UMMS-Baystate Medical Center Springfield, Massachusetts
Aditya Kalakonda, MD1, Kavya Kelagere Mayigegowda, MD1, David J. Desilets, MD, PhD2; 1UMMS-Baystate Medical Center, Springfield, MA; 2University of Massachusetts Medical School, Springfield, MA
Introduction: Diagnostic yields of brush cytology and forceps biopsy for malignant biliary strictures vary considerably. Endoscopic ultrasound with needle biopsy is preferred for tissue diagnosis but is often not available. ERCP with brush cytology is still the primary method in the community setting. Few bother with forceps biopsies, as these are technically difficult, and there is a consensus that the addition of forceps biopsies to brush cytology does not significantly increase the overall yield. We report our data on the diagnostic yield of biliary brush cytology and forceps biopsy performed in a standard fashion over 13 years to determine by what amount the addition of forceps biopsies informs the diagnosis. Methods: Data were entered into a database of 4447 ERCPs over 17 years by a single operator at a tertiary referral center. Outcomes were available from 2004 onward, comprising 379 patients who had ERCP with forceps biopsy or brush cytology for a biliary stricture. Of these, 159 patients had a diagnosis of cholangiocarcinoma or pancreatic adenocarcinoma on the ultimate follow up. Of these 159 patients with primary pancreas/biliary cancer, 137 had both brushings and forceps biopsies. The same technique was used for obtaining brush cytology and forceps biopsy on all patients by a single operator. Results: The results are shown in Table 1. In the right clinical setting, our surgeons and oncologists accept “suspicious for adenocarcinoma” as a positive diagnosis, so we grouped definite for adenocarcinoma and suspicious for adenocarcinoma together. Table 2 shows the outcomes when brushings and forceps biopsies are taken together. Discussion: Our data show that, for malignant biliary strictures, brush cytology and forceps biopsy have similar yields (62% and 58%, respectively, p=NS). However, in the 52 patients that had negative brushings (38%), the forceps were positive in 24, increasing the yield by 18% to an overall yield of 80%. We conclude that the addition of forceps biopsies to brush cytology can increase the diagnostic yield by 18%, reducing the number of subsequent referrals for additional biopsies by 18%. Routine use of biliary forceps biopsies in this setting should be encouraged, and the technical ability to obtain forceps biopsies of biliary strictures with standard devices should be in the armamentarium of every endoscopist performing ERCP for suspected malignant strictures.
Disclosures: Aditya Kalakonda indicated no relevant financial relationships. Kavya Kelagere Mayigegowda indicated no relevant financial relationships. David Desilets indicated no relevant financial relationships.