Rösch Thomas, Hofrichter Kim, Frimberger Eckart, Meining Alexander, Born Peter, Weigert Norbert, Allescher Hans-Dieter, Classen Meinhard, Barbur Marius, Schenck Ulrich, Werner Martin
Department of Internal Medicine II, Department of Pathology, Technical University of Munich, Munich, Germany.
Gastrointest Endosc. 2004 Sep;60(3):390-6. doi: 10.1016/s0016-5107(04)01732-8.
BACKGROUND: The accuracy of ERCP-based brush cytology or forceps biopsy for tissue diagnosis is relatively low (usually not exceeding 70%). By contrast, reported accuracy rates for EUS-guided FNA of pancreatobiliary masses are over 80%. This prospective study compared these two modalities for the first time in the diagnosis of indeterminate biliary strictures and pancreatic tumors. METHODS: Fifty consecutive patients (29 men, 21 women; mean age 62.1 years) with obstructive jaundice in whom a tissue diagnosis was required were included. During ERCP, intraductal specimens were obtained with a forceps and with two different types of brush (conventional and spiral suction) in random order. During EUS, only visible mass lesions or localized bile duct wall thickening were aspirated (22-gauge needle), with at least two passes yielding material sufficient for assessment. A cytopathologist was not present in the procedure room to evaluate specimen adequacy. The reference methods were surgery, other biopsy results, follow-up until death, or the conclusion of the study (mean follow-up 20 months). RESULTS: The final diagnoses were malignancy, 28 (16 pancreatic, 12 biliary), and benign biliary stricture, 22. Sensitivity and specificity for ERCP-guided biopsy were 36% and 100%, respectively; for ERCP-guided cytology (when using conventional and spiral suction brushes), 46% and 100%, respectively; and for EUS-guided FNA, 43% and 100%, respectively. If the punctured lesions are considered (n=28) alone, the sensitivity of EUS-guided FNA was 75%. In general, sensitivity was better for ERCP-based techniques in the subgroup biliary tumor (ERCP 75% vs. EUS 25%), whereas EUS-guided biopsy was superior for pancreatic mass (EUS 60% vs. ERCP 38%). CONCLUSIONS: For biliary strictures, combined ERCP- and EUS-guided tissue acquisition seems to be the best approach to tissue diagnosis. From a clinical standpoint, it appears reasonable, when a tissue diagnosis is required, to start with ERCP if biliary malignancy is suspected and with EUS when a pancreatic tumor is thought to be the cause of a biliary stricture.
背景：基于内镜逆行胰胆管造影（ERCP）的刷检细胞学或钳取活检进行组织诊断的准确性相对较低（通常不超过70%）。相比之下，报道的超声内镜引导下细针穿刺抽吸活检（EUS-FNA）诊断胰胆管肿块的准确率超过80%。这项前瞻性研究首次比较了这两种方法在诊断不明原因胆管狭窄和胰腺肿瘤中的应用。 方法：纳入50例连续的需要进行组织诊断的梗阻性黄疸患者（29例男性，21例女性；平均年龄62.1岁）。在ERCP过程中，随机顺序使用活检钳和两种不同类型的刷子（传统刷和螺旋吸引刷）获取导管内标本。在EUS检查时，仅对可见的肿块病变或局限性胆管壁增厚进行抽吸（22G针），至少穿刺两次获取足够用于评估的材料。操作室内没有细胞病理学家评估标本是否充足。参考方法为手术、其他活检结果、随访直至死亡或研究结束（平均随访20个月）。 结果：最终诊断为恶性肿瘤28例（16例胰腺肿瘤，12例胆管肿瘤），良性胆管狭窄22例。ERCP引导下活检的敏感性和特异性分别为36%和100%；ERCP引导下细胞学检查（使用传统刷和螺旋吸引刷时）分别为46%和100%；EUS引导下FNA分别为43%和100%。若仅考虑穿刺的病变（n = 28），EUS引导下FNA的敏感性为75%。总体而言，在胆管肿瘤亚组中，基于ERCP的技术敏感性更好（ERCP为75%，EUS为25%），而EUS引导下活检对胰腺肿块更具优势（EUS为60%，ERCP为38%）。 结论：对于胆管狭窄，联合ERCP和EUS引导下获取组织似乎是组织诊断的最佳方法。从临床角度来看，当需要组织诊断时，如果怀疑胆管恶性肿瘤，先进行ERCP检查似乎合理；如果认为胰腺肿瘤是胆管狭窄的原因，则先进行EUS检查。
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