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The Role of Endoscopy in the Evaluation and Treatment of Patients with Biliary Neoplasia

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The Role of Endoscopy in the Evaluation and Treatment of Patients with Biliary Neoplasia GUIDELINE The role of endoscopy in the evaluation and treatment of patients with biliary neoplasia This is one of a series of statements discussing the use of INTRODUCTION GI endoscopy in common clinical situations. The Stan- dards of Practice Committee of the American Society for This document reviews the approach to the evaluation Gastrointestinal Endoscopy (ASGE) prepared this text. This and treatment of the patient with suspected biliary neo- guideline is an update of a previous ASGE guideline pub- plasia (Table 2). A discussion of the role of endoscopy for lished in 2005.1 In preparing this guideline, a search of ampullary adenomas can be found in another ASGE the medical literature was performed by using PubMed. document.1 Additional references were obtained from the bibliogra- Patients with biliary neoplasia may present with abnor- phies of the identified articles and from recommendations mal imaging studies or serum chemistries or with symp- of expert consultants. When few or no data exist from toms such as jaundice, abdominal pain, anorexia, and well-designed prospective trials, emphasis is given to results weight loss. Elevations of bilirubin and alkaline phospha- from large series and reports from recognized experts. tase suggest biliary obstruction. A history of inflammatory bowel disease should be sought and a complete physical Guidelines for appropriate use of endoscopy are based on examination should be performed. Once there is clinical a critical review of the available data and expert consen- suspicion of biliary neoplasia, further investigation with sus at the time that the guidelines are drafted. Further abdominal imaging studies is appropriate. A chest x-ray or controlled clinical studies may be needed to clarify aspects CT scan may also be appropriate to assist in diagnosis, of this guideline. This guideline may be revised as neces- staging, and therapeutic planning. Obtaining serum mark- sary to account for changes in technology, new data, or ers, such as CA 19-9 and carcinoembryonic antigen, may other aspects of clinical practice. The recommendations be considered, but their utility is controversial.3,4 are based on reviewed studies and are graded on the strength of the supporting evidence (Table 1).2 The strength of individual recommendations is based on both AMPULLARY ADENOCARCINOMA the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommenda- Ampullary adenocarcinoma is usually suspected based tions are indicated by phrases such as “We suggest,” on the demonstration of obstructive jaundice, often with whereas stronger recommendations are typically stated as dilation of the pancreatic and biliary ducts seen on ab- 5 “We recommend.” dominal imaging studies. Ampullary adenocarcinoma may present with bleeding and, if accompanied by jaun- This guideline is intended to be an educational device dice, silver- or pewter-colored stool. Unlike pancreatic or to provide information that may assist endoscopists in biliary malignancies in which infection is rare, relapsing providing care to patients. This guideline is not a rule and cholangitis is a presentation for ampullary adenocarci- should not be construed as establishing a legal standard of noma. Rarely, patients may not be jaundiced and the care or as encouraging, advocating, requiring, or discour- tumor may be diagnosed incidentally at the time of EGD aging any particular treatment. Clinical decisions in any when biopsy samples can usually be more easily obtained particular case involve a complex analysis of the patient’s with a side-viewing endoscope. condition and available courses of action. Therefore, clin- Transabdominal US (TUS) may demonstrate biliary duct ical considerations may lead an endoscopist to take a dilation, but it is not sensitive for detecting ampullary course of action that varies from these guidelines. tumors.6 Cross-sectional abdominal imaging, such as CT, magnetic resonance imaging (MRI), and magnetic reso- nance cholangiography (MRC), are useful for confirming dilation of the biliary and/or pancreatic ducts and staging more advanced disease,5,7 but are inferior to side-viewing endoscopy and EUS for detecting small ampullary lesions.6 Copyright © 2013 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 Duodenoscopy by using a side-viewing endoscope per- http://dx.doi.org/10.1016/j.gie.2012.09.029 mits direct visualization of the ampulla and tissue acqui- sition,1,8,9 and EUS permits diagnosis as well as staging via www.giejournal.org Volume 77, No. 2 : 2013 GASTROINTESTINAL ENDOSCOPY 167 Endoscopy in the evaluation and treatment of patients with biliary neoplasia TABLE 1. GRADE system for