Cytopathologic grading of hepatocellular carcinoma on fine-needle aspiration

Cytological Comparison between Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma by Image Analysis Software Using Touch Smear Samples of Surgically Resected Specimens

To investigate useful cytological features for differential diagnosis of hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC), this study cytologically compared HCC to ICC using image analysis software. Touch smear specimens of surgically resected specimens were obtained from a total of 61 nodules of HCC and 16 of ICC. The results indicated that the major/minor axis ratio of ICC is significantly larger than that of HCC (1.67 ± 0.27 vs. 1.32 ± 0.11, p < 0.0001) in Papanicolaou staining. This result means that the nucleus of HCC is close to round and the nucleus of ICC is close to an oval. This significant difference in the major/minor axis ratio between ICC and HCC was consistently observed by the same analyses using clinical samples of cytology (4 cases of HCC and 13 cases of ICC) such a fine-needle aspiration, brushing and ascites (ICC: 1.45 ± 0.13 vs. HCC: 1.18 ± 0.056, p = 0.004). We also confirmed that nuclear position center-positioned nucleus (p < 0.0001) and granular cytoplasm (p < 0.0001) are typical features of HCC tumor cells compared to ICC tumor cells. The research study found a significant difference in the nuclear morphology of HCC (round shape) and ICC (oval shape) in Papanicolaou-stained cytology specimens. This simple and objective finding will be very useful for the differential cytodiagnosis of HCC and ICC.

High expression of Snail and NF-κB predicts poor survival in Chinese hepatocellular carcinoma patients

In this study, we explored the roles of Snail and NF-κB in hepatocellular carcinoma (HCC). Samples of HCC tumor tissue were collected from 83 Chinese HCC patients. Snail and NF-κB expression was then examined based on immunohistochemical staining, and the relations between Snail and NF-κB expression and the clinical characteristics of the patients were assessed using Cox model analysis. Snail and NF-κB were both expressed in HCC tissue, and their levels were strongly correlated. In addition, levels of both Snail and NF-κB expression were negatively related to tumor differentiation, which was an independent factor predictive of survival in HCC patients. Snail and NF-κB may thus be useful markers of tumor differentiation and survival in HCC, and may also be useful for guiding treatment and exploring molecular mechanisms.

Role of Diffusion Weighted Imaging (DWI) for Hepatocellular Carcinoma (HCC) Detection and its Grading on 3T MRI: A Prospective Study

BACKGROUND

Limited studies have evaluated the role of diffusion weighted imaging (DWI) and apparent diffusion coefficient (ADC) for histologically grading the hepatocellular carcinoma (HCC).

OBJECTIVE

To compare the efficacy of DWI with dynamic contrast enhanced magnetic resonance (DCEMR) in detection of HCC in cirrhosis, and to evaluate whether DWI can be used instead of DCEMR.

METHODS

20 patients of either sex with cirrhosis and suspected of having HCC on screening USG were included in this prospective study approved by the Institutional Ethics Committee. All patients underwent DCEMR of the abdomen on 3T scanner and fine needle aspiration of the lesions. MR protocol included T1WI, T2WI, DWI, and dynamic CEMR. The results of diffusion weighted imaging were compared with DCEMR to find the efficacy of DWI vis-à-vis CEMR.

RESULTS

DWI had a sensitivity and specificity of 100%, for diagnosis of lesions in cases having single lesion on CEMR, and sensitivity of 75% and specificity of 100% for diagnosis of lesions in cases having multiple lesions. There was a decreasing trend of ADC values with increasing grade of the tumor; however, the decreasing trend was not statistically significant. A cut-off ADC value of 0.8705 resulted in a sensitivity of 75% and specificity of 50% for differentiating between well-differentiated and other grades of HCC.

CONCLUSION

DWI can be used as an alternative for the detection and characterization of HCC, especially in patients with impaired renal function or contrast allergies precluding the use of contrast. In addition, DWI with ADC measurement may be helpful for non-invasive and preoperative prediction of the degree of differentiation of HCC.

