Fine-needle aspiration biopsy of hepatocellular carcinoma and related hepatocellular nodular lesions in cirrhosis: controversies, challenges, and expectations

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.

The strength of cytomorphology and efficacy of immuno-cytochemistry in distinguishing hepatocellular carcinoma from its mimics on fine-needle aspiration cytology

BACKGROUND

Cytomorphologic distinction of hepatocellular carcinoma (HCC) from its mimics on fine-needle aspiration cytology (FNAC) is often problematic. The present study evaluates the strength of cytomorphology and the utility of an immuno-panel of arginase-1, glypican-3, HepPar-1, thyroid transcription factor (TTF-1) and CK-19 in resolving this diagnostic issue.

METHODS

FNAC features of 71 nodular hepatic lesions were studied with an immunocyto/ histochemical (ICC/IHC) panel of arginase-1, glypican-3, HepPar-1, TTF-1 taking 10% positivity as "cut-off." Cytomorpholologic diagnoses were compared with diagnoses made on combined cytomorphologic and ICC/IHC approach.

RESULTS

Of 71 cases, 32, 10 and 29 had histopathologic, cell block and clinico-radiologic correlation respectively with 55 metastatic adenocarcinomas (MAC), 13 HCCs and one case each of hepatic adenoma (HA), cirrhotic nodule (CN) and intrahepatic cholangiocarcinoma (CC). Cytoplasmic positivity of HepPar-1 and glypican-3 were noted in 11/13 and 8/13 HCCs respectively; while only 3/13 and 1/13 HCCs revealed cytoplasmic positivity for arginase-1 and TTF-1 respectively. Benign hepatic lesions were negative for glypican-3 and TTF-1, but expressed both arginase-1and HepPar-1. Twenty-one of 55 MACs and the lone case of CC were positive for CK-19; however, all MACs and CC cases were negative for HepPar-1, arginase-1, glypican-3 and TTF-1. The immune-panel had sensitivity, specificity and diagnostic accuracy of 100%, 88.9% and 90.6%, respectively, for differentiating HCC from its morphologic mimics.

CONCLUSION

Though a meticulous cytologic evaluation in conjunction with clinicoradiologic profile helps in distinguishing HCC from its benign and malignant mimics; an immunopanel of arginase-1, glypican-3, HepPar-1, TTF-1 and CK-19 drastically improves the diagnostic accuracy.

Optimizing small liver biopsy specimens: a combined cytopathology and surgical pathology perspective

Both fine-needle aspiration (FNA) and core needle biopsy (CNB) are widely used to obtain liver biopsy specimens, particularly from mass lesions. However, the advantages and disadvantages of FNA versus CNB in terms of appropriate use, diagnostic yield, complications, and whether or not specimens should be handled by cytopathologists, surgical pathologists, or both remain subjects of controversy. This review addresses the issues of sample adequacy, appropriate use of each technique and complications, and challenges regarding the diagnosis of both hepatic tumors and non-neoplastic liver disease.

Role of fine-needle aspiration in post liver transplant patients: A clinical/cytological review

BACKGROUND

Fine-needle aspiration (FNA) of superficial and deep-seated lesions has been used with high sensitivity and specificity in the diagnosis of neoplastic and nonneoplastic lesions. However, literature of FNA in posttransplant patients is sparse, especially in postliver transplant. We undertook a retrospective study to evaluate the utility of FNA in the clinical management of post liver transplant patients.

METHODS

We searched our institution's surgical/cytologic databases (November1993-February2016) to identify liver transplant cases and FNA procedures performed on allograft liver recipients. Institutional IRB approval was obtained for this study.

RESULTS

886 liver allograft recipients were reviewed, 41(5%) of which were transplanted for hepatocellular carcinoma. 62/886(7%) underwent an FNA procedure. 39males and 23females included with mean age of 58years. Mean time between transplant and FNA was 34months. 21/62(34%) were malignant neoplasms, most common malignancy was adenocarcinoma: 8cases(3lung,3pancreas,1colon,1cholangiocarcinoma)and 8cases of transplanted hepatocellular carcinoma patients had recurrence, 6 in the allograft liver and 1case each of metastasis to the iliac bone and periportal lymph node. 3cases were squamous-cell carcinoma (2lung and 1scalp). 2cases were posttransplant lymphoproliferative disorders. 34/62(55%) cases were benign aspirates from various organs (8lung,6liver,5pancreas,4breast,3thyroid,3lymph-nodes and 1case each of salivary gland, bile-duct,intraabdominal,abdominal wall,and oral cavity) 0.6/62(10%) cases were inflammatory. 22cases had histologic correlation: 5true-positives,16true-negatives,1false-negative (a patient with parotid mucoepidermoid carcinoma whose FNA diagnosis was sialadenitis), and no false-positive. The sensitivity was 83% and the specificity was 100%. The positive predictive value was 100% and the negative predictive value was 94%.

