Diagnostic accuracy of fine-needle aspiration biopsy in patients with hepatocellular carcinoma

Prevalence of benign focal liver lesions and non-hepatocellular carcinoma malignant lesions in liver cirrhosis

Liver cirrhosis is associated with an increased risk of developing hepatocellular carcinoma (HCC). However, other benign and malignant liver lesions may co-exist or may be the only focal liver lesion (FLL) detected. Compared to HCC, comparatively little is known about the frequency and natural history of benign FLL in patients with established liver cirrhosis.

This review analyses the prevalence and frequency of benign and malignant FLL others than hepatocellular carcinoma (HCC) in liver cirrhosis including imaging and autopsy studies. Understanding these data should be helpful in avoiding misdiagnoses.

Contemporary role of liver biopsy in hepatocellular carcinoma

A correct diagnosis of hepatocellular carcinoma (HCC) in cirrhotic patients with focal liver lesions is one of the most important issues nowadays. Probably one of the oldest debates in the hepatology community is whether to perform liver biopsy (LB) in all cirrhotic patients with focal liver lesions. We now face a time when oncology is moving towards personalized medicine. According to the current European Association for the study of Liver diseases HCC guidelines, LB has only a minor role in the management of HCC. However, the current recommendations were made more than five years ago. As time has passed, the development of high-throughput molecular technologies has helped reveal the main molecular mechanism involved in HCC development and progression. Several subtypes of HCC, with both molecular and histological characterization, have been described. Importantly, some of these subtypes have prognostic impact. In the context of personalized treatment, the role of LB will be carefully reconsidered. Until then, it is mandatory to know the various techniques of LB, their performances, complications and limitations. The balance of risk and benefit defines many of the decisions that we make as providers of medical care. In this review, we discuss not only the risks associated with LB, but also the benefits of biopsy in various clinical scenarios. Not long from now, the role of LB will be reconsidered. It is possible that we will go back in time and once again use biopsy for HCC diagnosis. Then again, we may move back to the future to try to improve the use of liquid biopsy in the follow-up of HCC patients after various treatment modalities.

[Diagnosis and treatment of hepatocellular carcinoma. Update consensus document from the AEEH, SEOM, SERAM, SERVEI and SETH]

Hepatocellular carcinoma is the most common primary malignancy of the liver and one of the most frequent causes of death in patients with liver cirrhosis. Simultaneously with the recognition of the clinical relevance of this neoplasm, in recent years there have been important developments in the diagnosis, staging and treatment of HCC. Consequently, the Asociación Española para el Estudio del Hígado has driven the need to update clinical practice guidelines, continuing to invite all the societies involved in the diagnosis and treatment of this disease to participate in the drafting and approval of the document (Sociedad Española de Trasplante Hepático, Sociedad Española de Radiología Médica, Sociedad Española de Radiología Vascular e Intervencionista y Sociedad Española de Oncología Médica). The clinical practice guidelines published in 2009 accepted as Clinical Practice Guidelines of the National Health System has been taken as reference document, incorporating the most important advances that have been made in recent years. The scientific evidence for the treatment of HCC has been evaluated according to the recommendations of the National Cancer Institute (www.cancer.gov) and the strength of recommendation is based on the GRADE system.

Role of FNA and Core Biopsy of Primary and Metastatic Liver Disease

Objective. To examine our experience with cytology and histology biopsy of the liver and to define methods for improvement of diagnosis of primary liver tumors. Methods. This include retrospective study of 189 biopsies of 185 liver masses for cytological or histological analysis. Patients were subdivided into two groups. Group 1 consisted of 124 suspected metastasis. Group 2 consisted of 61 suspected primary neoplasms. Biopsies were considered positive or equivocal. In equivocal cases, special stains were performed. In Group 2, cases were classified by contrast CT or MRI as to (I) classic HCC, (II) infiltrated HCC, or (Ill) equivocal. Results. Definitive diagnosis was obtained in 117/124 masses (94%) in Group 1, 48/61 masses (79%) in Group 2, and (Ill) equivocal 13 cases in Group II. In two equivocal cases in which special stains were performed, they were reclassified as HCC. In 8/13 cases, CT findings were consistent with HCC. Conclusion. Liver biopsies are useful in obtaining a definitive diagnosis of suspected metastatic liver disease. Biopsy results are less reliable in patients with suspected primary liver tumors. In these situations, strategies can include basing treatment on imaging criteria or use of newer special pathological stains. Advances in Knowledge. Use of newer special immunological stains improves accuracy in definitive diagnosis of primary liver tumors.

