- Email: [email protected]
Percutaneous fine needle aspiration biopsy (FNAB) of focal hepatic lesions - diagnostic utility and preprocedure predictors
April 1995
HOMOLOGOUS AND AUTOLOGOUS BLOOD TRANSFUSION FOR HEPATECTOMY IN PATIENTS WITH CIRRHOSIS AND HEPATOCELLULAR CARCINOMA: IS THERE A DIFFERENCE IN MORBIDITY AND PROGNOSIS? A PROSPECTIVE AND RETROSPECTIVE STUDY K.-J. Paque~, W. Ruppert, A. Lazar, Deot. of Surgery and Anaesthesiology, HEINZ-KALK-Hosoital, D-97688 Bad Kissingen, Germany Periooerative homologous blood transfusion (hbt) zs associated with many problems such as transmission of certain disease, graft- versus- host disease, or altered immunologic activity. In addition, hbt zs associated with hepstotoxic effects caused by hemolytic and immunologic reactions, further increasing morbidity after hepatectomy. Patients with hepetocellular carcinoma (HCC) frequently have cirrhosis, anO thus s little hepatic reserve. They may experience hepatic failure. Toxicity associated with hbt is therefore an important consideration in patients with cirrhosisundergoing hepateetomy. Autologous bt for this indicatior was introduced in our hospital from January 1, 1987. From Jan. 1, 1987 ~o Jan. 1, 1994 15 patients with histologically proven cirrhosis and unilocular HCC of 5 diameter in lumen were considered for segmentectomy or bisegmenteetomy and prospectively followed up. They were compared to a group of 13 patients, ooerated because of the same indication from Jan. 1, 1982 to Jan. 1, i987. Both patients were comparable concerning the frequency of portal hypertension (63 vs. 74%), etiology and severity of disease. Operating time 173 + 23 (110-360) during the first period and 186 ~ 20 (131-320), during the second period. There was no difference between surgical blood loss (892 ~ 71 vs. 901 + 82) and ~ype of resection. However, there was a szgnificant difference in morbidity, early ano long mortality. Postoperative total bilirubine concentrations were szgnificantly higher in the oatients with transfused homologous blood. Morbidity could be reduced from 56 to 22% and nospital mortality from 25 (3 patients) to 6.6% (1 patient), which is highly statistically significant (p < 0.01). Five years survival time of the first group was 41% and of the second group 63% (p < 0.05). - Conclusion: Autologous blood transfusion yields clinically superzor results for hepatectomy in patients with cirrhosis and comeared with homologous blood transfusion.
• PROPHYLACTIC SCLEROTHERAPY IN HIGH-RISK CIRRHOTICS SELECTED BY ENDOSCOPIC AND HEMODYNAMICCRITERIA A SECOND PROSPECTIVE CONTROLLED RANDOMIZED TRIAL K.-J. Paquet, J.-F. Kalk, C.-P. Klein, Dept. of Surgery and Medicine, HEINZ-KALK-Hospital, Am Gradierbau 3, 0-97688 Bad Kissingen, Germany Although the f i r s t variceal bleeding in patients with l i v e r c i r r h o s i s has an extremely high m o r t a l i t y rate, prophylaxis is a matter of controversy. Thirteen controlled t r i a l s of sclerotherspy f o r the prevention of the f i r s t variceal hemorrhage in c i r r h o t i c s have given c o n f l i c t e d results although the f i r s t two w e r e p o s i t i v e . Main reasons were d i f f e r e n t patients" populations and d i f f e r e n t selection c r i t e r i a . Therefore, we designed a new study in which 89 from 396 investigated patients a f t e r endoscopic and hemodynamic selection were randomised either to sclerotherapy (44 patients) or control (45 patients). Admission criteria were no history of variceal bleeding, the presence of high risk varices, i.e. varices degree III and IV with minivarices on their top and a portal pressure over 16mmHg. Sclerotherapy sessions were performed at time d, 7, 14, 21, 28 days, until the vsrices were reduced at least for two degrees in size end completely covered by fibrous tissue. Follow-up endoscopy was performed at four and thereafter at six month intervals. Control patients underwent repeated clinical investigation and endoscopy at s i x months intervals. Bleeding episodes were treated by emergency sclerotherapy (EES) in both groups, whenever possible. Mean follow-up WaS 33 months. Analysis of the results were performed by Students" T- and Longrank test. Variceal bleeding occured in 12 sclerotherapy patients (27.3%) and 33 controls (73.3%) (p < 0.01). Overall-mortality was 31.8% in sclerotherapy patients end 68.9% in controls (p < 0.01). PES was able to prolong survival in CHILD class A and B but not in C. It is concluded, that PES does reduce the incidence of first vsriceal bleeding in cirrhotics and is able to prolong survival in patients with good liver function if only high risk patients are selected and PES is performed by endoscopic experts.
