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Case Study of Pancreatic Mass with Bile Duct Dilation: Diagnosis and Cytologic Challenges

This case study discusses a 70-year-old female presenting with obstructive jaundice, diagnosed via CT scan with a pancreatic head mass. An ERCP revealed significant intra- and extra-hepatic biliary dilation, prompting the placement of an endobiliary stent. Bile duct brushings were analyzed for malignancy based on established cytologic criteria. Findings indicated choledochitis with marked duct dilation and intestinal metaplasia, ultimately negative for malignancy. The study emphasizes the importance of recognizing false positives and negatives in bile duct brushing cytology.

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Case Study of Pancreatic Mass with Bile Duct Dilation: Diagnosis and Cytologic Challenges

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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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