The discovery of a disruption of the right branch of the hepatic artery should not affect management of the biliary stricture when if a Hepp-Couinaud repair is performed.

We have investigated whether liver resection and needle liver biopsy cause dissemination of liver cells into peripheral blood circulation, using a reverse-transcription polymerase chain reaction (RT-PCR)-based assay targeted against ␣-fetoprotein (AFP) mRNA. Twelve patients with and 16 without primary liver cancer (PLC) undergoing liver resection were tested before skin incision, after liver mobilization, after hepatic parenchyma transection, after abdominal wall suture, and 4 days after surgery. Two patients with and 20 without PLC were tested before, 20 minutes after, and 24 hours after needle liver biopsy. Six of 14 patients with and 0 of 36 patients without PLC scored positive before intervention (P F .001). Liver cell spreading was induced at different times after surgery and liver biopsy in 14 of 14 patients with but also 23 of 36 without PLC (P F .05). We conclude that liver resection and needle liver biopsy induce release of cells from the liver, which are not necessarily liver tumor cells, into the peripheral blood circulation. This may be, however, an important mechanism of liver cancer cell dissemination deserving further investigations. (HEPATOL-OGY 1999;29:879-882.)Despite several previous reports on the dissemination of tumorous cells during needle liver biopsy, 1-6 the issue of surgical and diagnostic iatrogenic speading of liver cells has never been addressed with appropriated molecular methods and study design.The possibility of detecting circulating tumorous cells in patients with solid tumors, through highly sensitive reversetranscription polymerase chain reaction (RT-PCR)-based assays, has raised major interest and hopes during the last 5 years. 7 We and others 8,9 have used ␣-fetoprotein (AFP)-specific primers to detect spontaneously circulating tumorous cells in patients with primary liver cancer (PLC) and found that a positive test directly correlates with the risk of developing extrahepatic metastases. 10 We have now applied this method, with a carefully defined specificity and sensitivity, to patients with and without PLC. The protocol used consisted in blood sampling before and at different time points during and after liver resection and needle liver biopsy.Our results show that hematogenous dissemination of liver cells is induced very early in surgically treated patients, after liver mobilization, and before hepatic parenchyma transection. It also occurs, albeit less frequently, during needle liver biopsy. These data, therefore, point out a potentially important mechanism of liver cancer spreading that deserves further investigations.

The prognosis for patients with primary liver cancer (PLC)Despite advances in the appraisal of the impact and role often depends on tumor recurrence and the development of of etiologic factors, improvement in diagnostic tools and surextrahepatic metastases, particularly after liver transplanta-gical and nonsurgical treatments, primary liver cancer (PLC), tion. We have developed a sensitive test to detect both sponta-the eighth commonest tumor worldwide, still represents a neous circulation of tumor cells and the spread of liver cells therapeutic challenge. [1][2][3][4][5][6] In Western countries, PLC generally due to chemoembolization and alcoholization. Reverse-tran-develops on a background of cirrhosis; this hampers surgical scription polymerase chain reaction was used to search for and nonsurgical efforts to eradicate the disease because circells expressing a-fetoprotein (AFP) messenger RNA in the rhosis is a permanent source of tumorous nodules, and it peripheral blood of 84 patients with PLC and 102 controls complicates treatment with severe liver failure. 7-11(55 patients with chronic hepatitis and/or cirrhosis, 10 paPartial hepatic resection is limited by tumor characteristics tients with benign liver tumors or liver metastases from intes-such as size, multifocality, topography, and severity of associtinal cancers, and 37 healthy individuals). By spiking the ated cirrhosis. Only 10% of patients with PLC are considered blood of healthy volunteers with HepG2 cells, we assessed acceptable for resection and, of these, the 3-year recurrence the sensitivity limit: one HepG2 cell mixed with 10 7 leuko-rate ranges from 60% to 80%, and the survival rate ranges cytes. All 102 controls tested negative. In contrast, 28 patients from 40% to 70%. 4,[11][12][13][14][15][16] An alternative treatment for small (33.3%) with PLC tested positive. Positivity for the test was tumors is alcoholization, 17 but the advantages of this apsignificantly associated with portal thrombosis, tumor size, proach are currently being debated. 18 The treatment of adintravascular tumor emboli, serum AFP level, and extrahe-vanced liver cancers by transarterial chemoembolization patic metastases. Patients were followed up for a mean period (TACE), chemotherapy, and hormonal treatment with taof 39 { 51 weeks: the probability of developing extrahepatic moxifen has provided discouraging results in previous pubmetastases was significantly higher in positive than in nega-lished trials. 2, 19 tive patients. Eighteen negative patients with PLC were testedDespite this overall poor prognosis, a main feature of PLC before, 1 hour after, and 24 hours after locoregional therapy: is the rarity of extrahepatic metastases, which generally only 9 tested positive either 1 or 24 hours after alcoholization or become evident at a late tumor stage.20 Liver transplantation chemoembolization. In conclusion, we have developed a has, therefore, been proposed to cure both liver cancer and highly specific and sensitive test to detect circulating tumor cirrhosis.1,21-24 S...

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