A new study supports exhausting noninvasive methods to diagnose hepatocellular carcinoma (HCC) before attempting biopsy. In an analysis of data from the National Cancer Database, overall survival (OS) was lower in HCC patients who underwent preoperative tissue diagnosis compared with those with a clinical diagnosis.
“Preoperative tissue diagnosis of HCC is associated with decreased overall survival in patients in this national cohort,” said Fadi Dahdaleh, MD, a cancer surgeon and clinical assistant professor of surgery at Edward-Elmhurst Health, in Chicago, who presented the study at the 2020 annual meeting of the Society of Surgical Oncology (abstract 63).
A primary hepatic malignancy that typically arises in the setting of chronic liver disease, HCC has a characteristic radiographic appearance on contrast-enhanced imaging, with a predominant arterial blood supply that enables noninvasive diagnosis in high-risk subjects. The American College of Radiologists uses the Liver Imaging Reporting and Data System (LI-RADS) for standardized reporting. Specificity of clinical diagnosis using LI-RADS is over 90% in higher-risk patient populations, rendering biopsy unnecessary for many.
Noting that “tumor dissemination along the needle tract is a well-documented phenomenon estimated to occur in 2.5% to 10% of cases,” Dahdaleh said that when seeding occurs, the chest wall and peritoneal recurrences may arise. Thus, tissue diagnosis can convert localized to disseminated disease, he said.
In the new study, researchers hypothesized that tissue diagnosis confirming HCC would confer inferior OS. To assess this, the investigators conducted a retrospective case–control, propensity score–matched analysis of the National Cancer Database. Patients were included if they were older than 18, had a pathologic diagnosis of HCC, and were treated with major hepatic resection or transplantation. Patients were excluded if they had alternative diagnostic testing such as surgical exploration or open/laparoscopic surgical biopsies, underwent inadequate resections or had missing information about chemotherapy or radiation. The primary outcome was OS from the time of HCC diagnosis.
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Of 172,283 cases identified between 2006 and 2015, 16,366 met the inclusion criteria. Overall, 12,100 (73.9%) were men and the mean age was 66.8 years. Curative procedures were divided equally between hepatectomies and transplantation (48.4% and 51.6%, respectively). The researchers found that 70.4% of cases had a clinical diagnosis and 29.6% underwent tissue diagnosis. After matching, 4,251 patients were selected from each group. Patients who underwent tissue diagnosis had decreased OS compared with the clinical diagnosis group (median, 121.76 vs. 63.38 months, respectively; P<0.001). Similarly, five-year survival was lower in the tissue diagnosis group (median, 68.2% vs. 51.6%; P<0.001). The OS advantage with clinical diagnosis persisted after matching (85.6 vs. 65.5 months; P<0.001) and so did five-year survival (60.9% vs. 47.6%; P<0.001). In a stratified analysis among patients who had transplantation, survival advantage persisted with clinical diagnosis (mean, 89.4 months in the tissue diagnosis group vs. 100.28 months in the clinical diagnosis group; P<0.001).
“The effect of tissue diagnosis was maintained after propensity-matching for factors known to impact biopsy method and survival in patients with HCC including age, Charlson score, tumor size and lymphovascular invasion,” Dahdaleh said. “Those findings suggest biopsy [should be avoided] whenever possible.”
Dahdaleh said the study was limited in that it was a retrospective analysis, which was inherently susceptible to selection and observational biases, and the National Cancer Database did not include important end points such as recurrence patterns and disease-free survival.
“This study is certainly informative for clinical practice and reaffirms how many practice,” said Laleh Melstrom, MD, an assistant professor of surgery and immuno-oncology at City of Hope National Medical Center, in Duarte, Calif. “If a lesion meets clinical and imaging characteristics most clinicians that take care of patients with HCC do not pursue a biopsy. This is a well-established tenet of care, and it is excellent that these investigators were able to demonstrate an association with survival.”
在2006年至2015年间确定的172283例病例中，有16366例符合纳入标准。总体而言，男性为12,100（73.9％），平均年龄为66.8岁。肝切除和移植之间的治疗方法均分（分别为48.4％和51.6％）。研究人员发现，有70.4％的病例具有临床诊断，有29.6％的组织进行了诊断。匹配后，从每组中选出4,251名患者。与临床诊断组相比，接受组织诊断的患者的OS降低（中位值分别为121.76和63.38个月； P <0.001）。同样，组织诊断组的五年生存率较低（中位数，分别为68.2％和51.6％； P <0.001）。匹配后仍具有临床诊断的OS优势（85.6 vs. 65.5个月； P <0.001），五年生存期也如此（60.9％vs. 47.6％； P <0.001）。在接受移植的患者中进行分层分析后，临床诊断仍具有生存优势（组织诊断组平均89.4个月，临床诊断组平均100.28个月； P <0.001）。