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Chandrasekar et al. Mini-invasive Surg 2021;5:33 Mini-invasive Surgery
DOI: 10.20517/2574-1225.2021.12

Review Open Access

Diagnosis and treatment of biliary malignancies:

biopsy, cytology, cholangioscopy and stenting

Viveksandeep Thoguluva Chandrasekar, Douglas Faigel
Mayo Clinic, Scottsdale, AZ 85259, USA.

Correspondence to: Prof. Douglas Faigel, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, Arizona 85259, USA. E-mail:
faigel.douglas@mayo.edu

How to cite this article: Chandrasekar VT, Faigel D. Diagnosis and treatment of biliary malignancies: biopsy, cytology,
cholangioscopy and stenting. Mini-invasive Surg 2021;5:33. https://dx.doi.org/10.20517/2574-1225.2021.12

Received: 2 Feb 2021 First Decision: 8 May 2021 Revised: 18 May 2021 Accepted: 11 Jun 2021 Available online: 17 Jun 2021

Academic Editor: Jean-François Rey Copy Editor: Xi-Jun Chen Production Editor: Xi-Jun Chen

Abstract
Biliary tract malignancies include cancers of the intra-hepatic and extra-hepatic bile ducts. Cholangiocarcinoma is
the predominant biliary tract malignancy with nearly 60% of them occurring in the peri-hilar region. They can
present with biliary strictures causing jaundice but can be insidious and present late in their clinical course. Recent
advances in imaging and other diagnostic modalities help in the earlier identification of these tumors. Diagnosis
should be suspected in anyone presenting with jaundice with evidence of biliary ductal dilatation or in patients with
primary sclerosing cholangitis with worsening clinical status. The diagnostic approach consists of obtaining tumor
markers, mainly CA 19-9, imaging modalities which include computed tomography and/or magnetic resonance
imaging to establish the level of biliary obstruction and presence or absence of mass. Tissue sampling is performed
with endoscopic retrograde cholangiopancreatography (ERCP) guided cytology and biopsies and with endoscopic
ultrasound (EUS) if a mass is visible on imaging. Indeterminate strictures after initial biopsies could be further
evaluated by cholangioscopy directed biopsies. Treatment for resectable and distal bile duct cancers involves
surgical referral, but palliative biliary drainage is the key for unresectable cancers. Metal stents are generally
preferred for distal cancers and plastic stents for proximal cancers. EUS guided biliary drainage can be an
alternative approach in patients with failed ERCP.

Keywords: Cholangiocarcinoma, malignant biliary strictures, endoscopic retrograde cholangiopancreatography,
stent, endoscopic ultrasound

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing,
adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as
long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and
indicate if changes were made.

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