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Complications of percutaneous biopsy and treatment under ultrasonographic guidance for hepatocellular carcinomas
AASLDA991
April 2000
1136
1138
TRANSARTERIAL CHEMOEMBOLIZATION (TACE) IN PATIENTS WITH UNRESECTABLE DIFFUSE VS. FOCAL HEPATOCELLULAR CARCINOMA (HCC).
COMPLICATIONS OF PERCUTANEOUS BIOPSY AND TREATMENT UNDER ULTRASONOGRAPIDC GUIDANCE FOR HEPATOCELLULAR CARCINOMAS.
Shi-Hui Pan, Carlos Ramirez, Allen Hoffman, Linda Sher, Sergio Rojter, Richard R. Lopez, St Vincent's Med Ctr, LA, CA.
Mikiya Kitamoto, Shoichi Takahashi, Hiroshi Aikata, Koji Kamada, Michio Imamura, Hirotaka Kono, Akiko Matsumoto, Waka Ohishi, Yoshiiku Kawakami, Toshio Nakanishi, Goro Kajiyama, lst Dept of Internal Med, Hiroshima Univ Sch of Med, Hiroshima, Japan; Hiroshima Univ Sch of Med, Hiroshima, Japan.
HCC varies in histology and growth patterns which may affect response to treatment and survival. We prospectively compared the clinical outcomes of TACE in patients with unresectable, diffuse vs. focal HCC. Methods: From 9/95 to 12/99, 77 TACE treatments (Txs) were performed in 38 patients with focal HCC and 18 in 15 patients with diffuse HCC. Selective embolization was performed after infusion of chemoagents. Clinical and biochemical effects were monitored at regular intervals. Mean follow-up was 744 days with a range from 30-1480 days. Childs-Pugh classification (C-P Class), length of hospital stay (LOS), readmission, o-fetoprotein (AFP) response, complications, and mean survival were analyzed. Results: 44 of 53 (83%) patients had cirrhosis: 14 (93%) in the diffuse group and 30 (79%) in the focal group (p=O.4). Mean tumor size in the focal group was 7 cm and 24 patients had > 1 tumor. 12 patients with diffuse tumors had a mean AFP level of 29,931 vs. 3,439 ng/ml for 25 patients with focal tumors (p< 0.01). The AFP response was greater with focal tumors: 76% of patients had a mean decrease of 76% in AFP I month following treatment. This decrease was sustained over time with additional TACE. All 9 readmits in the diffuse group were due to complications of cirrhosis. In the focal group 7 of 8 readmits were due to complications of the procedure. The actual 1 year survival was 0% (0/14) in the diffuse group vs. 65% (15/23) in the focal group. Table 1 shows the results of TACE in these 2 groups. Conclusions: In patients with diffuse HCC, TACE results in significant morbidity and does not impact survival. However, TACE is well tolerated in patients with focal HCC and may provide a survival benefit.
