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

Impact of pretransplant diagnosis of hepatocellular carcinoma on cadveric liver allocation in the era of MELD

The allocation system based on the Model for End-stage Liver Disease (MELD) has led to more patients diagnosed with hepatocellular carcinoma (HCC) being transplanted. We hypothesized that more patients misdiagnosed with HCC are also being transplanted, leading to inappropriate organ allocation. Therefore, we retrospectively analyzed all liver transplants at our center from July 14, 2000, to October 22, 2002 (N = 172; 129 pre-MELD, 43 post-MELD), comparing pretransplant HCC diagnosis to explant histology. Thirty patients met the United Network for Organ Sharing (UNOS) diagnostic criteria for pretransplant HCC diagnosis. There were 25 men (median age, 52.5 yr), and 80% had hepatitis C. The proportion of patients transplanted who had an HCC diagnosis increased from 12% (15/129) pre-MELD to 35% (15/43) post-MELD implementation (P < 0.01). Three of 15 (20%) transplanted pre-MELD and 5 of 15 (33%) transplanted post-MELD lacked HCC in the explant (P = 0.10). Of the three false-positives pre-MELD, one was Status 2B already, and two received living-donor livers. Of the 5 false-positives post-MELD, three had score upgrades that led to early transplantation (13 to 29, 20 to 29, and 9 to 24) while two had MELD scores of 35 and 36 already. The percentage of organs that could have gone to patients with more advanced liver disease without HCC increased from 0% (0/129) pre-MELD to 7% (3/43) post-MELD (P < 0.01). Since the implementation of MELD, the proportion of patients transplanted who had an HCC diagnosis nearly tripled, and a small but significant proportion of organs are now going to patients misdiagnosed with HCC. More stringent HCC diagnostic criteria will be required to decrease the effect that misdiagnosis has on organ allocation.

Spiral computed tomography versus ultrasound in the follow-up of cirrhotic patients previously treated for hepatocellular carcinoma: a prospective study

BACKGROUND/AIMS

To assess the value of hepatic-arterial-phase computed tomography (HAP-CT) versus ultrasound (US) plus alpha-fetoprotein (AFP) in the surveillance of cirrhotic patients with previously treated hepatocellular carcinoma (HCC).

METHODS

Thirty-six cirrhotic patients, treated for single nodular HCC <4cm with complete response and no evidence of other focal lesions, were enrolled in a prospective study and underwent simultaneous AFP/US/spiral-CT follow-up every 6 months. Focal lesions were considered recurrences when they appeared as globular enhancement areas (EA) at HAP-CT and increased in size during the follow-up.

RESULTS

Fifteen of 36 patients showed at least one focal lesion for a total of 43 EA: 38/43 increased in size, four did not change and one disappeared. EA were first observed after a follow-up of 9+/-4 (range 6-18) months. At the same time, no patient had either nodular lesion at US examination or diagnostic levels of AFP. In 22 matched lesions, diagnosis by CT was 8.2+/-3.5 months earlier than by US. In 13 patients, one evolved EA was submitted to US-guided biopsy and histological examination showed HCC in all cases.

CONCLUSIONS

Periodical spiral-CT examination is more effective than US-AFP in early detection of HCC recurrence in cirrhotic patients successfully treated for HCC.

Diagnosis of hepatocellular carcinoma: fine needle aspiration cytology or needle core biopsy

Needle core biopsy (NCB) has been the standard procedure for histopathologic diagnosis of hepatic lesions for more than 50 years. In recent years fine needle aspiration cytology (FNAC) has emerged as a minimally invasive, relatively inexpensive and a rapid method of pathologic evaluation of primary or metastatic hepatic masses. The specificity and the positive predictive value of FNAC is very high however, the sensitivity of the procedure widely ranges between 67% to 93%. The two major areas of diagnostic difficulties are differentiation of benign and non-neoplastic hepatic nodules from well differentiated HCC and identification of obviously malignant cells as HCC, cholangiocarcinoma, or metastasis. Preparation of cell blocks, immunohistochemical stains and application of other ancillary techniques are often helpful in difficult cases. In presence of characteristic features a diagnosis of HCC can be established on FNAC however, a negative result does not exclude malignancy. The role of pathologic diagnosis in the assessment of large hepatic masses is well established however, its role in the evaluation of small hepatic nodules (<3 cm) detected during surveillance of high risk patients is still evolving. Considering the overall advantages and cost-analysis, FNAC can be suggested as the initial method of choice for evaluation of hepatic masses in most clinical settings. However, the final choice of the diagnostic procedure should be decided on the basis of working clinical diagnosis and the institutional experience.

