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发表于 2004-8-24 02:24
Focal Liver Lesions
The differential diagnosis of focal liver lesions includes a broad spectrum
of benign, malignant, and infectious aetiologies. Age, gender, use of oral
contraceptives, presence of cirrhosis, travel history, fever, and presence
of extrahepatic malignancy help narrow the differential diagnosis.
Radiological studies are often diagnostic, and tumour markers may support a
suspected diagnosis. Although radiological-guided biopsy is at times needed,
biopsy may carry risks of bleeding and needle-track seeding.
Biopsy of focal liver lesions is often not necessary. Most focal liver
lesions have characteristic findings on CT or MRI. For example, cavernous
haemangiomas may have peripheral feeders with the same attenuation as the
aorta. Focal nodular hyperplasia may demonstrate a focal enhancement of a
central scar during arterial phase.[63] Confident characterization by
imaging can obviate the need for biopsy. Furthermore, biopsy is often
non-diagnostic for hepatic adenomas and focal nodular hyperplasia. Biopsy of
hepatic adenomas, focal nodular hyperplasia, and haemangiomas also carries
an increased bleeding risk.[64] One group of investigators studied 160
patients referred for the evaluation of focal liver lesions. Preoperative
fine needle biopsy of the lesions was not performed. Patients subsequently
underwent surgery, and in 98% of cases the preoperative diagnosis was
confirmed.[65]
In some cases imaging is not conclusive, and the patient may need to undergo
surgical resection for definitive diagnosis. For example, if imaging cannot
distinguish between focal nodular hyperplasia and hepatic adenoma, surgical
resection could be performed. Resection would prevent cancer and
catastrophic bleeding, which could develop if the lesion were a hepatic
adenoma. Fine needle biopsy may be avoided because of the likelihood of a
non-diagnostic result and the risk of bleeding.
The occurrence of a focal liver lesion in a cirrhotic is suspicious for
hepatocellular carcinoma. Among cirrhotics the sensitivity of fine needle
biopsy has been shown to be between 86 and 90% for the detection of
hepatocellular carcinoma. The accuracy of diagnosis is influenced by nodule
location and size. Biopsy is more sensitive for lesions over 3 cm.[66-68]
Non-invasive methods of diagnosing hepatocellular carcinoma include tumour
markers and radiological studies. Although a-fetoprotein is normal in up to
40% of patients with hepatocellular carcinoma, a significantly elevated
value can confirm the diagnosis. For example, one study of cirrhotic
patients, 170 of whom were diagnosed with hepatocellular carcinoma, showed
that an a-fetoprotein of 200 ng/mL had a 99% specificity for hepatocellular
carcinoma. Lower elevations in a-fetoprotein had lower specificity.[69]
Other diagnostic markers including des-?-carboxy prothrombin, are under
study. Cross-sectional imaging has shown excellent diagnostic accuracy in
defining the presence of hepatocellular carcinoma. One study showed that CT
had 86-89% sensitivity and 99% specificity for identifying hepatocellular
carcinoma.[70]
In recent years investigators have determined that biopsy of hepatocellular
carcinomas carries a significant risk of needle-track seeding
(1.6-5%).[66,67,71] The occurrence of needle-track seeding has provided
impetus for defining conditions in which biopsy may be avoided. An
a-fetoprotein over 200 ng/mL or features suggestive of hepatocellular
carcinoma on CT or MRI is over 99% specific for the presence of
hepatocellular carcinoma. A recent consensus guideline suggests that
hepatocellular carcinoma may be diagnosed without biopsy if a characteristic
mass >2 cm in a cirrhotic liver is detected by two imaging techniques (out
of ultrasound, CT and MRI). Elevated a-fetoprotein (over 400 ng/mL) may also
confirm the diagnosis.[72] At our institution, fine-needle liver biopsy of
suspected hepatocellular carcinoma is generally reserved for patients in
whom no definitive surgical intervention is planned. Biopsy is obtained at
the time of non-surgical treatment (radiofrequency ablation, alcohol
ablation, or chemoembolization).
Conclusions
Liver biopsy is commonly performed to diagnose liver disease, prognosticate,
and help to determine treatment. In hepatitis C, liver biopsy plays an
important role in staging and grading the extent of disease and predicting
disease progression. Often the severity of liver disease seen on biopsy is
the key determinant to whether a patient will undergo a treatment which is
long in duration, has a limited chance for success, and carries a high rate
of side-effects. An important exception is the patient with genotype 2 or 3,
who may be willing to accept treatment regardless of findings on liver
biopsy because treatment is shorter in duration and more likely to succeed.
For hepatitis B, liver biopsy does give some prognostic information, but
hepatitis B serologies and hepatic biochemical tests are the primary
determinants of treatment candidacy and response. NAFLD can be accurately
diagnosed without a liver biopsy, although liver biopsy can provide
important prognostic information. Because there is no proven treatment for
NAFLD, liver biopsy does not generally influence treatment recommendations
outside of research studies. In some cases advanced findings on biopsy may
motivate some patients to consider investigational drugs and pursue risk
factor modification. There is a difference of opinion between the
rheumatology and dermatology literature regarding the use of liver biopsy to
assess for methotrexate-induced hepatotoxicity. Until the controversy is
resolved, it would seem reasonable to perform a liver biopsy in selected
patients who have risk factors for chronic liver disease and persistent
elevations of transaminases and are on chronic methotrexate therapy.
Finally, patients with focal liver lesions usually do not require biopsy,
and biopsy of hepatocellular carcinoma carries a risk of needle-track
seeding. In short, the role of liver biopsy depends on the specific
situation. It should be undertaken when a physician and patient feel that a
biopsy would help to clarify situations where there is sufficient
uncertainty about diagnosis, severity of disease, prognosis and treatment
decisions.
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Funding Information
No financial support was required for this study.
Reprint Address
Correspondence to: Professor K.R. Reddy, Hospital of the University of
Pennsylvania, Division of Gastroenterology, 3 Ravdin, 3400 Spruce Street,
Philadelphia, PA 19104, USA. E-mail: [email protected]
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