EASL Campus

A 44-year-old man with primary sclerosing cholangitis (PSC), with a mild ulcerative colitis (UC), former smoker, without other significant comorbidities, showed at his last annual abdominal ultrasound (US) newly dilatated intrahepatic bile ducts. Blood tests showed slightly increased cholestasis compared to previous tests (normal bilirubin levels, GGT 155 U/L (previous 67), ALP 176 IU/L (previous 110). He underwent a magnetic resonance cholangiopancreatography (MRCP), which confirmed the presence of dilated intrahepatic bile ducts, while the gadoxetic MR evidenced a 3 cm perihilar biliary stricture, highly suspicious for an extrahepatic cholangiocarcinoma (eCCA). A chest CT scan excluded lung metastases. The patient is asymptomatic with preserved liver function, CA19.9 is 38 IU/mL. Last endoscopy showed neither evidence of active UC lesions nor colorectal cancer lesions.

Do you think this patient should be considered for histological/cytological diagnosis of eCCA, and if so, by which procedure?

A. Attempts to obtain an unequivocal histological or cytological diagnosis should be considered only in patients with an indication for surgery and ERCP with brush cytology is sufficiently accurate for the diagnosis.

B. Attempts to obtain an unequivocal histological or cytological diagnosis should be considered only in patients without an indication for surgery while ERCP with cholangioscopy-directed biopsies is always mandatory in the other cases.

C. Attempts to obtain an unequivocal histological or cytological diagnosis should be carried out in all patients using ERCP brush cytology and, whenever possible, ERCP-guided endobiliary forceps biopsy.

D. At present liquid biopsies from bile or plasma have become the modalities of choice for eCCA diagnosis.