Accurate preoperative evaluation of liver mass lesions without fine-needle biopsy

Diagnostic value and complications of fine needle aspiration for primary liver cancer and its influence on the treatment outcome-a study based on 3011 patients in China

AIM

To determine the diagnostic value and major complications of fine-needle aspiration (FNA) for primary liver cancer (PLC) and its influence on the treatment outcome and prognosis.

METHODS

Information was gathered retrospectively for 3011 patients who presented with suspected PLC. Of which 2528 cases underwent ultrasound-guided fine-needle aspiration (US-FNA) biopsy. Patients were followed up through repeated office visits and imaging studies with a median follow-up of 7 months (range, 1-29 months).

RESULTS

The sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of cytological diagnosis by FNA biopsy for detection of liver malignancy were 91.5%, 100.0%, 100.00%, 59.1% and 92.4% respectively. All patients with AFP> or = 400 microg/L were associated with malignancy. Of 1154 patients with AFP<400 microg/L who were finally proved PLC, 945 were detected by FNA alone. Major complications included bleeding in 11 cases (5 of them died later), occurred mainly in hepatocellular carcinoma with superficial location, large tumors and severe cirrhosis, and implantation metastases in 5 cases, which were recognized as a subcutaneous nodule at the previous biopsy site. Implantation metastases were treated with resection or radiotherapy.

CONCLUSION

FNA biopsy is valuable for the diagnosis of PLC. However, complications of post-biopsy hemorrhage should not be ignored, as such bleeding may be fatal. Implantation seems to have little effect on the prognosis.

Clinical impact of the surgical margin status in hepatectomy for solitary mass-forming type intrahepatic cholangiocarcinoma without lymph node metastases

BACKGROUND AND OBJECTIVES

The clinical impact of the surgical margin status in macroscopic curative hepatectomy for intrahepatic cholangiocarcinoma (ICC) has not yet been fully investigated.

METHODS

The data of 57 consecutive patients with mass-forming (MF) type ICC who underwent macroscopic curative hepatectomy during a 10-year period were retrospectively examined, and the relationship between the surgical margin status and patient survival was analyzed.

RESULTS

Lymph node metastases were found to be independently associated with poor survival. The overall 5-year survival rates and the median survival term in the 38 patients without lymph node metastases were 56.8% and 62 months, respectively. Among these 38 patients, the survival rate was better in the negative surgical margin group as compared with that in the positive surgical margin group. However, there was no statistically significant difference between the narrow and wide surgical margin groups.

CONCLUSIONS

Negative surgical margin had a definite favorable impact on the survival of patients with a solitary ICC without lymph node metastases. Surgery should be conducted in patients without lymph node metastases even if a wide surgical margin cannot be obtained, but careful attention should be paid not to expose tumors during hepatic dissection.

Assessing liver tumor stiffness by transient elastography

BACKGROUND AND AIMS

Transient elastography is a novel noninvasive method to assess liver fibrosis by measuring liver stiffness. This study is a first step toward the provision of a noninvasive measurement of hepatic tumor stiffness by transient elastography.

PATIENTS AND METHODS

Patients with liver tumor larger than 5 cm in diameter and located near the liver surface were enrolled between June 2004 and February 2005. Histology of each tumor was evaluated on ultrasound-guided liver biopsy specimens. Transient elastography (Fibroscan, Echosens, Paris) was used to measure tumor stiffness. Tumor stiffness was measured as follows. First, by using B-mode ultrasound, we searched for the optimal right intercostal position for tumor stiffness measurement while keeping the ultrasound probe and body surface at right angles. Then the vibrator for transient elastography was applied at the same position and angle, and stiffness was measured according to the manufacturer's instruction.

RESULTS

Tumor stiffness was measured in 40 patients, 17 with hepatocellular carcinoma (HCC), six with cholangiocellular carcinoma (CCC), 16 with metastatic tumors (mostly adenocarcinoma), and one with malignant lymphoma. The median value was 55 kPa in HCC, 75 kPa in CCC, 66.5 kPa in metastatic tumor, and 16.9 kPa in malignant lymphoma. The stiffness value of CCC was significantly higher than that of HCC and metastatic tumors (P = .049).

CONCLUSION

We showed that stiffness of liver tumors could be measured with transient elastography. Improvements in the device, such as smaller and variable region of interest of measurement and real-time B-mode display, may ensure wider clinical application.

Accuracy of clinical criteria for the diagnosis of hepatocellular carcinoma without biopsy in a Hepatitis B virus-endemic area

OBJECTIVES

Several sets of criteria have been suggested for clinical diagnosis of hepatocellular carcinoma (HCC) without biopsy but there are no comprehensive data to support the usefulness of these criteria. Here, we sought to validate the accuracy of our clinical criteria for HCC diagnosis in a cohort of patients, and further tested the effect of HBV and clinical cirrhosis status on diagnostic accuracy.

METHODS

A total of 232 patients with liver nodules >1 cm in diameter who underwent surgical resection or liver biopsy, and had fulfilled all required examinations for clinical non-invasive diagnosis of HCC were reviewed retrospectively.

RESULTS

Hepatitis B virus (HBV) was positive in 170 patients (73.3%). One hundred and eighty-nine cases were diagnosed as HCC using the clinical criteria and 186 cases of HCC were confirmed by pathologic examination. The overall sensitivity, specificity and positive predictive value of the clinical criteria were 95.1, 73.9 and 93.7%, respectively. The accuracy was not significantly affected by lesion size (1-2 cm vs. >2 cm) or the presence of clinical cirrhosis. The sensitivities were 97.3 and 86.8% in the HBsAg positive group and non-HBV group, respectively (P<0.001), and the specificities were 56.5 and 91.3%, respectively (P<0.001).

CONCLUSIONS

The clinical criteria for the diagnosis of HCC showed an acceptable accuracy irrespective of lesion size or the presence of clinical cirrhosis in an HBV-endemic population. However, the presence of HBV affected the sensitivity and specificity of the clinical criteria for HCC diagnosis in an HBV endemic area.

Seeding following percutaneous diagnostic and therapeutic approaches for hepatocellular carcinoma. What is the risk and the outcome? Seeding risk for percutaneous approach of HCC

BACKGROUND

Tumour biopsy is usually considered mandatory for patient management by oncologists. Currently percutaneous ablation is used therapeutically for cirrhotic patients with small hepatocellular carcinoma (HCC), not suitable for resection or waiting for liver transplantation. However malignant seeding is a recognized complication of both diagnostic and therapeutic procedures in patients with HCC. Although percutaneous therapy whether with or without biopsy of a suspected HCC nodule may minimize the risk of seeding, this has not been confirmed.

AIM

To evaluate the risk of seeding, defined as new neoplastic disease occurring outside the liver capsule, either in the subcutaneous tissue or peritoneal cavity following needle biopsy and/or local ablation therapy (LAT).

