title: Monitoring dominant strictures in primary sclerosing cholangitis with brush cytology and FDG-PET.
abstract: OBJECTIVE
  Despite a high risk of cholangiocellular adenocarcinoma (CCA) it is unclear how surveillance of patients with primary sclerosing cholangitis (PSC) should be performed.
  
  
  METHODS
  We evaluated a follow-up algorithm of brush cytology and positron emission tomography/computed tomography with [(18)F] fluorodeoxyglucose ([(18)F]FDG-PET/CT), measured as maximum standardized uptake values, normalized to the liver background (SUVmax/liver) at 180 min, in PSC patients with dominant bile duct strictures.
  
  
  RESULTS
  Brush cytology with high grade dysplasia (HGD) was detected in 12/70 patients (17%), yielding a diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 56%, 89%, 75%, and 88%, respectively. Preemptive liver transplantations due to repeated HGD before manifest CCA were performed in six patients. Receiver operating characteristic (ROC) analysis of [(18)F]FDG uptake showed that a SUVmax/liver quotient of 3.3 was able to discriminate between CCA and non-malignant disease with a sensitivity, specificity, PPV and NPV for CCA of 89%, 92%, 62%, 98%, respectively. A SUVmax/liver >3.3 detected CCA in 8/9 patients whereas a quotient <2.4 excluded CCA. Combining brush cytology and quantitative [(18)F]FDG-PET/CT yielded a sensitivity for HGD and/or CCA of 100% and a specificity of 88%.
  
  
  CONCLUSIONS
  Early detection of HGD before manifest CCA is feasible with repeated brush cytology and may allow for preemptive liver transplantation. [(18)F]FDG-PET/CT has a high sensitivity for manifest CCA and a negative scan indicates a non-malignant state of the disease. Brush cytology and [(18)F]FDG-PET/CT are complementary in monitoring and managing PSC patients with dominant strictures.
authors.affiliation: Gastroenterology Research Group, Department of Medical Sciences, Uppsala University Hospital, Sweden.
authors.forename: Per
authors.initials: P
authors.lastname: Sangfelt
authors.affiliation: Department of Radiology, Uppsala University Hospital, Sweden.
authors.forename: Anders
authors.initials: A
authors.lastname: Sundin
authors.affiliation: Department of Immunology, Genetics and Pathology, Uppsala University Hospital, Sweden.
authors.forename: Alkwin
authors.initials: A
authors.lastname: Wanders
authors.affiliation: Department of Surgery, Falun County Hospital, Falun, Sweden.
authors.forename: Ib
authors.initials: I
authors.lastname: Rasmussen
authors.affiliation: Department of Surgical Sciences, Uppsala University Hospital, Sweden.
authors.forename: Britt-Marie
authors.initials: BM
authors.lastname: Karlson
authors.affiliation: Department of Molecular Medicine and Surgery, Karolinska University Hospital & Karolinska Institutet, Stockholm, Sweden; Department of Gastroenterology and Hepatology, Karolinska University Hospital & Karolinska Institutet, Stockholm, Sweden.
authors.forename: Annika
authors.initials: A
authors.lastname: Bergquist
authors.affiliation: Gastroenterology Research Group, Department of Medical Sciences, Uppsala University Hospital, Sweden. Electronic address: fredrik.rorsman@medsci.uu.se.
authors.forename: Fredrik
authors.initials: F
authors.lastname: Rorsman
mesh_terms: D000230:Adenocarcinoma / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000473:pathology; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000473:pathology; D001653:Bile Ducts, Intrahepatic; D018281:Cholangiocarcinoma / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000473:pathology; D015209:Cholangitis, Sclerosing / Q000000981:diagnostic imaging* / Q000473:pathology*; D003251:Constriction, Pathologic / Q000000981:diagnostic imaging / Q000473:pathology; D003584:Cytological Techniques / Q000379:methods*; D018450:Disease Progression; D005240:Feasibility Studies; D005260:Female; D019788:Fluorodeoxyglucose F18; D005500:Follow-Up Studies; D006801:Humans; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D049268:Positron-Emission Tomography / Q000379:methods*; D011446:Prospective Studies; D012680:Sensitivity and Specificity
chemical_list: D019788:Fluorodeoxyglucose F18
keywords: Biliary dysplasia; Brush cytology; Cholangiocellular adenocarcinoma; Endoscopic retrograde cholangiography; Positron emission tomography; [(18)F]FDG