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===Liver Biopsy=== | ===Liver Biopsy=== | ||
The [[diagnosis]] of hepatocellular carcinoma is confirmed by [[percutaneous]] [[biopsy]] and [[histopathologic]] analysis. [[Percutaneous]] [[biopsy]] should only be performed when [[Diagnosis|diagnostic]] imaging results are uncertain. | The [[diagnosis]] of hepatocellular carcinoma is confirmed by [[percutaneous]] [[biopsy]] and [[histopathologic]] analysis. [[Percutaneous]] [[biopsy]] should only be performed when [[Diagnosis|diagnostic]] imaging results are uncertain. | ||
* [[Percutaneous]] core [[liver]] [[biopsy]] is the [[Gold standard (test)|gold standard test]] for the [[diagnosis]] of hepatocellular carcinoma. | * [[Percutaneous]] core [[liver]] [[biopsy]] is the [[Gold standard (test)|gold standard test]] for the [[diagnosis]] of hepatocellular carcinoma. | ||
* In addition to the percutaneous approach, there are various other approaches to obtain a sample of the hepatic tissue, such as:<ref name="pmid16636018">{{cite journal |vauthors=Cholongitas E, Quaglia A, Samonakis D, Senzolo M, Triantos C, Patch D, Leandro G, Dhillon AP, Burroughs AK |title=Transjugular liver biopsy: how good is it for accurate histological interpretation? |journal=Gut |volume=55 |issue=12 |pages=1789–94 |year=2006 |pmid=16636018 |pmc=1856467 |doi=10.1136/gut.2005.090415 |url=}}</ref><ref name="pmid14562197">{{cite journal |vauthors=Hollerbach S, Reiser M, Topalidis T, König M, Schmiegel W |title=Diagnosis of hepatocellular carcinoma (HCC) in a high-risk patient by using transgastric EUS-guided fine-needle biopsy (EUS-FNA) |journal=Z Gastroenterol |volume=41 |issue=10 |pages=995–8 |year=2003 |pmid=14562197 |doi=10.1055/s-2003-42920 |url=}}</ref><ref name="pmid21291633">{{cite journal |vauthors=Wang L, Geng J, Li J, Li T, Matsumori A, Chang Y, Lu F, Zhuang H |title=The biomarker N-terminal pro-brain natriuretic peptide and liver diseases |journal=Clin Invest Med |volume=34 |issue=1 |pages=E30–7 |year=2011 |pmid=21291633 |doi= |url=}}</ref> | * In addition to the percutaneous approach, there are various other approaches to obtain a sample of the hepatic tissue, such as:<ref name="pmid16636018">{{cite journal |vauthors=Cholongitas E, Quaglia A, Samonakis D, Senzolo M, Triantos C, Patch D, Leandro G, Dhillon AP, Burroughs AK |title=Transjugular liver biopsy: how good is it for accurate histological interpretation? |journal=Gut |volume=55 |issue=12 |pages=1789–94 |year=2006 |pmid=16636018 |pmc=1856467 |doi=10.1136/gut.2005.090415 |url=}}</ref><ref name="pmid14562197">{{cite journal |vauthors=Hollerbach S, Reiser M, Topalidis T, König M, Schmiegel W |title=Diagnosis of hepatocellular carcinoma (HCC) in a high-risk patient by using transgastric EUS-guided fine-needle biopsy (EUS-FNA) |journal=Z Gastroenterol |volume=41 |issue=10 |pages=995–8 |year=2003 |pmid=14562197 |doi=10.1055/s-2003-42920 |url=}}</ref><ref name="pmid21291633">{{cite journal |vauthors=Wang L, Geng J, Li J, Li T, Matsumori A, Chang Y, Lu F, Zhuang H |title=The biomarker N-terminal pro-brain natriuretic peptide and liver diseases |journal=Clin Invest Med |volume=34 |issue=1 |pages=E30–7 |year=2011 |pmid=21291633 |doi= |url=}}</ref> | ||
