Introduction Liver hilar pathology has traditionally been challenging to investigate as histological diagnosis is often difficult to obtain. The diagnostic yield of existing techniques including ERCP is suboptimal. Patients have consequently been managed in the absence of histological diagnosis, with the attendant hazards, including potential metal stent placement or unwarranted surgery in the absence of malignant disease. Upto 15% of patients with suspected biliary malignancy who undergo surgery are found to have benign disease. The utility of endoscopic ultrasound has not been established and our study aims to evaluate the role of EUS in this setting.
Methods This is a retrospective review of all patients with a hepatic hilar stricture and or mass, who were reviewed at the hepatobiliary multidisciplinary meeting between July 2006 and September 2011 and went on to have an EUS examination. Patients with presumed benign disease were followed until they underwent definitive surgery, or for 1-year with serial cross sectional imaging.
Results 95 patients with hilar lesions underwent 114 EUS examinations. 67 (70%) patients were diagnosed to have malignant disease. 58 patients had biliary tarct cancer. EUS-FNA yielded a positive cytological diagnosis in 52 (78%) patients. In 15 patients EUS cytology was false negative. 28 patients were diagnosed with benign disease. Factors that predicted malignant disease at EUS examination included the presence of a bile duct associated mass lesion (p value 0.0001) and an EUS morphological diagnosis of cancer (p value 0.03). The presence of “pathological” lymph nodes was not statistically significant (p value 0.79). Sensitivity in obtaining a cytological diagnosis, accuracy in defining benign and malignant disease, specificity and negative predictive value of EUS were 78%, 85%, 100%, and 66% respectively. Metal stent insertion was contemplated in atleast two patients following cross sectional imaging but was abandoned after EUS confirmed the benign nature of their condition.
Conclusion In the largest series to date we report high sensitivity (80%) for EUS cytology in the diagnosis of malignant disease and accuracy (85%) in distinguishing malignant from benign disease. EUS had a significant impact on the clinical management of our patients, including prevention of potential metal stent placement in atleast two patients who were eventually diagnosed with benign disease.
Competing interests None declared.
Reference 1. Fritscher-Ravens A, Broering DC, Knoefel WT, et al. EUS-guided FNA of suspected hilar cholangiocarcinoma in potentially operable patients with negative brush cytology. Am J Gastroenterol 2004;99:45–51.
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