ERCP or EUS for tissue diagnosis of biliary strictures? A prospective comparative study.
BACKGROUND
The accuracy of ERCP-based brush cytology or forceps biopsy for tissue diagnosis is relatively low (usually not exceeding 70%). By contrast, reported accuracy rates for EUS-guided FNA of pancreatobiliary masses are over 80%. This prospective study compared these two modalities for the first time in the diagnosis of indeterminate biliary strictures and pancreatic tumors.


METHODS
Fifty consecutive patients (29 men, 21 women; mean age 62.1 years) with obstructive jaundice in whom a tissue diagnosis was required were included. During ERCP, intraductal specimens were obtained with a forceps and with two different types of brush (conventional and spiral suction) in random order. During EUS, only visible mass lesions or localized bile duct wall thickening were aspirated (22-gauge needle), with at least two passes yielding material sufficient for assessment. A cytopathologist was not present in the procedure room to evaluate specimen adequacy. The reference methods were surgery, other biopsy results, follow-up until death, or the conclusion of the study (mean follow-up 20 months).


RESULTS
The final diagnoses were malignancy, 28 (16 pancreatic, 12 biliary), and benign biliary stricture, 22. Sensitivity and specificity for ERCP-guided biopsy were 36% and 100%, respectively; for ERCP-guided cytology (when using conventional and spiral suction brushes), 46% and 100%, respectively; and for EUS-guided FNA, 43% and 100%, respectively. If the punctured lesions are considered (n=28) alone, the sensitivity of EUS-guided FNA was 75%. In general, sensitivity was better for ERCP-based techniques in the subgroup biliary tumor (ERCP 75% vs. EUS 25%), whereas EUS-guided biopsy was superior for pancreatic mass (EUS 60% vs. ERCP 38%).


CONCLUSIONS
For biliary strictures, combined ERCP- and EUS-guided tissue acquisition seems to be the best approach to tissue diagnosis. From a clinical standpoint, it appears reasonable, when a tissue diagnosis is required, to start with ERCP if biliary malignancy is suspected and with EUS when a pancreatic tumor is thought to be the cause of a biliary stricture.
Department of Internal Medicine II, Department of Pathology, Technical University of Munich, Munich, Germany.
Thomas
T
Rösch
Kim
K
Hofrichter
Eckart
E
Frimberger
Alexander
A
Meining
Peter
P
Born
Norbert
N
Weigert
Hans-Dieter
HD
Allescher
Meinhard
M
Classen
Marius
M
Barbur
Ulrich
U
Schenck
Martin
M
Werner
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017734:Bile Ducts, Extrahepatic / Q000473:pathology; D001706:Biopsy / Q000295:instrumentation*; D044963:Biopsy, Fine-Needle / Q000295:instrumentation*; D002760:Cholangiopancreatography, Endoscopic Retrograde; D001651:Cholestasis, Extrahepatic / Q000473:pathology* / Q000601:surgery; D003937:Diagnosis, Differential; D019160:Endosonography / Q000295:instrumentation*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010179:Pancreas / Q000473:pathology; D010190:Pancreatic Neoplasms / Q000473:pathology* / Q000601:surgery; D011446:Prospective Studies; D012680:Sensitivity and Specificity