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* There is a small but significant risk associated with [[liver biopsy]], and the underlying [[cirrhosis]] in the patients with HCC itself predisposes to complications due to [[liver biopsy]].<ref>{{cite journal |last=Grant |first=A|year=1999 | title=Guidelines on the use of liver biopsy in clinical practice |journal=Gut |volume=45 |issue=Suppl 4 |pages=1-11 |id=PMID 10485854 |url=http://gut.bmj.com/cgi/content/full/45/suppl_4/IV1|quote=The main cause of mortality after percutaneous liver biopsy is intraperitoneal haemorrhage as shown in a retrospective Italian study of 68,000 percutaneous liver biopsies in which all six patients who died did so from intraperitoneal haemorrhage. Three of these patients had had a laparotomy, and all had either cirrhosis or malignant disease, both of which are risk factors for bleeding. }}</ref> | * There is a small but significant risk associated with [[liver biopsy]], and the underlying [[cirrhosis]] in the patients with HCC itself predisposes to complications due to [[liver biopsy]].<ref>{{cite journal |last=Grant |first=A|year=1999 | title=Guidelines on the use of liver biopsy in clinical practice |journal=Gut |volume=45 |issue=Suppl 4 |pages=1-11 |id=PMID 10485854 |url=http://gut.bmj.com/cgi/content/full/45/suppl_4/IV1|quote=The main cause of mortality after percutaneous liver biopsy is intraperitoneal haemorrhage as shown in a retrospective Italian study of 68,000 percutaneous liver biopsies in which all six patients who died did so from intraperitoneal haemorrhage. Three of these patients had had a laparotomy, and all had either cirrhosis or malignant disease, both of which are risk factors for bleeding. }}</ref> | ||
*Risks of [[liver biopsy]] include: | *Risks of [[liver biopsy]] include: | ||
There is a 3% risk of tumor spread in the percutaneous needle path<ref name="pmid22047762">{{cite journal |vauthors=Clavien PA, Lesurtel M, Bossuyt PM, Gores GJ, Langer B, Perrier A |title=Recommendations for liver transplantation for hepatocellular carcinoma: an international consensus conference report |journal=Lancet Oncol. |volume=13 |issue=1 |pages=e11–22 |year=2012 |pmid=22047762 |pmc=3417764 |doi=10.1016/S1470-2045(11)70175-9 |url=}}</ref> | |||
*[[Bleeding|Hemorrhage]] | |||
*[[Bile duct|Biliary]] [[peritonitis]] | |||
*[[Hematoma]] | |||
*[[Perforation]] of other [[Viscus|viscera]] | |||
*[[Mortality rate|Mortality rates]] of between 0.01% and 0.1% | |||
* Patients with moderate [[coagulopathy]]: | * Patients with moderate [[coagulopathy]]: | ||
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=== Diagnostic Criteria === | === Diagnostic Criteria === | ||
* Hepatocellular carcinoma may be diagnosed at any time if the following criteria is met: | * Hepatocellular carcinoma may be diagnosed at any time if the following criteria is met: | ||
** Two out of the following three positive stains upon liver biopsy confirm HCC:<ref name="pmid19177576" /> | ** Two out of the following three positive stains upon liver biopsy confirm HCC:<ref name="pmid19177576" /><ref name="pmid28280721">{{cite journal |vauthors=Di Tommaso L, Roncalli M |title=Tissue Biomarkers in Hepatocellular Tumors: Which, When, and How |journal=Front Med (Lausanne) |volume=4 |issue= |pages=10 |year=2017 |pmid=28280721 |pmc=5322593 |doi=10.3389/fmed.2017.00010 |url=}}</ref> | ||
*** [[Glypican 3]] | *** [[Glypican 3]] | ||
*** [[Heat shock protein 70 (Hsp70) internal ribosome entry site (IRES)|Heat shock protein 70]] | *** [[Heat shock protein 70 (Hsp70) internal ribosome entry site (IRES)|Heat shock protein 70]] | ||
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Latest revision as of 22:08, 29 July 2020
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Hepatocellular carcinoma Microchapters |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Dildar Hussain, MBBS [2]
Overview
Other diagnostic studies for hepatocellular carcinoma include biopsy and hepatic venous pressure gradiant.
Other Diagnostic Studies
Liver Biopsy
The diagnosis of hepatocellular carcinoma is confirmed by percutaneous biopsy and histopathologic analysis. Percutaneous biopsy should only be performed when diagnostic imaging results are uncertain.
- Percutaneous core liver biopsy is the gold standard test for the diagnosis of hepatocellular carcinoma.