METHODS

A literature search resulted in 179 events in 99 articles between January 1983 and February 2007: 66 seedings followed liver biopsy, 26 percutaneous ethanol injection (PEI), 1 microwave, 22 radiofrequency ablation (RFA), and 64 after combined biopsy and percutaneous treatment (5 microwave; 33 PEI; 26 RFA).

RESULTS

In 41 papers specifying the total number of patients biopsied and/or treated, the median risk of seeding was 2.29% (range 0-11%) for biopsy group; 1.4% (1.15-1.85%) for PEI when used with biopsy and 0.61% (0-5.56%) for RFA without biopsy, 0.95% (0-12.5%) for RFA with biopsy and 0.72% (0-10%) for liver nodules (including non-HCC nodules) biopsied and ablated.

CONCLUSION

Risk of seeding with HCC is substantial and appears greater with using diagnostic biopsy alone compared to therapeutic percutaneous procedures. This risk is particularly relevant for patients being considered for liver transplantation.

Hepatocellular cancer: a guide for the internist

Hepatocellular cancer is the third leading cause of cancer-related deaths worldwide. Its incidence has increased dramatically in the United States because of the spread of hepatitis C virus infection and is expected to increase for the next 2 decades. Hepatitis B virus, hepatitis C virus, and chronic heavy alcohol use leading to cirrhosis of the liver remain the most important causes. The diagnosis of hepatocellular cancer rests on a combination of radiologic, serologic, and histopathologic criteria. Liver transplantation is the only definitive treatment. Resection of the tumor and other percutaneous therapies are more commonly used in practice, because most hepatocellular cancers are detected at an advanced stage. Patients who are at high risk for the development of hepatocellular cancer should be screened with an ultrasound of the liver every 6 months. The prognosis is dependent on both the underlying liver function and the stage at which the tumor is diagnosed. The aim of this review is to familiarize internists in screening, diagnosis, and referral of patients with hepatocellular cancer in an appropriate and timely fashion.

Contrast-enhanced intraoperative ultrasonography during surgery for hepatocellular carcinoma in liver cirrhosis: is it useful or useless? A prospective cohort study of our experience

BACKGROUND

Preliminary results showed that contrast-enhanced intraoperative ultrasonography (CEIOUS) could provide information not obtainable with conventional IOUS during surgery for hepatocellular carcinoma (HCC). The aim of the study was to prospectively validate the role of CEIOUS on the basis of a larger experience and to establish a new classification that takes into account its findings.

METHODS

Eighty-seven consecutive patients underwent hepatecomies for HCC. Those patients with new lesions at IOUS underwent CEIOUS: for that patients received intravenously 4.8 mL sulphurhexafluoride microbubbles. Pattern of enhancement was classified in 4 categories: A1 (full enhancement in the arterial phase and wash-out in the delayed phases), A2 (intralesional signs of neovascularization during all phases), A3 (no nodular enhancement but detectability during the liver enhancement), and B (undetectability during the liver enhancement). Resection was recommended for A1-3 nodules and no treatment for B nodules.

RESULTS

Twenty-nine patients (33%) had 59 new lesions at IOUS and underwent CEIOUS. Twenty-seven nodules showed a B pattern at CEIOUS and were not removed; 32 nodules were classified as A1 in 5 patients, A2 in 11 patients, and A3 in 16 patients. The nodules were removed, and by histology, five A1, nine A2, and six A3 nodules were confirmed to be HCC. CEIOUS modified the operative decision making in 79% of these patients.

CONCLUSIONS

CEIOUS is useful during surgery for HCC; it complements the accuracy of IOUS and affects the radicalness of the surgical. Specificity of CEIOUS has to be further improved, although intrinsic drawbacks exist in the diagnostic criterion of tumor vascularity.

Single hepatocellular carcinoma ranging from 3 to 5 cm: radiofrequency ablation or resection?

BACKGROUND

The optimal therapy for hepatocellular carcinoma (HCC) is transplantation. For all those patients not eligible for transplantation (or on the waiting list) among the treatments of choice used more frequently in recent years are resection (RES) and radiofrequency ablation (RFA). RFA is less efficacious for HCC ranging over 3 cm. The aim of this study was to compare RFA to RES in a restricted cohort of patients with a single naive HCC ranging from 3 to 5 cm in size and without end-stage liver disease. PATIENTS AND METHODS. A total of 102 patients who had never been treated before were enrolled. Those patients whose HCC position would have required too much parenchymal loss at RES (central or close to main vascular structures) were treated with RFA (n=60), and the others underwent RES (n=42). The two groups were similar for HCC size and liver disease status. The outcome was considered in terms of overall survival (OS) and disease-free survival (DFS) calculated by the Kaplan-Meier method. Differences among groups were validated by log-rank test.

RESULTS

The RES group seemed to present a better long-term OS (91%, 57%, and 43% vs 96%, 53%, and 32% at 1, 3, and 5 years, respectively) and DFS (74%, 35%, and 14% vs 68%, 18%, and 0%, respectively) but there was no statistical significance. Age, gender, virus etiology, HCC size and alpha-fetoprotein levels did not correlate with survival. Patients with recurrence within the first 12 months after treatment showed a worse long-term survival (p=0.011). Patients in Child-Pugh class B had poor prognoses compared with those in class A (p=0.047).

CONCLUSION

Even if RES seemed to promise better long-term results, in the medium term this difference had no statistical significance. Survival in this series was more closely related to the stage of the underlying liver disease than to treatment (RES/RFA).

Prediction of recurrence of hepatocellular carcinoma after curative ablation using three tumor markers

Three tumor markers for hepatocellular carcinoma (HCC) are available in daily practice in Japan: alpha-fetoprotein (AFP), des-gamma-carboxy prothrombin (DCP), and lens culinaris agglutinin-reactive fraction of alpha-fetoprotein (AFP-L3). To elucidate the predictability of these tumor markers on HCC recurrence after curative ablation, we enrolled 416 consecutive patients with naïve HCC who had been treated by percutaneous ablation at our department from July 1997 to December 2002. Tumor marker levels were determined immediately before and 2 months after the treatment. Complete ablation was defined on CT findings as nonenhancement in the entire lesion with a safety margin. Tumor recurrence was also defined as newly developed lesions on CT that showed hyperattenuation in the arterial phase with washout in the late phase. We assessed the predictability of recurrence via tumor markers in multivariate analysis, using proportional hazard regression after adjusting for other significant factors in univariate analysis. Until the end of follow-up, tumor recurrence was identified in 277 patients. Univariate analysis revealed the following factors to be significant for recurrence: platelet count; size and number of tumors; AFP, AFP-L3, and DCP preablation; and AFP and AFP-L3 postablation. Multivariate analysis indicated that AFP >100 ng/mL and AFP-L3 >15%, both pre- and postablation, were significant predictors. The positivity of AFP and AFP-L3 preablation that turned negative postablation was not significant. In conclusion, tumor markers pre- and post-ablation were significant predictors for HCC recurrence and can complement imaging modalities in the evaluation of treatment efficacy.