Blood oxygen level-dependent liver MRI: can it predict microvascular invasion in HCC?

PURPOSE

To assess Blood Oxygen Level-Dependent (BOLD) Magnetic Resonance Imaging (MRI) for noninvasive preoperative prediction of Microvascular Invasion (MVI) in Hepatocellular Carcinoma (HCC).

MATERIALS AND METHODS

In this prospective, institutional review board approved study, 26 patients (21 men and 5 women age range, 34-77 years with mean age of 61 years) with HCC were evaluated preoperatively with liver MRI including baseline and post oxygen (O2) breathing BOLD MRI. Post processing of MRI data was performed to obtain R2* values (1/s) and correlated with histopathological assessment of MVI. Statistical analysis was performed to assess correlation of baseline R2*, post O2 R2* and R2* ratios to presence of MVI in HCC by binary logistic regression analysis.

RESULTS

MVI was present in 15/26 (58%) of HCC on histopathology. The mean R2* values ± SD at baseline and post O2 with and without MVI were 35 ± 12, 36 ± 12, 38 ± 10, 42 ± 17. The R2* values between the groups with and without MVI were not significantly different statistically.

CONCLUSION

BOLD MRI is unable to accurately predict MVI in HCC. The noninvasive preoperative MRI detection of MVI in HCC remains elusive.

Usefulness of contrast-enhanced intraoperative ultrasound using Sonazoid in patients with hepatocellular carcinoma

OBJECTIVE

To assess the usefulness of contrast-enhanced intraoperative ultrasound (CE-IOUS) using Sonazoid (gaseous perflubutane) in patients with hepatocellular carcinoma (HCC).

BACKGROUND

Contrast-enhanced intraoperative ultrasound using Sonazoid, a novel ultrasonic contrast agent enabling Kupffer imaging, may enable differentiation of HCC among new focal liver lesions found during fundamental intraoperative ultrasound (fundamental-NFLLs).

METHODS

Between February 2007 and February 2009, a total of 192 consecutive patients were enrolled. Fundamental intraoperative ultrasound and CE-IOUS were performed successively after laparotomy. The vascularity of 1 representative lesion was examined in harmonic mode for approximately 1 minute after the intravenous injection of Sonazoid (vascular phase). Approximately 15 minutes after the vascular phase, total liver scanning in the harmonic mode was commenced (Kupffer phase). One additional injection of Sonazoid was allowed to examine the vascularity of another lesion, if necessary. A tentative diagnosis of HCC was made when a lesion was either hypervascular during the vascular phase or hypoechoic during the Kupffer phase. A final diagnosis of HCC was made on the basis of the results of a histological examination or dynamic computed tomography findings obtained during the 12-month postoperative period.

RESULTS

Seventy-nine fundamental-NFLLs were found in 50 patients (26%), 17 (22%) of which were finally diagnosed as HCC. The sensitivity, specificity, and accuracy of CE-IOUS for differentiating HCC among fundamental-NFLLs were 65%, 94%, and 87%, respectively. Contrast-enhanced intraoperative ultrasound identified 21 additional new hypoechoic lesions in 16 patients, of which 14 lesions (67%) in 11 patients were finally diagnosed as HCC. This prospective study protocol was approved by the institutional review board of the Tokyo University Hospital. An English-language summary of the protocol was submitted (registration ID: UMIN000003046) to the Clinical Trials Registry managed by the University Hospital Medical Information Network in Japan (http://www.umin.ac.jp/ctr/index.htm).

CONCLUSIONS

With help of CE-IOUS using Sonazoid, more accurate intraoperative staging for HCC can be performed.

Microvascular invasion in hepatocellular carcinoma: is it predictable with pretransplant MRI?