CONCLUSIONS

This review shows that 40/62(65%) of the aspirates were benign lesions, indicating that a conservative approach is recommended in the clinical management of these patients, especially since the interval between transplant and FNA was on average 34months. FNA is a safe, minimally invasive method to follow-up these patients.

When and how should we perform a biopsy for HCC in patients with liver cirrhosis in 2018? A review

The role of liver biopsy in the diagnosis of hepatocellular carcinoma (HCC) has changed over time. The diagnostic algorithm for this tumor is nowadays mainly based on radiological imaging, relegating histology to controversial cases, in which imaging techniques cannot establish a clear-cut diagnosis. This most commonly happens in small lesions, where biopsies frequently become mandatory, or in larger hypovascularized lesions. In this case however, the histological examination may not be reliable enough to grade the lesion, as different cell clones, deriving from sequential mutations, can originate heterogeneous cell populations. The risk of complications of liver biopsy, such as tumor seeding and intra-abdominal bleeding, needs to be reconsidered in light of new scientific evidence and of the technical improvements that have been introduced. Furthermore, increasing knowledge of the immunohistochemical and molecular characteristics of hepatocellular carcinoma opens a new scenario in which biopsy may play a decisive role in defining prognosis, and even treatment, by identifying the patient populations who could most benefit from target-driven hepatocellular carcinoma treatments, and therefore improving the success rate of experimental therapies. All the above reasons suggest that, overall, the role of liver biopsy in the management of HCC needs a reappraisal.

Latest developments in precancerous lesions of hepatocellular carcinoma

Hepatocarcinogenesis in human chronic liver diseases is a multi-step process in which hepatic precancerous lesions progress into early hepatocellular carcinoma (HCC) and progressed HCC, and the close surveillance and treatment of these lesions will help improve the survival rates of patients with HCC. The rapid development and extensive application of imaging technology have facilitated the discovery of nodular lesions of ambiguous significance, such as dysplastic nodules. Further investigations showed that these nodules may be hepatic precancerous lesions, and they often appear in patients with liver cirrhosis. Although the morphology of these nodules is not sufficient to support a diagnosis of malignant tumor, these nodules are closely correlated with the occurrence of HCC, as indicated by long-term follow-up studies. In recent years, the rapid development and wide application of pathology, molecular genetics and imaging technology have elucidated the characteristics of precancerous lesions. Based on our extensive review of the relevant literature, this article focuses on evidence indicating that high-grade dysplastic nodules are more likely to transform into HCC than low-grade dysplastic nodules based on clinical, pathological, molecular genetic and radiological assessments. In addition, evidence supporting the precancerous nature of large cell change in hepatitis B virus-related HCC is discussed.

Hepatobiliary Tumors: Update on Diagnosis and Management

Tumors of the liver and biliary tree, mainly hepatocellular carcinoma and cholangiocarcinoma, are the second leading cause of cancer related death worldwide and the sixth leading cause of cancer related death among men in developed countries. Recent developments in biomarkers and imaging modalities have enhanced early detection and accurate diagnosis of these highly fatal malignancies. These advances include serological testing, micro-ribonucleic acids, fluorescence in situ hybridization, contrast-enhanced ultrasound, and hepatobiliary-phase magnetic resonance imaging. In addition, there have been major developments in the surgical and nonsurgical management of these tumors, including expansion of the liver transplantation criteria, new locoregional treatments, and molecularly targeted therapies. In this article, we review various types of hepatobiliary tumors and discuss new developments in their diagnosis and management.

The emerging role of positron emission tomography in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a leading cause of cancer mortality worldwide. HCC a heterogeneous disease occurring on the background of cirrhosis. The presence of cirrhosis limits the sensitivity of conventional imaging modalities in differentiating HCC from surrounding cirrhotic parenchyma. Positron emission tomography (PET) using ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) is widely used for assessing a variety of malignancies, however, has poor sensitivity in the evaluation of HCC. This has led to the investigation of other radiotracers such as ¹¹C-acetate and ¹¹C-choline, with improved sensitivity in terms of detection and therapeutic response. In this review, we discuss the emerging field of PET imaging for the detection, staging and assessment of treatment response in HCC. In particular we discuss the role of ¹⁸F-FDG-PET in imaging hepatocellular cancer, the limitations of this PET tracer and emerging novel PET tracers being investigated that exploit key metabolic processes including fatty acid and lipid synthesis, choline kinase activity and gene expression.

