Hepatocellular carcinoma other diagnostic studies: Difference between revisions
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The diagnosis of hepatocellular carcinoma is confirmed by [[percutaneous]] [[biopsy]] and histopathologic analysis. | The diagnosis of hepatocellular carcinoma is confirmed by [[percutaneous]] [[biopsy]] and histopathologic analysis. | ||
* Core liver [[biopsy]] is the gold standard test for the diagnosis of hepatocellular carcinoma. | * Core liver [[biopsy]] is the gold standard test for the diagnosis of hepatocellular carcinoma. | ||
* Sample of the liver is obtained by:<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> | |||
**[[Percutaneous]] | |||
**Transjugular | |||
**Laparoscopic radiographically- guided fine-needle approach | |||
* Percutaneous [[biopsy]] of focal lesions may be performed in combination with either [[ultrasound]] or [[CT|CT imaging]].<ref name="pmid15278290">{{cite journal |vauthors=Schirmacher P, Fleig WE, Tannapfel A, Langner C, Dries V, Terracciano L, Denk H, Dienes HP |title=[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)] |language=German |journal=Pathologe |volume=25 |issue=5 |pages=337–48 |year=2004 |pmid=15278290 |doi=10.1007/s00292-004-0692-7 |url=}}</ref> | |||
* Percutaneous [[liver biopsy]] remains the cornerstone of diagnosis. It is quick and simple to perform [[liver biopsy]] in a patient with normal [[Platelet|platelet count]] and [[Prothrombin time|INR]].<ref name="pmid22833761">{{cite journal |vauthors=Tannapfel A, Dienes HP, Lohse AW |title=The indications for liver biopsy |journal=Dtsch Arztebl Int |volume=109 |issue=27-28 |pages=477–83 |year=2012 |pmid=22833761 |pmc=3402072 |doi=10.3238/arztebl.2012.0477 |url=}}</ref> | |||
* Two out of the following three positive stains upon liver biopsy confirm HCC:<ref name="pmid19177576">{{cite journal |vauthors= |title=Pathologic diagnosis of early hepatocellular carcinoma: a report of the international consensus group for hepatocellular neoplasia |journal=Hepatology |volume=49 |issue=2 |pages=658–64 |year=2009 |pmid=19177576 |doi=10.1002/hep.22709 |url=}}</ref><ref name="pmid20400233">{{cite journal |vauthors=Karabork A, Kaygusuz G, Ekinci C |title=The best immunohistochemical panel for differentiating hepatocellular carcinoma from metastatic adenocarcinoma |journal=Pathol. Res. Pract. |volume=206 |issue=8 |pages=572–7 |year=2010 |pmid=20400233 |doi=10.1016/j.prp.2010.03.004 |url=}}</ref> | * Two out of the following three positive stains upon liver biopsy confirm HCC:<ref name="pmid19177576">{{cite journal |vauthors= |title=Pathologic diagnosis of early hepatocellular carcinoma: a report of the international consensus group for hepatocellular neoplasia |journal=Hepatology |volume=49 |issue=2 |pages=658–64 |year=2009 |pmid=19177576 |doi=10.1002/hep.22709 |url=}}</ref><ref name="pmid20400233">{{cite journal |vauthors=Karabork A, Kaygusuz G, Ekinci C |title=The best immunohistochemical panel for differentiating hepatocellular carcinoma from metastatic adenocarcinoma |journal=Pathol. Res. Pract. |volume=206 |issue=8 |pages=572–7 |year=2010 |pmid=20400233 |doi=10.1016/j.prp.2010.03.004 |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]] | ||
**[[Glutamine synthetase]] | **[[Glutamine synthetase]] | ||
* A [[biopsy]] is not necessary if the [[clinical]], [[Medical laboratory|laboratory]], and [[Radiologic sign|radiologic]] data suggest hepatocellular carcinoma. | |||
* [[Liver biopsy]] may be suggestive of [[etiology]]: | |||
** [[Alcoholic liver disease]] : [[Liver biopsy]] may show [[hepatocyte]] necrosis, presence of [[Mallory body|mallory bodies]], neutrophilic infiltration and perivenular inflammation. | |||
** [[Primary biliary cirrhosis|Primary biliary cirrhosis]] : Gold standard diagnostic modality is the detection of [[antimitochondrial antibodies]] along with [[liver biopsy]] as confirmation if florid [[bile duct]] lesions. | |||
* There is a small but significant risk of [[liver biopsy]], and the underlying cirrhosis in the patients with HCC itself predisposes for 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: | |||