OBJECTIVE

The purpose of this article is to correlate clinicopathologic and MRI parameters with the presence of microvascular invasion at histopathologic examination in patients with hepatocellular carcinoma (HCC) who are undergoing liver transplantation.

MATERIALS AND METHODS

In this retrospective single-center study, we assessed 60 patients (47 men and 13 women; mean age, 58 years) with HCC who underwent liver transplantation and pretransplant MRI (performed within 90 days before liver transplantation). Two observers analyzed the following tumor parameters in consensus: number, size, T1 and T2 signal intensity, margins, presence of capsule or pseudocapsule, distance to closest vessel, distance to liver capsule, and quantitative tumor enhancement. The size and number of HCCs, tumor differentiation, and the presence or absence of microvascular invasion were determined at histopathologic examination. Odds ratios (ORs) were calculated and logistic regression analysis was performed to assess the utility of these clinicopathologic and imaging parameters for predicting microvascular invasion.

RESULTS

None of the clinical parameters or morphologic and enhancement MRI features of HCC was predictive of microvascular invasion. Tumor multifocality, on both MRI and pathologic examination, was the only variable that predicted microvascular invasion (OR = 2.43 and p = 0.013 for MRI; OR = 1.94 and p = 0.013 for pathologic examination). The presence of three or more tumors on MRI and four or more tumors at pathologic examination had high specificity (88.2% and 91.2%, respectively) for the prediction of microvascular invasion.

CONCLUSION

Tumor multifocality on MRI was the only parameter that correlated significantly with microvascular invasion. All other MRI tumor characteristics failed to predict microvascular invasion.

Diagnosis of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the commonest cancers worldwide, particularly in parts of the developing world, and is increasing in incidence. This article reviews the current modalities employed for the diagnosis of HCC, including serum markers, radiological techniques and histological evaluation, and summarises international guidelines for the diagnostic approach to HCC.

Liver transplantation for hepatocellular carcinoma without preoperative tumor biopsy

BACKGROUND

Progress in liver imaging has made pretransplantation tumor biopsy no longer systematic in patients with hepatocellular carcinoma (HCC).

OBJECTIVES

Our aim was to evaluate the accuracy of a preoperative diagnosis of HCC based on clinical and radiological findings in 102 cirrhotics qualified for liver transplantation (LT) between January 1995 and August 2003 at our institution.

METHODS

The diagnostic accuracy of our policy was assessed by comparing pretransplant diagnosis with the pathologic report of explanted livers.

RESULTS

Sensitivity, specificity, positive, and negative predictive values for the preoperative clinical and radiological diagnosis of HCC were 89%, 94.3%, 77%, and 93.3%, respectively. A false-positive preoperative diagnosis was made in 20 of 102 patients (19.6%) (dysplastic nodules [n=9], regenerative nodules [n=5] cholangiocellular carcinoma [n=1], hemangioma [n=1], and no lesion [n=4]). All tumors larger than 3 cm were correctly diagnosed, irrespective of serum alpha-fetoprotein (sAFP) levels. The risk of overestimating the diagnosis of HCC in the subgroup of patients with tumors less than 3 cm was conversely correlated with preliver transplantation sAFP (sAFP<or=100 ng/L: 28%; sAFP>100: 11%; sAFP>200: 0%).

CONCLUSION

In cirrhotics with nodules larger than 3 cm irrespective of sAFP or nodules less than 3 cm with sAFP greater than 200 ng/L, the pretransplant diagnosis of HCC can be made without performing biopsy. In other cases (i.e., nodules less than 3 cm and sAFP lower than 200 ng/L), histologic confirmation of HCC or a close follow-up imaging should be considered.

Hepatocellular carcinoma with indeterminate or false-negative findings at initial MR imaging: effect on eligibility for curative treatment initial observations

PURPOSE

To retrospectively evaluate the effect of indeterminate or false-negative findings at magnetic resonance (MR) imaging on eligibility for curative treatment of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This HIPAA-compliant retrospective study was approved by the institutional review board; the need for informed consent was waived. Of 166 patients with cirrhosis in whom HCC was detected with MR imaging, 21 (13 men, eight women; mean age, 60 years) had 33 proved HCCs that were not detected on previous MR images obtained 6-24 months earlier. MR imaging included T1-weighted, T2-weighted, and dynamic contrast material-enhanced T1-weighted imaging. Serial MR images and treatment records were reviewed to evaluate nodule growth and the effect of delayed diagnosis on treatment eligibility.