- In addition to the percutaneous approach, there are various other approaches to obtain a sample of the hepatic tissue, such as:[1][2][3]
- Transjugular approach
- Laparoscopic radiographically- guided fine-needle approach
- Endoscopic ultrasound (EUS)-guided fine-needle biopsy (EUS-FNA)
- Percutaneous biopsy of focal lesions may be performed in combination with either ultrasound or CT imaging.[4]
- Percutaneous liver biopsy remains the cornerstone of diagnosis. It is quick and simple to perform liver biopsy in a patient with normal platelet count and INR.[5]
- Surgical resection
- Two out of the following three positive stains upon liver biopsy confirm HCC:[6][7]
Hep Par 1 Antibody Stain Tissue microarray technology is uses to test Hep Par 1 antibody stain which is showing promising results in differential diagnosis of HCC.[8]
- A biopsy is not necessary if the clinical, laboratory, and radiologic data suggest hepatocellular carcinoma.
- Liver biopsy may be suggestive of etiology:
- Alcoholic liver disease : Liver biopsy may show hepatocyte necrosis, presence of mallory bodies, neutrophilic infiltration and perivenular inflammation.
- Primary biliary cirrhosis : Gold standard diagnostic modality is the detection of antimitochondrial antibodies along with liver biopsy as confirmation of florid bile duct lesions.
- There is a small but significant risk associated with liver biopsy, and the underlying cirrhosis in the patients with HCC itself predisposes to complications due to liver biopsy.[9]
- Risks of liver biopsy include:
There is a 3% risk of tumor spread in the percutaneous needle path[10]
- Hemorrhage
- Biliary peritonitis
- Hematoma
- Perforation of other viscera
- Mortality rates of between 0.01% and 0.1%
- Patients with moderate coagulopathy:
- Plugged liver biopsy : Injection of gelatin sponges or metal coils down the tract after biopsy
- Laparoscopic liver biopsy performed on a sedated patient with moderate coagulopathy
- Advantage:
- Allows direct visualisation of the liver
- Advantage:
Transjugular liver biopsy:
- Used in patients with severe clotting disorders
- Advantage:
- Risk of intraperitoneal bleed is less
- Disadvantages:
- Advantage:
The comparison table for diagnostic studies of choice for hepatocellular carcinoma:[11]
| Diagnostic Test | Sensitivity | Specificity |
|---|---|---|
| Percutaneous Ultrasound guided liver biopsy | 90% | 91% |
| Percutaneous CT guided liver biopsy | 92% | 98% |
Sequence of Diagnostic Studies
The core needle biopsy should be performed when:[12]
- A positive hepatic leision is detected in the patient on imaging studies.
- The patient has underlying risk factors i.e HBV infection,HCV infection or liver cirrhosis.
Diagnostic Criteria
- Hepatocellular carcinoma may be diagnosed at any time if the following criteria is met:
Hepatic venous pressure gradient measurement
- Hepatic venous pressure gradient (HVPG) measurement is the difference between hepatic venous wedge pressure (HVWP) and free hepatic venous pressure (FHVP).
- HVPG reflects the intra-sinusoidal pressure.[14]
- The HVPG of over 10 mmHg is associated with a 6-fold increase of HCC risk.[15]
- HVPG is measured through insertion of a catheter in right internal jugular vein.[16]
{{#ev:youtube|9cEOpr-MRL4|500}}
References
- ↑ Cholongitas E, Quaglia A, Samonakis D, Senzolo M, Triantos C, Patch D, Leandro G, Dhillon AP, Burroughs AK (2006). "Transjugular liver biopsy: how good is it for accurate histological interpretation?". Gut. 55 (12): 1789–94. doi:10.1136/gut.2005.090415. PMC 1856467. PMID 16636018.
- ↑ Hollerbach S, Reiser M, Topalidis T, König M, Schmiegel W (2003). "Diagnosis of hepatocellular carcinoma (HCC) in a high-risk patient by using transgastric EUS-guided fine-needle biopsy (EUS-FNA)". Z Gastroenterol. 41 (10): 995–8. doi:10.1055/s-2003-42920. PMID 14562197.
- ↑ Wang L, Geng J, Li J, Li T, Matsumori A, Chang Y, Lu F, Zhuang H (2011). "The biomarker N-terminal pro-brain natriuretic peptide and liver diseases". Clin Invest Med. 34 (1): E30–7. PMID 21291633.
