Journal of Hepatology
Volume 45, Issue 4 , Pages 476-479, October 2006

Diagnosis of cholangiocarcinoma in patients with PSC: A sight on cytology☆

  • E.S. Baskin-Bey

      Affiliations

    • Mayo Clinic College of Medicine, Department of Transplantation Surgery, Miles and Shirely Fiterman Center for Digestive Disease, Rochester, MN 55905, USA
    • ,
  • L.E. Moreno Luna

      Affiliations

    • Mayo Clinic College of Medicine, Department of Gastroenterology and Hepatology, Miles and Shirely Fiterman Center for Digestive Disease, Rochester, MN 55905, USA
    • ,
  • G.J. Gores

      Affiliations

    • Mayo Clinic College of Medicine, Department of Gastroenterology and Hepatology, Miles and Shirely Fiterman Center for Digestive Disease, Rochester, MN 55905, USA
    • Corresponding Author InformationCorresponding author. Tel.: +1 507 284 0686; fax: +1 507 284 0762.

published online 25 July 2006.

Article Outline

 

Primary sclerosing cholangitis (PSC) is an idiopathic, chronic, cholestatic, liver disease characterized by inflammatory destruction of the biliary tree. The most devastating complication of PSC is the development of cholangiocarcinoma (CCA) [1]. The prevalence of CCA in PSC patients varies from 5% to 36% [2], [3], [4], [5], [6]. Several risk factors have been proposed that increase the occurrence of CCA in PSC patients, including smoking [7], alcohol [8], older age at onset of PSC [9], and a longer history of inflammatory bowel disease before diagnosis of PSC [10]. Unexpectedly, the duration of PSC is not a risk factor, and the incidence of CCA is greatest within the first two years after diagnosis of PSC [10], [11].

The cholangiographic findings and clinical symptoms of CCA are non-specific and are difficult to differentiate from benign dominant bile duct strictures, which are common in PSC [12]. Neither serum tumor markers, assessment of DNA mutations in bile, nor imaging studies have proven to be accurate for detecting CCA in the presence of PSC, making cholangiocarcinoma in this setting extremely difficult to diagnose. Advanced CCA is rapidly fatal; however, because the majority of patients with PSC will not develop CCA, pre-emptive liver transplantation with its mortality and morbidity cannot be justified. In contrast, early stage CCA in the setting of PSC can be amenable to successful liver transplantation, especially at centers employing neoadjuvant protocols [13], [14], [15]. Therefore, an early and reliable marker of malignancy in PSC is paramount when therapy with excellent outcomes can be obtained.

Because of the non-specificity of current imaging modalities, direct cholangiography with cytologic acquisition is essential for early diagnosis of cholangiocarcinoma. Endoscopic retrograde cholangiography (ERC) allows for biliary sampling. Unfortunately, tissue diagnosis is difficult given limited access to the bile duct, and the highly desmoplastic nature of biliary tract cancers. Negative biopsies and brushings, therefore, do not exclude bile duct cancers [16]. The distinction between malignant and inflammatory strictures is confounded in PSC as the inflammation associated with this disorder complicates cytologic assessment. Most cytology in PSC is read as: negative for malignancy, atypical favoring reactive changes due to inflammation, suspicious for malignancy, and diagnostic of malignancy. The category of atypical favoring reactive changes due to inflammation is the category which thwarts the interpretation of biliary cytology obtained from PSC patients.

In this issue of the Journal, Boberg et al. [17] examined the utility of biliary brush cytology in the diagnosis of CCA in patients with PSC. In an elegant fashion, this group performed a prospective analysis of patients with PSC over a 4-year period. Cytology specimens were collected during ERC by stricture brushing and or retrieved from a biliary stent after removal. Boberg et al. [17] utilized the WHO histological classification of tumors of the gallbladder and extrahepatic ducts [18] to pigeonhole collected cytologic specimens into the following categories: insufficient material for diagnosis, normal and/or irregular non-dysplastic changes, indefinite for dysplasia, low-grade dysplasia, and high-grade dysplasia/adenocarcinoma. They demonstrated reproducibility of cytologic classification between multiple samples. More importantly, the sensitivity and specificity of brush cytology for the diagnosis of CCA was 100% and 84%, respectively, when low-grade and high-grade dysplasia/adenocarcinoma were combined. Boberg and colleagues [17] also observed a decrease in sensitivity and increase in specificity to 73% and 95%, respectively, for high-grade dysplasia/adenocarcinoma only.

At present, such impressive predictive values for routine brush cytology by ERC for identifying cancer in PSC have not been reported [19], [20], [21], [22], [23], [24]. In our institution, we prospectively analyzed cytology results in 86 PSC patients [25]. Cytologic diagnoses were classified using the traditional classification: negative for malignancy, atypical favoring reactive changes due to inflammation, suspicious for malignancy, and diagnostic of malignancy. When only specimens interpreted as diagnostic for cancer were considered positive, the overall sensitivity was only 17% but the specificity was perfect at 100%. If specimens also interpreted as suspicious for malignancy were considered positive for cancer, the sensitivity increased to 39% and the specificity dropped minimally to 97%. None of our specimens were classified as dysplastic. Indeed, some authors have found dysplasia to be rare [26] and the pathologic/cytologic criteria unreliable rendering the diagnosis of dysplasia a highly subjective interpretation of uncertain value [27]. Furthermore, the concept of biliary dysplasia is fraught with controversy and not universally accepted. How do we reconcile these differences between institutions with considerable experience in PSC and CCA?

