“FLYING RIBBON” SIGN: A NOVEL CHOLANGIOSCOPY FEATURE OF CHOLANGIOCARCINOMA

Aims:

A set of cholangioscopic features discriminating cholangiocarcinoma from benign biliary lesions has been described recently. These include ulceration, scarring, papillary projections, mass lesion, abnormal vessels, stricture, coarse granular mucosa and others. We are introducing a new feature named “flying ribbon” sign. It is defined as punctual spiral-like underwater bleeding resembling flying ribbon, occurring either spontaneously or after gentle contact of the tip of cholangioscope with a lesion.

Methods:

The study was performed in a center with previous experience of 50 cholangioscopies (Spyglass DS; Boston Scientific). All consecutive patients examined for indeterminate biliary lesion between January 2016 and June 2017 were included. All examinations were recorded and retrospectively analysed. “Flying ribbon” sign was described as present or absent.

Results:

Among 28 patients, 15 (54%) were males and 13 (46%) were females. Mean age was 68 ± 11.4 years. The visualization of the lesion was achieved in all cases. Lesions were located in extrahepatic duct 12 (43%), confluens 14 (50%) and intrahepatic ducts 2 (7%). The final diagnosis was malignant in 11 (39%) and benign in 17 (61%) of cases. 3 (11%) cases were excluded due to the insufficient quality of recording. From the remaining 25 lesions, 8 (32%) were malignant and 17 (68%) were benign. “Flying ribbon” sign was present in 7 (88%) of malignant and in none of benign lesions, resulting in sensitivity 88% and specificity 100% to detect malignant lesion.

Conclusions:

“Flying ribbon” sign defined as spiral-like underwater bleeding during cholangioscopy seems to be associated with malignant biliary lesions. Promising diagnostic accuracy in our pilot study needs to be evaluated in larger prospective studies.