Yield of biliary stent cytology: Is it time to think lean?

 

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Abstract

Background and study aims During evaluation of pancreaticobiliary strictures, it is common practice to send biliary stents for cytologic analysis. However, in recent years, complementary tissue acquisition techniques ranging from cholangioscopy to fine-needle biopsy have improved the ability to acquire tissue and diagnose malignancy. Data are limited on the current diagnostic yield and cost effectiveness of biliary stent analysis.

Patients and methods We performed a retrospective study of all pancreaticobiliary stents sent for analysis in a tertiary care academic medical center from June 2013 to September 2016. Patient demographics, stent information, and final diagnosis history were collected through chart review. Costs were determined using published reimbursement rates for Medicare.

Results Two hundred thirty-one stents from 175 patients were sent for cytologic analysis during the study period. Of the 62 stents obtained from patients ultimately diagnosed with malignancy, only one (1.6 %) had positive cytology for malignant cells, while the others were acellular/non-diagnostic (2/62, 3.2 %), negative (48/62, 77.4 %), or atypical (11/62, 17.7 %). The sensitivity of stent cytology for diagnosis of malignancy was 1.6 % (1/62). No cases were identified in which stent cytology changed clinical management. From a payer perspective, the mean estimated cost for each stent cytologic analysis is greater than $ 70.00.

Conclusions While stent cytologic analysis is a common clinical practice, the diagnostic yield and cost effectiveness of the practice must be reevaluated. With the rise of newer diagnostic technologies such as digital cholangioscopy and endoscopic ultrasound-guided fine-needle biopsy, it may be time to “think lean” and acknowledge a sunset for biliary stent cytology.

• References

• 1 Bledsoe JR, Shinagare SA, Deshpande V. Difficult Diagnostic Problems in Pancreatobiliary Neoplasia. Arch Pathol Lab Med 2015; 139: 848-857
  CrossrefPubMedGoogle Scholar
• 2 Burnett AS, Bailey J, Oliver JB. et al. Sensitivity of alternative testing for pancreaticobiliary cancer: a 10-y review of the literature. J Surg Res 2014; 190: 535-547
  CrossrefPubMedGoogle Scholar
• 3 Kalaitzakis E, Levy M, Kamisawa T. et al. Endoscopic retrograde cholangiography does not reliably distinguish IgG4-associated cholangitis from primary sclerosing cholangitis or cholangiocarcinoma. Clin Gastroenterol Hepatol 2011; 9: 800-803 e2
  CrossrefPubMedGoogle Scholar
• 4 Pereira P, Peixoto A, Andrade P. et al. Peroral cholangiopancreatoscopy with the SpyGlass(R) system: what do we know 10 years later. J Gastrointestin Liver Dis 2017; 26: 165-170
  CrossrefPubMedGoogle Scholar
• 5 De Moura DTH, Moura EGH, Bernardo WM. et al. Endoscopic retrograde cholangiopancreatography versus endoscopic ultrasound for tissue diagnosis of malignant biliary stricture: Systematic review and meta-analysis. Endosc Ultrasound 2018; 7: 10-19
  CrossrefPubMedGoogle Scholar
• 6 Mohamadnejad M, Mullady D, Early DS. et al. Increasing number of passes beyond 4 does not increase sensitivity of detection of pancreatic malignancy by endoscopic ultrasound-guided fine-needle aspiration. Clin Gastroenterol Hepatol 2017; 15: 1071-1078 e2
  CrossrefPubMedGoogle Scholar
• 7 Banafea O, Mghanga FP, Zhao J. et al. Endoscopic ultrasonography with fine-needle aspiration for histological diagnosis of solid pancreatic masses: a meta-analysis of diagnostic accuracy studies. BMC Gastroenterol 2016; 16: 108
  CrossrefPubMedGoogle Scholar
• 8 DiMaio CJ, Kolb JM, Benias PC. et al. Initial experience with a novel EUS-guided core biopsy needle (SharkCore): results of a large North American multicenter study. Endosc Int Open 2016; 4: E974-989
  Article in Thieme ConnectPubMedGoogle Scholar
• 9 Cheng B, Zhang Y, Chen Q. et al. Analysis of fine-needle biopsy versus fine-needle aspiration in diagnosis of pancreatic and abdominal masses: a prospective, multicenter, randomized controlled trial. Clin Gastroenterol Hepatol 2018; 16: 1314-1321
  CrossrefPubMedGoogle Scholar
• 10 Foutch PG, Kerr DM, Harlan JR. et al. A prospective, controlled analysis of endoscopic cytotechniques for diagnosis of malignant biliary strictures. Am J Gastroenterol 1991; 86: 577-580
  PubMedGoogle Scholar
• 11 Leung JW, Sung JY, Chung SC. et al. Endoscopic scraping biopsy of malignant biliary strictures. Gastrointest Endosc 1989; 35: 65-66
  PubMedGoogle Scholar
• 12 Devereaux BM, Fogel EL, Bucksot L. et al. Clinical utility of stent cytology for the diagnosis of pancreaticobiliary neoplasms. Am J Gastroenterol 2003; 98: 1028-1031
  CrossrefPubMedGoogle Scholar
• 13 Physician Fee Schedule (MPFS). Centers for Medicare & Medicaid Services. Available at: https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/ Accessed January 4, 2019
  PubMedGoogle Scholar
• 14 Procedural Reimbursement Guide for Endoscopy 2016. Boston Scientific. Available at: https://www.bostonscientific.com/content/dam/bostonscientific/Reimbursement/Gastroenterology/2016/2016_Procedural_Reimbursement_Guide_Endoscopy.pdf/ Accessed January 4, 2019
  PubMedGoogle Scholar
• 15 Survival statistics for bile duct cancers. American Cancer Society. Available at: https://www.cancer.org/cancer/bile-duct-cancer/detection-diagnosis-staging/survival-by-stage.html Accessed January 4, 2019
  PubMedGoogle Scholar
• 16 Fritscher-Ravens A, Broering DC, Knoefel WT. et al. EUS-guided fine-needle aspiration of suspected hilar cholangiocarcinoma in potentially operable patients with negative brush cytology. Am J Gastroenterol 2004; 99: 45-51
  CrossrefPubMedGoogle Scholar
• 17 Jailwala J, Fogel EL, Sherman S. et al. Triple-tissue sampling at ERCP in malignant biliary obstruction. Gastrointest Endosc 2000; 51: 383-390
  CrossrefPubMedGoogle Scholar
• 18 Mehmood S, Loya A, Yusuf MA. Biliary brush cytology revisited. Acta Cytol 2016; 60: 167-172
  CrossrefPubMedGoogle Scholar
• 19 Onda S, Ogura T, Kurisu Y. et al. EUS-guided FNA for biliary disease as first-line modality to obtain histological evidence. Therap Adv Gastroenterol 2016; 9: 302-312
  CrossrefPubMedGoogle Scholar
• 20 Kozarek RA. The future of ERCP. Endosc Int Open 2017; 5: E272-E274
  Article in Thieme ConnectPubMedGoogle Scholar
• 21 Ubel PA, Asch DA. Creating value in health by understanding and overcoming resistance to de-innovation. Health Affairs 2015; 34: 239-244
  CrossrefPubMedGoogle Scholar