RESULTS

Of 33 HCCs in 21 patients, 24 corresponding nodules (73%) were described on previous MR images as benign or indeterminate. Five additional nodules were visible at retrospective evaluation, but only on arterial phase images. The diameters of these 29 visible but indeterminate nodules were initially 0.6-1.9 cm (mean, 1.1 cm) and increased to 0.9-4.5 cm (mean, 1.9 cm) at HCC diagnosis (mean follow-up, 378 days). The mean doubling time was 856 days for diameter and 285 days for volume. All nine HCCs with a delayed diagnosis of less than 1 year were smaller than 3 cm at diagnosis, and the patients had undergone liver transplantation (n=3) or technically successful ablation or embolization (n=6). All 10 subcentimeter indeterminate nodules were smaller than 2 cm at HCC diagnosis, and none progressed to untreatable HCC.

CONCLUSION

Indeterminate nodules smaller than 2 cm did not become untreatable HCC with delayed HCC diagnosis of 6-12 months.

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.

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.

Survival of patients with early hepatocellular carcinoma treated by percutaneous alcohol injection

BACKGROUND

Once small (<10 mm) nodules, suspicious for hepatocellular carcinoma, are detected in cirrhotics, the European Association for the Study of the Liver guidelines recommend to delay histological confirmation and treatment until they increase in size.

AIM

To validate this policy by evaluating survival of 450 cirrhotics in Child-Pugh class A or B with unifocal 'early' hepatocellular carcinoma treated by percutaneous alcohol injection.

METHODS

Patients were sorted by nodular size into three groups: < or =10 mm (n = 36, group A), >10 to < or = 20 mm (n = 142, group B) and >20 to < or = 30 mm (n = 272, group C). Overall and tumour-free survivals were estimated by Kaplan-Meier method.

RESULTS

In groups A, B and C, mean follow-up was 33 +/- 26, 34 +/- 22 and 35 +/- 25 months (P = 0.89), mean survival time was 63 +/- 54, 57 +/- 48 and 62 +/- 66 months (P = 0.69) and mean tumour-free survival was 44 +/- 47, 46 +/- 58 and 41 +/- 68 months (P = 0.51), respectively. When patients were sorted by Child status, mean survival time was 76 +/- 82 and 38 +/- 29 months in Child A and B (P < 0.0001).

CONCLUSIONS

The comparable survival of percutaneous alcohol injection-treated patients with single, early hepatocellular carcinoma sorted by nodular size supports the European Association for the Study of the Liver 'wait-and-see' policy for patients with lesions <10 mm, and suggests that allowing the nodules to grow prior to taking further diagnostic or therapeutic actions would not harm these patients.

General management

Hepatocellular carcinoma is one of the most common malignancies worldwide. The general management of hepatocellular carcinoma begins with an accurate diagnosis. With advances in imaging studies, noninvasive diagnosis has become an accepted standard of care for hepatocellular carcinoma, though pathologic examination is still required in selected cases. Following diagnosis, accurate staging is the next most important step in selecting the most appropriate treatment modality. Patients with localised tumor and compensated liver disease should be considered for partial hepatectomy, and patients with poor hepatic function but early tumor stage are candidates for liver transplantation. Patients who do not qualify for either of these curative treatments may be evaluated for palliative therapy, of which transarterial chemoembolisation is most widely used. This review will discuss the role of biopsy, the pros and cons of noninvasive and pathologic tissue diagnosis as well as the general approach to choose the most appropriate treatment for patients with hepatocellular carcinoma.

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.