AASLD A l 1 4 3
• PROGNOSIS OF UNILOCULAR HEPATOCELLULAR CARCINOMA (HCC) IN CIRRHOTIC LIVERS AFTER RESECTION AND TREATMENT OF CONCOMITANT VARICEAL HEMORRHAGE BY TWO DIFFERENT MODALITIES A PROSPECTIVE STUDY Paquet K.-d., Lazar A., Kalk d.-Fr., Dept. of Surgery and Vascular Surgery, Medicine and GastroenterologyHEINZ KALK-Hospitel, Am Gradierbsu 3, D-97688 Bad Kissingen, Germany Repeated ultrasound examination of the liver and determination of serum-alpha-fetoproteine have led to detection of increasing number of small HCC in pet. with cirrhosis. Resection of HCC is currently the only hope for long-term survival. It could be shown by our group (Br J Surg 78:459-62, 1991) that resection of unilocular HCC is possible with an acceptable risk, and able to improve survival. Is this also true for patients with additional portal hypertension (PH) and recurrent vsriceal hemorrhage? Is their prognosis limited and influenced by different treatment modalities like endoscopic sclerotherapy (ES) or surgery? From Jan. 1, 1982~to Jan. 1, 1994 in 157 (14%) of 9S5 regular screened pat. with liver cirrhosis 30 (19.1%) were selected for surgery according to the above mentioned criteria: 10 pay. (33%) (group I) had no PH or of minor degree with esophageal varices degree I-II (Endoscopy 14:4-5,1982); 20 pat. (66%) had one or recurrent or uncontrollable variceal bleeding ; the pat. with one variceal hemorrhage were managed by ES (group II:lO pat.); the remaining pat. with recurrent or uncontrollable hemorrhage in spite of short or long-term ES were treated by emergent devassularisation procedure (DP) (2) or elective distal splenorenal (DSRS) (3) or narrow-lumen mesocaval shunt (NLMCS) (5) (group III). There were no~aignificant differences in hospital mortality (13%), early and long-term survival (70-80%) after one year and 45-55% after five Years). This prosp, study demonstrates that hepatic resection in selected cirrhotic pat. with HCC is possible with low risk and able to improve survival; PR with va÷iceal bleeding (VS) doesn't enlarge the risk or worsen the prognosis. Current treatment modelities of VB are ES (first step); in case of uncontrollable devascularisation procedure or TIPS and of recurrent hemorrhage managedsuccessfully by ES, elective DSRS or NLMCS are the best treatment modalities.
