77
American Journal of Roentgenology 1991.156:77-78.
Percutaneous a Bioptome Keith Terasaki,1 Gerhard Daniel Lucas1
Transluminal A. Wittich,1 Gerhard
Technical
Note
Biopsy of Biliary Strictures
with
Lycke,1 Reinhard
Several techniques are currently available to perform biopsy of biliary duct strictures. If an associated mass is seen on CT, sonography, or cholangiography, percutaneous fine-needle aspiration biopsy can often be performed, with a sensitivity of 50-90% for malignant obstruction [1 , 2]. When biliary obstruction is due to a small tumor, endoluminal biopsy techniques may be preferable to standard percutaneous biopsy techniques. Cytologic examination of bile after percutaneous biliary drainage is easy to perform and inexpensive, but detects only 34% of malignant biliary strictures [3]. Brush biopsy performed via a percutaneous transhepatic transluminal approach or during endoscopic retrograde cholangiography is reported to yield malignant cells in 50-70% of malignant cases [4]. Because of the relatively low sensitivity of available methods for diagnosis of malignant biliary strictures, we performed percutaneous transluminal biopsy with a flexible bioptome in six patients with biliary strictures.
Walter,1 Kent Nowels,2
In three
three
dilatation
and Methods
to 72 years. carcinoma,
Five renal
patients
had
cell carcinoma,
a history lymphoma,
of malignant
disease
(colonic
cholangiocarcinoma,
and
pancreatic carcinoma) that had been treated with either primary tumor resection or chemotherapy. One patient had a primary tumor in the head of the pancreas. Each patient then presented with obstructive jaundice.
Sonographic
three
and CT examinations
showed
biliary
dilatation.
January
1991 0361-803x/91/1561-0077
C American
Roentgen
be seen
the
patient,
appeared
to the duct,
right
in one
duct
in one
soft-tip
guiding
patient,
the
patient.
in
bile duct in
main
The
left
duct
obstruction
mass in five patients and was
After
passed
cannulation
through
catheter
performed
the common
in another
patient.
was
was
involving
ducts
a guidewire
or 8-French
hepatis. In the for the biliary
porta
accounting
cholangiography
strictures
both
duct
the
and
on CT or sonography.
main
and
near
mass
to be due to an extraluminal
intrinsic biliary
seen
transhepatic
patients,
in one
was
no definite
each case and showed
of a peripheral
the
stenosis
(Schneider-Shiley,
and
a
6-
Minneapolis,
MN)was inserted through an 8-French peel-away sheath. The guiding catheter was advanced far enough to abut the area of stricture soon on
the
cholangiogram.
Bloomington, catheter,
A 50-cm,
IN) or 5-French
Bloomington,
IN) and
for transjugular
(Fig.
biopsy
scopic guidance
of
specimens and
biopsy,
stricture
endomyocardial
The
to five
the
then
3-French (Cordis, was
biopsy sent
biopsies.
through performed
the
design
Cook, guiding
under
were designed Their
(Cook,
FL, and
fluoro-
primarily
is similar
to an
but they are shorter and of smaller caliber.
were samples for
bioptome
Miami,
inserted
(Fig. 2). These bioptomes
wire forceps,
biopsy
flexible,
bioptome
1) was
endoscopic
1 to 2 mm were
cytologic
an external-internal
biliary
in diameter.
taken
from
and
cell-block
drain
was
In each
different
portions
examination. placed
in five
patient, of the After patients,
and an endoprosthesis was placed in one patient. All patients received IV antibiotics before the procedure. Results In all six patients, the malignancy and correlated
Received February 7, 1990: accepted after revision June 14, 1990. This work was supported in part by academic training grant HLO 7425 from the National I Department of Diagnostic Radiology and Nuclear Medicine, Stanford University School Terasaki (Am. H2321). 2 Department of Pathology, Stanford University School of Medicine, Stanford, CA 94304. AJR 156:77-78,
could
stricture
The six patients in the study were all men, ranging in age from 46
a mass
patients,
Percutaneous
three Subjects
patients,
other
David Swanson,1
biopsy results were positive for with the patient’s known primary
Heart, Lung, and Blood Institute of the National of Medicine, Stanford, CA 94305-5105. Address
Ray Society
Institutes of Health. reprint requests to K.
78
TERASAKI
ET AL.
AJR:156,
Fig. 1.-Flexible
5-French
January
1991
bioptome.
American Journal of Roentgenology 1991.156:77-78.
