Fine needle biopsy of focal liver lesions: The hepatologist's point of view
2004; Lippincott Williams & Wilkins; Volume: 10; Issue: S2 Linguagem: Inglês
10.1002/lt.20037
ISSN1527-6473
AutoresEugenio Caturelli, Giorgia Ghittoni, Paola Roselli, Mariagrazia de Palo, M. Anti,
Tópico(s)Hepatitis B Virus Studies
ResumoLiver TransplantationVolume 10, Issue S2 p. S26-S29 Original ArticleFree Access Fine needle biopsy of focal liver lesions: The hepatologist's point of view Eugenio Caturelli, Corresponding Author Eugenio Caturelli e.caturelli@tiscalinet.it Unità Operativa di Gastroenterologia, Ospedale “Belcolle”, Viterbo, Italy Telephone: 39-0761-339495; FAX: 39-0761-339471Unità Operativa di Gastroenterologia, Ospedale Belcolle, Strada Sammartinese, I-01100 Viterbo, ItalySearch for more papers by this authorGiorgia Ghittoni, Giorgia Ghittoni Unità Operativa di Gastroenterologia, Ospedale “Belcolle”, Viterbo, ItalySearch for more papers by this authorPaola Roselli, Paola Roselli Unità Operativa di Gastroenterologia, Ospedale “Belcolle”, Viterbo, ItalySearch for more papers by this authorMariagrazia De Palo, Mariagrazia De Palo Unità Operativa di Gastroenterologia, Ospedale “Belcolle”, Viterbo, ItalySearch for more papers by this authorMarcello Anti, Marcello Anti Unità Operativa di Gastroenterologia, Ospedale “Belcolle”, Viterbo, ItalySearch for more papers by this author Eugenio Caturelli, Corresponding Author Eugenio Caturelli e.caturelli@tiscalinet.it Unità Operativa di Gastroenterologia, Ospedale “Belcolle”, Viterbo, Italy Telephone: 39-0761-339495; FAX: 39-0761-339471Unità Operativa di Gastroenterologia, Ospedale Belcolle, Strada Sammartinese, I-01100 Viterbo, ItalySearch for more papers by this authorGiorgia Ghittoni, Giorgia Ghittoni Unità Operativa di Gastroenterologia, Ospedale “Belcolle”, Viterbo, ItalySearch for more papers by this authorPaola Roselli, Paola Roselli Unità Operativa di Gastroenterologia, Ospedale “Belcolle”, Viterbo, ItalySearch for more papers by this authorMariagrazia De Palo, Mariagrazia De Palo Unità Operativa di Gastroenterologia, Ospedale “Belcolle”, Viterbo, ItalySearch for more papers by this authorMarcello Anti, Marcello Anti Unità Operativa di Gastroenterologia, Ospedale “Belcolle”, Viterbo, ItalySearch for more papers by this author First published: 30 January 2004 https://doi.org/10.1002/lt.20037Citations: 17 AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Abstract Guided biopsy of hepatocellular carcinoma has been recently discussed again due to the progress of imaging techniques and the risk of malignant seeding after the procedure. Ultrasound is probably still the most accurate imaging modality for early detection of nodules arising on cirrhosis, even when compared with more advanced imaging techniques. It can be easily employed in the surveillance of high-risk cirrhotic patients. Ultrasound-guided biopsy has very high sensitivity and almost absolute specificity, which allows the appropriate treatment to start after a positive diagnosis. It also allows correct diagnosis of lymphomatous nodules, the incidence of which is increased in hepatitis C virus-related cirrhosis. The risk of seeding appears limited according to the currently available epidemiological data; this should be considered against the risk of false-positive diagnosis of malignancy based on imaging studies alone. Ultrasound-guided biopsy is a valuable tool also for the diagnosis of small nodules (less than 10 mm in diameter). The best accuracy in the sampling of hepatocellular carcinoma nodules is obtained by combining smear cytology and microhistology. This can be achieved by a single biopsy with a fine cutting needle that furnishes pathologic material suitable for both examinations, reducing risks and costs. (Liver Transpl 2004;10:S26–S29.) Abbreviations: FNB, fine-needle biopsy; EASL, European Association for the Study of the Liver; US, ultrasound; HCC, hepatocellular carcinoma. Role of Fine-Needle Biopsy and the European Association for the Study of the Liver Guidelines Fine needle biopsy (FNB) of hepatocarcinoma diagnosis was widely used during the late 1980s and the early 1990s. During the last decade, advances in cross-sectional imaging1-5 has lead to a drastic limitation of liver nodules biopsy. In the guidelines from the European Association for the Study of the Liver (EASL) Conference in Barcelona,6 the use of ultrasound (US) guided FNB for