PERCUTANEOUS FINE NEEDLE ASPIRATION BIOPSY (FNAB) OF FOCAL HEPATIC LESIONS - DIAGNOSTIC UTILITY AND PREPROCEDURE PREDICTORS. DN Parkin, RL Hope, SJ Williams, M Greenberg, JM Little, and C Liddle. Departments of Gastroenterology & Hepatotogy, Cytology and Surgery, Westmead Hospital, Australia. Between Jan. 199i and Dec. 1993, 120 pts {67M, 53F; median age 63 yrs (range 11-86)} undergoing FNAB of focal hepatic lesions were analysed to assess the diagnostic utility in malignant and benign conditions and to describe any predictors of diagnosis or complications. Pre-FNAB investigations included LFTs, aFP, CEA, platelet and coagulation profile. Vascularity of the lesion using RBC scanning &/or angiography was assessed when appropriate. FNAB was performed under CT control in 99 (82.5%) and US in 15 (12.4%) and cytological assessment was immediate. The median number of passes was 3 (range 1-8). RESULTS: The'overall diagnostic rate of FNAB was 75.8% (91/120). The Table shows the final cytological diagnosis vs the presumed diagnosis. CYTOLOGICAL DIAGNOSIS Presumed Dx. Malignant HCC Benign Non Dx'ic Malignancy (n=87) 65 (75%) 1(1%) 2 (2%) 19(22%) HCC (n=17) 4 (24%) 9 (53%) 1(5%) 3 (18%) Benign (n=16) 2 (12%) 7 (44%) 7 (44%) In pts with presumed malignancy (non-HCC) FNAB was confirmatory in 65 (75%). A further 3 pts (3.4%) had other diagnostic cytology; 19 pts (21~8%) had non diagnostic cytology. Cytology was diagnostic in 14 (82.3%) with presumed HCC (confirming HCC in 9 [52.9%]). For presumed benign lesions the diagnostic rate was 56.3% (9/16). In 29 pts where FNAB was not helpful, 15 (51.7%) had +ve tissue diagnosis on further investigation. 7 pts were treated presumptively for metastatic disease without tissue diagnosis. The diagnostic rate did not alter between US. & CT guided FNAB, number of hepatic lesions or number of FNAB passes performed. Logistic regression analysis demonstrated ALP (p = 0.004) & number of lesions (p=0.016) to significantly predict malignancy (non HCC)'. Non significant predictors included age, previous history of malignancy, bilil GGT, ALT & CEA. There were no statistically significant predictors of HCC including aFP: Minimal complications occurred in 4 pts (3.3%) including pain in 3 & cough in 1. Age & wt approached significance as predictors of complication. CONCLUSIONS: 1. FNAB is a safe & reliable method of tissue diagnosis for focal hepatic lesions, particularly ifi those thought to have malignant disease. It is less 'sensitive' for presumed benign disease. 2. Increased ALP & number, of lesions are predictive of a positive cytological diagnosis of malignancy. '.
HOMOLOGOUS AND AUTOLOGOUS BLOOD TRANSFUSION FOR HEPATECTOMY IN PATIENTS WITH CIRRHOSIS AND HEPATOCELLULAR CARCINOMA: IS THERE A DIFFERENCE IN MORBIDITY AND PROGNOSIS? A PROSPECTIVE AND RETROSPECTIVE STUDY K.-J. Paque~, W. Ruppert, A. Lazar, Deot. of Surgery and Anaesthesiology, HEINZ-KALK-Hosoital, D-97688 Bad Kissingen, Germany Periooerative homologous blood transfusion (hbt) zs associated with many problems such as transmission of certain disease, graft- versus- host disease, or altered immunologic activity. In addition, hbt zs associated with hepstotoxic effects caused by hemolytic and immunologic reactions, further increasing morbidity after hepatectomy. Patients with hepetocellular carcinoma (HCC) frequently have cirrhosis, anO thus s little hepatic reserve. They may experience hepatic failure. Toxicity associated with hbt is therefore an important consideration in patients with cirrhosisundergoing hepateetomy. Autologous bt for this indicatior was introduced in our hospital from January 1, 1987. From Jan. 1, 1987 ~o Jan. 1, 1994 15 patients with histologically proven cirrhosis and unilocular HCC of 5 diameter in lumen were considered for segmentectomy or bisegmenteetomy and prospectively followed up. They were compared to a group of 13 patients, ooerated because of the same indication from Jan. 1, 1982 to Jan. 1, i987. Both patients were comparable concerning the frequency of portal hypertension (63 vs. 74%), etiology and severity of disease. Operating time 173 + 23 (110-360) during the first period and 186 ~ 20 (131-320), during the second period. There was no difference between surgical blood loss (892 ~ 71 vs. 901 + 82) and ~ype of resection. However, there was a szgnificant difference in morbidity, early ano long mortality. Postoperative total bilirubine concentrations were szgnificantly higher in the oatients with transfused homologous blood. Morbidity could be reduced from 56 to 22% and nospital mortality from 25 (3 patients) to 6.6% (1 patient), which is highly statistically significant (p < 0.01). Five years survival time of the first group was 41% and of the second group 63% (p < 0.05). - Conclusion: Autologous blood transfusion yields clinically superzor results for hepatectomy in patients with cirrhosis and comeared with homologous blood transfusion.