Prediction of hepatocellular carcinoma biological behavior in patient selection for liver transplantation

Morphological criteria have always been considered the benchmark for selecting hepatocellular carcinoma (HCC) patients for liver transplantation (LT). These criteria, which are often inappropriate to express the tumor’s biological behavior and aggressiveness, offer only a static view of the disease burden and are frequently unable to correctly stratify the tumor recurrence risk after LT. Alpha-fetoprotein (AFP) and its progression as well as AFP-mRNA, AFP-L3%, des-γ-carboxyprothrombin, inflammatory markers and other serological tests appear to be correlated with post-transplant outcomes. Several other markers for patient selection including functional imaging studies such as ¹⁸F-FDG-PET imaging, histological evaluation of tumor grade, tissue-specific biomarkers, and molecular signatures have been outlined in the literature. HCC growth rate and response to pre-transplant therapies can further contribute to the transplant evaluation process of HCC patients. While AFP, its progression, and HCC response to pre-transplant therapy have already been used as a part of an integrated prognostic model for selecting patients, the utility of other markers in the transplant setting is still under investigation. This article intends to review the data in the literature concerning predictors that could be included in an integrated LT selection model and to evaluate the importance of biological aggressiveness in the evaluation process of these patients.

Retrospective study of cytologic features of well-differentiated hepatocellular carcinoma in dogs

BACKGROUND

Cytologic diagnosis of hepatocellular carcinoma is possible when hepatocytes have prominent criteria of malignancy, but is problematic when hepatocytes have a relatively normal morphologic appearance.

OBJECTIVES

The aim of this study was to determine the cytologic features of histologically confirmed well-differentiated hepatocellular carcinomas (WD-HCC) in dogs to develop reasonable criteria for an accurate diagnosis when obvious criteria of malignancy in hepatocytes are lacking.

METHODS

Slides of ultrasound-guided fine-needle aspirates of 15 histologically confirmed WD-HCC in dogs were evaluated retrospectively using a scoring system (0-3) established for 33 cytologic features. For comparison, 15 cytologic samples of non-nodular non-neoplastic liver were evaluated using the same criteria. Statistical analysis included multiple hypothesis testing using the Benjamini-Hochberg method or false discovery rate control to correct for multiple comparisons.

RESULTS

The most significant and useful cytologic features in the diagnosis of canine WD-HCC were dissociation of hepatocytes, acinar or palisading arrangements of neoplastic cells, and the presence of naked nuclei and capillaries, together with mild anisocytosis, anisokaryosis, multinuclearity, and increased N:C ratios.

CONCLUSIONS

Cytologic features of canine WD-HCC were determined. Further studies are warranted to compare these cytologic criteria among WD-HCC, hepatomas, and hyperplastic nodules and to examine co-variance of the 33 cytologic features.

Fine-needle aspiration of renal cell carcinoma: is accurate Fuhrman grading possible on cytologic material?

The Fuhrman grading system of renal cell carcinoma (RCC) consists of four grades based on nuclear size/contour and nucleolar conspicuousness. Fuhrman grading of histpathologic material is an independent prognostic parameter for RCC. Although widely used in surgical pathology, Fuhrman grading is not routinely performed on cytologic material. Thirty-three cases of renal fine needle aspirations (FNAs) with histologically proven RCC were retrieved from the cytopathology archives at Johns Hopkins Hospital. Fuhrman grade was determined independently and blindly by three faculty cytopathologists and compared with the Fuhrman grade of the subsequent surgical pathology specimen. The 33 resection specimens had the following Fuhrman grades: 0/33, grade I; 24/33 (73%), grade II; 9/33 (27%), grade III; and 0/33, grade IV. After Fuhrman grading was applied to the FNA material, diagnostic sensitivity was 83% for grade II versus 44% for grade III. The specificity and accuracy were 50 and 75%, respectively, for grade II versus 100% and 84% for grade III. Diagnostic sensitivity for grade II tumors ranged from 38 to 83%, grade III 44-62%. Diagnostic specificity for grade II tumors ranged from 50 to 78%, grade III 80-100%. Accuracy ranged from 48 to 75% for grade II and 75-87% for grade III. Using a two-tier grading model, accuracy improved to 84.2%. In our experience, Fuhrman grading of FNA specimens yielded variable results. There was only moderate agreement between cytopathologists, with an overall tendency to undergrade the tumor when compared with the resection specimen. Averaging the participants' grading and using a two-tier instead of four-tier system improved overall performance.

