European Radiology

, Volume 28, Issue 2, pp 522–529 | Cite as

Fluoroscopic percutaneous brush cytology, forceps biopsy and both in tandem for diagnosis of malignant biliary obstruction

  • Johannes Boos
  • Raphael J. Yoo
  • Jennifer Steinkeler
  • Gamze Ayata
  • Muneeb Ahmed
  • Ammar Sarwar
  • Jeffrey Weinstein
  • Salomao Faintuch
  • Olga R. BrookEmail author



To evaluate percutaneous brush cytology, forceps biopsy and a tandem procedure consisting of both, in the diagnosis of malignant biliary obstruction.


A retrospective review of consecutive patients who underwent biliary brush cytology and/or forceps biopsy between 01/2010 and 09/2014 was performed. The cytology and pathology results were compared to the composite outcome (including radiological, pathological and clinical data). Cost for tandem procedure compared to brush cytology and forceps biopsy alone was calculated.


A total of 232 interventions in 129 patients (70.8 ± 11.0 years) were included. Composite outcome showed malignancy in 94/129 (72.9%) patients. Sensitivity for brush cytology, forceps biopsy and tandem procedure was 40.6% (95% CI 32.6–48.7%), 42.7% (32.4–53.0%) and 55.8% (44.7–66.9%) with 100% specificity, respectively. There were 9/43 (20.9%) additional cancers diagnosed when forceps biopsy was performed in addition to brush cytology, while there were 13/43 (30.2%) more cancers diagnosed when brush cytology was performed in addition to forceps biopsy. Additional costs per additionally diagnosed malignancy if tandem approach is to be utilised in all cases was $704.96.


Using brush cytology and forceps biopsy in tandem improves sensitivity compared to brush cytology and forceps biopsy alone in the diagnosis of malignant biliary obstruction.

Key points

Tandem procedure improves sensitivity compared to brush cytology and forceps biopsy.

Brush cytology may help to overcome “crush artefacts” from forceps biopsy.

The cost per diagnosed malignancy may warrant tandem procedure in all patients.


Biliary obstruction Brush cytology Forceps Biopsy Malignancy 



Percutaneous Transhepatic Biliary Drainage


Interventional Radiology




Compliance with ethical standards


The scientific guarantor of this publication is Olga R. Brook.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.


The authors state that this work has not received any funding.

Statistics and biometry

One of the authors has significant statistical expertise (Alexander Brook).

Ethical approval

Institutional review board approval was obtained.

Informed consent

Written informed consent was waived by the institutional review board.

Study subjects or cohorts overlap

None of the study subjects or cohorts have been previously reported.


• retrospective

• diagnostic or prognostic study

• performed at one institution

Supplementary material

330_2017_4987_MOESM1_ESM.docx (14 kb)
Appendix Table 1 (DOCX 13 kb)
330_2017_4987_MOESM2_ESM.docx (13 kb)
Appendix Table 2 (DOCX 13 kb)


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Copyright information

© European Society of Radiology 2017

Authors and Affiliations

  • Johannes Boos
    • 1
    • 2
  • Raphael J. Yoo
    • 1
  • Jennifer Steinkeler
    • 1
  • Gamze Ayata
    • 1
  • Muneeb Ahmed
    • 1
  • Ammar Sarwar
    • 1
  • Jeffrey Weinstein
    • 1
  • Salomao Faintuch
    • 1
  • Olga R. Brook
    • 1
    Email author
  1. 1.Department of RadiologyBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonUSA
  2. 2.Medical Faculty, Department of Diagnostic and Interventional RadiologyUniversity DusseldorfDusseldorfGermany

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