Preoperative diagnosis with versus without MRI in resection for hepatocellular carcinoma

Diagnostic utility of EUS-FNA in distinguishing hepatocellular carcinoma from gastric submucosal tumor: A case report

INTRODUCTION AND IMPORTANCE

Extrahepatically growing hepatocellular carcinoma (HCC) account for only 0.3 %-2.4 % of all hepatocellular carcinoma cases. We present the rare case of a patient in whom endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was used to distinguish an extrahepatically growing HCC from a gastric submucosal tumor.

CASE PRESENTATION

The patient was a 44-year-old man who underwent an esophagogastroduodenoscopy (EGD) and was found to have a submucosal tumor (SMT). A gastrointestinal stromal tumor was suspected. Computed tomography (CT) showed an unclear connecting between the tumor and the liver. On immunohistochemical analysis, the tumor cells were positive for CK7, PIVKA-II, and glypican-3, and negative for C-kit. Based on these findings, HCC was suspected, and ethoxybenzyl diethylenetriamine-enhanced magnetic resonance imaging (EOB-MRI) was performed. EOB-MRI revealed the connecting of the tumor and the liver. Thus, the patient was diagnosed as having an extrahepatically protruding HCC, and laparoscopic S2 partial hepatectomy was performed. Pathologically, the tumor was identified as a moderately differentiated HCC. According to the 8th edition of the UICC TNM Classification, the tumor was classified as T1bN0M0 and stage IB.

CLINICAL DISCUSSION

Owing to its rarity, the diagnosis of an extrahepatically protruding HCC is often difficult when the differentiation of a gastric SMT and HCC is unclear on CT. As in this case, if an HCC is also differentiated on hematoxylin and eosin staining after EUS-FNA, immunohistochemistry findings can help in the diagnosis.

CONCLUSION

The findings show that EUS-FNA could be helpful for diagnosis when an HCC needs to be differentiated from a gastric SMT.

Selection of patients with esophageal varices for liver resection of hepatocellular carcinoma

The presence of esophageal varices (EV) is a phenotype of portal hypertension, and the indications of liver resection for hepatocellular carcinoma (HCC) in patients with concomitant EV are conflicting. This retrospective study aimed to elucidate if there is justification for liver resection in patients with EV. The surgical outcomes were compared between the patients who underwent resection for HCC with EV (EV group) and those without EV (non-EV group) after propensity-score matching. More bleeding was prevalent (P < 0.001) and refractory ascites was more frequently observed (P = 0.031) in the EV group (n = 277) compared with the non-EV group (n = 277); however, the numbers of patients with morbidities (P = 0.740) and re-operation (P = 0.235) were not significantly different between the two groups. After a median follow-up period of 3.0 years, the median overall and recurrencefree survival periods of patients with EV were 4.8 years (95% confidence interval [CI], 4.1-5.9) and 1.7 years (1.5-2.0), respectively, and were significantly shorter than those of patients without EV (7.6 years [95% CI, 6.3.9.7], P < 0.001, and 2.2 years [1.9-2.5], P = 0.016). On multivariate analysis, the independent factors for overall survival in the EV group were indocyanine green clearance rate at 15 minutes, des-gamma carboxyprothrombin, and the presence of multiple tumors. Considering that liver resection for patients with EV can be safely performed, it should not be contraindicated. However, surgical outcomes of these patients were unsatisfactory, suggesting that candidates for resection for HCC should be carefully selected.

Significance of hypovascular lesions on dynamic computed tomography and/or gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging in patients with hepatocellular carcinoma

BACKGROUND AND AIM

The natural course and clinical implications of hypovascular lesions on dynamic computed tomography and/or gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging were investigated.

METHODS

We followed the patients with hepatocellular carcinoma (HCC) who underwent hepatectomy between April 2009 and August 2012 to determine whether new classical HCCs developed from these unresected borderline lesions or emerged in different areas.

RESULTS

One hundred and eleven patients with HCC were identified to have undergone examinations using both imaging methods before hepatic resection. A total of 54 hypovascular lesions were detected. Gadolinium ethoxybenzyl-enhanced magnetic resonance imaging detected 51 lesions, while dynamic computed tomography identified 21 lesions. Eleven lesions were resected at the time of the hepatectomy together with the main HCCs. Classical HCCs had developed from 52.5% of the 43 unresected lesions at 3 years after hepatic resection. Subsequently, we conducted a patient-by-patient analysis to compare the development of classical HCC from these hypovascular lesions and the emergence of de novo classical HCC in other areas. The 3-year occurrence rate was 62.2% for the former group and 55.0% for the latter group (P = 0.83). Thus, although 52.2% of these hypovascular lesions had developed into classical HCCs at 3 years after the initial hepatectomy, de novo HCCs also occurred at other sites. Furthermore, new hypovascular lesions emerged after hepatectomy in 18-29% of patients irrespective of the presence or absence of hypovascular lesions at hepatectomy.

CONCLUSIONS

It remains uncertain whether these hypovascular lesions should be resected together with the main tumors at the time of hepatectomy.