Abstract
The role of hepatic fine-needle aspiration (FNA) biopsy has evolved. Advances in imaging modalities have obviated the need for tissue confirmation in most hepatocellular carcinomas (HCCs). There is risk of needle-tract seeding. Increasingly, small nodules are being detected on ultrasound surveillance of high-risk patients. Diagnostic challenges associated with cirrhosis include distinction of benign hepatocellular nodules, namely, large regenerative nodules and dysplastic nodules, from reactive hepatocytes; and distinction of well-differentiated HCCs from benign hepatocellular nodules. This paper will discuss (i) controversies regarding preoperative/pretransplantation FNA diagnosis of HCC, (ii) update of biological evolution, nomenclature, and histopathologic criteria for diagnosis of precancerous nodules and small HCCs, and (iii) algorithmic approach to FNA diagnosis of hepatocellular nodules. Optimal results depend on dedicated radiologist-cytopathologist team, on-site cytology service; combined cytohistologic approach, immunohistochemistry, and clinicopathologic correlation. Hepatic FNA is likely to be incorporated as a point of care as we move towards personalized medicine.
Highlights
The incidence of hepatocellular carcinoma (HCC) has risen as a result of increased global burden of chronic liver disease due to hepatitis B and C virus infections, aflatoxin B1, alcoholism, and nonalcoholic fatty liver disease/nonalcoholic steatohepatitis associated with the metabolic syndrome
The natural history in high-risk patients is the occurrence of dysplastic foci in a cirrhotic background from which precancerous dysplastic nodules may ensue with some transforming to become HCC [2, 3]
Much progress has been achieved over the years with regard to detection/screening, diagnosis, surveillance, and multimodal treatment approaches leading to improvement in prognosis of HCC [4, 5]
Summary
The incidence of hepatocellular carcinoma (HCC) has risen as a result of increased global burden of chronic liver disease due to hepatitis B and C virus infections, aflatoxin B1, alcoholism, and nonalcoholic fatty liver disease/nonalcoholic steatohepatitis associated with the metabolic syndrome. A coaxial technique allows multiple samples to be obtained without repeated placement of the needle; potentially reducing the risk of needletract seeding This approach helps to reduce the number of inadequate biopsies and is preferred for small and distant lesions. Despite a potential bias due to sampling errors, FNA biopsy might help identify patients having well-differentiated HCCs with low risk of vascular invasion and good prognosis after transplantation. Much research is being done in genomics and proteomics to determine the molecular signatures of HCCs. With the advent of molecular testing for better clinical tools for screening, diagnosis, surveillance, prediction of efficacy of treatment, monitoring of response, prognostication, and for rational targeted therapies, it is foreseen that FNA biopsy will be the most minimally invasive technique available to obtain samples of tumor and peritumoral tissues for molecular profiling [5, 6]. In developing/less developed countries where patients tend to present with more advanced disease, the practice of percutaneous US-guided FNA is still popular due to cost effectiveness, nonavailability of state-ofthe-art imaging technologies, limited treatment options, and individual preference and expertise
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