Systematic review of radiological imaging for hepatocellular carcinoma in cirrhotic patients

We systematically reviewed the evidence for determining the best radiological imaging for characterizing hepatocellular carcinoma (HCC) in cirrhotic patients in 997 articles between 1995 and 2001. We selected only prospective and retrospective cohorts of patients, excluding both case reports and studies without separate data on HCC. Only 29 studies, comprising 918 patients, fulfilled the inclusion criteria: 10 used the explanted liver as the reference standard of diagnosis. All except one, either found no statistically significant difference between imaging modalities or had no direct comparison of sensitivity between different modalities of imaging; 16 studies evaluated HCC among cirrhotic patients and had biopsy or imaging as the reference standard for diagnosis. However, no one imaging technique was shown to be superior. In two studies, data of a HCC subgroup was derived from the studies evaluating different kinds of focal hepatic lesions. No conclusion could be drawn because of the small sample size. One study addressed the issue of therapeutic impact. The evidence for choosing the best modality of imaging for characterizing HCC in cirrhotic patients is inadequate. Large multicentre studies with defined reference standards for diagnosis, and studies evaluating therapeutic impact are needed.

Endoscopic ultrasound-guided fine needle aspiration cytology of solid liver lesions: a large single-center experience

OBJECTIVES

The aim of this study was to report the sensitivity, cytological diagnoses, endoscopic ultrasound (EUS) features, complications, clinical impact, and long term follow-up of a large single-center experience with endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of benign and malignant solid liver lesions.

METHODS

A database of cytologic specimens from EUS-FNA was reviewed to identify all hepatic lesions aspirated between January, 1997, and July, 2002. Procedural indications, prior radiographic data, patient demographics, EUS examination results, complications, and follow-up data were obtained and recorded.

RESULTS

EUS-FNA of 77 liver lesions in 77 patients was performed without complications. Of these 77 lesions, 45 (58%) were diagnostic for malignancy, 25 (33%) were benign, and seven (9%) were nondiagnostic. A total of 22 lesions were confirmed as negative for malignancy by follow-up (mean 762 days, range 512-1556 days) or intraoperative examination; however, seven lesions could not be classified as benign or malignant. Depending on the status of the seven unclassified lesions, sensitivity of EUS-FNA for the diagnosis of malignancy ranged from 82 to 94%. When compared with benign lesions, EUS features predictive of malignant hepatic masses were the presence of regular outer margins (60% vs 27%; p = 0.02) and the detection of two or more lesions (38% vs 9%; p = 0.03). Of the 42 patients with malignancy identified by EUS-FNA and other available imaging records, EUS detected the malignancy in 41% of patients with previously negative examinations. For the 45 subjects with cytology positive for malignancy, EUS-FNA changed management in 86% of subjects.

CONCLUSION

EUS-FNA of the liver is a safe and sensitive procedure that can have a significant impact on patient management. Prospective studies comparing the accuracy and complication rate of EUS-FNA and percutaneous fine needle aspiration (P-FNA) for the diagnosis of liver tumors are needed.

Percutaneous fine-needle aspiration cytology in the diagnosis and management of liver tumours

BACKGROUND

The aim of the study was to investigate the value of percutaneous fine-needle aspiration cytology (FNAC) in the diagnosis and management of liver tumours.

METHODS

FNAC followed by histopathological examination was carried out in 216 patients with suspected liver tumours. The final diagnosis was primary liver cancer in 106, colorectal metastases in 51, non-colorectal metastases in 46, benign tumour in nine and no tumour in four patients.

RESULTS

Cytology resulted in correct classification of the lesion as benign or malignant in 87 per cent of patients, correct discrimination between primary and secondary malignancy in half of the patients, and a correct diagnosis of tumour type in one-third of patients. The tumour was erroneously classified as benign or malignant in 22 patients (11 per cent) and four patients (2 per cent) respectively. When FNAC showed malignancy, the predictive value was 98 per cent, whereas the predictive value was 27 per cent when it did not. FNAC guided investigations and treatment in one-quarter of patients. Implantation metastases were recorded in seven patients (3 per cent), including five (10 per cent) of 51 patients with colorectal liver metastases, and caused major local problems and death in four patients.

CONCLUSION

FNAC was valuable in about a quarter of patients with liver tumour. The risks of implantation metastases and a false-negative finding do not justify its use in candidates for curative therapy of liver tumours.