Staging hepatocellular carcinoma by a novel scoring system (BALAD score) based on serum markers

BACKGROUND & AIMS

Previously proposed staging systems for hepatocellular carcinoma (HCC) involve clinical, imaging, or pathologic factors in the evaluation. We established and validated a novel staging system for HCC that is based on simply serum markers.

METHODS

The new scoring system is based on 5 serum markers: bilirubin, albumin, Lens culinaris agglutinin-reactive alpha-fetoprotein (AFP-L3), alpha-fetoprotein (AFP), and des-gamma-carboxy prothrombin (DCP) and thus is termed the BALAD score. The system was validated in 2600 HCC patients from 5 institutions. The power of our system to predict patient survival and its discriminative ability were compared with those of previously reported staging systems.

RESULTS

The best tumor marker cutoff values were 400 ng/dL for AFP, 15% for AFP-L3, and 100 milli-arbitrary unit/mL for DCP. The patients were classified into 6 categories on the basis of 5 laboratory values. The categories reflected patient survival well. The discriminative ability was comparable to that of previously reported staging systems.

CONCLUSIONS

The new staging system for HCC combining serum albumin, serum bilirubin, and 3 tumor markers predicts patient outcomes with excellent discriminative ability. The system is easy to use and objective. In addition, stage can be evaluated with the use of only 1 serum sample. It also allows global comparison of patients with HCC or comparison of patients from different time periods with the same standard.

Chronic hepatitis C and screening for hepatocellular carcinoma

It is now at least theoretically possible to prevent patients with hepatocellular carcinoma (HCC) from dying of HCC. Screening identifies small potentially curable lesions, and the diagnostic algorithm allows for efficient investigation and diagnosis. Radiofrequency ablation completely ablates more than 05% of lesions smaller than 2 cm. Second primary cancers can be dealt with in the same manner as the initial primary. If the management of HCC is so efficient and effective, liver transplantation may come to be used as a last resort, rather than the treatment of choice. This benefits patients with hepatitis C and other liver diseases because more organs become available for treatment of other liver diseases.

An analysis of the UNOS liver transplant registry: high serum alpha-fetoprotein does not justify an increase in MELD points for suspected hepatocellular carcinoma

The current United Network for Organ Sharing (UNOS) criteria for liver transplantation gives priority to patients with elevated serum alpha-fetoprotein (AFP; > or = 500 ng/mL) in the absence of radiologic evidence of a hepatic mass. Reports have shown that an elevated serum AFP is a poor diagnostic indicator for hepatocellular carcinoma (HCC) in patients with cirrhosis. Our aim was to determine if an AFP level above 500 ng/mL, in the absence of a liver mass by imaging study, correlates with the presence of HCC. Using the UNOS database we identified all patients transplanted for HCC in the United States between February 2002 and October 2005 based on these criteria. The data collected included: patient demographics, clinical information, and pathological outcomes. The data was analyzed using a chi-squared t-test and confirmed by logistic regression modeling. A total of 22 patients received a cadaveric liver transplant, while 1 received a living donor transplant during the study period. HCC was confirmed posttransplantation in only 6 patients (26%). There was no difference in race, gender, etiology of liver disease, or AFP level between patients with and without HCC but a significant difference in age (59.8 yr for HCC patients vs. 51.3 yr for the non-HCC group; P = 0.01). In conclusion, the majority of the patients who received extra Model for End-Stage Liver Disease (MELD) points based on an elevated AFP did not have HCC. Older age was a significant predictor for the presence of HCC in patients with a serum AFP greater than 500 ng/mL. These results demonstrate the poor correlation of serum AFP with the presence of HCC in patients awaiting liver transplantation.

Evaluation of nonmalignant liver masses

Nonmalignant liver masses are increasingly being recognized with the widespread use of imaging modalities such as ultrasonography, computed tomography, and magnetic resonance imaging. The majority of these lesions are detected incidentally in asymptomatic patients. Based on the radiologic appearance, benign lesions can be categorized as solid or cystic, single or multiple, hypervascular or hypovascular. Based on histologic characteristics, they are classified as of hepatocellular, biliary, or mesenchymal origin. In the majority of patients, a proper diagnosis can be made based on these characteristics on imaging modalities alone. An invasive approach is seldom required. This review discusses the various characteristics of the most common benign liver lesions and recommends a practical approach.

Does preoperative fine needle aspiration-biopsy produce tumor recurrence in patients following liver transplantation for hepatocellular carcinoma?

INTRODUCTION

Liver transplantation (OLT) has been advocated for patients with carcinoma hepatocellular (HCC). A preoperative biopsy (fine needle aspiration biopsy) [FNA] facilitates preoperative diagnosis of adverse pathological factors: vascular invasion or histologicalic differentiation. But a biopsy may cause abdominal dissemination and be related to a higher incidence of recurrence.

PATIENTS AND METHODS

From April 1986 to December 2003, we performed 95 OLT for HCC. We divided them in two groups: group A without FNA-biopsy (67.9%) and group B with FNA-biopsy (32.1%).

RESULTS

We obtained the diagnosis of HCC in only 15 patients (57.6%). In two patients an OLT was avoided due to the presence of abdominal dissemination at the time of transplant. Recurrence incidence was higher among group B patients (5.9% vs 31.8%; P = .003) due to extrahepatic recurrence (2% vs 27.3%; P = .003). No differences were observed in morbidity or mortality. The two groups were homogeneous in epidemiological and pathological variables except: sex distribution, Child status, AFP level, tumor size, and pTNM stage. If we compare recurrence rates in the two groups attending to these nonhomogeneous variables, it was significantly higher among patients with tumors larger than 3 cm, pTNM I-III stage, Child B-C, AFP >200 ng/mL, and males or females.

CONCLUSIONS

Preoperative liver biopsy is associated with a larger incidence of tumor recurrence, so we believe that it is not necessary prior to an OLT for HCC.

[Early diagnosis of liver cancer]

Hepatocellular carcinoma is a frequent neoplasm that usually develops in patients with liver cirrhosis. Because it is the main cause of death in these patients, they should be included in a surveillance program in order to identify these tumors at an early stage and be able to indicate curative treatment (liver transplantation, surgical resection or percutaneous ablation therapy) and to reduce mortality. Surveillance should include determination of alpha-fetoprotein and abdominal ultrasound every 6 months. This strategy should only be applied to patients suitable to receive curative treatment if diagnosed of hepatocellular carcinoma. Using this approach, 40-80% of tumors identified are solitary at diagnosis, although only half of these patients can benefit from curative treatment.