the diagnosis of nodules in cirrhosis has been limited to those ranging from 10 to 20 mm in diameter. In this guideline, small nodules (diameter < 10 mm) need a closer follow-up with US coupled with evaluation of α-fetoprotein serum level. Computed tomography and magnetic resonance imaging have been recommended for lesions larger than 20 mm. Complications of Fine-Needle Biopsy Although the risk of malignant seeding during biopsy is considered rare (0.003–0.009%)7-11 it remains a problem for surgically treatable tumors. Two small series12, 13 have recently described high incidence (3.4% and 1.6%, respectively) of malignant seeding after FNB of hepatocellular carcinoma (HCC) nodules; larger series are required. Mortality (6–37 cases of 100,000) and serious complications (50–230 cases of 100,000)7-11 after FNB are rare. These complications include bleeding episodes, hematomas, sepsis, pancreatitis, local infections, pneumothorax, and hypotension. Considering its accuracy, US-guided FNB can be a first choice for HCC diagnosis.1-5 A study from Japan14 compared digital subtraction angiography, magnetic resonance imaging, and US-guided biopsy for the diagnosis of 180 HCC nodules ≤20 mm in diameter. Only 68% of the lesions measuring 11 to 20 mm in diameter could be diagnosed by imaging, the others required biopsy. The contribution of biopsy was even more important for diagnosis of nodules smaller than 10 mm: no more than 45% could be diagnosed only by imaging findings. US-guided biopsy has a very high sensitivity and, above all a high specificity,15-17 allowing the prompt start of appropriate treatment after a positive diagnosis. Imaging techniques have some false positive results. In a Japanese study,18 focal lesions were evaluated exclusively on the basis of imaging findings. Four of 160 patients (2.5%) were misdiagnosed and underwent surgery for a non-malignant lesion.7 US-guided biopsy of HCC has only a few false negative results. A second biopsy after unsuccessful first sampling19, 20 is efficient in only ⅓ of cases due to necrotic areas in large HCCs and sampling errors in smaller ones. A second biopsy after a first negative cytological and/or histological sampling should not be repeated because of low probability of success. Diagnostic Role of US for HCC Detection The diagnostic accuracy of US-guided FNB depends on the possibility to identify the HCC nodules by US. Various reports have emphasized the underestimation of imaging techniques for extension of HCC nodules when compared to serial pathologic explanted livers.21, 22 Nevertheless, US is probably the most accurate imaging modality for visualizing small liver nodules,3, 4, 17 and US follow-up of high-risk cirrhotic patients has become widespread in clinical practice because early detection of HCC23, 24 improves the prognosis.25, 26 Objections Against EASL Policy As the size of detectable liver nodule decreases, the ability to distinguish malignant from premalignant (dysplastic) or even benign (regenerative) nodules on the basis of US (or those of other imaging modalities) decreases.1-3, 5, 27 Though detection of a nodule in a cirrhotic liver during US follow-up raises suspicion of HCC, the authors of the EASL6 recommend a “wait and see” policy for lesions less than 10 mm in diameter. According to EASL, only half of the small lesions are HCC and the probability to obtain a correct diagnosis with actual tools is low. In our opinion, several facts are against this policy. First, it seems strange to work on detecting smaller and smaller lesions and, once they have been detected, wait for their growth. Second, the consideration that nodules smaller than 10 mm found in cirrhosis are not HCC but simply regenerative or mildly dysplastic lesions is based on the results of pathological studies28 comparing pretransplantation US scanning (that often misses small lesions) with analysis of explanted livers.21, 22, 29 We think that the meaning of nodules detected by US in cirrhosis during follow-up is probably quite different from those found only at autopsy or following liver explantation. In the recent past, various studies have regarded the development of a focal lesion in a previously nodule-free cirrhotic liver as probable evidence of a neoplastic or at least pre-neoplastic process.30-32 In the current literature, there is little information on the true nature of the nodules disclosed by US during the follow-up