The histological study of the liver, has been the gold standard for the diagnosis of malignant liver pathologies through time. With the technological advances, knowledge and newer therapeutic options in medical science today, the need for histological confirmation of these pathologies has changed .
The Fine Needle Aspiration Liver Biopsy is a well established method for the diagnosis of intraabdominal tumors , with a sensibility of 75-90% and a percentage of false negatives around 12.5%. In spite of the fact that it has shown to be a relatively safe procedure, it is not exempt of complications. It has been reported previously in the literature, a mortality of 0.008% and morbidity of 0.05%.
At present, multiple reports have described an incidence of complications ranging from 0.05 to 6%. The more commonly reported complications are: hemorrhage, biliary leaks, pneumothorax, intrahepatic hematomas, infections, hemoperitoneum and pancreatitis. It is important to have in mind that because these tumors are hypervascularized, the risk of hemorrhage is very high.
Currently, the topic of major concern, is tumor cell seeding in the needle tract or even hematogenous spread. Also, an intrahepatic dissemination can occur when the needle crosses a peritumoral artery , and a migration of neoplastic cells is facilitated by a communication between a zone of high arterial pressure, and a low pressure zone (portal). Once the cells spread through the portal branches, the invasion to other segments of the liver can be expected.
Takamori et al revealed in their study, that 5% of the patients submitted to FNA for intraabdominal tumors, suffered tumor seeding. Ryd et al in their study showed that FNA could induce seeding of 1000 to 100.000 cells along the needle tract; the vast majority in the subcutaneous abdominal tissue or in the area of the thoracic wall . Tumor seeding can change a well localized and curable illness , into a metastatic disease, diminishing the effectiveness of locoregional treatments.
The current literature shows that the FNA should not be used indiscriminately. Data in the patient's medical history, laboratory and imaging studies, often help guide treatment strategies without having to depend on a biopsy. Clinical reports advise to the avoidance of FNA biopsy in those cases of hepatocellular carcinoma that can be subject to resection or to a liver transplant; and on the contrary, FNA is adviced only in those cases in which there is no surgical intervention planned, because of the patient's medical condition or an unresectable tumor, or because a histological confirmation is required to continue with non surgical strategies.
This maximizes the opportunity of cure for HCC. The conclusions of the Conference of the EASL in Barcelona in the year 2000, protocolized the use of the FNA in chirrotic patients. What's important about this report are its conclusions, establishing that tumor seeding can change the prognosis of the patient. Besides it makes it clear that modern imaging and laboratory studies can offer an accurate diagnosis without the need of histological confirmation, basing medical criteria only on CT scan, magnetic resonance or angiography and the values of AFP.
In conclusion, any patient with a liver nodule, a value of AFP >250ng/ml, a medical history and an adequate physical examination, does not require FNA, because the probability of it being an HCC are very high and the possibilities of cure with resection or in specific cases, transplant, are greater. The bad prognosis given by tumor seeding after this procedure, preclude its indiscriminate use.
Liver Transplantation 2000, 6(1):73-75; J Hepatol 2001, 35:421-430; Ultrasound Med Biol 1984, 10:629-634; J R Coll Surg Edinb 1991, 36:127; J Clin Gastroenterol 1993, 17:350-352; Hepatology 1999, 29:879-882; Gastrointest radiol 1988, 13:253-255; Am J Surg 2004, 188:165-167; J Hepatology 1993, 18:276-278; Liver Transpl 2000, 6(1);
At present, multiple reports have described an incidence of complications ranging from 0.05 to 6%. The more commonly reported complications are: hemorrhage, biliary leaks, pneumothorax, intrahepatic hematomas, infections, hemoperitoneum and pancreatitis. It is important to have in mind that because these tumors are hypervascularized, the risk of hemorrhage is very high.
Currently, the topic of major concern, is tumor cell seeding in the needle tract or even hematogenous spread. Also, an intrahepatic dissemination can occur when the needle crosses a peritumoral artery , and a migration of neoplastic cells is facilitated by a communication between a zone of high arterial pressure, and a low pressure zone (portal). Once the cells spread through the portal branches, the invasion to other segments of the liver can be expected.
Takamori et al revealed in their study, that 5% of the patients submitted to FNA for intraabdominal tumors, suffered tumor seeding. Ryd et al in their study showed that FNA could induce seeding of 1000 to 100.000 cells along the needle tract; the vast majority in the subcutaneous abdominal tissue or in the area of the thoracic wall . Tumor seeding can change a well localized and curable illness , into a metastatic disease, diminishing the effectiveness of locoregional treatments.
The current literature shows that the FNA should not be used indiscriminately. Data in the patient's medical history, laboratory and imaging studies, often help guide treatment strategies without having to depend on a biopsy. Clinical reports advise to the avoidance of FNA biopsy in those cases of hepatocellular carcinoma that can be subject to resection or to a liver transplant; and on the contrary, FNA is adviced only in those cases in which there is no surgical intervention planned, because of the patient's medical condition or an unresectable tumor, or because a histological confirmation is required to continue with non surgical strategies.This maximizes the opportunity of cure for HCC. The conclusions of the Conference of the EASL in Barcelona in the year 2000, protocolized the use of the FNA in chirrotic patients. What's important about this report are its conclusions, establishing that tumor seeding can change the prognosis of the patient. Besides it makes it clear that modern imaging and laboratory studies can offer an accurate diagnosis without the need of histological confirmation, basing medical criteria only on CT scan, magnetic resonance or angiography and the values of AFP.
In conclusion, any patient with a liver nodule, a value of AFP >250ng/ml, a medical history and an adequate physical examination, does not require FNA, because the probability of it being an HCC are very high and the possibilities of cure with resection or in specific cases, transplant, are greater. The bad prognosis given by tumor seeding after this procedure, preclude its indiscriminate use.
Liver Transplantation 2000, 6(1):73-75; J Hepatol 2001, 35:421-430; Ultrasound Med Biol 1984, 10:629-634; J R Coll Surg Edinb 1991, 36:127; J Clin Gastroenterol 1993, 17:350-352; Hepatology 1999, 29:879-882; Gastrointest radiol 1988, 13:253-255; Am J Surg 2004, 188:165-167; J Hepatology 1993, 18:276-278; Liver Transpl 2000, 6(1);
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