Fig. 2.-After percutaneous biliary drainage, a flexible bioptome (arrow) has been inserted through a 60-French guiding catheter for biopsy of a stricture in common bile duct.
tumor. The 3-French bioptome was used in two patients and the 5-French bioptome in four patients. In one patient with recurrent pancreatic carcinoma, separate biopsies were performed in both the right and left hepatic ducts; results of both biopsies were positive. In the patient with recurrent cholangiocarcinoma, multiple biopsies along the left hepatic duct were performed to determine the extent of cholangiocarcinoma. Results of biopsies at each of these sites were positive for carcinoma. No major complications occurred. Minor hemobilia developed after biopsy in one patient and cleared within 24 hr.
Discussion Our initial experience with use of the flexible bioptome for percutaneous transluminal biopsy of biliary strictures has shown that the procedure is simple and easy to perform in conjunction with percutaneous biliary drainage and can be used to obtain tissue for pathologic diagnosis. As the bioptome is an intraluminal device, it allows accurate biopsy of lesions even when no mass is seen on CT or sonography. This is often the case in cholangiocarcinoma and when attempting to differentiate recurrent tumor from a postsurgical or a radiation-induced bile duct stricture. Because the bioptome can be positioned accurately with use of the guiding catheter, the biopsy specimen can be obtained from the area of the stricture most narrowed or irregular on the cholangiogram. This presumably has the greatest chance of yielding malignant cells. As the site of biopsy can be determined, the extent of tumor involvement also can be ascertained. This could be important when determining the surgical resectability of certain tumors. As the biopsy specimen is 1 -2 mm thick, extramucosal, intramural lesions may be diagnosed. Biliary obstruction is often due to lymph node metastases to the porta hepatis with incomplete tumor invasion through the duct wall. In five of our cases, the stricture appeared to be due to an extrinsic mass, but biopsy with the bioptome obtained malignant tissue. In patients with hemobilia or cholangitis, the biopsy should be deferred for several days because bioptome biopsy in-
creases the amount of bile duct manipulation. If percutaneous biliary access is impossible, or if the stricture is too difficult to reach, bioptome biopsy is not possible. If the stricture cannot be crossed with a guidewire, the bioptome can still be advanced up the stricture and a biopsy sample obtained there. The theoretical risks of performing transmural biopsies of the common bile duct wall include injury to an adjacent blood vessel or development of a bile leak. This did not occur in our six patients. Biopsy of biliary duct strictures with a forceps has been reported. Palayew and Stein [5] first used a postoperative Ttube tract to introduce a bronchial forceps for biopsy. Burhenne [6] also reported the use of a forceps biopsy via a subhepatic T-tube tract in 1 3 patients. Nishimura et al. [7] used a transhepatic access to introduce a 20-French choledochoscope and visually direct biopsy with a 7-French bioptome, while Elyaderani and Gabrielle [8] used a 1 2-French transhepatic catheter to introduce a biopsy forceps. The advantage of our bioptome is that after external drainage of an obstructed biliary system, it can be quickly and easily used through an 8-French tract.
REFERENCES 1 . Cohan RH, Illescas FF, Braun SD, Newman GE, Dunnick NA. Fine needle aspiration biopsy in malignant obstructive jaundice. Gastointest Radio! 1986:11 :145-1 50 2. Teplick 5K, Haskin PH, Kline TS, Sammon JK, Laffey PA. Percutaneous pancreaticobiliary biopsies in 1 73 patients using primarily ultrasound or fluoroscopic guidance. Cardiovasc Intervent Radio! 1988:11:26-28 3. Muro A, Mueller PR, Ferrucci JT, Taft PD. Bile cytology: a routine addition to percutaneous biliary drainage. Radiology 1983:149:846-847 4. Mendez G Jr, Russell E, Levi JU, Koolpe H, Cohen M. Percutaneous brush
5. 6. 7. 8.
biopsy and intemal drainage of biliary tree through endoprosthesis. AJR 1980:134:653-659 Palayew MJ, Stein L. Postoperative biopsy of the common bile duct via the T-tube tract. AJR 1978:130:287-289 Burhenne HJ. Biliary tract. In: Marguilis AA, Burhenne HJ, eds. Alimentary tract radiology. St. Louis: Mosby, 1983:2334-2336 Nishimura A, Otsu H, Hiura T. Forceps biopsy of the bile duct under choledochoscopic control. Endoscopy 1980: 1 2 : 23-29 Elyaderani MK, Gabrielle OF. Brush and forceps biopsy of biliary ducts via percutaneous transhepatic catheterization. Radiology 1980:1 35: 777-778
American Journal of Roentgenology 1991.156:77-78.