Table 1Results ofTACE indiffuse vs. focal HCC data in Mean ± SO
C-PClass (Aand B)
Diffuse HCC N=15 Focal HCC N=38 pvalue
11/14 (79%) 30/30 (100%) <0.05
LOS (days)
Readmits (No.llxs)
AFP response
Survival (days)
2.6
9/18 (50%) 8/77 (10%) <0.01
3/12 (25%) 19/25 (76%) <0.01
104 ±76 372 ± 226 <0.01
± 1.9 1.7 ± 1.0 <0.01
Background/Aim:Fine needle aspiration biopsy (FNAB), percutaneous ethanol injection therapy (PElT) and percutaneous microwave coagulation therapy (PMCT) have become widely used in the diagnosis and treatment for hepatocellular carcinoma (HCCs). But these percutaneous procedures under ultrasonographic guidance have been reported to cause serious complications rarely. Here, we evaluated the safety of these percutaneous procedures for HCCs. Patients and Methods:FNAB for 545 focal nodules of liver, PElT for 456 HCCs, and PMCT for 97 HCCs were performed during a 11 year period from 1989 to 1999. We retrospectively reviewed complications in all patients undergone these percutaneous procedures. Results:The incidence of serious complications on these percutaneous procedures, such as intraperitoneal bleeding, hepatic infarction, needle tract implantation, and abscess formation, was 1.1% (12/1098). Intraperitoneal bleeding was occurred in four patients, one patient treated by PElT with slight ascites and three treated by PMCT. These four cases were subsided without transfusion. Hepatic infarction occurred in three patients treated by PElT followed by transcatheter arterial chemolipiodolization. Although they had high-grade fever and the elevation of transaminase in a few days, they recovered with conservative treatment. Four cases of needle tract implantation occurred, one after FNAB alone and three after PElT followed by FNAB. Histological findings of primary HCC were well-differentiated type in one patient and moderately differentiated type in three. At diagnosis of needle tract implantation, one patient had already bone metastasis failing to radical treatment, and the remaining cases were treated by surgical resection. Among three treated cases, 2 had no extrahepatic metastasis, but I had multiple distant metastasis. The patient with abscess formation after PMCT was recovered spontaneously with oozing pus from puncture site revealing no local recurrence 2 years after treatment. No deaths were related to these procedures. Conclusion:FNAB, PElT, and PMCT can be safely performed in most cases, but it is fact that they rarely caused several serious complications. Especially, FNAB has the possibility of causing serious complication such as needle tract implantation, therefore it should be performed only for patients who can not be diagnosed by any other imaging procedures.
1137
1139
RECURRENCE OF HEPATITIS C VIRUS·RELATED HEPATOCELLULAR CARCINOMA INCREASES WITH SEVERITY OF LIVER FmROSIS - A PROSPECTIVE ANALYSIS OF 221 CONSECUTIVE PATIENTS-.
THE UTILITY OF FINE-NEEDLE BIOPSY OF LIVER MASS LESIONS IN PATIENTS WITH CIRRHOSIS AND SERUM ALPHAFETOPROTEIN LESS THAN SOO.
Yukihiro Koike, Yasushi Shiratori, Shuichiro Shiina, Takuma Teratani, Shuntaro Obi, Keisuke Hamamura, Shinpei Sato, Yoshiyuki Dan, Masatoshi Imamura, Yasuo Imai, Haruhiko Yoshida, Masao Ornata, Tokyo Univ Hosp, Tokyo, Japan. Background & Aims. Hepatocellular carcinoma (HCC) has frequent intrahepatic recurrence even after complete ablation of tumor by percutaneous ethanol injection (PElT) and percutaneous microwave coagulation therapy (PMCT), or surgical resection. Since oncogenic process may be different between hepatitis B virus (HBY)- and hepatitis C virus (HCY)-related HCC, the present study was conducted to elucidate the predicting factor for HCC recurrence after classification according to viral infection state. Methods. 221 patients with single HCC nodule who underwent complete ablation of tumor by PElT and/or PMCT, or surgical resection at Tokyo University Hospital from 1993 to 1997 were enrolled. The 221 patients were classified into 3 groups; HBY group (HBs Ag+, HCY Ab-, n=16), HCY group (HBs-Ag-, HCY Ab+ n=188) and NBNC group (HBs Ag-, HCY Ab-, n= 16). After treatment of HCC, the patients were followed for detection of HCC recurrence by mesurement of tumor markers every 1-2 months, US, CT and MRI every 3-6 months at outpatient clinic for a mean period of 22 months (range; 2-72 months). HCC recurrence was confirmed by biopsy or imaging techniques. Results. The overall intrahepatic recurrence rate at 1,2,3 and 5 year was 19.3%,43.5/%,51.1% and 57.1%, respectively. The recurrence rate at 3 years for HBY, HCY, and NBNC group was respectively 73 % , 52 % and 35 %. Among HCY-related HCC, fibrosis staging and pathological grading of HCC were significantly linked to intrahepatic recurrence of HCC by univariate analysis, and the fibrosis staging was the strongest by multivariate analysis (Odds ratio:2.22, P
