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Case 4

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

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  1. Case 4 Stewart M. Knoepp, M.D., Ph.D. Department of Pathology University of Michigan Medical School

  2. 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.

  3. 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)*

  4. Pitfalls (False Negatives) • Sampling. • Scarcity of tumor cells (versus desmoplasticstroma). • Cell loss during processing. • Preparation artifact

  5. Pitfalls (False Positives) • Inflammation (e.g., choledocholithiasis) • Stent atypia • Metaplasia • Primary sclerosingcholangitis • Dysplasia

  6. 28

  7. 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.

  8. Reactive Changes

  9. BilIN-1

  10. BilIN-2

  11. BilIN-3

  12. 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

  13. 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

  14. 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

  15. Thank You!

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