Pre-operative liver biopsy in cirrhotic patients with early hepatocellular carcinoma represents a safe and accurate diagnostic tool for tumour grading assessment

BACKGROUND & AIMS

Knowledge of pre-operative tumour grade is crucial in the management of hepatocellular carcinoma (HCC) because it can influence recurrence and survival after surgery. The accuracy of pre-operative needle core biopsy (NCB) in tumour grading has been assessed in only a few studies with conflicting results. Our aim was to determine the long-term safety and the overall accuracy of NCB in assessing tumour grading in subjects who had undergone liver resection for a single HCC.

METHODS

Eighty-one cirrhotic patients with HCC who had undergone NCB before liver resection were selected. Only patients with a single HCC and with at least a five-year-follow-up were included. Tumour grading was scored according to a modified Edmondson-Steiner classification: well/moderately (low grade) vs poorly-differentiated (high grade).

RESULTS

In the 81 patients with a solitary HCC (mean size 4.1 ± 2.3cm) tumour grade was correctly identified by NCB in 74 out of 81 (91.4%) HCCs. NCB overall sensitivity and specificity were 65% and 98.1%, respectively, with a PPV of 92% and an NPV of 91%. No major complications (in particular tumour seeding) were observed. The overall survival rates at 1, 3, and 5 years were 83%, 62%, and 44%, respectively; the recurrence rate after a 5-year-follow-up was 56.2% for low grade and 82.3% for high grade tumours (p<0.007).

CONCLUSIONS

Pre-operative NCB can be performed on early (<5 cm) HCC cirrhotic patients because it provides histologically useful information for HCC management with good accuracy and a low complication rate.

Management of an incidental liver mass

The increased use of sensitive imaging modalities has led to increased identification of the incidental liver mass (ILM). A combination of careful consideration of patient factors and imaging characteristics of the ILM enables clinicians to recommend a safe and efficient course of action. Using an algorithmic approach, this article includes pertinent clinical factors and the specific radiologic criteria of ILMs and discusses the indications for potential procedures. It is the aim of this article to assist with the development of an individualized strategy for each patient with an ILM.

Preoperative assessment of hepatocellular carcinoma tumor grade using needle biopsy: implications for transplant eligibility

OBJECTIVE

To examine the diagnostic agreement of preoperative needle core biopsy (NCB) grading of hepatocellular carcinoma (HCC) compared with the final surgical pathologic tumor grade.

SUMMARY BACKGROUND DATA

Some centers have adopted protocols for selecting patients with HCC for transplantation based on tumor grade as determined by preoperative NCB. The validity of NCB to predict final tumor grade has not been previously assessed.

METHODS

A total of 211 patients who underwent hepatic resection, open radiofrequency, or transplantation for HCC between 1998 and 2004 were identified. Clinicopathologic, NCB, and surgical data were collected and analyzed using chi and kappa statistics.

RESULTS

A total of 120 (67.4%) of the 178 who underwent resection or transplantation had an NCB. On preoperative NCB, the majority of HCC cases were classified as well-differentiated (n = 35; 37.6%) or moderately differentiated (n = 44; 47.3%), while 14 (15.1%) cases were categorized as poorly differentiated. In contrast, when tumor grading was based on the final surgical specimen, there was a significantly higher proportion of HCC cases graded as poorly differentiated (well-differentiated, n = 34; 36.6%; moderately differentiated, n = 33; 35.5%; poorly differentiated, n = 26; 27.9%) (P < 0.05). The overall percent agreement of NCB and surgical pathology to determine tumor grade was poor (kappa = 0.18, P < 0.0001). Whereas final pathologic tumor grade predicted the presence of microscopic vascular invasion (well, 15.7%; moderate; 31.9%, poor; 58.4%; P = 0.001), NCB grade did not (well, 23.7%; moderate, 28.0%; poor, 25.4%; P = 0.65).

CONCLUSIONS

Selection of candidates for transplantation based on NCB tumor grade may be misleading, as NCB tumor grade often did not correlate with grade or presence of microscopic vascular invasion on final pathology. Clinicomorphologic criteria (tumor size, number) should remain the major determinants of eligibility for transplantation.

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