge (NA-10J-1, NA-10J-KB, or NA-200H-8022; Olympus Medical System Corp. Ltd., Tokyo, Japan), or 25-gauge (Echo-tip; Boston Scientific, Boston, USA) nee- dles. Patients were followed up for 24 h to monitor post- procedural complications. The EUS-FNA aspirates were processed and cytologically analyzed as already described in this respect [16, 17]. The same experienced cytopa- thologists (WH, YY) interpreted the cytological findings of all samples. Our EUS-FNA sampling protocol was to first puncture the regional intra-abdominal lymph nodes (LNs) when Fig. 1 Algorithm for patient selection and exclusion criteria. GBC gallbladder carcinoma, ERC endoscopic retrograde cholangiography, enlarged and accessible (Fig. 2a), and to puncture the gall EUS-FNA endoscopic ultrasound guided fine-needle aspiration bladder (GB) mass itself only if the regional nodes were 123 652 J Hepatobiliary Pancreat Sci (2012) 19:650–655 Fig. 2 EUS-FNA. a EUS-FNA for regional intra-abdominal lymph nodes. b The diffuse and irregular wall of a thickened GB. c EUS-FNA for a GB wall- thickened lesion. EUS-FNA endoscopic ultrasound-guided fine-needle aspiration, GB gallbladder, LN lymph node, insuff insufficient aspirate not enlarged, inaccessible, or yielded negative sampling Continuous variables are described as means and stan- (Fig. 2b, c) [14]. dard deviations, and dichotomous variables are expressed as simple proportions. The v2 test (with Yates correction) Evaluation of complications was used for comparative statistics. Data were statistically analyzed using SPSS software for Windows, release 11 All patients were followed-up for 24 h after the procedure (SPSS Inc, Chicago, IL, USA). A P value of \0.05 was with clinical observation and measurement of serum considered significant. amylase, C-reactive protein (CRP) and hematologic pro- files. Post-procedural pancreatitis was diagnosed based on abdominal pain and/or a four-fold rise in baseline serum Results amylase. The possibility of tumor seeding, which may be associated with these procedures, was evaluated by the ERC sampling presence or absence of any apparent tumor involvement of the gastrointestinal wall, along the needle track, and during Among the 83 patients, 59 (71.0%) presented with follow-up through imaging modalities (e.g. CT, MRI). obstructive jaundice and underwent ERC cytopathological sampling. Evidence of malignancy was obtained in 28 Statistical analysis (47.4%) of them (95% CI 34.3–60.8%). Bile aspiration and subsequent cytological examination Samples obtained by ERC and/or EUS-FNA were catego- was performed in 30 (50.8%) of these 59 patients, and ERC rized as positive or negative for malignancy. Any specimen add-on procedures (e.g. brushing and or biopsy forceps) interpreted as suspicious, atypical or non-diagnostic was were used in the remaining 29 (49.2%). Figure 3 shows considered negative for malignancy. Our standard refer- details of the ERC results. ences were either postoperative cytopathological findings The malignancy detection rates of bile aspirate cytology from surgical patients, or the results of EUS-FNA coupled and the add-on ERC cytopathology were 43.3% (13/30) with the clinical, imaging and follow-up management and 51.7% (15/29), respectively with no statistical differ- results for non-operable patients. ence between these 2 groups (P = 0.31). 123 J Hepatobiliary Pancreat Sci (2012) 19:650–655 653 Fig. 3 Details of ERC results. The malignancy detection rates of bile aspirate cytology and the add-on ERC cytopathology were 43.3% (13/ 30) and 51.7% (15/29), respectively, with no statistical differences between these 2 groups (P = 0.31).
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