Liver resection for primary hepatic neuroendocrine tumours: report of three cases and review of the literature

Primary neuroendocrine tumours are rare especially in the liver, which is more often site of metastatic tumours. We report three cases of primary hepatic neuroendocrine tumours, which underwent hepatic resection. Review of the diagnostic and therapeutic approaches to these tumours are discussed.

Selection of patients with hepatocellular carcinoma for liver transplantation

Background

Orthotopic liver transplantation (OLT) plays a pivotal role in the management of selected patients with initial hepatocellular carcinoma (HCC). After disappointing early results and a shortage of cadaveric grafts, patients are currently selected for OLT on the basis of tumour size and number. Limitations of these criteria and the advent of living donation have prompted their re-evaluation. The principal aims of this review were to define the limitations of current transplant criteria for HCC, and to identify potential areas for improvement.

Methods

A Medline search using the terms ‘liver transplantation’ and ‘hepatocellular carcinoma’ was conducted. Additional references were sourced from key articles.

Results and conclusion

In patients with HCC, biological properties of the tumour are more accurate than radiological criteria in determining outcome after transplantation. Despite the risks of tumour biopsy, which may have been previously overstated, histological evaluation before transplantation may have a role and warrants further study. By expanding the donor pool and eliminating waiting times, live donor liver transplantation is a valuable resource that has yet to fulfil its potential because of unresolved ethical issues concerning the safety of the donor. The availability of long-term outcome data may help to clarify this in the near future.

Fine needle aspiration biopsy of the liver: Algorithmic approach and current issues in the diagnosis of hepatocellular carcinoma

The role of fine needle aspiration biopsy (FNAB) in the evaluation of focal liver lesions has evolved. Guided FNAB is still useful to procure a tissue diagnosis if clinical, biochemical and radiologic findings are inconclusive. Major diagnostic issues include: (i) Distinction of benign hepatocellular nodular lesions from reactive hepatocytes, (ii) Distinction of well-differentiated hepatocellular carcinoma (WD-HCC) from benign hepatocellular nodular lesions, (iii) Distinction of poorly differentiated HCC from cholangiocarcinoma and metastatic carcinomas, (iv) Determination of histogenesis of malignant tumor, and (v) Determination of primary site of origin of malignant tumor. This review gives a general overview of hepatic FNAB; outlines an algorithmic approach to cytodiagnosis with emphasis on HCC, its variants and their mimics; and addresses current diagnostic issues. Close radiologic surveillance of high-risk cirrhotic patients has resulted in the increasing detection of smaller lesions with many subjected to biopsy for tissue characterization. The need for tissue confirmation in clinically obvious HCC is questioned due to risk of malignant seeding. When a biopsy is indicated, core needle biopsy is favored over FNAB. The inherent difficulty of distinguishing small/early HCC from benign hepatocellular nodular lesions has resulted in indeterminate reports. Changing concepts in the understanding of the biological behavior and morphologic evolution of HCC and its precursors; and the current lack of agreement on the morphologic criteria for distinguishing high-grade dysplastic lesions (with small cell change) from WD-HCC, have profound impact on nomenclature, cytohistologic interpretation and management. Optimization of hepatic FNAB to enhance the yield and accuracy of diagnoses requires close clinicopathologic correlation; combined cytohistologic approach; judicious use of ancillary tests; and skilled healthcare teams.

A long-term follow-up study on hepatitis B surface antigen-positive patients undergoing allogeneic hematopoietic stem cell transplantation

The long-term hepatic complications after allogeneic hematopoietic stem cell transplantation (HSCT) in hepatitis B virus (HBV) endemic area are unknown. We examined the serological and liver-related outcome of 803 consecutive patients who received allogeneic HSCTs, with a median follow-up period of 83 months (range, 0.5-155 months). Late HBV-related hepatitis occurred in 2 of the 721 hepatitis B surface antigen-negative (HBsAg-) recipients compared with 16 of the 82 HBsAg+ recipients after HSCT (0.3% vs 19.5%; P < .001 by log-rank). Liver cirrhosis developed in 8 of the 82 HBsAg+ recipients compared with none of the 721 HBsAg- recipients (9.8% vs 0%; P < .001 by log-rank). Twenty of the 31 (64.5%) HBsAg+ recipients of hematopoietic stem cells from donors with natural immunity to HBV had sustained serologic clearance of HBsAg after HSCT. Eight of the 62 recipients without sustained HBsAg clearance compared with none of the 20 recipients with sustained HBsAg clearance developed liver cirrhosis (12.9% vs 0%; P = .02 by log-rank). Our study showed that long-term hepatic complications occur in a significant proportion of HBsAg+ patients after HSCT and the incidence of liver cirrhosis is reduced in those with sustained serologic clearance of HBsAg after HSCT.

The progression of hepatitis B- and C-infections to chronic liver disease and hepatocellular carcinoma: presentation, diagnosis, screening, prevention, and treatment of hepatocellular carcinoma

Much information has been gained in the diagnosis and treatment of HCC during the last 15 years. Ever improving imaging technology has made nonhistologic diagnostic criteria possible, albeit controversial. Liver transplantation, resection, and RFA are considered curative options. Yet, HCC incidence is steadily rising because of limited progress on disease prevention. Accurate and cost-effective screening is necessary. Presently, only 10% to 15% of HCC patients present with a curative stage of disease. Because the field of HCC is rapidly changing, patients with HCC should be referred to liver centers with a full array of services, from surgical to oncologic. The prognosis for HCC patients will surely improve with a multi-disciplinary approach to care and further clinical research. Better screening and prevention of recurrence should eventually improve survival. It is hoped that antiviral treatment studies will lower the risk of HCC, and that these changes will occur soon enough to help the many patients at risk for or diagnosed with HCC over the next several years.

Improving the prediction of hepatocellular carcinoma in cirrhotic patients with an arterially-enhancing liver mass

In the United States, cirrhotic patients with known or suspected hepatocellular carcinoma (HCC) are prioritized for liver transplantation. Noninvasive criteria for the diagnosis of HCC rely on arterial enhancement of a mass. The aim of this study was to determine whether clinical, laboratory, and / or radiologic data can improve the prediction of HCC in cirrhotic patients with an arterially-enhancing mass. Between May 2002 and June 2003, dynamic gadolinium-enhanced magnetic resonance imaging (MRI) of consecutive patients with liver cirrhosis and a solid mass were reviewed by 2 radiologists blinded to the clinical diagnosis. Clinical, laboratory, and radiologic data were recorded for all patients. A total of 94 patients with cirrhosis and an arterially-enhancing liver mass were studied, 66 (70%) of whom had HCC. Alpha-fetoprotein (AFP) >20 ng/mL (P = .029), tumor size >2 cm (P = .0018), and delayed hypointensity (P = .0001) were independent predictors of HCC. Delayed hypointensity of an arterially-enhancing mass had a sensitivity of 89% and a specificity of 96% for HCC. The presence of delayed hypointensity was the only independent predictor of HCC among patients with arterially-enhancing lesions <2 cm (odds ratio, 6.3; 95% confidence interval [CI], 1.8-13), with a sensitivity of 80% and a specificity of 95%. In conclusion, delayed hypointensity of an arterially-enhancing mass was the strongest independent predictor of HCC, regardless of the size of the lesion. If additional studies confirm our results, the noninvasive criteria utilized to make a diagnosis of HCC should be revised.

