Does percutaneous liver biopsy of hepatocellular carcinoma cause hematogenous dissemination? An in vivo study with quantitative assay of circulating tumor DNA using methylation-specific real-time polymerase chain reaction

Selecting patients with hepatocellular carcinoma for liver transplantation: incorporating tumor biology criteria

Liver transplantation (LT) is the optimal therapeutic option for patients with liver cirrhosis and hepatocellular carcinoma (HCC). Due to universal donor shortage, only the patients with limited tumor burden (under the so-called Milan criteria) are considered as potential candidates for LT in most institutions. It is expected that in the near future, more liver grafts will be available for patients with HCC due to the implementation of new direct antivirals against hepatitis C, leaving a prone scenario to consider expanding Milan criteria. A moderate expansion of Milan criteria could be implemented without increasing the risk of tumor recurrence if patients with favorable biological behavior are carefully selected. Incorporating information regarding tumor biology in the decision-making algorithm would result in a more rational use of LT in patients with HCC. In the present review, surrogate markers of tumor biology are critically evaluated as potential tools to be combined with existing radiological criteria. In addition, the current state of liquid biopsy is discussed, as this cutting-edge technology may reshape the management of HCC in the upcoming years.

Usefulness of a New Three-Dimensional Simulator System for Radiofrequency Ablation

Multipuncture radiofrequency ablation is expected to produce a large ablated area and reduce intrahepatic recurrence of hepatocellular carcinoma; however, it requires considerable skill. This study evaluated the utility of a new simulator system for multipuncture radiofrequency ablation. To understand positioning of multipuncture electrodes on three-dimensional images, we developed a new technology by expanding real-time virtual ultrasonography. We performed 21 experimental punctures in phantoms. Electrode insertion directions and positions were confirmed on computed tomography, and accuracy and utility of the simulator system were evaluated by measuring angles and intersections for each electrode. Moreover, to appropriately assess placement of the three electrodes, puncture procedures with or without the simulator were performed by experts and non-experts. Technical success was defined as maximum angle and distance ratio, as calculated by maximum and minimum distances between electrodes. In punctures using 2 electrodes, correlations between angles on each imaging modality were strong (ultrasound vs. simulator: r = 0.991, p<0.001, simulator vs. computed tomography: r = 0.991, p<0.001, ultrasound vs. computed tomography: r = 0.999, p<0.001). Correlations between distances in each imaging modality were also strong (ultrasound vs. simulator: r = 0.993, p<0.001; simulator vs. computed tomography: r = 0.994, p<0.001; ultrasound vs. computed tomography: r = 0.994, p<0.001). In cases with 3 electrodes, distances between each electrode correlated strongly (yellow-labeled vs. red-labeled: r = 0.980, p<0.001; red-labeled vs. blue-labeled: r = 0.953, p<0.001; yellow-labeled vs. blue-labeled: r = 0.953, p<0.001). Both angle and distance ratio (expert with simulator vs. without simulator; p = 0.03, p = 0.02) were significantly smaller in procedures performed by experts using the simulator system. The new simulator system appears to accurately guide electrode positioning. This simulator system could allow multipuncture radiofrequency ablation to be performed more effectively and comfortably.

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.

Does the taking of biopsies affect the metastatic potential of tumours? A systematic review of reports on veterinary and human cases and animal models

Clinicians and pathologists are sporadically asked by owners whether the taking of tumour biopsies may affect the behaviour of the tumour, including its potential to metastasise. Unfortunately, systematic studies on this subject are unavailable in veterinary medicine, and the aim of this study was to estimate the risk of adverse effects of biopsy taking on tumour progression in animals. A systematic review of veterinary and human case reports and clinical studies as well as experimental animal models of biopsy-induced tumour metastasis was undertaken. There were only two veterinary case reports of needle tract metastases (NTM) following the taking of needle biopsies from urogenital and pulmonary tumours. Seventeen experimental studies found a high incidence of NTM but only a rat osteosarcoma and a hamster squamous carcinoma model showed an increased incidence of distant or regional metastases after incision or excision biopsy. In human medicine, the occurrence of NTM has been reported after the taking of biopsies from mesotheliomas (15%), melanomas (11%) and gall bladder tumours (11%), liver metastases of colon carcinomas (4%) and mammary carcinomas (4%) but an incidence of only <1% for all other tumours. Circulating tumour cells increased immediately after the taking of biopsies from human squamous cell, prostate, breast and hepatocellular carcinomas. Although no increased risk of biopsy-induced distant metastasis has been reported for any type of tumour, this is inconclusive due to a lack of non-biopsied control groups in human studies. Reports of biopsy-induced metastasis in animal tumours indicate that the taking of transcutaneous biopsies from urogenital tumours may be associated with a risk of NTM. However, there is no evidence of a general increase in risk of distant metastases in any tumour type in people or animals. The overall risk therefore appears to be negligible when compared to the valuable information obtained from biopsies in veterinary practice.

Surgery and Hematogenous Dissemination: Comparison Between the Detection of Circulating Tumor Cells and of Tumor DNA in Plasma Before and After Tumor Resection in Rats

BACKGROUND

To examine the effects of the surgical manipulation of tumors on the hematogenous dissemination of tumors, we compared rates of detection of tumor-derived DNA in the buffy coat and in plasma from tumor-bearing rats before and after tumor resection.