• PROPHYLACTIC SCLEROTHERAPY IN HIGH-RISK CIRRHOTICS SELECTED BY ENDOSCOPIC AND HEMODYNAMICCRITERIA A SECOND PROSPECTIVE CONTROLLED RANDOMIZED TRIAL K.-J. Paquet, J.-F. Kalk, C.-P. Klein, Dept. of Surgery and Medicine, HEINZ-KALK-Hospital, Am Gradierbau 3, 0-97688 Bad Kissingen, Germany Although the f i r s t variceal bleeding in patients with l i v e r c i r r h o s i s has an extremely high m o r t a l i t y rate, prophylaxis is a matter of controversy. Thirteen controlled t r i a l s of sclerotherspy f o r the prevention of the f i r s t variceal hemorrhage in c i r r h o t i c s have given c o n f l i c t e d results although the f i r s t two w e r e p o s i t i v e . Main reasons were d i f f e r e n t patients" populations and d i f f e r e n t selection c r i t e r i a . Therefore, we designed a new study in which 89 from 396 investigated patients a f t e r endoscopic and hemodynamic selection were randomised either to sclerotherapy (44 patients) or control (45 patients). Admission criteria were no history of variceal bleeding, the presence of high risk varices, i.e. varices degree III and IV with minivarices on their top and a portal pressure over 16mmHg. Sclerotherapy sessions were performed at time d, 7, 14, 21, 28 days, until the vsrices were reduced at least for two degrees in size end completely covered by fibrous tissue. Follow-up endoscopy was performed at four and thereafter at six month intervals. Control patients underwent repeated clinical investigation and endoscopy at s i x months intervals. Bleeding episodes were treated by emergency sclerotherapy (EES) in both groups, whenever possible. Mean follow-up WaS 33 months. Analysis of the results were performed by Students" T- and Longrank test. Variceal bleeding occured in 12 sclerotherapy patients (27.3%) and 33 controls (73.3%) (p < 0.01). Overall-mortality was 31.8% in sclerotherapy patients end 68.9% in controls (p < 0.01). PES was able to prolong survival in CHILD class A and B but not in C. It is concluded, that PES does reduce the incidence of first vsriceal bleeding in cirrhotics and is able to prolong survival in patients with good liver function if only high risk patients are selected and PES is performed by endoscopic experts.
AASLD A l 1 4 3
• PROGNOSIS OF UNILOCULAR HEPATOCELLULAR CARCINOMA (HCC) IN CIRRHOTIC LIVERS AFTER RESECTION AND TREATMENT OF CONCOMITANT VARICEAL HEMORRHAGE BY TWO DIFFERENT MODALITIES A PROSPECTIVE STUDY Paquet K.-d., Lazar A., Kalk d.-Fr., Dept. of Surgery and Vascular Surgery, Medicine and GastroenterologyHEINZ KALK-Hospitel, Am Gradierbsu 3, D-97688 Bad Kissingen, Germany Repeated ultrasound examination of the liver and determination of serum-alpha-fetoproteine have led to detection of increasing number of small HCC in pet. with cirrhosis. Resection of HCC is currently the only hope for long-term survival. It could be shown by our group (Br J Surg 78:459-62, 1991) that resection of unilocular HCC is possible with an acceptable risk, and able to improve survival. Is this also true for patients with additional portal hypertension (PH) and recurrent vsriceal hemorrhage? Is their prognosis limited and influenced by different treatment modalities like endoscopic sclerotherapy (ES) or surgery? From Jan. 1, 1982~to Jan. 1, 1994 in 157 (14%) of 9S5 regular screened pat. with liver cirrhosis 30 (19.1%) were selected for surgery according to the above mentioned criteria: 10 pay. (33%) (group I) had no PH or of minor degree with esophageal varices degree I-II (Endoscopy 14:4-5,1982); 20 pat. (66%) had one or recurrent or uncontrollable variceal bleeding ; the pat. with one variceal hemorrhage were managed by ES (group II:lO pat.); the remaining pat. with recurrent or uncontrollable hemorrhage in spite of short or long-term ES were treated by emergent devassularisation procedure (DP) (2) or elective distal splenorenal (DSRS) (3) or narrow-lumen mesocaval shunt (NLMCS) (5) (group III). There were no~aignificant differences in hospital mortality (13%), early and long-term survival (70-80%) after one year and 45-55% after five Years). This prosp, study demonstrates that hepatic resection in selected cirrhotic pat. with HCC is possible with low risk and able to improve survival; PR with va÷iceal bleeding (VS) doesn't enlarge the risk or worsen the prognosis. Current treatment modelities of VB are ES (first step); in case of uncontrollable devascularisation procedure or TIPS and of recurrent hemorrhage managedsuccessfully by ES, elective DSRS or NLMCS are the best treatment modalities.