Approaches to the diagnosis of hepatocellular carcinoma

The advent of screening programs for hepatocellular carcinoma in patients with chronic viral hepatitis and cirrhosis has resulted in detection of smaller and smaller lesions in the liver. Some of these are small carcinomas, but many are not malignant in nature or are potential precursors to malignancy. Neither radiology nor biopsy can be used confidently to distinguish between these possibilities when the lesions are smaller than approximately 1.5 cm in diameter. Therefore, diagnostic algorithms must be developed to assist physicians in investigating these small lesions and deciding when they are truly malignant, when treatment is necessary, or whether a watchful waiting course is appropriate. The diagnostic difficulties are presented, with examples of diagnostic algorithms that may be helpful in managing these patients.

Screening for hepatocellular carcinoma

There is currently no evidence that screening patients at risk for hepatocellular carcinoma reduces mortality from the disease. Nonetheless, screening is widely practiced. Screening is a process that includes selecting patients, applying screening tests, deciding on recall policies, and subsequently proving or disproving the presence of cancer. The literature on screening for hepatocellular carcinoma is confusing at best, and does not adequately consider the many biases that result from uncontrolled and retrospective studies. Nonetheless, screening can be justified because it is likely that mortality is decreased by adequate treatment of small cancers, particularly in the era of liver transplantation. False-positive screening test results are common. Once an abnormal screening result is obtained there is little guidance from the literature as to how patients should be investigated further, nor about how to determine whether the screening test result was a false-positive. This should at minimum include short interval follow-up with CT scans and MRI's.

Incidence of benign pathology in patients undergoing hepatic resection for suspected malignancy

BACKGROUND

Confirming the presence of hepatic or proximal bile duct malignancy pre-operatively remains difficult and some patients may undergo surgical resection for suspected malignant lesions which subsequently turn out to be benign. The aim of this study was to establish whether improvements in pre-operative staging might better identify this patient population.

METHODS

Analysis of a prospectively collected database, which has been maintained in our unit since 1988.

RESULTS

Of 250 consecutive patients undergoing hepatic resection for presumed malignancy, 18 (7.2%) were shown to have benign pathology. These "false positive" rates were 4 out of 160 (2.5%) resections for colorectal metastases, 4 out of 49 (8.2%) resections for other solid hepatobiliary tumours and 10 out of 41 (24.4%) resections for hilar cholangiocarcinoma. Four of the 18 patients (22%) developed post-operative complications but there was no postoperative mortality.

CONCLUSION

Although hepatic resection remains a potentially curative procedure for patients with tumours involving the liver parenchyma or proximal bile ducts, pre-operative confirmation of malignancy remains difficult. Despite appropriate investigation a subset of patients with benign disease will still be subjected to major hepatic resection which should be undertaken in a specialist unit.

Gd-EOB-DTPA Enhanced MRI for Hepatocellular Carcinoma: Quantitative Evaluation of Tumor Enhancement in Hepatobiliary Phase

OBJECTIVE

The purpose of this study was to evaluate the utility of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) for the quantitative evaluation of hepatocellular carcinoma (HCC) and dysplastic nodules in the hepatobiliary phase.

MATERIAL AND METHODS

The subjects comprised 12 patients with 27 lesions (22 HCCs and 5 dysplastic nodules). Chemical-shift-selective fat-suppressed T1-weighted sequences were obtained before and 10, 20, and 40 min after the injection of Gd-EOB-DTPA. Quantitative analyses were performed with the enhancement ratio of the lesion and the contrast-to-noise (C/N) ratio.

RESULTS

The enhancement ratios of the HCCs were 44.0+/-36.5, 44.7+/-46.8, and 47.7+/-52.8 (%) at 10, 20, and 40 min, respectively, after the injection of Gd-EOB-DTPA. The enhancement ratios of the dysplastic nodules were 36.2+/-34.3, 44.3+/-37.3, and 40.1+/-46.8 (%). The C/N ratios of the HCCs were 0.2+/-6.6 for the precontrast image, and -9.2+/-12.6, -9.9+/-14.8, and -12.7+/-15.7 at 10, 20, and 40 min, respectively, after the injection of Gd-EOB-DTPA. The C/N ratios of the dysplastic nodules were 1.4+/-8.0, -13.7+/-11.1, -13.3+/-7.6, and -13.1+/-10.4. No significant differences were found between the HCCs and the dysplastic nodules in the enhancement ratio and the C/N ratio. Only two HCCs showed a positive C/N ratio value, and these HCCs were pathologically confirmed to be a well differentiated and a moderately differentiated carcinoma, respectively.

CONCLUSION

HCCs and some of the dysplastic nodules showed hypointensity in the hepatobiliary phase in Gd-EOB-DTPA-enhanced MRI. No specific enhancement was observed, regardless of tumor differentiation.

Cost-effectiveness of hepatocellular carcinoma surveillance in patients with hepatitis C virus-related cirrhosis

BACKGROUND & AIMS

HCV-related cirrhosis is a leading risk factor for hepatocellular carcinoma (HCC). Surveillance might detect HCC at a treatable stage. We estimated the clinical and economic consequences of a common HCC surveillance strategy in patients with HCV-related cirrhosis in the context of alternative HCC treatment strategies.

METHODS

With a Markov model, we examined surveillance with serum alpha-fetoprotein and ultrasound every 6 months in patients with compensated HCV-related cirrhosis from age 45-70 years or death, and HCC treatment with resection, cadaveric liver transplantation (CLT), or living donor liver transplantation (LDLT).

RESULTS

Compared to natural history in the base case, surveillance with resection, listing for CLT, or LDLT increased life expectancy by 0.49, 2.58, and 3.81 quality-adjusted life-years (QALYs), respectively, all at costs less than 51,000 US dollars/QALY gained. The consequences of surveillance were most sensitive to the outcomes and costs of HCC treatments but not surveillance test performance characteristics or cost. Prioritizing CLT for patients with HCC over those with decompensated cirrhosis resulted in greater overall life expectancy with minimal increase in cost.

CONCLUSIONS

Surveillance for HCC in patients with compensated HCV-related cirrhosis might gain QALYs at acceptable costs. The impact of surveillance depends most on the outcomes and costs of HCC treatments, rather than surveillance test characteristics. By increasing organ availability for timely definitive treatment, LDLT might achieve the greatest gain in life expectancy at acceptable costs. Prioritizing CLT for HCC might increase the population-wide benefits of CLT.

