Endoscopic methods for the diagnosis of pancreatobiliary neoplasms
- Isaac Raijman, MD
Isaac Raijman, MD
- Clinical Associate Professor of Medicine
- Baylor College of Medicine, Houston, TX
- Digestive Associates of Houston, PA
The diagnosis of biliary neoplasms is usually accomplished through a combination of imaging modalities and tissue sampling. Optimal methods to diagnose these tumors depend upon the clinical setting, the characteristics of the individual tests, and the available resources.
This topic review will focus primarily on the accuracy of endoscopic methods to diagnose biliary neoplasms. General discussions on the diagnosis of the individual tumors are presented separately on the corresponding topic reviews.
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
Endoscopic retrograde cholangiopancreatography (ERCP) permits the visualization of the biliary neoplasms while providing the opportunity to obtain tissue samples and to perform therapeutic maneuvers (such as biliary decompression) when necessary. Thus, it continues to have a central role in the diagnosis and management of biliary neoplasms.
Radiographic appearance — Cholangiographic findings during ERCP can help distinguish benign from malignant neoplasms. Biliary neoplasms typically appear as a stricture during ERCP. However, strictures caused by benign processes (such as pancreatitis) can have the appearance of malignancies and vice versa. In addition, a neoplasm can develop in a long-standing benign stricture and its recognition may be difficult, such as in patients with primary sclerosing cholangitis and chronic pancreatitis. Some of the characteristics of the stricture suggestive of malignancy include a length of more than 10 mm, a ragged contour, and the presence of a fixed filling defect and/or an abrupt transition from relatively normal to the stricture, so called shouldering, typically located above the stricture.
In addition, strictures involving the hilum should raise concerns of malignancy. The majority of hilar strictures are due to either malignancy or extrinsic compression by lymph nodes. Our experience and that reported in the literature supports the view that hilar strictures should be considered malignant until proven otherwise. Exceptions are patients who have recently undergone liver transplantation. Tissue confirmation should be sought in the majority of patients. The clinical setting, radiographic appearance, and cholangiographic findings may be sufficient to establish the diagnosis of malignancy in patients in whom tissue sampling is not feasible.
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- ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
- Radiographic appearance
- Tissue sampling during ERCP
- - Brush cytology
- - Scraping cytology
- - Primary sclerosing cholangitis
- - Tumor type
- - Technique
- - New tools
- - Forceps biopsy
- - Endoscopic fine-needle aspiration
- - Bile aspiration
- Tumor markers
- - p53 and K-ras
- - Telomerase RNA
- - Measures of DNA proliferation
- Cholangioscopy during ERCP
- ENDOSCOPIC ULTRASOUND AND INTRADUCTAL PROBES
- Intraductal ultrasonography
- SUMMARY AND RECOMMENDATIONS