Nyingi M. Kemmer, Brian W. Goodacre, Sanjeeb Shrestha, Emil P. Miskovsky, The Univ of Texas Med Branch, Galveston, TX; Univ of Washington, Seattle, WA. Background: Hepatocellular carcinoma (HCC) is one of the most common tumors worldwide, with an increasing incidence in the United States. The role of fine needle biopsy (FNB) in the diagnosis of HCC is controversial. In patients with cirrhosis and liver mass lesions, a serum AFP level about 5OOng/ml is considered diagnostic, whereas those with AFP less than 5OOng/ml require FNB for confirmation of HCC. Aim: To assess the role of FNB of liver mass lesions in the evaluation of patients with cirrhosis and an AFP level less than 5OOng/m!. Methods: Patients with cirrhosis, liver mass lesions identified by imaging, and AFP less than 500 who had ultrasound guided FNB at our institution from January 1996 to September 1999 were included in this study. Clinical features, laboratory data, histologic diagnosis, and radiological findings were obtained retrospectively by chart review. Results: Sixty-six patients with the above criteria were identified. Fifty-eight (89%) patients had HCC; the remaining diseases were regenerative nodules (10%) and adenoma (1%). Of the 58 patients with HCC, 10 patients were Child A, 22 patients were Child B, and 26 patients were Child C, as compared to those without HCC, in which 6 patients were Child A, 2 patients were Child B, and no patients were Child C. Of the 66 patients evaluated, 47 patients (71%) had HCY, the other aetiologies include alcohol (17%), HBY (4%), cryptogenic (4%), autoimmune (2%) and hemochromatosis (2%). (In the non-HCC group, 5 patients had HCY, 2 had ETOH, and 1 had autoimmune.) Conclusion: FNB does not seem to be important in confirming the diagnosis of HCC in patients with Child C cirrhosis who are found to have a liver mass and an AFP less than 500. However, patients with Child A cirrhosis would benefit from FNB to confirm or exclude the diagnosis of HCC, since 40% of patients in our study with Child A did not have HCC. Those patients with Child B cirrhosis would need to be evaluated on an individual basis, but the majority had HCC in our study.
April 2000
1136
1138
TRANSARTERIAL CHEMOEMBOLIZATION (TACE) IN PATIENTS WITH UNRESECTABLE DIFFUSE VS. FOCAL HEPATOCELLULAR CARCINOMA (HCC).
COMPLICATIONS OF PERCUTANEOUS BIOPSY AND TREATMENT UNDER ULTRASONOGRAPIDC GUIDANCE FOR HEPATOCELLULAR CARCINOMAS.
Shi-Hui Pan, Carlos Ramirez, Allen Hoffman, Linda Sher, Sergio Rojter, Richard R. Lopez, St Vincent's Med Ctr, LA, CA.
Mikiya Kitamoto, Shoichi Takahashi, Hiroshi Aikata, Koji Kamada, Michio Imamura, Hirotaka Kono, Akiko Matsumoto, Waka Ohishi, Yoshiiku Kawakami, Toshio Nakanishi, Goro Kajiyama, lst Dept of Internal Med, Hiroshima Univ Sch of Med, Hiroshima, Japan; Hiroshima Univ Sch of Med, Hiroshima, Japan.
HCC varies in histology and growth patterns which may affect response to treatment and survival. We prospectively compared the clinical outcomes of TACE in patients with unresectable, diffuse vs. focal HCC. Methods: From 9/95 to 12/99, 77 TACE treatments (Txs) were performed in 38 patients with focal HCC and 18 in 15 patients with diffuse HCC. Selective embolization was performed after infusion of chemoagents. Clinical and biochemical effects were monitored at regular intervals. Mean follow-up was 744 days with a range from 30-1480 days. Childs-Pugh classification (C-P Class), length of hospital stay (LOS), readmission, o-fetoprotein (AFP) response, complications, and mean survival were analyzed. Results: 44 of 53 (83%) patients had cirrhosis: 14 (93%) in the diffuse group and 30 (79%) in the focal group (p=O.4). Mean tumor size in the focal group was 7 cm and 24 patients had > 1 tumor. 12 patients with diffuse tumors had a mean AFP level of 29,931 vs. 3,439 ng/ml for 25 patients with focal tumors (p< 0.01). The AFP response was greater with focal tumors: 76% of patients had a mean decrease of 76% in AFP I month following treatment. This decrease was sustained over time with additional TACE. All 9 readmits in the diffuse group were due to complications of cirrhosis. In the focal group 7 of 8 readmits were due to complications of the procedure. The actual 1 year survival was 0% (0/14) in the diffuse group vs. 65% (15/23) in the focal group. Table 1 shows the results of TACE in these 2 groups. Conclusions: In patients with diffuse HCC, TACE results in significant morbidity and does not impact survival. However, TACE is well tolerated in patients with focal HCC and may provide a survival benefit.
