Resection of Hepatocellular Carcinoma Without Preoperative Tumor Biopsy

Abstract

ObjectiveTo evaluate the need for a preoperative tumor biopsy of liver lesions suspicious for hepatocellular carcinoma (HCC). Summary Background DataWith advances in liver imaging, the results of recent studies have suggested a very high accuracy of preoperative evaluation of liver masses suspicious of HCC, making preoperative tumor biopsy unnecessary. MethodsA retrospective analysis was conducted of all liver resections for HCC at the Toronto General and Mt. Sinai Hospitals, Toronto, between October 1994 and December 1998. ResultsSixty patients underwent 65 liver resections without a preoperative liver biopsy. The median age was 61 years. Sixty percent of the patients had cirrhosis and 38.5% had noncirrhotic chronic hepatitis. HCC was confirmed histologically in the surgical specimen in 63 of the 65 cases (96.9%). Both patients without HCC had a significant risk factor for HCC (chronic hepatitis C and alcohol in one and chronic hepatitis B and previous resection for HCC in the other). The lesions were 2 cm and 2.7 cm in diameter, and the alpha-fetoprotein level was low (Ͻ5 and 22 ng/mL, respectively). In such patients, with tumor 3 cm or smaller and an alpha-fetoprotein level less than 100 ng/mL (10 patients), the false-positive rate for the preoperative diagnosis was 2/10 (20%). ConclusionsPreoperative diagnosis of HCC was highly accurate in lesions larger than 3 cm. Tumor biopsy is unnecessary in these patients. However, in a subgroup of patients with lesions less than 3 cm, particularly those with alpha-fetoprotein levels less than 100 ng/mL, there is a higher false-positive diagnostic rate, and tumor biopsy should be considered.Hepatic resection of hepatocellular carcinoma (HCC) is a major operation in high-risk patients (mostly cirrhotic or with chronic hepatitis), with a postoperative death rate of 5% in most recent large series.

Management of hepatocellular carcinoma

“…If AFP is greater than 200 ng/mL and the radiological appearance of the mass is suggestive of HCC (large and/or mutifocal disease with arterial hypervascularity), the likelihood that the lesion is HCC is high and biopsy is not essential. 151,152 If the imaging appearances are atypical, the differential diagnosis is broader, and tumor biospy should be considered.…”

“…Such lesions should be treated as HCC 3,151,152 since the positive predictive value of the clinical and radiological findings exceeds 95%. 3,151,152 If the vascular profile on dynamic imaging is not characteristic and the AFP is less than 200 ng/mL a biopsy is recommended. More recently the value of "washout" in the venous phase has been recognized.…”

Tissue Diagnosis of Hepatocellular Carcinoma

“…However false-positive results from imaging techniques have also occurred. 14,15 Now there is a need to decide the strategy accordingly in an individual patient. It has to be weighed whether the risk of futile transplantation is more or the risk of seeding?…”

“…Otherwise, these lesions should not be treated as HCC without histological evidence because of a rate of false positives as high as 20%. 14,15 Recent prospective studies have reported that up to 67% of new nodules smaller than 2 cm identified during surveillance imaging in patients with cirrhosis are indeed HCC. 16 Although the specificity of contrast enhanced MRI has been reported as high as 96% for hepatic nodules of 1-2 cm in size, a significant proportion of small HCC may appear hypovascular or have atypical features, resulting in a false-negative rate of 20%-38%.…”

A Liver Inflammatory Pseudotumor Misdiagnosed as Liver Cancer Using Noninvasive Diagnostic Methods

“…A feature of liver cancer is that it allows for diagnosis with non-invasive examination without a liver biopsy [4]. The sensitivity and specificity of non-invasive diagnosis for liver cancer with nodules >2 cm and cirrhosis are more than 95% [5,6]. We report a case that was misdiagnosed as liver cancer using ultrasound, multi-detector computed tomography (MDCT), and Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI), and confirmed as liver IPT by biopsy.…”