Validation of a new prognostic staging system for hepatocellular carcinoma: the JIS score compared with the CLIP score

The Japan Integrated Staging score (JIS score), which combines the Child-Turcotte-Pugh classification and tumor-node-metastasis staging, has been proposed as a better prognostic staging system for hepatocellular carcinoma (HCC) than the Cancer of the Liver Italian Program (CLIP) scoring system. In this study, validation was performed among a larger patient population. A total of 4,525 consecutive patients with HCC who had been diagnosed at five institutions were included. Stratification ability, prognostic predictive power, and reproducibility were analyzed and compared with results from the CLIP scoring system. Only 45% (1,951 of 4,525) of all patients were categorized as early stage HCC according to JIS score (0 or 1), whereas 63% (2,878 of 4,525) of the patients were categorized as having a CLIP score of 0 or 1. Significant differences in survival curves were not observed among CLIP scores 3 to 6. In contrast, survival curves showed significant differences among all the JIS scores. The same JIS scoring subgroups showed a similar prognosis, and good internal reproducibility was observed in each of the institutions. Multivariate analysis of the prognosis in all 4,525 patients proved the JIS score to be the best prognostic factor. Furthermore, the Akaike information criteria proved that the JIS scoring system was statistically a better model for predicting outcome than the CLIP scoring system. In conclusion, the stratification ability and prognostic predictive power of the JIS score were much better than that of the CLIP score and were simple to obtain and remember.

Hepatocellular carcinoma: current surgical management

Hepatocellular carcinoma (HCC) is the fifth most common malignancy in the world, responsible for 500,000 deaths globally every year. Although HCC is a slow-growing tumor, it is often rapidly fatal because it is usually not discovered until the disease is advanced. HCC occurs primarily in individuals with cirrhosis, a condition that increases the risk of performing potentially curative surgical therapy. Over the last 2 decades, however, the safety of surgical resections has greatly improved because of advances in radiologic assessment, patient selection, and perioperative care. As such, the operative mortality rate for hepatectomy has decreased from the 10%-20% level seen in the 1980s to less than 5% today. The ultimate goal of treatment of HCC is to prolong the quality of life by eradicating the malignancy while preserving hepatic function. For treatment with a curative intent, the gold standard remains surgical resection, by either partial hepatectomy or total hepatectomy followed by liver transplantation. Resectability and choice of procedure depend on many factors, including baseline liver function, absence of extrahepatic metastases, size of residual liver, availability of resources including liver graft, and expertise of the surgical team. Patients without cirrhosis can tolerate extensive resections, and partial hepatectomy should be considered first. For Child class B and C patients with a small HCC, liver transplantation offers the best results, whereas partial liver resection is indicated in patients with well-compensated cirrhosis. Living donor liver transplantation should be considered using the same criteria as that used for cadaveric transplantation.

Diagnosis and staging of hepatocellular carcinoma

The diagnosis of hepatocellular carcinoma (HCC) includes detection of the index lesion, staging of the lesion within the liver, and assessment for extrahepatic metastasis. HCC is a highly vascular neoplasm usually arising in a cirrhotic liver. Based on this concept, consensus criteria have been developed for the radiographic diagnosis of HCC. These include: (1) identification of a mass >2 cm in diameter in a cirrhotic liver in 2 imaging modalities, and (2) contrast enhancement on computed tomography, magnetic resonance, or angiography. A mass lesion within a cirrhotic liver in the presence of a serum alpha-fetoprotein level >400 ng/mL also is diagnostic. For lesions <2 cm in diameter, histological confirmation is required. Serum markers for the diagnosis of early HCC (<2 cm in diameter) have not been established. Staging HCC for metastases is insensitive and is based on conventional criteria (eg, pulmonary nodules, skeletal metastases, and lymphadenopathy). Additional diagnostic techniques based on cytological advances, genomics, and proteomics are needed for the diagnosis and staging of this highly malignant neoplasm.

Contrast-enhanced sonographic appearance of hepatocellular carcinoma in patients with cirrhosis: comparison with contrast-enhanced helical CT appearance

OBJECTIVE

We sought to investigate the efficacy of contrast-enhanced sonography using a second-generation contrast agent for the evaluation of hepatocellular carcinoma in patients with cirrhosis by comparing the results to those obtained with contrast-enhanced helical CT.

SUBJECTS AND METHODS

Between October 2002 and March 2003, 74 patients with cirrhosis (60 men and 14 women; age range, 47-80 years; mean age, 67 years) who had a single nodule of hepatocellular carcinoma were selected to be studied from a cohort of 437 patients with cirrhosis. The size range of the 74 nodules was 9-65 mm (mean, 28.2 mm). Twenty-eight (38%) were 20 mm smaller (range, 9-20 mm; mean, 16.6 mm), and 46 (62%) were larger than 20 mm (range, 21-65 mm; mean, 35.2 mm). Contrast-enhanced sonography was performed at a low mechanical index after IV administration of the contrast agent SonoVue. CT scans were obtained in all patients. The enhancement pattern related to tumor hypervascularity was analyzed. The chi-square test was used for statistical analysis.

RESULTS

For the 28 hepatocellular carcinomas 20 mm or smaller, contrast-enhanced sonography showed 15 (53.6%) as hypervascular and 10 (35.7%) as avascular; three (10.7%) carcinomas were missed. On CT, 12 (42.9%) of the 28 hepatocellular carcinomas appeared hypervascular, 13 (46.4%) appeared hypovascular, and three (10.7%) were missed. For the 46 hepatocellular carcinomas larger than 20 mm, contrast-enhanced sonography showed 42 (91.3%) as hypervascular and four (8.7%) as avascular. On CT, 35 (76.1%) hepatocellular carcinomas appeared hypervascular, eight (17.4%) appeared hypovascular, and three (6.5%) were missed. Differences between CT appearance of hepatocellular carcinomas and contrast-enhanced sonographic appearance of the carcinomas were not statistically significant. Concordance between contrast-enhanced sonographic and CT appearances was observed in 61 (82.4%) of 74 cases.

CONCLUSION

Contrast-enhanced sonography is similar to CT for detecting hepatocellular carcinoma hypervascularity. It could be complementary to conventional unenhanced sonography for evaluation of liver nodules.

Contrast-enhanced ultrasonography during liver surgery

Worthy of wider evaluation

Selection of candidates with HCC for transplantation in the MELD era

1. Liver transplantation is the main option for patients with early HCC who are not optimal candidates for surgical resection. 2. Shortage of donors is its main limitation, as waiting for a liver allows the tumor to progress and induce exclusion from the waiting list and death. 3. The absence of randomized controlled trials hinders the establishment of the most effective therapy to prevent tumor progression while waiting. 4. Live donation may be a cost-effective approach if optimal results are expected and the mortality risk for the donor is kept below .3%. 5. Priority policies have to be developed and refined to provide a fair and effective distribution of cadaveric organs.