Screening for hepatocellular carcinoma

To determine the role of screening and to screen in a cost-effective manner, it is important to define the high-risk patient population that is most likely to benefit from screening and to identify a readily available diagnostic modality that is sensitive, specific, and inexpensive. Moreover, to have a major effect on the outcome of hepatocellular carcinoma, the test should be applicable in the majority of high-risk subjects. Herein, we identify the high-risk patient population, discuss various diagnostic modalities, and recommend a practical and cost-effective strategy for screening.

Surgical management of hepatocellular carcinoma: resection and ablation

In this article, the author reviews the recent advances in the surgical management of hepatocellular carcinoma (HCC). Partial hepatic resection or, in some instances, liver transplantation provides the best chance for cure. Risk of perioperative mortality after partial hepatectomy is less than 5% in most experienced centers. Careful preoperative assessment of hepatic function is important to reduce the risk of postoperative liver failure after liver resection. Long-term outcomes after resection are comparable to those with liver transplantation, with reported 5-year survival rates of 25%-50%. Although limited controlled comparative studies exist, surgical and nonsurgical local ablative therapies, including ethanol and radiofrequency ablation, may result in survival benefit.

Gray-scale ultrasound in hepatic cirrhosis and chronic hepatitis: diagnosis, screening, and intervention

Chronic hepatitis and hepatic cirrhosis are pathologies with high prevalence in the world population. Ultrasound (US) allows for a quick and precise examination of the liver parenchyma, the vascular structures, the biliary tract, and the abdominal cavity. Changes can be detected in the pattern of liver echostructure that suggest the presence of chronic liver disease, portal hypertension, and the presence of liver tumors. Moreover, US guidance provides an easy way for performing interventional procedures, such as biopsies for classifying the degree and type of liver disease, biopsies of focal liver lesions, and the application of percutaneous treatments for hepatocellular carcinoma (HCC). In this article we discuss the multiple applications of US in the management of patients with chronic liver disease.

Hepatic arterial blood flow in large hepatocellular carcinoma with or without portal vein thrombosis: assessment by transcutaneous duplex Doppler sonography

BACKGROUND

As liver cirrhosis progresses, the portal venous blood (PVBF) flow decreases, accompanied by an increase in hepatic arterial blood flow. Large hepatocellular carcinoma is a hypervascular tumour with a rapid growth, which seems to require an increase of the tumoral arterial blood flow. Furthermore, hepatocellular carcinoma is frequently associated with portal vein thrombosis, which subsequently impedes portal blood supply.

METHODS

The purpose of our study was to estimate alterations in the hepatic arterial blood flow in large hepatocellular carcinomas occurring in liver cirrhosis, in comparison with liver cirrhosis and controls. Liver blood flow measurements were determined by duplex Doppler sonography in 47 patients with large hepatocellular carcinomas (13 with portal vein thrombosis and 34 without this thrombosis), 42 liver cirrhosis patients and 30 controls. The Doppler perfusion index was calculated as the ratio of hepatic arterial blood flow to total hepatic blood flow.

