Value Of Brush Cytology In The Surveillance Of Patients With Primary Sclerosing Cholangitis

Background: Primary Sclerosing Cholangitis (PSC) is a chronic inflammatory biliary disease with increased risk to develop cholangiocarcinoma (CCC). To date, liver transplantation is the only curative therapy for PSC which requires careful selection of patients at risk. The present retrospective study aims at assessing the role of cytology as prognostic factor. Methods: During a period of 14 years (10/1991 - 02/2005) 88 patients with PSC were identified whose inclusion criteria were: PSC, no signs of tumor, stable health condition, ERC realizable, bile specimen cytology evaluable. In all patients biliary specimens were obtained by ERC-guided brush cytology and bile aspiration. Survival was calculated by using the Kaplan-Meier algorithm. Results: Of the 88 PSC patients (27% female, 73% male, mean age 42 ± 13 (range 18-78) years) brush and/or bile cytology revealed carcinoma in 14.7% (13/88), high grade dysplasia in 37.5% (33/88), medium grade dysplasia in 22.7% (20/88) and low grade dysplasia in 5.7% (5/88) as well as inflammation or normal findings in 19.3% (17/88). 5 patients with microscopic cholangiocarcinoma (no tumor signs on image modalities) received liver transplantation. Of those, 1 patient died due to tumor recurrence while 4 patients are still alive with a mean survival of 2.7 ± 0.3 years. In contrast, 4 out of 8 patients with the cytological diagnosis of cholangiocarcinoma and conservative management died within 1 year (mean survival time 1.2 ± 0.2 years). 10 patients with high grade dysplasia on biliary cytology also underwent liver transplantation. 1 patient died due to postoperative complications 4 weeks after transplantation while 9 patients are still alive resulting in a mean survival of 4.9 ± 0.6 years. 23 further patients with high grade dysplasia without surgical therapy showed a mean survival of 3.0 years and 6 fatal courses, 4 of them due to tumor progression and 2 due to liver failure. Conclusion: Screening ERC with cytological investigation of bile specimen was able to identify patients with cholangiocarcinoma in 15% of cases at a time point where no other diagnostic modality was able to detect the tumor. Liver transplantation of patients with cytological diagnosis of cholangiocarcinoma was highly successful since 5 out of 6 patients turned out to be long term survivors. The approach of screening ERC and cytological investigation is a promising approach for PSC patients.