Boberg et al. undoubtedly have established accepted criterion for dysplasia at their institution, an expertise which affords them an opportunity to examine the relationship between biliary dysplasia and CCA in the setting of PSC. This expertise can be developed as other authors have observed a strong association between biliary dysplasia and CCA in patients with PSC, and were able to demonstrate agreement between pathologists on specific criterion for diagnosis of dysplasia in PSC [27]. In this regard, the current study by Boberg and colleagues represents an advance in this field. However, there is uncertainty as to whether their experience can be extrapolated beyond highly specialized centers.

The distinction between inflammatory changes and dysplasia is difficult in biopsy specimens where the basement membrane, cell polarity, and consistency of findings between adjacent cells cannot be reliably assessed. In cytologic specimens, this tissue architecture is lost, and cellular architecture in cytologic specimens has many artifacts. This is especially true of “gland forming epithelia” such as the biliary epithelia. For example, although dysplastic changes in human squamous cell cervical cytologic specimens have been standardized and widely accepted, endocervical cytology for adenocarcinoma of the endocervix, due to considerable inter-observer variation, has not reached the same level of acceptance [28], [29], [30], [31], [32]. In this regard, the current United Network of Organ Sharing (UNOS) proposal to allow MELD exceptions for patients with PSC and CCA does not accept dysplasia as a criterion for transplantation in the United States.

To address the issue of cytologic interpretation, new and advanced diagnostic objective methods have been developed. Digital Image Analysis (DIA) and Fluorescence in situ Hybridization (FISH) are two cytologic techniques that have been shown to significantly increase the diagnostic sensitivity of biliary tract malignancies over cytology while maintaining the high specificity of cytology [33], [34], both techniques being based on identifying aneuploidy, a hallmark of cancer [35]. In fact, in limited studies, both techniques have shown promise in accurately identifying malignant pancreaticobiliary strictures [33], [34]. DIA is a technique that uses a microscope and camera to quantify the amount of cellular DNA by measuring the intensity of nuclei stained with Feulgen dye, a cytochemical stain that stoichiometrically binds to nuclear DNA [36]. Therefore, this technique is able to quantitate aneuploidy in small populations of cells. FISH is a technique that utilizes fluorescently labeled DNA probes to detect chromosome number in cells and has been shown to detect malignancy in cytologic specimens from different body sites [37], [38], [39]. In our prospective analysis of 86 patients with PSC [25], we analyzed the sensitivity and specificity of DIA, in samples where brush cytology was neither positive, nor suspicious for malignancy. In this analysis, DIA had a sensitivity of 14% and a specificity of 88%. Thus, an additional 14% of tumors would be identified by employing DIA routinely while preserving the specificity of routine cytology. FISH yielded a sensitivity of 60% and 87% specificity, respectively, when brush cytology was neither positive nor suspicious for malignancy. Thus, FISH appears to be a valuable adjunct to cytology when interpreting cytology from suspicious cholangiographic lesions in PSC. What is now needed is a comparison of FISH, DIA and diagnosis of biliary dysplasia in multiple centers to determine their relative performance characteristics for biliary neoplasia in PSC.

The goal of these techniques is not only to identify cholangiocarcinoma but perhaps PSC patients in evolution to cholangiocarcinoma. Indeed, this has been achieved, in part, in ulcerative colitis, a disease often associated with PSC. Surveillance colonoscopy with random biopsies to determine the existence of dysplasia is now the standard of care of patients with ulcerative colitis. Patients with dysplasia are counseled about their risk for colon cancer and the potential risks and benefits of prophylactic colectomy. Perhaps in the future we will also have a similar strategy for patients with PSC vis-à-vis surveillance strategies to guide decisions regarding liver transplantation. However, we do not yet have sufficient information regarding the assessment of biliary dysplasia, DIA or FISH to make these recommendations.

In summary, patients with PSC have an increased risk of CCA, which carries a dismal survival rate. Therefore a reliable early marker for CCA in the setting of PSC is of great significance. Brush cytology and diagnosis of dysplasia in conjunction with other diagnostic parameters such as DIA and FISH may be the future of diagnostic modalities for CCA in PSC patients. Unfortunately, at this time additional data are required before such techniques can be widely applied in clinical practice.

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☆ This work was supported by NIH Grants T32 DK07198 (to ESB) and DK41876 (to GJG), and the Mayo Foundation.

PII: S0168-8278(06)00379-5

doi:10.1016/j.jhep.2006.07.006

Journal of Hepatology
Volume 45, Issue 4 , Pages 476-479, October 2006

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