Table 1Results ofTACE indiffuse vs. focal HCC data in Mean ± SO
C-PClass (Aand B)
Diffuse HCC N=15 Focal HCC N=38 pvalue
11/14 (79%) 30/30 (100%) <0.05
LOS (days)
Readmits (No.llxs)
AFP response
Survival (days)
2.6
9/18 (50%) 8/77 (10%) <0.01
3/12 (25%) 19/25 (76%) <0.01
104 ±76 372 ± 226 <0.01
± 1.9 1.7 ± 1.0 <0.01
Background/Aim:Fine needle aspiration biopsy (FNAB), percutaneous ethanol injection therapy (PElT) and percutaneous microwave coagulation therapy (PMCT) have become widely used in the diagnosis and treatment for hepatocellular carcinoma (HCCs). But these percutaneous procedures under ultrasonographic guidance have been reported to cause serious complications rarely. Here, we evaluated the safety of these percutaneous procedures for HCCs. Patients and Methods:FNAB for 545 focal nodules of liver, PElT for 456 HCCs, and PMCT for 97 HCCs were performed during a 11 year period from 1989 to 1999. We retrospectively reviewed complications in all patients undergone these percutaneous procedures. Results:The incidence of serious complications on these percutaneous procedures, such as intraperitoneal bleeding, hepatic infarction, needle tract implantation, and abscess formation, was 1.1% (12/1098). Intraperitoneal bleeding was occurred in four patients, one patient treated by PElT with slight ascites and three treated by PMCT. These four cases were subsided without transfusion. Hepatic infarction occurred in three patients treated by PElT followed by transcatheter arterial chemolipiodolization. Although they had high-grade fever and the elevation of transaminase in a few days, they recovered with conservative treatment. Four cases of needle tract implantation occurred, one after FNAB alone and three after PElT followed by FNAB. Histological findings of primary HCC were well-differentiated type in one patient and moderately differentiated type in three. At diagnosis of needle tract implantation, one patient had already bone metastasis failing to radical treatment, and the remaining cases were treated by surgical resection. Among three treated cases, 2 had no extrahepatic metastasis, but I had multiple distant metastasis. The patient with abscess formation after PMCT was recovered spontaneously with oozing pus from puncture site revealing no local recurrence 2 years after treatment. No deaths were related to these procedures. Conclusion:FNAB, PElT, and PMCT can be safely performed in most cases, but it is fact that they rarely caused several serious complications. Especially, FNAB has the possibility of causing serious complication such as needle tract implantation, therefore it should be performed only for patients who can not be diagnosed by any other imaging procedures.
1137
1139
RECURRENCE OF HEPATITIS C VIRUS·RELATED HEPATOCELLULAR CARCINOMA INCREASES WITH SEVERITY OF LIVER FmROSIS - A PROSPECTIVE ANALYSIS OF 221 CONSECUTIVE PATIENTS-.
THE UTILITY OF FINE-NEEDLE BIOPSY OF LIVER MASS LESIONS IN PATIENTS WITH CIRRHOSIS AND SERUM ALPHAFETOPROTEIN LESS THAN SOO.