Screening and treatment for hepatocellular carcinoma

Surveillance for hepatocellular carcinoma (HCC) has become routine despite a lack of evidence of efficacy. Suitable candidates for surveillance include patients with cirrhosis and some subsets of noncirrhotic chronic hepatitis B carriers. The best surveillance testis ultrasonography at 6- to 12-month intervals. Serological tests are less effective. Defining an abnormal result is difficult in the cirrhotic liver. Diagnosis requires radiological investigations and may require a biopsy if the lesion is between 1 and 2 cm in diameter. In the face of an abnormal surveillance test and failure to confirm the diagnosis initially, enhanced follow-up is required. HCC can be treated for cure by liver transplantation, resection, or local ablation. For patients with suitable lesions, liver transplantation offers the best form of therapy. Chemoembolization offers increased survival over no therapy. Several experimental therapies are being investigated.

Review article: the evolving role of liver biopsy

Liver biopsy is traditionally the 'gold standard' for the evaluation of liver diseases. There are several situations in which its role is being challenged. In hepatitis C, liver biopsy helps assess prognosis and treatment candidacy. An important exception is genotype 2 or 3 because treatment is more likely to succeed and therapy is relatively short in duration. For hepatitis B, liver biopsy gives some prognostic information, but serologic tests and hepatic biochemical tests are the primary determinants of treatment candidacy. Non-alcoholic fatty liver disease can be accurately diagnosed without a liver biopsy and, furthermore, there are no specific therapies available. The role of liver biopsy to assess methotrexate-associated hepatotoxicity remains controversial. Finally, patients with focal liver lesions usually do not require biopsy and, in the case of hepatocellular carcinoma, biopsy carries a risk of needle-track seeding. In short, the need for liver biopsy depends on the specific situation and should be performed when there is sufficient uncertainty about diagnosis, severity of disease, prognosis, and treatment decisions.

Cost-effectiveness of screening for hepatocellular carcinoma in patients with cirrhosis due to chronic hepatitis C

BACKGROUND

Screening for hepatocellular carcinoma in cirrhotic patients using abdominal ultrasonography and alpha-foetoprotein levels is widely practiced.

AIM

To evaluate its cost-effectiveness using a Markov decision model.

METHODS

Several screening strategies with abdominal ultrasonography or computerized tomography and serum alpha-foetoprotein at 6-12-month intervals in 40-year-old patients with chronic hepatitis C and compensated cirrhosis were simulated from a societal perspective, resulting in discounted costs per quality-adjusted life-year saved. Extensive sensitivity analysis was performed.

RESULTS

For the least efficacious strategy, annual alpha-foetoprotein/ultrasonography, the incremental cost-effectiveness ratio (vs. no screening) was $23 043/quality-adjusted life-year. Biannual alpha-foetoprotein/annual ultrasonography, the most commonly used strategy in the United States, was more efficacious, with a cost-effectiveness ratio of $33 083/quality-adjusted life-year vs. annual alpha-foetoprotein/ultrasonography. The most efficacious strategy, biannual alpha-foetoprotein/ultrasonography, resulted in a cost-effectiveness ratio of $73 789/quality-adjusted life-year vs. biannual alpha-foetoprotein/annual ultrasonography. Biannual alpha-foetoprotein/annual computerized tomography screening resulted in a cost-effectiveness ratio of $51 750/quality-adjusted life-year vs. biannual alpha-foetoprotein/annual ultrasonography screening.

CONCLUSIONS

Screening for hepatocellular carcinoma is as cost-effective as other accepted screening protocols. Of the strategies evaluated, biannual alpha-foetoprotein/annual ultrasonography gives the most quality-adjusted life-year gain while still maintaining a cost-effectiveness ratio <$50 000/quality-adjusted life-year. Biannual alpha-foetoprotein/annual computerized tomography screening may be cost-effective.

Pathogenesis and screening for hepatocellular carcinoma

Hepatocellular carcinoma is an increasingly common clinical problem. Investigators have begun to understand aspects of the pathogenesis of the tumor, mainly from a morphologic point of view. Preneoplastic lesions and early cancer may be difficult to distinguish radiologically. Nonetheless, programs for surveillance of liver cancer have been developed. Little uniformity exists in methods of surveillance, and even less in methods of investigation and follow-up after an abnormal result is obtained. This article attempts to bring some rigor to the understanding of hepatocellular carcinoma.

Hepatocellular carcinomas <2 cm in diameter complicating cirrhosis: ultrasound and clinical features in 153 consecutive patients

PURPOSE

To determine the frequencies of various echogenicity patterns in 153 consecutive unifocal hepatocellular carcinomas (HCCs) <2 cm detected in cirrhotic livers and to identify their relationships with clinical, laboratory, and microscopic features.

PATIENTS AND METHODS

The tumors were classified as hypoechoic, hyperechoic, isoechoic, or nodule-in-nodule. Correlation was evaluated between hypoechoic and hyperechoic patterns and the following variables: age, gender, serum alphafetoprotein (AFP), tumor size, ultrasound features of liver parenchyma, cirrhosis etiology, and cyto/histological tumor grading.

RESULTS

One hundred and seventeen tumors (76.4%) were hypoechoic, 26 (17.0%) were hyperechoic, 5 (3.3%) were isoechoic, and 5 (3.3%) had nodule-in-nodule patterns. The hyperechoic pattern was more common in patients under 69 years (25.0% vs. 11.3% in those under 69 years or older, P=0.033). Patients with a hyperechoic pattern displayed a trend towards lower AFP levels and higher prevalence of hepatitis C-related cirrhosis. The prevalence of well-differentiated tumors was identical (56.6% and 56.5%) in the hypoechoic and hyperechoic subgroups. AFP was higher than 400 ng/ml in only 11/153 cases (7.2%).

CONCLUSIONS

The hyperechoic pattern of HCC is by no means uncommon, particularly in patients under 70. Hyperechogenicity is not related to an increased frequency of well-differentiated tumors. AFP shows limited value as a confirmatory test of small HCC.