Small (<20 mm) enhancing hepatic nodules seen on arterial phase MR imaging of the cirrhotic liver: clinical implications

OBJECTIVE

To determine the significance in patients with cirrhosis of small (<20 mm) hepatic nodules that show no hyperintensity on T2-weighted MR images but that enhance during arterial phase MR imaging, we reviewed the cases of patients with such nodules.

MATERIALS AND METHODS

Our review of radiology reports yielded 68 nodules in 40 patients with cirrhosis that showed no hyperintensity on T2-weighted MR images but had rapid enhancement during arterial phase MR imaging after administration of a gadolinium contrast agent. Thirty-four patients (60 nodules) had multiple follow-up MR imaging examinations (range of length of follow-up, 1-72 months; average length of follow-up, 15 months 2 weeks). The final diagnosis of the nodule was determined by pathology reports or after at least 2 years of follow-up to ensure nodule stability and, therefore, benignity. Two radiologists independently reviewed MR images of the nodules, noting the size, signal intensity on T1- or T2-weighted images, and homogeneity of contrast enhancement.

RESULTS

Nine (13%) of the 68 nodules were hepatocellular carcinomas (HCCs). The size of nodules on the first MR examination was between 4 and 20 mm (mean size, 9.5 mm). No significant correlation between the diagnosis of HCC and nodule signal intensity (p = 0.48) or contrast enhancement homogeneity (p = 0.56) on first MR examination was found. Positive predictive value (PPV) and negative predictive value (NPV) for diagnosing HCC on the basis of nodule growth were 100% and 98%, respectively. For diagnosing HCC on the basis of a change in nodule signal intensity, the PPV was 60% and the NPV was 91%. For diagnosing HCC on the basis of a change of enhancement homogeneity, the PPV was 63%, and the NPV was 94%.

CONCLUSION

A finding of growth in small, early-enhancing nodules in patients with cirrhosis is highly predictive of HCC. When small nodules are observed on a single examination, close follow-up of the patient appears appropriate.

Ultrasonically guided fine-needle aspiration biopsy of portal vein thrombosis: a cytomorphological study of 14 patients

Portal vein tumor thrombosis is an important and consistent prognostic indicator in hepatocellular carcinoma. We reviewed 14 cases of ultrasonically guided fine-needle aspiration biopsy (FNAB) of the portal vein. All the patients had clinical evidence of portal vein thrombosis (PVT). Twelve of these patients had a preliminary diagnosis of hepatocellular carcinoma while the remaining two, initially, had a clinical diagnosis of end-stage liver disease. The mean age of the patients was 60 years. An average of 1.7 passes per case was made. No clinical complications were encountered. The cytomorphologic features of the aspirated materials were reviewed. Twelve of the 14 cases (85.7%) were judged neoplastic or thought to have probable neoplastic involvement of the portal vein while two were clearly benign. The cell block was found to be the most useful in diagnosis. We conclude that FNAB of the portal vein is a feasible method in evaluating PVT, especially in patients already known to have hepatocellular carcinoma.

Small (< or = 3 cm) hepatic lesions. Results of sonographically guided fine-needle biopsy in 385 patients

Three hundred ninety-five consecutive patients with sonographically detected hepatic lesions < or = 3 cm in diameter were submitted to ultrasonically guided fine-needle biopsy: 24 (6.1%) were < or = 1 cm in diameter; 142 (36%) were between 1.1 and 2 cm, and 229 (57.9%) were between 2.1 and 3 cm in diameter. In the 385 controlled cases, we obtained a cytohistological diagnosis of malignancy in 243 (63.1%): 135 hepatocellular carcinomas, 97 metastases, and 11 hepatic lymphomas. There were 104 true negatives (27%) and 38 false negatives (9.9%). The sensitivity of ultrasonically guided fine needle biopsy in the total series was 86.5%, the specificity 100%, with an overall accuracy of 90.1%. The overall accuracy was higher for lesions between 2.1 and 3 cm in diameter (90%) and was lower for lesions located in the sixth segment (84.6%). The correct diagnosis was obtained in the 83.3% (135/162) of small hepatocellular carcinomas versus 89.8% (97/108) in cases of small metastatic lesions.

