Polysomy and p16 deletion by fluorescence in situ hybridization in the diagnosis of indeterminate biliary strictures

doi:10.1016/j.gie.2011.08.022

Gastrointestinal Endoscopy

Volume 75, Issue 1, January 2012, Pages 74-79

https://doi.org/10.1016/j.gie.2011.08.022 Get rights and content

Background

The diagnosis of indeterminate biliary strictures is limited because of the low sensitivity of cytology. However, an accurate diagnosis of malignancy is critical in the management of patients with suspected biliary malignancy. Testing for chromosomal aneuploidy by fluorescence in situ hybridization (FISH) may increase the yield.

Objective

To evaluate the diagnostic accuracy of FISH in indeterminate biliary strictures and the additional value of including deletion of 9p21 (p16) in the diagnostic criteria of malignant biliary strictures.

Design

Retrospective review.

Setting

Academic medical center.

Patients

This study involved 76 consecutive patients who were seen for the evaluation of indeterminate strictures at our institution. These patients were screened, and 50 patients with either a final pathologic diagnosis or ≥12 months' conclusive follow-up were included in the analysis.

Main Outcome Measurements

Sensitivity, specificity, and area under the curve (AUC) analysis of cytology alone compared with the presence of FISH polysomy versus FISH polysomy and 9p21 deletion.

Results

The presence of increased copy numbers (polysomy) of chromosome 3, 7, or 17 by FISH increased the sensitivity of brush cytology from 21% to 58%, and when the presence of 9p21 deletion was included, the sensitivity increased to 89%. The specificity of FISH was 97% (vs 100% for cytology). The accuracy of cytology combined with FISH polysomy (AUC = 0.93) or p16 deletion was significantly greater than the accuracy of cytology alone (AUC 0.6; P < .001) or even cytology combined with FISH polysomy (AUC = 0.77; P ≤ .05).

Limitations

Sample size. There is a relatively high incidence of malignant biliary strictures in the entire cohort but low incidence among primary sclerosing cholangitis patients, and the majority of cancers are cholangiocarcinomas (as opposed to pancreatic).

Conclusion

FISH significantly improves the diagnostic accuracy of brush cytology in indeterminate biliary strictures. In our series, the addition of 9p21 deletion to FISH polysomy and cytology further improved sensitivity. This suggests that 9p21 deletion may be added to the diagnostic criteria in indeterminate strictures.

Section snippets

Patient selection

This study was approved by the Institutional Review Board of Columbia University. All consecutive patients who underwent ERCP or percutaneous transhepatic cholangiography at our institution for the evaluation of indeterminate strictures and had biliary brush cytology and FISH specimens obtained between February 2008 and February 2010 were included. Patients were excluded if they had biliary sampling without a dominant stricture (such as in PSC) or if sampling was done for abnormalities other

Clinical and histologic characteristics

Seventy-six patients underwent ERCP or percutaneous transhepatic cholangiography, with tissue obtained for cytology, and FISH during the period of the study. A total of 50 patients underwent surgery, reached a final diagnosis, or had reached ≥12 months' of follow-up (Fig. 2). Twenty-six patients were not included in the analysis because follow-up had not reached 12 months (15/26) or patients were lost to follow-up (8/26) or died within 12 months of the procedure (3/26). Of the 50 patients, 21

Discussion

The recent improvement in outcomes of medical and surgical treatment options for malignant biliary strictures highlights the importance of accurate diagnosis of indeterminate strictures.1, 4 Advances in imaging and cholangioscopy will continue to enhance our ability to characterize these strictures and target samples and perhaps guide therapy.¹⁶ Inherent to the growth pattern of bile duct cancers, it is likely that both cytology and biopsy will yield only a small amount of malignant cells. FISH

