Domenico Angelo Siena

Diagnosis of liver nodules observed in chronic liver disease patients during ultrasound screening for early detection of hepatocellular carcinoma

OBJECTIVES:The aim of our study was to evaluate the nature of focal liver lesions detected during the ultrasound follow-up of a population (prevalently anti-hepatitis C virus [anti-HCV] positive) with chronic liver disease.METHODS:The study population consisted of 1827 consecutive newly diagnosed chronic liver disease cases without liver nodules at enrollment. Patients were screened at 4-month intervals by ultrasound and serum α-fetoprotein assessment. All lesions detected on imaging studies (except those accompanied by diagnostic α-fetoprotein levels) were subjected to biopsy (histology and cytology).RESULTS:During the 7-yr follow-up period (mean = 43.1 months), one or more solid focal lesions were found in 287 patients. α-Fetoprotein was diagnostic for hepatocellular carcinoma in 51 patients. Ultrasound-guided fine-needle biopsy was performed in the remaining 236 patients, yielding a diagnosis in 214: 198 hepatocellular carcinomas, 11 dysplastic nodules, and five B-cell non-Hodgkins lymphomas (all confined to the liver and all in patients with chronic HCV infection). Twenty-two patients with nondiagnostic biopsies received diagnoses of hepatocellular carcinoma (20) or dysplastic nodules (two) based on arteriography or surgical biopsy.CONCLUSIONS:Focal lesions arising in patients with HCV-related chronic liver disease can be other than hepatocellular carcinoma, and ultrasound-guided fine-needle biopsy plays an important role in their diagnosis. The prevalence of non-Hodgkins lymphoma in this selected population was 0.31%. The fact that all five lymphoma patients had cirrhosis related to hepatitis C strengthens the hypothesis of an etiological correlation between the latter infection and B-cell lymphoproliferative disorders.

Hepatocellular carcinomas <2 cm in diameter complicating cirrhosis: ultrasound and clinical features in 153 consecutive patients

Abstract: Purpose: To determine the frequencies of various echogenicity patterns in 153 consecutive unifocal hepatocellular carcinomas (HCCs) <2 cm detected in cirrhotic livers and to identify their relationships with clinical, laboratory, and microscopic features.

Cytological vs microhistological diagnosis of hepatocellular carcinoma : Comparative accuracies in the same fine-needle biopsy specimen

There is still debate over the relative merits of cytology and histology in diagnosing hepatocellular carcinoma in cirrhotic livers. Previous comparisons of the diagnostic accuracies of these two methods may have been biased by sampling errors due to multiple punctures. We compared the diagnostic accuracies of cytology and microhistology using tissue and cells from the same point in liver nodules subsequently proved to be hepatocellular carcinoma. A single ultrasound-guided liver-nodule biopsy was obtained with a 20- to 21-G cutting needle from 131 cirrhotic patients. The solid portion of samples was used for microhistology; the remainder was subjected to smear cytology. The results of each type of examination were expressed as true positive, nonspecific malignancy, false negative, or inadequate for diagnosis. No false-positive diagnoses were made in 13 benign lesions. In 118 HCC nodules (particularly those <30 mm in diameter), cytology provided a significantly higher percentage of correct diagnoses (85.6%) that was only slightly inferior to that based on results of both studies (89.8%). The single-biopsy technique generally provides adequate tissue for histology and cytology specimens with a high cellularity. It reduces both the cost and the risks of fine-needle biopsy diagnosis of hepatocellular carcinoma.

Bleeding after invasive procedures is rare and unpredicted by platelet counts in cirrhotic patients with thrombocytopenia

BACKGROUND In cirrhotics with low circulating platelets (PLT), restoration of normal cell counts has been traditionally recommended before invasive procedures. However, there is neither consensus on the PLT transfusion threshold nor evidence of its clinical efficacy. PATIENTS In order to fill this gap of knowledge, we prospectively collected and analyzed data on circulating PLT counts [and International Normalized Ratio (INR)] values in a case series of 363 cirrhotics scheduled to undergo invasive investigations. PLT and/or fresh-frozen plasma (FFP) units were infused at the discretion of the attending physician, and the occurrence of post-procedural bleeding was related to pre-and post-infusion results. RESULTS 852 Procedures were carried out in 363 cirrhotics sub-grouped according to the Child-Pugh-Turcotte (CPT) classification (class A/B/C: 124/154/85). The infusion of PLT and/or FFP improved only marginally circulating PLT counts and INR values. Ten post-procedural bleeds occurred in the whole case series, i.e. 1 episode every 85 procedures or every 36 patients. Post-procedural bleeding was unrelated to the PLT counts, to the degree of INR abnormalities, nor to the CPT classes, but was more frequent in patients who underwent repeated investigations. In the 10 patients with the most profound alterations in PLT and/or INR values, no post-procedural bleeding occurred. CONCLUSIONS In cirrhotic patients with low PLT and/or abnormal INR values undergoing invasive investigations, post-procedural bleeding was rare and unpredicted by PLT counts or abnormal INR values. In particular, the recommendation to infuse platelets when counts are <50×103/L is not substantiated by this case series of cirrhotic patients.

Treatment of hepatocellular carcinoma: a single-center experience.

PurposeThe comparative efficacy of transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) in the treatment of hepatocellular carcinoma (HCC) was investigated.MethodsTwo hundred and sixty consecutive patients were retrospectively analyzed: 156 had received between one and six chemoembolization sessions at 3-month intervals, 33 had had PEI, and the remaining 71 patients refused any treatment. The follow-up ranged from 3 to 36 months. Survival rates were statistically analyzed by life-table analysis.ResultsPatients’ survival was affected by the number of nodules and by the Child’s and Okuda’s classes; no relationship was found between survival rates and the histologic grade or vascular supply of the tumor. In the case of a single lesion of Okuda’s class I, TACE was more effective than PEI. In multifocal HCC, TACE was better than no treatment in Okuda’s class I and Child’s class A.ConclusionWe suggest TACE as the treatment of choice in Child A or Okuda I patients with multifocal HCCs; it seems of little help in Child B-C or Okuda II–III patients.

Pulsed Doppler US diagnosis of hepatocellular carcinoma and other liver focal lesions

Objective: To assess the role of pulsed Doppler ultrasound in the differential diagnosis of focal liver lesion, based upon the presence of a Doppler signal and its waveform. Methods: The presence of a Doppler signal was accurately investigated in 267 focal liver lesions which had subsequently a definitive diagnosis. Most representative groups included hepatocellular carcinomas (188 cases), metastases (34 cases) and haemangiomas (42 cases). Results: Doppler signals were detected with a significantly higher rate in hepatocellular carcinomas than in metastases (P = 0.001) and haemangiomas (P < 0.0001). The detection rate in metastases was significantly higher than in haemangiomas (P = 0.001). Assuming the detection of a Doppler signal allows to classify a liver lesion as malignant, we obtained sensitivity of 84.9%, specificity of 90.5%, diagnostic accuracy of 85.8%, positive predictive value of 97.9% and negative predictive value of 52.8%. Considering only the presence of a pulsatile wave as a diagnostic sign of malignancy, these figures resulted 80.8%, 100%, 84.2%, 100% and 52.8%, respectively. Conclusions: The detection of Doppler signals from within a liver lesion has a clinical relevance. The finding of a pulsatile waveform makes it possible to differentiate a malignant lesion from haemangioma with high sensitivity and absolute specificity.