避免在肝细胞癌中进行活检

StephenW

Avoiding Biopsy in Hepatocellular Carcinoma

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.”

—Kate O’Rourke

StephenW

避免在肝细胞癌中进行活检

一项新的研究支持尝试进行活检之前用尽无创的无创方法来诊断肝细胞癌（HCC）。根据国家癌症数据库的数据分析，接受术前组织诊断的HCC患者的总生存率（OS）低于进行临床诊断的患者。

“在这个国家队列中，术前组织性肝癌的诊断与患者总体生存率降低有关，”位于芝加哥的爱德华·埃尔姆赫斯特健康中心的癌症外科医师，外科临床助理教授法迪·达达莱德医学博士说。外科肿瘤学会2020年年会（摘要63）。

HCC是一种典型的原发性肝恶性肿瘤，通常发生在慢性肝病的背景下，在对比增强成像中具有特征性的放射影像学表现，主要的动脉血供能够在高危受试者中进行无创诊断。美国放射科学院使用肝脏成像报告和数据系统（LI-RADS）进行标准化报告。在高危患者人群中，使用LI-RADS进行临床诊断的特异性超过90％，因此许多人无需进行活检。

Dahdaleh指出，“沿针道的肿瘤扩散是一个有据可查的现象，估计在2.5％到10％的病例中会发生”，Dahdaleh说，播种时可能会出现胸壁和腹膜复发。因此，组织诊断可以将局部疾病转化为散播疾病。

在这项新研究中，研究人员假设组织诊断证实肝癌会导致较差的OS。为了评估这一点，研究人员对美国国家癌症数据库进行了病例对照，倾向评分匹配的回顾性分析。如果患者年龄大于18岁，具有HCC的病理诊断，并接受了大范围肝切除或移植治疗，则将其包括在内。如果患者接受其他诊断性检查（例如手术探查或开腹/腹腔镜手术活检），切除不充分或缺少有关化学疗法或放射线的信息，则将其排除在外。主要结果是从HCC诊断开始的OS。
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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）。

Dahdaleh说：“在对可能影响肝癌患者活检方法和生存的因素进行倾向匹配后，可以维持组织诊断的效果，包括年龄，查尔森评分，肿瘤大小和淋巴管浸润，” “这些发现表明，应尽可能[避免]活检。”

Dahdaleh说，这项研究是有限的，因为它是一项回顾性分析，它固有地容易受到选择和观察偏见的影响，而且国家癌症数据库不包括重要的终点，如复发模式和无病生存。

加利福尼亚杜阿特市霍普国家医疗中心的外科和免疫肿瘤学助理教授Laleh Melstrom医学博士说：“这项研究肯定对临床实践具有指导意义，并重申了多少实践。如果病变符合临床和影像学特征大多数照顾HCC患者的临床医生不进行活检。这是行之有效的护理宗旨，而且这些研究人员能够证明与生存的关联非常好。”

凯特·奥罗克

hbv30year

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