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Performance of fluorescence in situ hybridization in biliary brushings with equivocal cytology: an institutional experience
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Biliary brushing (BB) cytology has a sensitivity of 15%-65% and specificity approaching 100% for detecting malignancy. Fluorescence in-situ hybridization (FISH) using the UroVysion probe set has been advocated to enhance the detection of malignancies with reported sensitivity of 43%-84%. We sought to evaluate the performance of FISH in BB with equivocal cytology at our institution.
Patients with atypical and suspicious BB with concurrent diagnostic FISH performed at our institution from 2014 to 2021 were identified through a query of our pathology database. FISH (using UroVysion probe set containing centromere enumeration probes to chromosomes 3, 7, and 17) was positive if at least 5 cells demonstrated polysomy. Electronic medical records were reviewed for pathology results and outcomes. Patients were classified malignant if they had positive pathology or documented clinical impression of malignancy and benign if they had negative pathology and/or documented benign clinical course for at least 12 months.
We identified 254 equivocal BB (238 atypical/16 suspicious) with concurrent FISH results from 191 patients (105 benign, 86 malignant). 12% (22/191) of patients were FISH positive. Twenty-four percent (21/86) of patients with malignancy had positive FISH but were nonspecific for pancreaticobiliary/ampullary adenocarcinomas. Almost all positive FISH were associated with malignancy (21/22; 95%). There was 1 positive FISH in a patient with primary sclerosing cholangitis who had a benign outcome.
The small number of positive FISH results in BB with equivocal cytology raises the question of the optimal criteria for malignancy. Using only polysomy could result in lower sensitivity.
Advanced endoscopy meets molecular diagnosis of cholangiocarcinoma
2023, Journal of Hepatology
Cholangiocarcinoma remains an aggressive and deadly malignancy that is often diagnosed late. Intrinsic tumour characteristics and the growth pattern of cancer cells contribute to the challenges of diagnosis and chemoresistance. However, establishing an early and accurate diagnosis, and in some instances identifying targetable changes, has the potential to impact survival. Primary sclerosing cholangitis, a chronic cholangiopathy prodromal to the development of a minority of cholangiocarcinomas, poses a particular diagnostic challenge. We present our diagnostic and theranostic approach to the initial evaluation of cholangiocarcinomas, focusing on extrahepatic cholangiocarcinoma. This involves a multipronged strategy incorporating advanced imaging, endoscopic methods, multiple approaches to tissue sampling, and molecular markers. We also provide an algorithm for the sequential use of these tools.
Multidisciplinary Approach to Indeterminate Biliary Strictures
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Digital Image Analysis has an Additive Beneficial Role to Conventional Cytology in Diagnosing the Nature of Biliary Ducts Stricture
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Conventional cytological evaluation (CCE) fails to identify nature indeterminate biliary duct stricture (IBDS) in many cases. Digital image analysis (DIA) has the ability to identify and analyze the DNA content of cells. This study assesses the role of DIA in recognizing the nature of IBDS compared to CCE.
A prospective observational study was conducted at the Al-Rajhi University Hospital. Fifty patients with IBDS, based on abdominal imaging, were subjected to endoscopic retrograde cholangiopancreatography (ERCP) and brush sampling. These samples were evaluated with CCE and DIA. Follow-up for at least 9 months and cost-analysis had also been done.
Based on the final diagnosis, 32 (64.0%) patients had malignant stricture, and 39 (78.0%) had distal stricture. DIA had 84.40% (95% CI; 67.20–94.70) sensitivity and 94.40% (95% CI; 72.70–99.90) specificity in identifying nature of IBDS, whereas CCE had 19.0% (95% CI; 7.20–36.40) sensitivity and 89.0% (95% CI; 65.30–98.60) specificity. Combination of both modalities had 84.40% (95% CI; 67.20–94.70) sensitivity and 83.30% (95% CI; 58.60–96.40) specificity in identification nature of IBDS. Based on CCE alone, only 6/32 (18.80%) of malignant stricture were diagnosed, and 26/32 (81.20%) were missed. However, DIA alone was able to diagnose 27/32 (84.40%) of malignant stricture, and only 5 cases were missed. Both procedures had detection rate of malignant stricture as DIA alone. Benign stricture was correctly diagnosed in 16/18 (88.80%), 17/18 (94.40%), and 15/18 (83.30%) using CCE alone, DIA alone, and both procedures together, respectively. Cost per detection additional one malignant stricture using DIA required 99.4$.
DIA is substantially better than CCE in diagnosing the nature of IBDS but at an increase cost and thus suggests its application in a wider role in clinical practice.