RESULTS

The patients with liver cirrhosis had a significant increase of hepatic arterial blood flow as compared to controls (P < 0.001), accompanied by a significant reduction in PVBF (P < 0.005). As a result, the Doppler perfusion index was increased in patients with liver cirrhosis as compared to controls (P < 0.001). The hepatic arterial blood flow was increased in patients with hepatocellular carcinoma but without portal vein thrombosis as compared to the cirrhotic patients (P < 0.001), with a significant reduction of PVBF (P < 0.001). Hepatic arterial blood flow was also increased in patients with both hepatocellular carcinoma and portal vein thrombosis as compared to the patients without this thrombosis (P < 0.001).

CONCLUSION

These results suggest that in large hepatocellular carcinomas there is a decreased PVBF, accompanied by an increased hepatic arterial blood flow. The hepatic arterial buffer response seems to be active in hepatocellular carcinomas and maintains liver perfusion to adequate levels.

Diagnosis of liver nodules observed in chronic liver disease patients during ultrasound screening for early detection of hepatocellular carcinoma

OBJECTIVES

The aim of our study was to evaluate the nature of focal liver lesions detected during the ultrasound follow-up of a population (prevalently anti-hepatitis C virus [anti-HCV] positive) with chronic liver disease.

METHODS

The study population consisted of 1827 consecutive newly diagnosed chronic liver disease cases without liver nodules at enrollment. Patients were screened at 4-month intervals by ultrasound and serum alpha-fetoprotein assessment. All lesions detected on imaging studies (except those accompanied by diagnostic a-fetoprotein levels) were subjected to biopsy (histology and cytology).

RESULTS

During the 7-yr follow-up period (mean = 43.1 months), one or more solid focal lesions were found in 287 patients. a-Fetoprotein was diagnostic for hepatocellular carcinoma in 51 patients. Ultrasound-guided fine-needle biopsy was performed in the remaining 236 patients, yielding a diagnosis in 214: 198 hepatocellular carcinomas, 11 dysplastic nodules, and five B-cell non-Hodgkin's lymphomas (all confined to the liver and all in patients with chronic HCV infection). Twenty-two patients with nondiagnostic biopsies received diagnoses of hepatocellular carcinoma (20) or dysplastic nodules (two) based on arteriography or surgical biopsy.

CONCLUSIONS

Focal lesions arising in patients with HCV-related chronic liver disease can be other than hepatocellular carcinoma, and ultrasound-guided fine-needle biopsy plays an important role in their diagnosis. The prevalence of non-Hodgkin's lymphoma in this selected population was 0.31%. The fact that all five lymphoma patients had cirrhosis related to hepatitis C strengthens the hypothesis of an etiological correlation between the latter infection and B-cell lymphoproliferative disorders.

Hepatocellular carcinoma: detection with gadolinium- and ferumoxides-enhanced MR imaging of the liver

PURPOSE

To test the hypothesis that the accuracy of gadolinium- and ferumoxides-enhanced magnetic resonance (MR) imaging is different in small (< or =1.5-cm) and large (>1.5-cm) hepatocellular carcinomas (HCCs).

MATERIALS AND METHODS

Forty-three consecutive patients with chronic liver disease were enrolled in this study. The imaging protocol included unenhanced breath-hold T1-weighted fast field-echo sequences, unenhanced respiratory-triggered T2-weighted turbo spin-echo (SE) sequences, dynamic gadolinium-enhanced T1-weighted three-dimensional turbo field-echo sequences, and ferumoxides-enhanced T2-weighted turbo SE sequences. Images of each sequence and two sets of sequences (ferumoxides set and gadolinium set) were reviewed by four observers. The ferumoxides set included unenhanced T1- and T2-weighted images and ferumoxides-enhanced T2-weighted turbo SE MR images. The gadolinium set included unenhanced T1- and T2-weighted images and dynamic gadolinium-enhanced three-dimensional turbo field-echo MR images. In receiver operating characteristic (ROC) curve analysis, the sensitivity and accuracy of the sequences were compared in regard to the detection of all, small, and large HCCs.