Yukihiro Koike, Yasushi Shiratori, Shuichiro Shiina, Takuma Teratani, Shuntaro Obi, Keisuke Hamamura, Shinpei Sato, Yoshiyuki Dan, Masatoshi Imamura, Yasuo Imai, Haruhiko Yoshida, Masao Ornata, Tokyo Univ Hosp, Tokyo, Japan. Background & Aims. Hepatocellular carcinoma (HCC) has frequent intrahepatic recurrence even after complete ablation of tumor by percutaneous ethanol injection (PElT) and percutaneous microwave coagulation therapy (PMCT), or surgical resection. Since oncogenic process may be different between hepatitis B virus (HBY)- and hepatitis C virus (HCY)-related HCC, the present study was conducted to elucidate the predicting factor for HCC recurrence after classification according to viral infection state. Methods. 221 patients with single HCC nodule who underwent complete ablation of tumor by PElT and/or PMCT, or surgical resection at Tokyo University Hospital from 1993 to 1997 were enrolled. The 221 patients were classified into 3 groups; HBY group (HBs Ag+, HCY Ab-, n=16), HCY group (HBs-Ag-, HCY Ab+ n=188) and NBNC group (HBs Ag-, HCY Ab-, n= 16). After treatment of HCC, the patients were followed for detection of HCC recurrence by mesurement of tumor markers every 1-2 months, US, CT and MRI every 3-6 months at outpatient clinic for a mean period of 22 months (range; 2-72 months). HCC recurrence was confirmed by biopsy or imaging techniques. Results. The overall intrahepatic recurrence rate at 1,2,3 and 5 year was 19.3%,43.5/%,51.1% and 57.1%, respectively. The recurrence rate at 3 years for HBY, HCY, and NBNC group was respectively 73 % , 52 % and 35 %. Among HCY-related HCC, fibrosis staging and pathological grading of HCC were significantly linked to intrahepatic recurrence of HCC by univariate analysis, and the fibrosis staging was the strongest by multivariate analysis (Odds ratio:2.22, P
Nyingi M. Kemmer, Brian W. Goodacre, Sanjeeb Shrestha, Emil P. Miskovsky, The Univ of Texas Med Branch, Galveston, TX; Univ of Washington, Seattle, WA. Background: Hepatocellular carcinoma (HCC) is one of the most common tumors worldwide, with an increasing incidence in the United States. The role of fine needle biopsy (FNB) in the diagnosis of HCC is controversial. In patients with cirrhosis and liver mass lesions, a serum AFP level about 5OOng/ml is considered diagnostic, whereas those with AFP less than 5OOng/ml require FNB for confirmation of HCC. Aim: To assess the role of FNB of liver mass lesions in the evaluation of patients with cirrhosis and an AFP level less than 5OOng/m!. Methods: Patients with cirrhosis, liver mass lesions identified by imaging, and AFP less than 500 who had ultrasound guided FNB at our institution from January 1996 to September 1999 were included in this study. Clinical features, laboratory data, histologic diagnosis, and radiological findings were obtained retrospectively by chart review. Results: Sixty-six patients with the above criteria were identified. Fifty-eight (89%) patients had HCC; the remaining diseases were regenerative nodules (10%) and adenoma (1%). Of the 58 patients with HCC, 10 patients were Child A, 22 patients were Child B, and 26 patients were Child C, as compared to those without HCC, in which 6 patients were Child A, 2 patients were Child B, and no patients were Child C. Of the 66 patients evaluated, 47 patients (71%) had HCY, the other aetiologies include alcohol (17%), HBY (4%), cryptogenic (4%), autoimmune (2%) and hemochromatosis (2%). (In the non-HCC group, 5 patients had HCY, 2 had ETOH, and 1 had autoimmune.) Conclusion: FNB does not seem to be important in confirming the diagnosis of HCC in patients with Child C cirrhosis who are found to have a liver mass and an AFP less than 500. However, patients with Child A cirrhosis would benefit from FNB to confirm or exclude the diagnosis of HCC, since 40% of patients in our study with Child A did not have HCC. Those patients with Child B cirrhosis would need to be evaluated on an individual basis, but the majority had HCC in our study.