**[[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]]: | |||
**Plugged [[liver biopsy]] : injection of gelatin sponges or metal coils down the tract after [[biopsy]] | |||
**[[Laparoscopic surgery|Laparoscopic]] [[liver biopsy]] performed on a sedated patient with moderate [[coagulopathy]] | |||
***Advantage: allows direct visualisation of the [[liver]] | |||
*Patients with severe clotting disorders: | |||
**Transjugular [[liver biopsy]]: | |||
***Risk of [[Peritoneum|intraperitoneal]] [[Bleeding|bleed]] is less | |||
*** Disadvantages: | |||
**** [[Biopsy|Biopsies]] are small: multiple [[Biopsy|biopsies]] required | |||
**** Taken 'blindly' | |||
==== The comparison table for diagnostic studies of choice for hepatocellular carcinoma:<ref name="pmid18471552">{{cite journal |vauthors=El-Serag HB, Marrero JA, Rudolph L, Reddy KR |title=Diagnosis and treatment of hepatocellular carcinoma |journal=Gastroenterology |volume=134 |issue=6 |pages=1752–63 |year=2008 |pmid=18471552 |doi=10.1053/j.gastro.2008.02.090 |url=}}</ref> ==== | ==== The comparison table for diagnostic studies of choice for hepatocellular carcinoma:<ref name="pmid18471552">{{cite journal |vauthors=El-Serag HB, Marrero JA, Rudolph L, Reddy KR |title=Diagnosis and treatment of hepatocellular carcinoma |journal=Gastroenterology |volume=134 |issue=6 |pages=1752–63 |year=2008 |pmid=18471552 |doi=10.1053/j.gastro.2008.02.090 |url=}}</ref> ==== | ||
Revision as of 15:37, 11 January 2018
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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 laparoscopy and biopsy.
Other Diagnostic Studies
Liver Biopsy
The diagnosis of hepatocellular carcinoma is confirmed by percutaneous biopsy and histopathologic analysis.
- Core liver biopsy is the gold standard test for the diagnosis of hepatocellular carcinoma.
- Sample of the liver is obtained by:[1]
- Percutaneous
- Transjugular
- Laparoscopic radiographically- guided fine-needle approach
- Percutaneous biopsy of focal lesions may be performed in combination with either ultrasound or CT imaging.[2]
- 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.[3]
- Two out of the following three positive stains upon liver biopsy confirm HCC:[4][5]
- 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 if florid bile duct lesions.
- There is a small but significant risk of liver biopsy, and the underlying cirrhosis in the patients with HCC itself predisposes for complications due to liver biopsy.[6]
- Risks of liver biopsy include:
- 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
- Patients with severe clotting disorders:
- Transjugular liver biopsy:
- Risk of intraperitoneal bleed is less
- Disadvantages:
- Transjugular liver biopsy:
The comparison table for diagnostic studies of choice for hepatocellular carcinoma:[7]
| 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:[8]
- 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:
- Two out of the following three positive stains upon liver biopsy confirm HCC:[4]
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.[9]
- The HVPG of over 10 mmHg is associated with a 6-fold increase of HCC risk.[10]
- HVPG is measured through insertion of a catheter in right internal jugular vein.[11]
{{#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.
- ↑ 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.
- ↑ 4.0 4.1 "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.
- ↑ 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.
- ↑ 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.
- ↑ 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.