RESULTS

Imaging performance was different with gadolinium- and ferumoxides-enhanced images in the detection of small and large HCCs. For detection of small HCCs, the sensitivity and accuracy with unenhanced and gadolinium-enhanced imaging (gadolinium set) were significantly (P =.017) superior to those with unenhanced and ferumoxides-enhanced imaging (ferumoxides set). The area under the composite ROC curves, or A(z), for the gadolinium set and the ferumoxides set was 0.97 and 0.81, respectively. For large HCC, the ferumoxides set was superior compared with the gadolinium set, but this difference was not statistically significant. Analysis of all HCCs demonstrated no significant differences for gadolinium- and ferumoxides-enhanced imaging.

CONCLUSION

For the detection of early HCC, gadolinium-enhanced MR imaging is preferred to ferumoxides-enhanced MR imaging because the former demonstrated significantly greater accuracy in the detection of small HCCs.

Primary liver cancer and occupation in men: a case-control study in a high-incidence area in Northern Italy

The objective of our study was to evaluate the association between occupation and risk of liver cancer. A hospital-based case-control study was carried out during 1997-1999 in the Province of Brescia, a highly industrialized area in Northern Italy with a high incidence of this neoplasm. The cases were 144 male patients with incident liver cancer (96% hepatocellular carcinoma). Controls were 283 male patients, matched to cases on age (+/-5 years), period and hospital of admission. Information on lifetime occupational history and alcohol consumption was obtained via interview. Specific occupational exposures to pesticides, solvents and other suspected hepatocarcinogens were evaluated. A blood sample was collected to detect hepatitis B and C infections. Odds ratios (OR) of occupational exposure and 95% confidence intervals (CI), adjusted for age, residence, education, heavy alcohol intake, hepatitis B surface antigen and hepatitis C virus antibodies positivity were computed. A statistically significant increased OR was observed for employment in repair of motor vehicles (OR 3.7; 95% CI 1.1-12.3; 9 exposed cases, 10 exposed controls). Increased ORs, although not statistically significant, were found for field-crop farm workers, food and beverage processors, blacksmiths and machine-tool operators, electrical fitters, clerical workers, manufacture of industrial machinery and personal and household services. A slightly increased OR was noted in workers exposed to toluene and xylene (OR 1.4; 95% CI 0.7-3.0, 23 cases, 36 controls); the OR was 2.8 (95% CI 1.0-7.6, 11 cases, 12 controls) for 20 or more years of exposure and 2.0 (95% CI 0.9-4.1, 21 cases, 28 controls) for 30 or more years of time since first exposure. The increase in OR seemed to be independent from that of alcohol or viral infections. Our study showed that the role of occupational exposures in liver carcinogenesis is limited. However, prolonged exposure to organic solvents such as toluene and xylene may represent a risk factor for liver cancer.

Hemangioma-like lesions in chronic liver disease: diagnostic evaluation in patients

PURPOSE

To quantify the risk of misdiagnosis of focal hepatic lesions manifesting at ultrasonography (US) as typical hemangiomas in a population at high risk for hepatocellular carcinoma (HCC) and to identify the most effective approach to their diagnostic evaluation.

MATERIALS AND METHODS

A total of 1,982 patients with newly diagnosed cirrhosis underwent US and serum alpha-fetoprotein determinations for early detection of HCC. Focal lesions with typical features of hemangioma were evaluated with confirmatory findings of contrast material-enhanced dynamic or spiral computed tomography (CT) and/or single photon emission CT with technetium 99m-labeled red blood cells and, in the absence of confirmatory imaging findings, US-guided fine-needle biopsy. Patients whose initial US scan depicted no lesions or hemangiomas were enrolled in a US follow-up program. All hemangioma-like lesions detected during follow-up were evaluated, or biopsy was performed.

RESULTS

US depicted hemangioma-like lesions in 44 of 1,982 patients: 22 hemangiomas and 22 HCCs. Hemangioma-like lesions detected during follow-up in 1,648 patients were HCCs (n = 22) or dysplastic nodules (n = 4). Only 85 (22%) of 383 patients with HCC had alpha-fetoprotein levels suggestive of the diagnosis. The probability of a diagnosis of HCC (or preneoplastic lesion) is 100% for hemangioma-like lesions depicted on subsequent US scans.