Indication and contraindication for hepatic resection for liver tumors without fine-needle biopsy: validation and extension of an Eastern approach in a Western community hospital

Fine-needle biopsy (FNB) is associated with problems, such as tumor seeding, which are not negligible. The aim of this study was to validate prospectively the accuracy of our diagnostic work-up without FNB, not just to address but also to rule out from a surgical program patients with focal liver lesions (FLLs). From September 2001 to July 2003, 89 patients were seen at an outpatient clinic for FLLs. Nine patients were excluded because of previous FNB and 18 were excluded because carrier of advanced disease. Sixty-two patients with 101 FLLs were included. Preoperative diagnoses were established by means of clinical histories, serum tumor marker levels, ultrasonography (US), and spiral computed tomography (CT). Other imaging modalities were carried out when it was considered necessary. Forty-eight patients underwent surgery, with histological confirmation of the preoperative diagnosis. The remaining 14 patients underwent a close follow-up. The preoperative diagnoses of 47 of the 48 patients who underwent surgery were confirmed (97.9%). All of the 14 patients ruled out for surgical treatment did not show FLL progression at 6-24 months of follow-up. Of the 9 patients who had FNB previously in other centers, 2 had a wrong histological diagnosis. In view of these results, a diagnostic work-up without FNB seems adequate either to include or to exclude patients with potentially resectable FLL from the surgical program and once more highlight the fact that the use of FNB should be drastically limited.

Characteristics of image-detected solid renal masses: Implication for optimal treatment

BACKGROUND

Solid renal masses are found increasingly. Further analysis of the characteristics of solid renal masses is useful for optimal treatment.

METHODS

A retrospective analysis of all solid renal masses was conducted from December 1998 to May 2003 at the Urology Department, Central University Hospital of Saint-Etienne, France. A total of 162 solid renal masses were treated. The preoperative imaging diagnosis of ultrasound and computed tomography, and final pathological results were reviewed.

RESULTS

One hundred and forty-five tumors were pathologically confirmed to be renal cell carcinomas (RCC); 17 tumors (10.5%) were benign. There were eight renal oncocytomas, eight renal angiomyolipomas and one benign mixed epithelial/stroma tumor. Three oncocytomas and five angiomyolipomas were strongly suspected before surgery. The majority of the benign tumors were < or =4 cm. The percentage of small benign tumors (< or =4 cm) was significantly higher than large benign tumors (>4 cm). Although it is possible to use imaging to detect some benign tumors, the majority of benign tumors cannot be diagnosed definitively by imaging before surgery.

CONCLUSIONS

Malignancy in solid renal masses is tumor-size related. Benign solid renal tumors appear mainly as small-sized tumors. The preoperative differentiation between an RCC and a benign tumor can be difficult. Our data suggest that a biopsy is necessary in selected patients to achieve the maximum accuracy in order to provide optimal treatment.

Clinical significance of early hepatocellular carcinoma

Early hepatocellular carcinoma (HCC) is defined as a well-differentiated cancer containing Glisson's triad, but it remains unknown whether this lesion is curable by surgery. We studied 70 patients who had a single HCC smaller than 2 cm in diameter (Stage T1) and who underwent curative hepatectomy and long-term follow-up. Based on our typing system, the tumors were assigned as early HCC (n=15), overt HCC (n=52), and non-HCC tumor (n=3). The rate of microscopic regional spread was lower in early HCCs than in overt HCCs (7% vs. 42%; P=.01). After a median follow-up of 6.3 years, both overall survival and recurrence-free survival in the early HCC group were significantly better than those in the overt HCC group (P=.01; P=.001, respectively): the 5-year rates of overall survival were 93% and 54% and those of recurrence-free survival were 47% and 16%, respectively. The early HCC group was at a lower risk of recurrence (relative risk, 0.31; 95% confidence interval, 0.15-0.65; P=.002) and death (0.26; 0.09-0.73; P=.01) than was the overt HCC group. Early HCC is a distinct clinical entity with a high rate of surgical cure.

Contrast-enhanced intraoperative ultrasonography in surgery for hepatocellular carcinoma in cirrhosis

Intraoperative ultrasonography (IOUS) is the most accurate diagnostic technique for staging hepatocellular carcinoma (HCC), but has low accuracy in differentiating the new nodules detected in the cirrhotic liver. The aim of this preliminary report is to evaluate whether contrast-enhanced intraoperative ultrasonography (CE-IOUS) could provide additional information to IOUS in patients with HCC. From August 2002 to July 2003, a prospective validation cohort study was conducted. For this purpose, 16 consecutive patients underwent liver resection for HCC using IOUS and CE-IOUS. Intraoperatively, in all patients 4.8 mL of SonoVue was injected intravenously through a peripheral vein. IOUS depicted 16 new focal liver lesions: 10 with no enhancement peculiar to HCC at CE-IOUS pattern and at histology (4) or imaging follow-up (6) proved to be benign; the remaining 6 had enhancement peculiar to HCC and histology confirmed this diagnosis. Two different patterns of enhancement were also recognized at CE-IOUS in those HCC nodules depicted preoperatively: one had no similarity to that observed at CT. CE-IOUS added findings to those of unenhanced IOUS in 50% of patients. These results show that IOUS accuracy and specificity is improved by CE-IOUS, with a great impact on surgical strategy and oncological radicality. Furthermore, a wider experience with vascular enhancement patterns with CE-IOUS could provide a new classification for HCC nodules.

Liver transplantation in patients with hepatocellular carcinoma

The preferred therapy for hepatocellular carcinoma (HCC) apparently confined to the liver is surgical removal of the tumor. If the location of the tumor and the functional status of the liver are such that resection with an adequate margin can be achieved with low likelihood of subsequent hepatic failure, liver resection is the preferred approach. When HCC apparently localized to the liver is diagnosed in a patient who, by virtue of tumor characteristics or diminished hepatic reserve, is not a candidate for liver resection, liver transplantation becomes a consideration. This work outlines the approach at The Mount Sinai Hospital to the diagnosis, evaluation, preoperative management, transplantation, and posttransplant follow-up in patients with unresectable HCC. The allocation of livers to patients with HCC is reviewed, and predictors of tumor recurrence and results of liver transplantation for HCC are discussed. Finally, the impact of viral hepatitis and of immunosuppression on transplant outcome are discussed.

Fine needle biopsy of focal liver lesions: the hepatologist's point of view

Guided biopsy of hepatocellular carcinoma has been recently discussed again due to the progress of imaging techniques and the risk of malignant seeding after the procedure. Ultrasound is probably still the most accurate imaging modality for early detection of nodules arising on cirrhosis, even when compared with more advanced imaging techniques. It can be easily employed in the surveillance of high-risk cirrhotic patients. Ultrasound-guided biopsy has very high sensitivity and almost absolute specificity, which allows the appropriate treatment to start after a positive diagnosis. It also allows correct diagnosis of lymphomatous nodules, the incidence of which is increased in hepatitis C virus-related cirrhosis. The risk of seeding appears limited according to the currently available epidemiological data; this should be considered against the risk of false-positive diagnosis of malignancy based on imaging studies alone. Ultrasound-guided biopsy is a valuable tool also for the diagnosis of small nodules (less than 10 mm in diameter). The best accuracy in the sampling of hepatocellular carcinoma nodules is obtained by combining smear cytology and microhistology. This can be achieved by a single biopsy with a fine cutting needle that furnishes pathologic material suitable for both examinations, reducing risks and costs.