Considerations regarding current diagnosis and prognosis of hepatocellular carcinoma

Hepatocellular carcinoma is a major health issue, ranked the fifth most common tumor and currently being responsible for a third of the cancer-related deaths globally, with an ever-increasing number of fatalities. Current advances in contrast-enhanced imaging techniques such as contrast-enhanced ultrasonography, multi-detector computed tomography and diffusion-weighted magnetic resonance imaging are improving the rate of hepatocellular carcinoma diagnosis. Contrast-enhanced ultrasonography has widely become the first choice in liver tumor assessment, as it is faster, simpler and safer than other forms of diagnostic imaging. On the other hand, cross sectional computed tomography is frequently employed when a hepatic formation is suspected of malignancy and allows a more accurate characterization of lesions through multiphasic multi-detector computed tomography technology. Diffusion weighted magnetic resonance imaging represents another addition to the wide range of diagnostic and prognostic techniques available for patients with hepatocellular carcinoma and is currently regarded as one of the best tools for the characterization of these lesions. Furthermore, groundbreaking biomarkers for hepatocellular carcinoma are being discovered, although alpha-fetoprotein remains one of the most frequently used serum test in the early stages. Nonetheless, further advances are required for the detection of small liver carcinomas.

Cytopathologic diagnosis of liver mass lesions

The liver is a common site for metastatic malignancies, particularly from the gastrointestinal tract. It also may be involved by primary neoplasms, both benign and malignant. Cytopathologic examination of mass lesions of the liver with pertinent use of ancillary studies is a useful method of establishing a correct diagnosis for patient management. The authors reviewed the literature for articles pertaining to cytologic characteristics of specific tumor types, utility of immunohistochemical markers and pertinent molecular studies, differential diagnoses and pitfalls.

Arginase-1, HepPar-1, and Glypican-3 are the most effective panel of markers in distinguishing hepatocellular carcinoma from metastatic tumor on fine-needle aspiration specimens

Distinction of liver metastases from hepatocellular carcinoma (HCC) may present a diagnostic challenge. Arginase-1 (Arg-1) is a marker for HCC recently described in some literature. Immunohistochemical evaluation of Arg-1, hepatocyte paraffin-1 (HepPar-1), and glypican-3 expression was performed on 1,240 surgical specimens and 62 liver fine-needle aspiration specimens (29 HCCs, 28 metastatic tumors, and 5 benign liver cases). The staining results on tissue microarray sections showed that 2.7% and 3.1% of nonhepatic tumor cases were positive for HepPar-1 and glypican-3, respectively; none was positive for Arg-1. For fine-needle aspiration specimens, 19 HCCs were positive for all 3 markers; 9 were positive for 1 or 2 markers; and only 1 case was negative for all 3 markers. These data demonstrate that Arg-1 is the most specific marker in differentiating a non-HCC from HCC. It is recommended to use 3 markers as a panel in distinguishing HCC from metastatic carcinoma.

Cytologic comparison between malignant and regenerative nodules in the background of cirrhosis

BACKGROUND

Incidence of hepatocellular carcinoma has been increased as the sixth most common cancer in the world. Improvement in imaging techniques has decreased the need for tissue confirmation in diagnosis of hepatocellular carcinoma (HCC). Meanwhile, false negative and positive cases are present. Fine needle aspiration (FNA) biopsy can be helpful to identify well-differentiated HCCs with low risk of vascular invasion and better prognosis following transplantation.

OBJECTIVES

We conducted this study to find useful criteria for cytological differential diagnosis between nodules of well differentiated hepatocellular in the background of cirrhosis and pure cirrhotic regenerative nodules in cytology smears.

MATERIALS AND METHODS

140 fine needle aspirations (FNA) of fresh cirrhotic hepatectomy specimens were studied (100 pure regenerative nodules and 40 HCC nodules). All slides were reviewed by two expert pathologists. The most useful criteria were selected and evaluated in 560 cytology smears stained by Pap and Wright methods.

RESULTS

None of the smears from cirrhotic patients showed mitosis, transgressing endothelium, eccentric nuclei, and scant cytoplasm, but thick nuclear membrane, spindle cells and abundant, thick and monotonous cytoplasm were found in many cases with cirrhosis. Large nucleoli (2 %), multiple nucleoli (6 %), increased N/C ratio (4 %), and broad cores (2 %) were found very rarely in the smears of regenerative nodules, but they were present in 50 %, 72.5 %, 87 %, and 77.5 % of HCC nodules, respectively.

CONCLUSIONS

Combination of cytologic criteria can be helpful for differential diagnosis between HCC and regenerative nodules.