CONCLUSION

If initial US examination of a cirrhotic liver depicts a hemangioma, confirmatory findings of imaging studies are necessary since 50% of hemangiomas in this study were hyperechogenic HCCs. US-guided biopsy can be safely performed, and its findings can be used to confirm the diagnosis.

Resection of hepatocellular carcinoma without preoperative tumor biopsy

OBJECTIVE

To evaluate the need for a preoperative tumor biopsy of liver lesions suspicious for hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

With advances in liver imaging, the results of recent studies have suggested a very high accuracy of preoperative evaluation of liver masses suspicious of HCC, making preoperative tumor biopsy unnecessary.

METHODS

A retrospective analysis was conducted of all liver resections for HCC at the Toronto General and Mt. Sinai Hospitals, Toronto, between October 1994 and December 1998.

RESULTS

Sixty patients underwent 65 liver resections without a preoperative liver biopsy. The median age was 61 years. Sixty percent of the patients had cirrhosis and 38.5% had noncirrhotic chronic hepatitis. HCC was confirmed histologically in the surgical specimen in 63 of the 65 cases (96.9%). Both patients without HCC had a significant risk factor for HCC (chronic hepatitis C and alcohol in one and chronic hepatitis B and previous resection for HCC in the other). The lesions were 2 cm and 2.7 cm in diameter, and the alpha-fetoprotein level was low (<5 and 22 ng/mL, respectively). In such patients, with tumor 3 cm or smaller and an alpha-fetoprotein level less than 100 ng/mL (10 patients), the false-positive rate for the preoperative diagnosis was 2/10 (20%).

CONCLUSIONS

Preoperative diagnosis of HCC was highly accurate in lesions larger than 3 cm. Tumor biopsy is unnecessary in these patients. However, in a subgroup of patients with lesions less than 3 cm, particularly those with alpha-fetoprotein levels less than 100 ng/mL, there is a higher false-positive diagnostic rate, and tumor biopsy should be considered.

Assessment of the benefits and risks of percutaneous biopsy before surgical resection of hepatocellular carcinoma

BACKGROUND/AIMS

Because of a potential risk of needle tract seeding, the use of ultrasound (US)-guided biopsy for the diagnosis of hepatocellular carcinoma (HCC) is controversial. This study was aimed at determining the usefulness, accuracy and safety of this technique as well as the incidence of needle tract seeding.

METHODS

From 1986 to 1996, 137 patients who underwent resection or transplantation for suspected HCC had US-guided biopsy before surgery. The analysis of the resected liver was compared to the results of biopsy. Patients were assessed with a mean follow up of 38 months.

RESULTS

The diagnosis of HCC was established by biopsy in 122 patients (89%). Thirteen of the 15 patients with negative biopsy were shown to have HCC after surgery. The remaining two patients had non-malignant nodules. Sensitivity and accuracy of US-guided biopsy were 90 and 91%, respectively. Accuracy was significantly influenced by the location of the nodule but not by its size. Needle tract seeding occurred in two patients (1.6%).

CONCLUSIONS

In this series, the incidence of needle tract seeding was less than 2% and no recurrence was observed after local excision. This risk should be balanced with the risk of deciding an aggressive treatment in a patient without malignancy. Patients with negative biopsy should undergo a second biopsy and/or repeated investigations by imaging techniques.

CT demonstration of the spontaneous regression of a hypervascular lesion in cirrhotic liver

In patients with liver cirrhosis, arterial phase enhancement of nodular lesions on helical-CT is currently considered to be highly predictive of malignancy. We report the spontaneous regression of a hypervascular hepatic nodule in a patient with liver cirrhosis within 7 months demonstrated by helical-CT follow-up. This suggests that tumor angiogenesis known to be an obligatory step for acquisition of malignant properties could regress, and can be demonstrated by helical CT. Radiologists should be aware that CT detection of a hypervascular nodule in a cirrhotic liver is not always predictive of a malignant outcome.