The Evolving Role of Liver Biopsy

M.S. Campbell; K.R. Reddy

Disclosures

Aliment Pharmacol Ther. 2004;20(3) 

In This Article

Focal Liver Lesions

The differential diagnosis of focal liver lesions includes a broad spectrum of benign, malignant, and infectious aetiologies. Age, gender, use of oral contraceptives, presence of cirrhosis, travel history, fever, and presence of extrahepatic malignancy help narrow the differential diagnosis. Radiological studies are often diagnostic, and tumour markers may support a suspected diagnosis. Although radiological-guided biopsy is at times needed, biopsy may carry risks of bleeding and needle-track seeding.

Biopsy of focal liver lesions is often not necessary. Most focal liver lesions have characteristic findings on CT or MRI. For example, cavernous haemangiomas may have peripheral feeders with the same attenuation as the aorta. Focal nodular hyperplasia may demonstrate a focal enhancement of a central scar during arterial phase.[63] Confident characterization by imaging can obviate the need for biopsy. Furthermore, biopsy is often non-diagnostic for hepatic adenomas and focal nodular hyperplasia. Biopsy of hepatic adenomas, focal nodular hyperplasia, and haemangiomas also carries an increased bleeding risk.[64] One group of investigators studied 160 patients referred for the evaluation of focal liver lesions. Preoperative fine needle biopsy of the lesions was not performed. Patients subsequently underwent surgery, and in 98% of cases the preoperative diagnosis was confirmed.[65]

In some cases imaging is not conclusive, and the patient may need to undergo surgical resection for definitive diagnosis. For example, if imaging cannot distinguish between focal nodular hyperplasia and hepatic adenoma, surgical resection could be performed. Resection would prevent cancer and catastrophic bleeding, which could develop if the lesion were a hepatic adenoma. Fine needle biopsy may be avoided because of the likelihood of a non-diagnostic result and the risk of bleeding.

The occurrence of a focal liver lesion in a cirrhotic is suspicious for hepatocellular carcinoma. Among cirrhotics the sensitivity of fine needle biopsy has been shown to be between 86 and 90% for the detection of hepatocellular carcinoma. The accuracy of diagnosis is influenced by nodule location and size. Biopsy is more sensitive for lesions over 3 cm.[66,67,68] Non-invasive methods of diagnosing hepatocellular carcinoma include tumour markers and radiological studies. Although α-fetoprotein is normal in up to 40% of patients with hepatocellular carcinoma, a significantly elevated value can confirm the diagnosis. For example, one study of cirrhotic patients, 170 of whom were diagnosed with hepatocellular carcinoma, showed that an α-fetoprotein of 200 ng/mL had a 99% specificity for hepatocellular carcinoma. Lower elevations in α-fetoprotein had lower specificity.[69] Other diagnostic markers including des-γ-carboxy prothrombin, are under study. Cross-sectional imaging has shown excellent diagnostic accuracy in defining the presence of hepatocellular carcinoma. One study showed that CT had 86-89% sensitivity and 99% specificity for identifying hepatocellular carcinoma.[70]

In recent years investigators have determined that biopsy of hepatocellular carcinomas carries a significant risk of needle-track seeding (1.6-5%).[66,67,71] The occurrence of needle-track seeding has provided impetus for defining conditions in which biopsy may be avoided. An α-fetoprotein over 200 ng/mL or features suggestive of hepatocellular carcinoma on CT or MRI is over 99% specific for the presence of hepatocellular carcinoma. A recent consensus guideline suggests that hepatocellular carcinoma may be diagnosed without biopsy if a characteristic mass >2 cm in a cirrhotic liver is detected by two imaging techniques (out of ultrasound, CT and MRI). Elevated α-fetoprotein (over 400 ng/mL) may also confirm the diagnosis.[72] At our institution, fine-needle liver biopsy of suspected hepatocellular carcinoma is generally reserved for patients in whom no definitive surgical intervention is planned. Biopsy is obtained at the time of non-surgical treatment (radiofrequency ablation, alcohol ablation, or chemoembolization).

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