Percutaneous a Bioptome Keith Terasaki,1 Gerhard Daniel Lucas1
Transluminal A. Wittich,1 Gerhard
Technical
Note
Biopsy of Biliary Strictures
with
Lycke,1 Reinhard
Several techniques are currently available to perform biopsy of biliary duct strictures. If an associated mass is seen on CT, sonography, or cholangiography, percutaneous fine-needle aspiration biopsy can often be performed, with a sensitivity of 50-90% for malignant obstruction [1 , 2]. When biliary obstruction is due to a small tumor, endoluminal biopsy techniques may be preferable to standard percutaneous biopsy techniques. Cytologic examination of bile after percutaneous biliary drainage is easy to perform and inexpensive, but detects only 34% of malignant biliary strictures [3]. Brush biopsy performed via a percutaneous transhepatic transluminal approach or during endoscopic retrograde cholangiography is reported to yield malignant cells in 50-70% of malignant cases [4]. Because of the relatively low sensitivity of available methods for diagnosis of malignant biliary strictures, we performed percutaneous transluminal biopsy with a flexible bioptome in six patients with biliary strictures.
Walter,1 Kent Nowels,2
In three
three
dilatation
and Methods
to 72 years. carcinoma,
Five renal
patients
had
cell carcinoma,
a history lymphoma,
of malignant
disease
(colonic
cholangiocarcinoma,
and
pancreatic carcinoma) that had been treated with either primary tumor resection or chemotherapy. One patient had a primary tumor in the head of the pancreas. Each patient then presented with obstructive jaundice.
Sonographic
three
and CT examinations
showed
biliary
dilatation.
January
1991 0361-803x/91/1561-0077
C American
Roentgen
be seen
the
patient,
appeared
to the duct,
right
in one
duct
in one
soft-tip
guiding
patient,
the
patient.
in
bile duct in
main
The
left
duct
obstruction
mass in five patients and was
After
passed
cannulation
through
catheter
performed
the common
in another
patient.
was
was
involving
ducts
a guidewire
or 8-French
hepatis. In the for the biliary
porta
accounting
cholangiography
strictures
both
duct
the
and
on CT or sonography.
main
and
near
mass
to be due to an extraluminal
intrinsic biliary
seen
transhepatic
patients,
in one
was
no definite
each case and showed
of a peripheral
the
stenosis
(Schneider-Shiley,
and
a
6-
Minneapolis,
MN)was inserted through an 8-French peel-away sheath. The guiding catheter was advanced far enough to abut the area of stricture soon on
the
cholangiogram.
Bloomington, catheter,
A 50-cm,
IN) or 5-French
Bloomington,
IN) and
for transjugular
(Fig.
biopsy
scopic guidance
of
specimens and
biopsy,
stricture
endomyocardial
The
to five
the
then
3-French (Cordis, was
biopsy sent
biopsies.
through performed
the
design
Cook, guiding
under
were designed Their
(Cook,
FL, and
fluoro-
primarily
is similar
to an
but they are shorter and of smaller caliber.
were samples for
bioptome
Miami,
inserted
(Fig. 2). These bioptomes
wire forceps,
biopsy
flexible,
bioptome
1) was
endoscopic
1 to 2 mm were
cytologic
an external-internal
biliary
in diameter.
taken
from
and
cell-block
drain
was
In each
different
portions
examination. placed
in five
patient, of the After patients,
and an endoprosthesis was placed in one patient. All patients received IV antibiotics before the procedure. Results In all six patients, the malignancy and correlated
Received February 7, 1990: accepted after revision June 14, 1990. This work was supported in part by academic training grant HLO 7425 from the National I Department of Diagnostic Radiology and Nuclear Medicine, Stanford University School Terasaki (Am. H2321). 2 Department of Pathology, Stanford University School of Medicine, Stanford, CA 94304. AJR 156:77-78,
could
stricture
The six patients in the study were all men, ranging in age from 46
a mass
patients,
Percutaneous
three Subjects
patients,
other
David Swanson,1
biopsy results were positive for with the patient’s known primary
Heart, Lung, and Blood Institute of the National of Medicine, Stanford, CA 94305-5105. Address
Ray Society
Institutes of Health. reprint requests to K.
78
TERASAKI
ET AL.
AJR:156,
Fig. 1.-Flexible
5-French
January
1991
bioptome.
American Journal of Roentgenology 1991.156:77-78.