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UroVysion Fluorescent in Situ Hybridization (U-FISH) Remains the Most Sensitive Method for Pancreatobiliary Stricture Malignancy Detection
2021, Techniques and Innovations in Gastrointestinal Endoscopy
Reports on fluorescent in situ hybridization (FISH) of pancreatobiliary strictures have shown a wide range of sensitivities for malignancy detection. Our aim was to determine the sensitivity and specificity at our institution of biliary brushings, forceps biopsies, fine needle aspirations, FISH, and their combinations.
The study entailed a retrospective review of all cases with pancreatobiliary stricture specimens at our institution over a 5-year period. The medical record for each case was reviewed to independently confirm the presence or absence of malignancy. Sensitivities and specificities were calculated for each method.
The cohort consisted of 181 sampling procedures from 154 patients. Of the patients, 39 (25.3%) had primary sclerosing cholangitis (PSC) and 41 (26.6%) had malignancy. Brush cytology sensitivity ranged from 24 to 63%. Forceps biopsy sensitivity ranged from 24 to 49%. FNA sensitivity ranged from 32 to 60%. Brush FISH ranged from 58 to 95%. Specificity was 99% for brush FISH and 100% for all other methods. The one false positive was an isolated FISH result in a case of PSC.
FISH should be performed since it is more sensitive than all other methods and nearly perfect in specificity outside the context of PSC. In PSC, isolated positive FISH results should be interpreted with caution.
DNA flow cytometric analysis of paraffin-embedded tissue for the diagnosis of malignancy in bile duct biopsies
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Differentiation of reactive versus neoplastic epithelial changes can be challenging in bile duct biopsies. The samples are often scant, distorted, and mixed with significant inflammation, ulceration, and/or debris. Histological confirmation of malignancy is often required before the initiation of surgical therapy, and an erroneous diagnosis of malignancy can lead to unnecessary clinical management. Aneuploidy assessment by DNA flow cytometry was performed on formalin-fixed paraffin-embedded (FFPE) tissue from 63 bile duct biopsies: 10 with a malignant diagnosis (7 with adenocarcinoma and 3 with at least high-grade dysplasia [HGD]); 3 with an atypical diagnosis showing rare atypical glands/cells, concerning but not definite for malignancy; 28 likely reactive biopsies with acute/chronic inflammation, ulceration, and/or mild nuclear atypia; and 22 additional benign biopsies without significant inflammation, ulceration, or nuclear atypia. Aneuploidy was detected in 7 (70%) of the 10 biopsies with definite neoplasia (5 of 7 adenocarcinoma cases and 2 of 3 at least HGD cases), all 3 (100%) atypical biopsies, and none of the 50 benign biopsies. All 3 atypical cases with aneuploidy were subsequently found to have adenocarcinoma (n = 2) or HGD (n = 1). Among the 2 cases of at least HGD with aneuploidy, 1 case developed adenocarcinoma, but no follow-up information was available in the other case. The remaining 1 case of at least HGD, despite having normal DNA content, was found to have adenocarcinoma on follow-up. None of the 50 benign cases (further supported by normal DNA content) developed adenocarcinoma within a mean follow-up time of 37 months (range: 0–282 months). The estimated sensitivity of aneuploidy as a diagnostic marker of malignancy (adenocarcinoma and HGD) was 70%, with the specificity of 100%, positive predictive value of 100%, and negative predictive value of 94%. In conclusion, DNA flow cytometry using FFPE tissue from bile duct biopsies demonstrates a high rate of aneuploidy (70%) in malignant cases and normal DNA content in all benign biopsies. Although the sample size is small, the results indicate that this assay can be potentially useful in challenging atypical cases, where morphological evaluation is limited by scarcity of atypical glands/cells, inflammation, and/or ulceration.

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: DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

: If you would like to chat with an author of this article, you may contact Dr Gonda at [email protected].

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Original articleClinical endoscopyPolysomy and p16 deletion by fluorescence in situ hybridization in the diagnosis of indeterminate biliary strictures

Background

Objective

Design

Setting

Patients

Main Outcome Measurements

Results

Limitations

Conclusion

Section snippets

Patient selection

Clinical and histologic characteristics

Discussion

HPB (Oxford)

J Hepatol

Gastrointest Endosc

HPB (Oxford)

Gastrointest Endosc

Gastroenterology

J Hepatol

Hum Pathol

Gastrointest Endosc Clin N Am

Original article
Clinical endoscopy
Polysomy and p16 deletion by fluorescence in situ hybridization in the diagnosis of indeterminate biliary strictures