[48] Less data are available for the utility of serum CEA in CCA diagnosis. The Pittsburgh group reported that serum CEA level of > 5.2 ng/mL had a sensitivity of 68% and specificity of 82%.[44] One study showed that in patients with CCA, the biliary CEA level was about five times that of patients with benign strictures.[50] A combined index of serum CA 19-9 and CEA (CA 19-9 + [CEA × 40]) has been reported to correctly identified

10 of 15 patients with CCA, including 6 of 11 with radiographically occult disease; and without false positive.[46] This corresponded to an accuracy of 86% for CCA detection. A subsequent study however suggested that this score was no better than CA 19-9 alone in predicting the presence of CCA.[51] Afatinib price 6. Cholangiography with tissue acquisition has been the traditional technique to diagnose HCCA. Cholangioscopy may be performed to increase the diagnostic yield. Level of agreement: a—80%, b—20%, c—0%, d—0%, e—0% Quality of evidence: II-2 Classification of recommendation: B Endoscopic tissue acquisition during ERCP can be performed either via papilla under fluoroscopic guidance or via mother–baby cholangioscopy. In general, the diagnostic

sensitivity of transpapillary biopsy under fluoroscopic guidance for CCA ranges from 40% to 60%.[40, 52-55] Transpapillary biopsy enables the collection of a relatively Idelalisib manufacturer large amount of tissue because of the use of standard biopsy forceps. In contrast, mother–baby or spyglass or percutaneous cholangioscopy-assisted targeted

biopsy cannot always collect a sufficient amount of tissue because of the use of forceps with small jaws. In fact, the diagnostic sensitivity of cholangioscopy-targeted biopsy alone was previously reported to be suboptimal (49%).[56] However, the advantage of cholangioscopy is that it may additionally provide a cholangioscopic impression to better clarify some indeterminate cholagiographies. The pool data demonstrated that mother–baby cholangioscopy plus targeted biopsy can improve the sensitivity to detect biliary malignancy to 89–100% with the specificity of 87–96%.[57-59] 7. Cholangioscopy with image enhancement systems and Celecoxib possible targeted biopsy or probe-based confocal laser endomicroscopy (pCLE) may improve the accuracy of HCCA diagnosis. Level of agreement: a—73%, b—21%, c—6%, d—0%, e—0% Quality of evidence: III Classification of recommendation: C Although peroral cholangioscopy such as conventional mother–baby scope and spyglass system can be useful for detecting CCA, the images’ quality is still suboptimal because of the limitation in resolution of the fiber-optic choledochoscope. With the advent in video endoscope and the image enhancement technology such as narrow band imaging, the vascular pattern of neoplasm in the bile duct can be better characterized by a new video choledochoscope.