Value of brush cytology for optimal timing of liver transplantation in primary sclerosing cholangitis

Background and Aims Primary sclerosing cholangitis (PSC) is associated with a high risk of cholangiocarcinoma (CCA). Here we investigated the value of surveillance for dysplasia using brush cytology, to determine the optimal timing of liver transplantation in PSC. We compared our preoperative findings, with the final explanted liver histopathology. Methods 126 consecutive patients were transplanted for PSC from 1984-2012. Patients were divided into two groups: symptomatic (n = 91), and asymptomatic (n = 35). Results Brush cytology was available for 101 patients; 66 symptomatic and 35 asymptomatic. Suspicious cytological findings were found in 9 patients (14%) in the symptomatic group and 17 (49%) in the asymptomatic group. DNA flow cytometry was available for 49 patients (25 symptomatic, 24 asymptomatic), with aneuploidy detected in six patients (24%) in the symptomatic group and 15 (63%) in the asymptomatic group. Explanted liver histology showed biliary dysplasia or cholangiocarcinoma in 11 symptomatic patients (12%) and 15 asymptomatic patients (43%). A combination of cytological and DNA flow cytometry findings resulted in a test sensitivity of 68%, with a specificity of 86%. Ten-year survival in the asymptomatic group was 91%. Conclusions Dysplasia surveillance using brush specimens may help to select those patients likely to benefit from early liver transplantation. It remains unclear as to whether surveillance with brush cytology improves long-term survival, but there is presently no better method with which to predict transplantation timing. This article is protected by copyright. All rights reserved.