Strictures: Strictures: Diagnosis by ERCP, IDUS, Diagnosis by ERCP, IDUS, Cholangioscopy, and Tissue Cholangioscopy, and Tissue Sampling Sampling Janak N. Shah, MD Director of Pancreatic / Biliary Endoscopy Interventional Endoscopy Services - California Pacific Medical Center Director of Endoscopy- SFVAMC Associate Clinical Professor of Medicine - UCSF San Francisco, CA
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Indeterminate Biliary Strictures:Indeterminate Biliary Strictures:Diagnosis by ERCP, IDUS, Diagnosis by ERCP, IDUS,
Cholangioscopy, and Tissue SamplingCholangioscopy, and Tissue Sampling
Janak N. Shah, MD
Director of Pancreatic / Biliary Endoscopy
Interventional Endoscopy Services - California Pacific Medical Center
Director of Endoscopy- SFVAMC
Associate Clinical Professor of Medicine - UCSF
San Francisco, CA
What is an “indeterminate” biliary stricture ?
Biliary stricture without an identifiable cause (e.g. mass) on imaging (CT, MRI)
+/- prior negative tissue sampling
Endoscopist’s role in evaluating Endoscopist’s role in evaluating indeterminate strictures:indeterminate strictures:
Determine the cause: Benign or Malignant? Diff dx: cholangioCA, pancreatic CA, PSC, autoimmune (IGG4),
inflammatory (chronic pancreatitis), bile duct injury
Offer treatment options: benign - candidate for endo therapy? stent? malignant - resectable or unresectable? Stenting?
Available tools for evaluating Available tools for evaluating biliary strictures:biliary strictures:
ERCP
Cholangioscopy
Intraductal US (IDUS)
Endoscopic ultrasound (EUS)
ERCP in indeterminate stx:ERCP in indeterminate stx:
55% (in same study brush alone 30%; bx alone 43%)**
more difficult;often requires
sphincterotomy
* de Bellis M, GIE 2002** Jailwala J, GIE 2000
Improving yield at ERCP? Improving yield at ERCP? newer techniques in suspected malignancynewer techniques in suspected malignancy
Technique Method Utility
digital image analysis (DIA)
spectrophotometry to quantify DNA content
14% sensitivity in cyto-negative stx
*
fluorescence in-situ
hybridization (FISH)
fluorescently labeled DNA probes to detect loss / gain of chromosomes
62% sensitivity in cyto-negative stx
*
optical coherence
tomography (OCT)
catheter-based; cross-sectional, subsurface imaging (2mm) based on
measuring backscattered infrared light
1-2 abnl findings in 53-79% with
cancer **
confocal endomicroscopy
catheter-based, in-vivo microscopic imaging
abnl findings in 83% with cancer
***
* Levy MJ, AJG 2008** Arvanitakis M, Endosc 2009*** Giovannini M, Surg Endosc 2011
Cholangioscopy for indeterminate Cholangioscopy for indeterminate stricturesstrictures
Visualization of stricture and ability for direct tissue sampling
Some studies suggest improved detection of malignancy over standard ERCP techniques (e.g. brushings): 92% vs. 66% (p=0.25) tumor detection among 53 PSC
pts with dominant strictures * 89% tumor detection (16 of 18) among 62 pts with
“indeterminate strictures”, majority with prior neg sampling **
IDUS for indeterminate stricturesIDUS for indeterminate strictures Catheter-based US probe, over-the-wire, 12-30 MHz Abnl features in suspected malignant stx:
hypoechoic, infiltrating mass notching or irregular outer border intraductal papillary growth suspicious LN
Improved tumor detection -- no direct tissue sampling malig dx accurately predicted in 89% among 34 PSC and 52 non-PSC
pts with indeterminate stx (higher in non-PSC); malign dx in 86% of 21 pts with negative cytology *
Retrospective blinded review of 30pts with indeterminate stx: benign vs. malign dx correct in 90% with IDUS vs. 67% with ERCP/cyto **
Other uses: assessing tumor extension for operative planning and resectability
* Levy MJ, AJG 2008** Vasquez-Sequeiros, GIE 2002
IDUSIDUS
EUS for indeterminate stricturesEUS for indeterminate strictures Bile duct (from ampulla to hilum) well visualized from
duodenum
Abnl features in suspected malignant stx: hypoechoic mass focal, irregular wall thickening intraductal papillary growth suspicious LN liver metastases and distant LN
Immediate tissue sampling / on-site analysis
Sensitivity of EUS-FNA for bile duct CA: Sensitivity of EUS-FNA for bile duct CA: indeterminate stx with prior negative samplingindeterminate stx with prior negative sampling