METHODS

We injected DHD/K12-PROb cells subcutaneously into BD-IX rats. Three weeks later, we removed the tumors surgically. Group PERI was sacrificed 3 hours after surgery, group POST-2 was sacrificed 2 weeks later, group POST-4 was sacrificed another 2 weeks later, and group POST-LONG was sacrificed when rats were close to death. In group PERI, four perioperative blood samples were taken. In the other groups, only one blood sample was taken per rat, immediately before euthanasia. We used polymerase chain reaction to detect tumor-derived DNA in buffy-coat, plasma, and lung samples.

RESULTS

In group PERI, tumor DNA in plasma was more frequent than circulating tumor cells at all perioperative time points. The difference was statistically significant 3 hours after surgery (P = .035). In group POST-2, there was no detectable metastasis or tumor DNA in blood samples. There were lymphatic and lung metastases in most animals in group POST-4 and in all animals in group POST-LONG. In the last two groups, the frequencies of tumor DNA in the buffy coat and in plasma were similar.

CONCLUSIONS

In our animal model, the hematogenous dissemination of tumors due to surgery seemed to be more closely related to tumor-derived cell-free DNA than to circulating tumor cells. In addition, the surgical resection of primary tumors did not inhibit the development of metastases.

Postbiopsy Arterioportal Fistula in Patients with Hepatocellular Carcinoma: Clinical Significance in Transarterial Chemoembolization

OBJECTIVE

The purpose of this study was to determine, retrospectively, the frequency of postbiopsy arterioportal fistula in hepatocellular carcinoma and its significance in transarterial chemoembolization (TACE).

MATERIALS AND METHODS

Forty-one patients who underwent percutaneous liver biopsy for diagnosis of hepatocellular carcinoma were referred for TACE. The control population comprised 161 patients referred during the same period who underwent TACE without biopsy. We determined that an arterioportal fistula was present by opacification of the portal vein during the arterial phase of angiography or by opacification with iodized oil during TACE. We considered hepatocellular carcinoma to be responsive to TACE when the sum of iodized oil retention in the tumor and a low-attenuation area on CT was greater than 50% of tumor size. We compared the frequency of arterioportal fistula and the rate of tumor response to TACE in both groups and also evaluated possible factors associated with postbiopsy arterioportal fistula, such as age, sex, Child-Pugh score, tumor size, average number of needle passes, average distance that the needle traversed normal liver before reaching the mass, and average interval between biopsy and TACE.

RESULTS

Twenty-three (56.1%) of 41 patients in the biopsy group and 19 (11.8%) of 161 patients in the control group had an arterioportal fistula (p < 0.001). The rate of tumor response to TACE was 87.8% (36/41) in the biopsy group and 87.0% (140/161) in the control group (p = 0.5932). Of the possible related factors, only tumor size correlated negatively with the occurrence of arterioportal fistula.

CONCLUSION

Percutaneous liver biopsy in hepatocellular carcinoma patients apparently increases the rate of arterioportal fistula but does not seem to affect the rate of tumor response to TACE.

Hepatocellular carcinoma

PURPOSE OF REVIEW

The incidence of hepatocellular carcinoma (HCC) is expected to continue to increase over the next two decades. The risk factors for the development of HCC are unknown and there is a lack of standardization of the diagnostic criteria for HCC. Our aim is to review the latest information regarding the risk factors, surveillance and diagnosis of this tumor.

RECENT FINDINGS

Alcohol, tobacco, obesity, diabetes and viral etiology interact together to increase the risk of hepatocellular carcinoma in patients with cirrhosis, which may allow us to identify a high-risk group for HCC among patients with cirrhosis. Several studies showed that surveillance of cirrhotic patients is cost-effective and leads to an overall improvement in survival. This year a study from the United Network of Organ Sharing in the United States indicated that 30% of patients were understaged by imaging pre-transplant and 31% of patients with a diagnosis of stage 1 HCC (single lesion < 2 cm in diameter) did not have a tumor on the explant examination. Another study showed that washout of arterially enhancing lesions is very sensitive and specific for a diagnosis of HCC.

SUMMARY

Not all patients with cirrhosis have an equal risk for developing hepatocellular carcinoma. Therefore, further studies should stratify the risk of HCC so surveillance is tailored to those at the highest risk. Standardization of the diagnostic criteria of HCC is critically important for better patient care and future research. Washout of arterially enhancing lesions should be important criteria of HCC.

Complications des gestes interventionnels percutanés sous contrôle radioscopique, échographique ou scanographique

The purpose of this article is to describe potential complications following the most common image-guided (fluoroscopy, ultrasound or CT) percutaneous interventional procedures, both diagnostic and therapeutic, thoraco-abdominal and musculoskeletal, as well as to review risk factors and the best practice recommendations. Prior to any interventional procedure, it is necessary to ascertain the absence of any abnormality in coagulation, to secure enough time to explain the procedure to the patient, and to adhere to strict sterile technique. Indeed, infections and hemorrhagic complications are the principal causes of mortality and morbidity for all procedures. Following lung biopsy, CT scan detects an immediate pneumothorax in 30% of patients. Major complications following percutaneous liver biopsy occur within 3 to 6 hours. Following a percutaneous drainage, complications occur in less than 10% of cases. Following a radiofrequency thermal ablation of malignant tumors, the mortality rate is low (0,5 to 1,4%), infection and hemorrhage are the most frequent complications. While rare, septic arthritis is the main complication that can follow musculoskeletal procedures and is a cause of medical malpractice lawsuits brought by patients.