The evaluation of fine-needle procedures for the diagnosis of focal liver lesions in cirrhosis

To evaluate the diagnostic accuracy of fine-needle aspiration, fine-needle biopsy and extranodular fine needle biopsy in identifying focal lesions in cirrhosis, 100 consecutive ultrasound detected nodules were studied. Seventy-three were hepatocellular carcinomas (31 were well-differentiated hepatocellular carcinomas), 23 were benign lesions (one angioma and 22 large regenerative nodules) and two were metastases. The lesions were divided according to maximum diameter as follows: < 20 mm in 36, > 20 < 30 mm in 27, and > 30 mm in 33. In four cases there were multiple nodules of different sizes. Fine needle aspiration, intranodular fine needle biopsy and extranodular fine needle biopsy were obtained in each lesion. The sensitivity, specificity and diagnostic accuracy of each procedure were evaluated separately by three independent pathologists. Seven fine needle aspirations and three intranodular fine needle biopsies were considered inadequate. The highest diagnostic accuracy (96%) was obtained by the combined analysis of fine needle aspiration plus intranodular and extranodular fine needle biopsy, and this superiority was confirmed in each group of lesions. Fine needle aspiration showed a lower accuracy (48%) than intranodular fine needle biopsy (67%). When fine needle aspiration and intranodular fine needle biopsy were evaluated together, an accuracy of 91% was found. Intralesional fine needle biopsy plus extranodular fine needle biopsy analysis gave an accuracy of 78% and, particularly relevant, a specificity of 95%. These results indicate that, in patients with cirrhosis with nodular lesions < 30 mm, fine needle biopsy is superior to fine needle aspiration and that the combined evaluation of fine needle aspiration plus intranodular and extranodular fine needle biopsy is the most accurate approach.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined cytological and histological diagnosis of hepatocellular carcinoma in ultrasonically guided fine needle biopsy specimens

This study evaluates the usefulness of a combined cytological and histological approach to the diagnosis of hepatocellular carcinoma (HCC) when applied to fine needle biopsy specimens obtained under ultrasonic guidance. The material, aspirated from 51 focal liver lesions, was handled in such a way that there was sufficient material for both cytological and histological (cell block) assessment. Of the 29 cases of HCC studied, a confident cytological diagnosis was made in 23 (79%). In the remaining six cases, the cytological features were considered to be suspicious but not diagnostic of HCC. Examination of cell blocks in the six cases enabled a confident diagnosis of HCC to be made in all cases. This was due to the supplementary visual information provided by the histological features, particularly the pattern of arrangement of the tumour cells.

Diagnostic value of brush cytology in the diagnosis of bile duct carcinoma: a study in 65 patients with bile duct strictures

Malignant strictures of the extrahepatic bile ducts are difficult to distinguish from benign strictures, particularly in patients with primary sclerosing cholangitis. Because attempts at diagnosing small cancers with fine-needle aspiration biopsy are not possible in the absence of an associated mass lesion and because the sensitivity of exfoliative biliary cytology is controversial, brush cytology has been used as a potential means of establishing a specific diagnosis of bile duct carcinoma. Herein we report our experience with this technique when performed on 65 patients over a 5-yr period. Each had at least one brushing. Thirty-seven were found to have bile duct carcinoma and 28 were found to have benign strictures. Of these 37, the first brushing was positive for malignancy in 15 (40%), whereas four (11%) had cells suspected but not diagnostic of malignancy. Thirteen patients with bile duct carcinoma whose initial brushings were negative for malignancy had second brushings. Of these, five (38%) had malignant cells, whereas three (24%) yielded suspicious cells. Three of the eight whose first two brushings were negative for malignancy were found to have malignant cells on the third brushing. In contrast, of the 28 patients with benign strictures, malignant cells were never found. However, in two patients, suspicious cells were reported with the first but not the second brushing. A single negative or suspicious cytological finding decreased the probability of bile duct carcinoma to 43%. Two and three sequential negative tests reduced the probability to 32% and 0%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)