rating the quality of evidence for guidelines Quality of evidence Definition Symbol High quality Further research is very unlikely to change our confidence in the estimate of effect QQQQ Moderate quality Further research is likely to have an important impact on our confidence in the estimate of QQQŒ effect and may change the estimate Low quality Further research is very likely to have an important impact on our confidence in the estimate of QQŒŒ effect and is likely to change the estimate Very low quality Any estimate of effect is very uncertain QŒŒŒ BILIARY TRACT NEOPLASIA TABLE 2. Biliary neoplasia Cholangiocarcinoma Primary Radiologic imaging A primary tumor of the bile duct Ampullary neoplasia should be suspected based on clinical and imaging find- Malignant ings. TUS, CT, or MRC may demonstrate biliary dilation with or without a stricture or mass. The differentiation of Ampullary adenocarcinoma hilar versus nonhilar tumors is important because the ap- Benign proaches to surgical resection and endoscopic palliation differ depending on the location of the tumor. The Bis- Ampullary adenoma muth classification of cholangiocarcinoma is useful for Biliary tract neoplasia determining surgical resectability and type of surgery (Fig. Malignant 1). Although TUS and CT may suggest cholangiocarci- noma, MRC offers advantages. MRC relies on the use of Cholangiocarcinoma heavily T2-weighted image sequences that display fluid Gallbladder polyps and gallbladder as high signal intensity to define the level of a biliary adenocarcinoma stricture and identify features suggestive of malignancy, Benign such as a stricture length of more than 10 mm, irregular margins, and shouldering.16,17 MRC has a sensitivity of Epithelial tumors 77% to 86% and a specificity of 63% to 98% for the Adenomas, cystadenomas, papillomatosis diagnosis of malignant biliary obstruction caused by 18,19 Endocrine cholangiocarcinoma. Nonepithelial Endoscopic approaches Metastatic ERCP. ERCP is important in the diagnosis and manage- ment of cholangiocarcinoma because tissue confirmation Unclassified can be achieved with this technique. Brushings for cytol- Lymphoma ogy and biopsy samples for histology can confirm the diagnosis of cholangiocarcinoma. However, the sensitivity of these tests has been disappointing, ranging from 18% to 60%.20,21 Newer diagnostic tests, such as digital imaging FNA tissue sampling.10-12 EUS and intraductal US (IDUS) analysis and fluorescence in situ hybridization, may offer can assess the depth of invasion in relation to the muscu- increased sensitivity while maintaining the high specificity laris propria as well as intraductal extension and periam- of cytology.22 Other techniques that use DNA-ploidy, such pullary nodal involvement, facilitating selection of patients as flow cytometry, have been shown to improve the sen- who can undergo surgical ampullectomy instead of pan- sitivity of brush cytology while maintaining high specific- creaticoduodenectomy.13 Although not endorsed for rou- ity.23 However, these technologies are not routinely avail- tine clinical management, endoscopic ampullectomy has able nor are they uniformly validated. been described for the removal of early ampullary adeno- If the level of obstruction is located below the level of carcinomas.14 Once the lesion has been identified and the bifurcation (Bismuth type I lesions, Fig. 1), surgical staged, the techniques for palliation or surgical resection resection should be considered in medically stable pa- for cure are similar to the approach described for adeno- tients without metastatic disease. If the patient is a poor carcinoma of the pancreatic head.15 surgical candidate, palliation with plastic or metal stents 168 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 2 : 2013 www.giejournal.org Endoscopy in the evaluation and treatment of patients with biliary neoplasia Figure 1. Bismuth classification of cholangiocarcinoma. Reprinted with permission from Cheng et al.115 should be considered. If the level of obstruction is at or agent available in the United States, Photofrin (porfimer above the hilum, extensive injection of contrast should be sodium, Pinnacle Biologics, Inc., Bannockburn, IL), is ex- avoided to minimize the risk of postprocedural cholangitis pensive and not approved by the U.S. Food and Drug because the entire biliary tree may not drain adequately.24 Administration for the treatment of cholangiocarcinoma. MRC can be helpful in defining ductal anatomy before Catheter-based radiofrequency ablation is being evaluated ERCP to reduce the risk of this adverse event.25 Unilateral for palliation of cholangiocarcinoma complementary to endoscopic biliary stent placement directed by prior im- biliary stenting.46,47 aging has been shown to achieve palliation of jaundice Cholangioscopy. Cholangioscopy allows identifica- equal to that of bilateral stent
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