Indeterminate Strictures of Biliary System Role of Advanced Imaging

Transcription

1 Indeterminate Strictures of Biliary System Role of Advanced Imaging Viren Joshi MD, AGAF,FACG Clinical Professor Louisiana State University Professor University of Queensland,Australia Australia

2 Indeterminate Biliary Strictures : Inflammatory Autoimmune, PSC, Chronic Pancreatitis Trauma / Ischemia Chemoembolization Transplant / Biliary surgery Infections Choledochal cyst Malignant - Cholangiocarcinoma

3 Diagnostic Challenge Traditionally : EUS ( IDUS ), ERCP, Biomarkers ( Poor sensitivity ) 20% of biliary strictures remain indeterminate and need surveillance or surgery No standard prescription how to evaluate use tailored approach based on available technology

4 History Pathway Diagnosis : Radiologic Imaging Endoscopy - Brushing, FISH ( polysomy ) Biomarkers - CA 19-9 Advanced Imaging :Single operator Cholangioscopy, Endomicroscopy

5 PSC strictures / Cholangio CA : Increase yield with more samples EUS staging and FNA FISH also has not increased sensitivity Spyglass / Spybite forceps ( limited data, small numbers, cholangitis ) Recently Endomicroscopy to improve yield and target biopsies

6 Case: Indeterminate 73 Y/O with mild elevated liver tests Ca-19-9 normal, IgG4 Normal No Alarm symptoms Enlarged Lymph nodes Hilum Enlarged HOP MRCP

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8 Hilar Lesion:Single operator cholangioscope

9 Probe Based Endomicroscopy :pcle

10 IgG4 Negative Autoimmune Cholangitis :

11 Proposed diagnostic approach to biliary strictures.

12 Proximal :

13 Distal :

14 Intraductal Imaging of CBD: Challenging SOC ( Spyglass ) Endomicroscopy CLE Cholangioflex with delivered via swing tip canula

15 EMR Case Next Slides

16 Indeterminate Strictures : pcle Operating Characteristics kappa statistic, stent changes

17 Miami Criteria: 2009

18 Malignant:

19 Paris Criteria :

20 Paris Criteria :2015

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22 Inflammatory :

23 Validation with Paris Criteria:

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25 Kappa Statistic.56 ( moderate )

26 pcle Vs Tissue Sampling in Dominant PSC Strictures : Multivariate Regression analysis A U.S. Multi-Center, Prospective Registry Study Utilizing Probe-Based Confocal Laser Endomicroscopy (PCLE) to Distinguish Benign From Malignant Dominant Biliary Strictures in Patients With Primary Sclerosing Cholangitis Raj J. Shah, Vire dra Joshi, Miche Kaha eh, Adam S ivka, Pau R. Tar asky, Divyesh V. Sejpa, Amrita Sethi, Phi ip D. Tatma, Timothy M. Ty a, Sachi B. Wa i, Bria C. Brauer, Reem Z. Sharaiha, Prasha t Kedia, Cris Mo i a 1. pcle superior to tissue sampling 2. Paris criteria may have some limitations in these strictures due to Extensive scarring to detect neoplasia GIE ( DDW ) May 2017, Volume 85, Issue 5, Supplement, Pages AB611 AB612

27 Reflection / transmission - of Near infrared LASER light Creates an Image pattern described as hyper or hypo-refective

28 Why OCT in Bile duct? Can we better target biopsies?

29 NO Baloon Biliary Probe

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34 Normal

35 Duodenum Normal CBD

36 Normal Bile Duct Epithelium/Single Layer 1mm

37 Normal Bile Duct Epithelium/Single Layer Different image 1mm

38 PSC/Inflammatory Disease Thickening of wall + inflammation Eroded Surface Epithelium Inflamed bile duct wall

39 PSC/Inflammatory Disease Inflammation around peribiliary glands

40 CCA Image 1 Normal Surface Epithelium Infiltrating Malignant Glands Cholangiocarcinoma

41 CCA Image 1

42 CCA Image 2 Bile Duct Cholangiocarcinoma

43 A Pilot study of Safety and Efficacy of directed cannulation with a Low Profile catheter ( LP ) and imaging characteristics of bile duct wall using Optical Coherance tomography ( OCT ) for indeterminate biliary strictures Initial report on in-vivo evaluation during ERCP : : Virendra Joshi1, 6, Sandeep N. Patel5, Hendrikus Vanderveldt4, Irma oliva 3, Isaac Raijman5, Cris Molina1, David L. Carr-Locke2 Conclusion: 1. VLE of the bile duct using the Nvision platform and a novel LP catheter is feasible and safe 2. A two-layered structure in normal and inflammatory biliary strictures was seen consistantly, malignant strictures demonstrated complete loss of layering 3. VLE of pancreatobiliary system has potential to define abnormalities, target sampling and therapy DDW 2017, Chicago

44 Case Review : Pt. presents ith orma appeari g ampu a; ca u ated the CBD ith a sta dard sphi cterotome a d.025 ire, Omi paque i jected a d the Cho a giogram sho ed a mid to dista CBD stricture approximate y 2 cm i e gth. A sphi cterotomy as the do e. The ire as eft i a d the a VLE Lo Profi e probe as p aced a o g side the ire a d a fu sca as comp eted ithout a y difficu ty. VLE Tags ere aid at frame 560 begi i g of the stricture co firmed by f uoro a d 1059 e d of stricture co firmed by f ouro. Spyg ass as the used to visua ize the area of co cer a d bx s ere take. Brushi gs ere a so take of the suspected area. Patho ogy resu ts: Atypica ce s, ade ocarci oma

45 Cholangiogram

46 location of the LP PRobe

47 SpyGlass Image of strictured area

48 SpyGlass Image and Spybite Image

49 Beginning of stricture POSSIBLE INVASIVE MALIGNANT GLANDS, beginning of scalped appearance

50 Middle of stricture Frame 764 Loss of layering Eroded epithelium Scalloping look

51 Middle of stricture Frame 764 Loss of layering Eroded epithelium Scalloping look

52 Histology image from Spybite

53 Conclusion: CLE/VLE impact will only increase as enhanced user image interpretation capability and newly available technical improvements further the ability to identify and target advanced disease missed by other techniques. Artificial Intelligence and computer aided interpretation should be available in near future.. And MILES to go before I sleep. ( Sir Robert Frost )