PERCUTANEOUS FINE NEEDLE ASPIRATION BIOPSY (FNAB) OF FOCAL HEPATIC LESIONS - DIAGNOSTIC UTILITY AND PREPROCEDURE PREDICTORS. DN Parkin, RL Hope, SJ Williams, M Greenberg, JM Little, and C Liddle. Departments of Gastroenterology & Hepatotogy, Cytology and Surgery, Westmead Hospital, Australia. Between Jan. 199i and Dec. 1993, 120 pts {67M, 53F; median age 63 yrs (range 11-86)} undergoing FNAB of focal hepatic lesions were analysed to assess the diagnostic utility in malignant and benign conditions and to describe any predictors of diagnosis or complications. Pre-FNAB investigations included LFTs, aFP, CEA, platelet and coagulation profile. Vascularity of the lesion using RBC scanning &/or angiography was assessed when appropriate. FNAB was performed under CT control in 99 (82.5%) and US in 15 (12.4%) and cytological assessment was immediate. The median number of passes was 3 (range 1-8). RESULTS: The'overall diagnostic rate of FNAB was 75.8% (91/120). The Table shows the final cytological diagnosis vs the presumed diagnosis. CYTOLOGICAL DIAGNOSIS Presumed Dx. Malignant HCC Benign Non Dx'ic Malignancy (n=87) 65 (75%) 1(1%) 2 (2%) 19(22%) HCC (n=17) 4 (24%) 9 (53%) 1(5%) 3 (18%) Benign (n=16) 2 (12%) 7 (44%) 7 (44%) In pts with presumed malignancy (non-HCC) FNAB was confirmatory in 65 (75%). A further 3 pts (3.4%) had other diagnostic cytology; 19 pts (21~8%) had non diagnostic cytology. Cytology was diagnostic in 14 (82.3%) with presumed HCC (confirming HCC in 9 [52.9%]). For presumed benign lesions the diagnostic rate was 56.3% (9/16). In 29 pts where FNAB was not helpful, 15 (51.7%) had +ve tissue diagnosis on further investigation. 7 pts were treated presumptively for metastatic disease without tissue diagnosis. The diagnostic rate did not alter between US. & CT guided FNAB, number of hepatic lesions or number of FNAB passes performed. Logistic regression analysis demonstrated ALP (p = 0.004) & number of lesions (p=0.016) to significantly predict malignancy (non HCC)'. Non significant predictors included age, previous history of malignancy, bilil GGT, ALT & CEA. There were no statistically significant predictors of HCC including aFP: Minimal complications occurred in 4 pts (3.3%) including pain in 3 & cough in 1. Age & wt approached significance as predictors of complication. CONCLUSIONS: 1. FNAB is a safe & reliable method of tissue diagnosis for focal hepatic lesions, particularly ifi those thought to have malignant disease. It is less 'sensitive' for presumed benign disease. 2. Increased ALP & number, of lesions are predictive of a positive cytological diagnosis of malignancy. '.