经内镜逆行胰胆管造影胰胆管刷检的细胞病理学诊断

Endoscopic retrograde cholangiopancreatography-guided brush cytology diagnosis of pancreatobiliary tumors

目的探讨经内镜逆行胰胆管造影（ERCP）胰胆管刷检的细胞形态学诊断的敏感性和准确性，及其在诊断胆道和胰腺肿瘤中的作用。方法回顾性分析长海医院2004年1月至2006年12月行ERCP胰胆管刷片细胞学检查的病例212例，对照术后病理诊断及临床最终诊断，分析胆道及胰腺肿瘤的细胞学特点及意义。结果212例中样本满意率99％（2例无上皮细胞），细胞学报告阴性者137例，其中临床最终诊断恶性45例（阴性预告值60．2％）。细胞学报告低级别异型增生者11例，临床最终诊断恶性6例（阳性预告值54．5％）。细胞学报告高级别异型增生和恶性者可信性较高，高级别异型增生23例，1例失随访，临床最终诊断恶性19例（阳性预告值86．4％）。细胞学报告恶性41例，临床最终诊断均为恶性（阳性预告值100％）。细胞重叠、核大小不等、染色质增粗、黏附性差、坏死背景、核仁、病理性核分裂等特征具有诊断意义。结论提高诊断效率依赖于从取材、制片、固定到阅片诊断各个环节的质量控制；区分“低级别异型增生”和“高级别异型增生”，对临床实际工作的指导意义更大。

Objective To study the cytologic features of pancreatobiliary tumors in endoscopic retrograde cholangiopancreatography （ERCP）-guided brushing preparations and to evaluate the usefulness of cytology in the diagnosis of pancreatobiliary malignancy. Methods A retrospective analysis of 212 cases of ERCP-guided brush cytology smears performed during the period from January, 2004 to December, 2006. The cytologic diagnosis was confirmed either by the histologic diagnosis or the strict clinical criteria. Results Two of the cases studied were unsatisfactory for diagnosis, with no epithelial cells identified. One hundred and thirty-seven smears were diagnosed as ＂negative＂, 45 of which subsequently confirmed to be malignant （negative predictive value = 60. 2% ）. Six of the 11 cases with ＂low-grade atypia＂ were proven to be malignant （positive predictive value = 54. 5% ）, as compared to 19 of 23 cases of ＂high-grade atypia＂ （positive predictive value = 86. 4% ）. All of the 41 cases with cytologic diagnosis of ＂malignancy＂ were confirmed to be malignant （ positive predictive value = 100% ）. The cytologic features of malignancy in ERCP-guided brushing preparations included overlapping nuclei, anisonucleosis, coarse chromatin pattern, poor cellular cohesion, tumor diathesis, prominent nucleoli and atypical mitotic figures. Conclusions The accuracy of ERCP-guided brush cytology relies on good specimen preparation and application of morphologic criteria. Grading of cytologic atypia is of clinical significance. A ＂negative＂ or ＂low-grade atypia＂ cytologic diagnosis requires further diagnostic workup to rule out the possibility of underlying malignancy, while a ＂high-grade atypia＂ or ＂malignant＂ diagnosis is relatively specific in guiding subsequent management of suspected pancreatobiliary malignancy.