of cirrhosis. In a recent study,33 all 287 nodular lesions (mean diameter: 18 mm) detected during US follow-up of cirrhotic patients were either neoplastic (93.7% HCCs and 1.8% non-Hodgkin's lymphomas) or preneoplastic (4.5% dysplastic nodules). The relatively high prevalence of primary hepatic non-Hodgkin's lymphoma in this series, and the main role of US-guided FNB in establishing this diagnosis, must be stressed regarding the different treatment and prognosis compared to HCC. In another previous study,1 15 HCCs (46.9%) and 5 preneoplastic lesions (15.6%) of 32 small (≤ 20 mm) focal hepatic lesions were detected in 23 cirrhotic patients. Seven lesions of this series represented focal fatty changes, which usually have a non-nodular US appearance. If these lesions are excluded, the frequencies of HCCs and preneoplastic nodules increase considerably (60% and 20%, respectively). In light of the prognostic implications of early diagnosis and treatment of HCC, we feel that active attempts to identify these small lesions as soon as possible are fully justified. Third, US-guided FNB is a valuable diagnostic tool also for nodules with a diameter < 10 mm. The “wait and see” policy recommended by EASL for these lesions reflects the difficulties encountered with imaging studies for the diagnosis of small size liver nodules.1, 5, 27 Guided biopsy is often the only way to differentiate between benign and malignant nodules in a cirrhotic liver.3 Yet in 1994, a multicenter Italian survey,15 not confined to cirrhotic patients, found that US-guided FNB yielded correct diagnoses for 87.5% of all liver lesions ≤ 10 mm in diameter. Our experience on 114 nodules with a diameter ≤ 20 mm33 confirmed the diagnostic value of US-guided FNB, which displayed an overall accuracy of 95.6% and good performance (93.7%) for 16 lesions with diameter ≤ 10 mm in diameter. These results are similar to those of a recent French study,13 in which US-guided FNB diagnosed HCC nodules in cirrhotic livers with 91% of sensitivity, and again, its accuracy was not influenced by the size of the nodule. So, we feel that US-guided FNB can be successfully used as a first-step diagnostic tool also for nodules ≤ 10 mm in diameter. Contraindications of Fine-Needle Biopsy US-guided FNB limitations include: a severe impaired coagulation, absence of informed patient's consent, inexperience of the operator, and the unavailability of an experienced pathologist to evaluate the collected samples. Minimal values acceptable to perform a FNB are considered a platelet count of 50000 per mm3, and an international normalized ratio < 2, though an actual increased risk of bleeding after liver punction in patients with lower values has not been reported.34 Technical Notes Most investigators believe that both cytological and histological samples are necessary to distinguish well-differentiated HCC from macroregenerative lesions in cirrhotic livers35-37; some feel that biopsy of the nodule should also be compared with an extranodular sample.38 Such a policy led to perform at least 3 punctions to obtain a diagnosis.39 The combination of smear cytology with microhistology increases the accuracy.40 In our experience,41, 42 a single biopsy performed with a cutting needle can give samples for both smear cytology and microhistology, reducing the risk of bleeding complications and leading to a better cost-effective procedure. Our findings also suggest that smear cytology is of great value in small well differentiated HCC; this result has been recently confirmed by others.43, 44 The rates of inadequate sample preparation and the false negative of malignancy are usually lower for smear cytology compared to histology.42, 45 The “free hand technique” allows the operator to work alone using one hand to hold the US probe and the other hand to steer the needle.46 If the probe is maintained far from the sterile area of the puncture site, the needle may be introduced on a plane more perpendicular to the US beam. It is, therefore, possible to obtain a better visualization of the progression of the needle to the target, avoiding cumbersome cautions for covering and sterilizing the probe. Undoubtedly, the “free hand technique” requires a greater experience of the operator, but it is time and cost effective.47 References 1 Kanematsu M, Hoshi H, Yamada T, Murakami T, Kim T, Kato M, et al. 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