Fig. 2.-After percutaneous biliary drainage, a flexible bioptome (arrow) has been inserted through a 60-French guiding catheter for biopsy of a stricture in common bile duct.
tumor. The 3-French bioptome was used in two patients and the 5-French bioptome in four patients. In one patient with recurrent pancreatic carcinoma, separate biopsies were performed in both the right and left hepatic ducts; results of both biopsies were positive. In the patient with recurrent cholangiocarcinoma, multiple biopsies along the left hepatic duct were performed to determine the extent of cholangiocarcinoma. Results of biopsies at each of these sites were positive for carcinoma. No major complications occurred. Minor hemobilia developed after biopsy in one patient and cleared within 24 hr.
Discussion Our initial experience with use of the flexible bioptome for percutaneous transluminal biopsy of biliary strictures has shown that the procedure is simple and easy to perform in conjunction with percutaneous biliary drainage and can be used to obtain tissue for pathologic diagnosis. As the bioptome is an intraluminal device, it allows accurate biopsy of lesions even when no mass is seen on CT or sonography. This is often the case in cholangiocarcinoma and when attempting to differentiate recurrent tumor from a postsurgical or a radiation-induced bile duct stricture. Because the bioptome can be positioned accurately with use of the guiding catheter, the biopsy specimen can be obtained from the area of the stricture most narrowed or irregular on the cholangiogram. This presumably has the greatest chance of yielding malignant cells. As the site of biopsy can be determined, the extent of tumor involvement also can be ascertained. This could be important when determining the surgical resectability of certain tumors. As the biopsy specimen is 1 -2 mm thick, extramucosal, intramural lesions may be diagnosed. Biliary obstruction is often due to lymph node metastases to the porta hepatis with incomplete tumor invasion through the duct wall. In five of our cases, the stricture appeared to be due to an extrinsic mass, but biopsy with the bioptome obtained malignant tissue. In patients with hemobilia or cholangitis, the biopsy should be deferred for several days because bioptome biopsy in-
creases the amount of bile duct manipulation. If percutaneous biliary access is impossible, or if the stricture is too difficult to reach, bioptome biopsy is not possible. If the stricture cannot be crossed with a guidewire, the bioptome can still be advanced up the stricture and a biopsy sample obtained there. The theoretical risks of performing transmural biopsies of the common bile duct wall include injury to an adjacent blood vessel or development of a bile leak. This did not occur in our six patients. Biopsy of biliary duct strictures with a forceps has been reported. Palayew and Stein [5] first used a postoperative Ttube tract to introduce a bronchial forceps for biopsy. Burhenne [6] also reported the use of a forceps biopsy via a subhepatic T-tube tract in 1 3 patients. Nishimura et al. [7] used a transhepatic access to introduce a 20-French choledochoscope and visually direct biopsy with a 7-French bioptome, while Elyaderani and Gabrielle [8] used a 1 2-French transhepatic catheter to introduce a biopsy forceps. The advantage of our bioptome is that after external drainage of an obstructed biliary system, it can be quickly and easily used through an 8-French tract.
REFERENCES 1 . Cohan RH, Illescas FF, Braun SD, Newman GE, Dunnick NA. Fine needle aspiration biopsy in malignant obstructive jaundice. Gastointest Radio! 1986:11 :145-1 50 2. Teplick 5K, Haskin PH, Kline TS, Sammon JK, Laffey PA. Percutaneous pancreaticobiliary biopsies in 1 73 patients using primarily ultrasound or fluoroscopic guidance. Cardiovasc Intervent Radio! 1988:11:26-28 3. Muro A, Mueller PR, Ferrucci JT, Taft PD. Bile cytology: a routine addition to percutaneous biliary drainage. Radiology 1983:149:846-847 4. Mendez G Jr, Russell E, Levi JU, Koolpe H, Cohen M. Percutaneous brush
5. 6. 7. 8.
biopsy and intemal drainage of biliary tree through endoprosthesis. AJR 1980:134:653-659 Palayew MJ, Stein L. Postoperative biopsy of the common bile duct via the T-tube tract. AJR 1978:130:287-289 Burhenne HJ. Biliary tract. In: Marguilis AA, Burhenne HJ, eds. Alimentary tract radiology. St. Louis: Mosby, 1983:2334-2336 Nishimura A, Otsu H, Hiura T. Forceps biopsy of the bile duct under choledochoscopic control. Endoscopy 1980: 1 2 : 23-29 Elyaderani MK, Gabrielle OF. Brush and forceps biopsy of biliary ducts via percutaneous transhepatic catheterization. Radiology 1980:1 35: 777-778
