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Case 4. Stewart M. Knoepp, M.D., Ph.D. Department of Pathology University of Michigan Medical School. Case # 4. 70 year old female with two-week history of obstructive jaundice was evaluated with CT scan and found to have a pancreatic head mass.
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Case 4 Stewart M. Knoepp, M.D., Ph.D. Department of Pathology University of Michigan Medical School
Case # 4 • 70 year old female with two-week history of obstructive jaundice was evaluated with CT scan and found to have a pancreatic head mass. • ERCP demonstrated significant intra- and extra-hepatic biliary dilation for which an endobiliary stent was placed. • Bile duct brushing via ERCP is obtained.
Criteria for Malignancy in BDB*Best criteria (Renshaw et al. AJCP 1998;110;635-640) • Macronucleoli • Nuclear chromatin clumping* • Nuclear membrane irregularities • Increased N/C ratios* • Variation in nuclear size and cell size • Large cells • Single (atypical) cells • Architecture (loss of)*
Pitfalls (False Negatives) • Sampling. • Scarcity of tumor cells (versus desmoplasticstroma). • Cell loss during processing. • Preparation artifact
Pitfalls (False Positives) • Inflammation (e.g., choledocholithiasis) • Stent atypia • Metaplasia • Primary sclerosingcholangitis • Dysplasia
Hoang et al. Metaplastic Lesions of the Extrahepatic Bile Ducts: A Morphologic and Immunohistochemical Study. Mod Pathol 2001;14(11):1119-1125 • 13 of 32 (40%) neoplastic cases showed metaplastic changes. • 7 of 10 (70%) of inflammatory cases showed metaplastic changes. • Metaplastic changes consisted of pyloric gland metaplasia, intestinal metaplasia, squamousmetaplasia, and endocrine cells.
Case # 4 Diagnosis • Choledochitis with marked duct dilation, periductal fibrosis, extensive intestinal metaplasia and reactive epithelial changes. Negative for malignancy. Pancreas with patchy low-grade PanIN and mild chronic pancreatitis. 2
Avoiding False Positive Pitfalls in Bile Duct Brushing Cytology • Use well-established cytologic criteria. • Do NOT rely on one or two criteria, but use three or four. • Recognize known false-positive pitfalls such as intestinal metaplasia. 29
Summary • Bile duct brushing cytology is a moderately sensitive yet highly specific tool used to assess for the presence of pancreatobiliary malignancy. • Sensitivity increases with multiple procedures. • Specificity may be optimized by incorporating clinical information and avoiding known pitfalls 29