Role of Endoscopic Retrograde Cholangio- Pancreatography Guided Brush Cytology in Evaluation of Malignant Biliary Tract Strictures: Experience of a Tertiary Care Teaching Centre in Northern India.

Introduction: Endoscopic Retrograde Cholangio- Pancreatography (ERCP) is a gold standard procedure for evaluation of biliary tract lesions. There is a need to obtain a timely diagnosis without subjecting patient who harbours benign disease to major surgery. Strictures due to malignancy are one of the common reasons for obstructive jaundice in our set up. ERCP procedure is performed in such cases to relieve the block by stenting or papillotomy. Biliary strictures that are suspected to be malignant but lack a tissue diagnosis, termed indeterminate strictures, often pose a diagnostic dilemma. Pathological confirmation is desirable for deciding further management protocol. Brush cytology proves to be safe and sensitive procedure in diagnosis of biliary tract lesions. Aim: This study aims at evaluating the cytomorphological features of intra/extrahepatic malignant lesions directed by ERCP guided brush cytology and to establish the usefulness of biliary brushings in reaching a diagnosis in cases of malignant strictures presenting with obstructive jaundice. Materials and Methods: The study was a prospective study of one year time period. Cytological material was obtained from 40 cases of malignant strictures presenting with obstructive jaundice, who underwent ERCP for evaluation and treatment. Five cases of benign stricture were assessed to define benign baseline cytomorphology. The smears were prepared and analysed for standard cytological features. Results: Out of 40 malignant cases, smears from eight were classified as benign, five as reactive, five as NOS-suspicious, and 22 as malignant. Benign and reactive smears were considered as negative (13/40), suspicious and malignant smears (27/40) were considered as positive. On follow up 62.5% of the cases (25/40) were diagnosed as Carcinoma Gall bladder, 20% (8/40) as cholangiocarcinoma, 12.5% (5/40) as periampullary carcinoma and 5% (2/40) as pancreatic ductal adenocarcinoma. Detection rate by cytology was 100% in pancreatic ductal adenocarcinoma, 87.5% in cholangiocarcinoma, periampullary carcinoma (80%) and 56% in carcinoma gall bladder involving common bile duct. Overall sensitivity of brush cytology was 67.5%. Cytomorphological features of increased cellularity, loss of polarity, nuclear hyperchromasia, irregular nuclear outline and nucleolar prominence were found consistent with malignancy. Additional features seen in malignant diagnosis were nuclear variability, background atypical cells and multinucleate cells. Conclusion: The present study support that ERCP guided brush cytology is a sensitive method in evaluating cases of malignant biliary tract strictures. [ABSTRACT FROM AUTHOR]