- ↑ Schirmacher P, Fleig WE, Tannapfel A, Langner C, Dries V, Terracciano L, Denk H, Dienes HP (2004). "[Bioptic diagnosis of chronic hepatitis. Results of an evidence-based consensus conference of the German Society of Pathology, of the German Society for Digestive and Metabolic Diseases and of Compensated Hepatitis (HepNet)]". Pathologe (in German). 25 (5): 337–48. doi:10.1007/s00292-004-0692-7. PMID 15278290.
- ↑ Tannapfel A, Dienes HP, Lohse AW (2012). "The indications for liver biopsy". Dtsch Arztebl Int. 109 (27–28): 477–83. doi:10.3238/arztebl.2012.0477. PMC 3402072. PMID 22833761.
- ↑ 6.0 6.1 "Pathologic diagnosis of early hepatocellular carcinoma: a report of the international consensus group for hepatocellular neoplasia". Hepatology. 49 (2): 658–64. 2009. doi:10.1002/hep.22709. PMID 19177576.
- ↑ Karabork A, Kaygusuz G, Ekinci C (2010). "The best immunohistochemical panel for differentiating hepatocellular carcinoma from metastatic adenocarcinoma". Pathol. Res. Pract. 206 (8): 572–7. doi:10.1016/j.prp.2010.03.004. PMID 20400233.
- ↑ Fan, Zhen; van de Rijn, Matt; Montgomery, Kelli; Rouse, Robert V. (2003). "Hep Par 1 Antibody Stain for the Differential Diagnosis of Hepatocellular Carcinoma: 676 Tumors Tested Using Tissue Microarrays and Conventional Tissue Sections". Modern Pathology. 16 (2): 137–144. doi:10.1097/01.MP.0000052103.13730.20. ISSN 0893-3952.
- ↑ Grant, A (1999). "Guidelines on the use of liver biopsy in clinical practice". Gut. 45 (Suppl 4): 1–11. PMID 10485854.
The main cause of mortality after percutaneous liver biopsy is intraperitoneal haemorrhage as shown in a retrospective Italian study of 68,000 percutaneous liver biopsies in which all six patients who died did so from intraperitoneal haemorrhage. Three of these patients had had a laparotomy, and all had either cirrhosis or malignant disease, both of which are risk factors for bleeding.
- ↑ Clavien PA, Lesurtel M, Bossuyt PM, Gores GJ, Langer B, Perrier A (2012). "Recommendations for liver transplantation for hepatocellular carcinoma: an international consensus conference report". Lancet Oncol. 13 (1): e11–22. doi:10.1016/S1470-2045(11)70175-9. PMC 3417764. PMID 22047762.
- ↑ El-Serag HB, Marrero JA, Rudolph L, Reddy KR (2008). "Diagnosis and treatment of hepatocellular carcinoma". Gastroenterology. 134 (6): 1752–63. doi:10.1053/j.gastro.2008.02.090. PMID 18471552.
- ↑ Song DS, Bae SH (2012). "Changes of guidelines diagnosing hepatocellular carcinoma during the last ten-year period". Clin Mol Hepatol. 18 (3): 258–67. doi:10.3350/cmh.2012.18.3.258. PMC 3467428. PMID 23091805.
- ↑ Di Tommaso L, Roncalli M (2017). "Tissue Biomarkers in Hepatocellular Tumors: Which, When, and How". Front Med (Lausanne). 4: 10. doi:10.3389/fmed.2017.00010. PMC 5322593. PMID 28280721.
- ↑ Boyer TD (2006). "Wedged hepatic vein pressure (WHVP): ready for prime time". Hepatology. 43 (3): 405–6. doi:10.1002/hep.21118. PMID 16496346.
- ↑ Ripoll C, Groszmann RJ, Garcia-Tsao G, Bosch J, Grace N, Burroughs A, Planas R, Escorsell A, Garcia-Pagan JC, Makuch R, Patch D, Matloff DS (2009). "Hepatic venous pressure gradient predicts development of hepatocellular carcinoma independently of severity of cirrhosis". J. Hepatol. 50 (5): 923–8. doi:10.1016/j.jhep.2009.01.014. PMID 19303163.
- ↑ Chelliah ST, Keshava SN, Moses V, Surendrababu NR, Zachariah UG, Eapen C (2011). "Measurement of hepatic venous pressure gradient revisited: Catheter wedge vs balloon wedge techniques". Indian J Radiol Imaging. 21 (4): 291–3. doi:10.4103/0971-3026.90693. PMC 3249946. PMID 22223943.