Small angiomyolipoma of the liver diagnosed by fine-needle aspiration biopsy under ultrasound guidance

The first reported case of small hepatic angiomyolipoma to be diagnosed by fine-needle aspiration biopsy (FNAB) is described. A 53 year old man presented with a tumour in segment VI of the liver measuring 0.9 × 0.8 cm. The tumour was hyperechoic on ultrasound examination, showed relatively low density (+ 33 Hounsfield units) on computed tomography (CT), and was hypervascular on angiography. Computed tomography during arterial portography demonstrated a perfusion defect. Magnetic resonance imaging (MRI) revealed high intensity by both T1- and T2-weighted imaging. Diagnosis could not be obtained by these imaging modalities, but it was established successfully by FNAB under ultrasound guidance. Histologically, the tumour was an angiomyolipoma made up of three components: blood vessels, smooth muscle and fatty tissue. Surgery is unnecessary for this benign condition, and the patient has been followed up. Ten months later, the patient is currently doing well without growth of the hepatic angiomyolipoma.     

Clonality of large regenerative nodules in liver cirrhosis

Abstract: The role of the large regenerative nodule (RN) in hepatocarcinogenesis is not clear, although the incidence of hepatocellular carcinoma (HCC) is high in cirrhotic liver. This study was aimed at clarifying the preneoplastic nature of large RN without atypia. We analyzed the clonality of HCCs and large RNs, ranging in size from 0.6 to 1.2 cm, of cirrhotic liver by X-linked human androgen receptor (HUMARA) gene assay, using the principle of random X chromosome methylation and inactivation in females. Eleven cases of HCC and five cases of large RN without atypia from ten female patients were selected. All HCCs, large RNs and paired non-tumorous tissue from adjacent liver were selectively microdissected from deparaffinized hematoxylin and eosin stained slides. Genomic DNA was isolated and digested with Hha I. Polymerase chain reaction (PCR) amplification of the HUMARA gene was performed using a PCR mixture containing [α-³²P]-dCTP. The PCR products were separated by gel electrophoresis and analysed by autoradiography. HUMARA was informative in nine out of ten female patients. In the informative 10 HCCs from nine patients, 9 HCCs were monoclonal and one case was polyclonal. The HCC case that showed polyclonality contained many inflammatory cells in the tumor. All of the large RNs were polyclonal. No allelic loss of chromosome 18q was present in the large RNs in constrast to the 3 out of 7 HCCs, which showed allelic deletion in chromosome 18q. We conclude that all or most of the cells composing the large RNs without atypia are polyclonal and the size of a nodule may not be important in hepatocarcinogenesis. This clonality assay may be informative for the differentiation between regenerative and preneoplastic nodules in cirrhotic liver.     

Contrast-enhanced ultrasound in the diagnosis of nodules in liver cirrhosis

Contrast-enhanced ultrasound(CEUS)using microbubble contrast agents are useful for the diagnosis of the nodules in liver cirrhosis.CEUS can be used as a problem-solving method for indeterminate nodules on computed tomography(CT)or magnetic resonance imaging(MRI)or as an initial diagnostic test for small newly detected liver nodules.CEUS has unique advantages over CT and MRI including no renal excretion of contrast,real-time imaging capability,and purely intravascular contrast.Hepatocellular carcinoma(HCC)is characterized by arterial-phase hypervascularity and later washout(negative enhancement).Benign nodules such as regenerative nodules or dysplastic nodules are usually isoechoic or slightly hypoechoic in the arterial phase and isoechoic in the late phase.However,there are occasional HCC lesions with atypical enhancement including hypovascular HCC and hypervascular HCC without washout.Cholangiocarcinomas are infrequently detected during HCC surveillance and mostly show rimlike or diffuse hypervascularity followed by rapid washout.Hemangiomas are often found at HCC surveillance and are easily diagnosed by CEUS.CEUS can be effectively used in the diagnostic work-up of small nodules detected at HCC surveillance.CEUS is also useful to differentiate malignant and benign venous thrombosis and to guide and monitor the local ablation therapy for HCC.     

112例代偿性肝硬化患者超声影像与肝穿病理结果关系的探讨

探讨代偿性肝硬化患者超声检测结果与肝脏穿刺病理结果之间的关系,回顾性分析112例临床确诊为代偿性肝硬化患者的超声检测的肝脏形态、回声结果及肝脏活组织穿刺的病理结果。超声诊断代偿性肝硬化患者78例,占69．64％,肝穿诊断代偿性肝硬化65例,占58．03％,超声与肝穿均诊断为肝硬化者54例,占48．21％。超声检查无创、方便,诊断代偿性肝硬化准确性较高,可作为早期诊断代偿性肝硬化的一种重要的辅助方法。     

Diagnosis of small hepatic nodules detected by surveillance ultrasound in patients with cirrhosis: Comparison between contrast-enhanced ultrasound and contrast-enhanced helical computed tomography.

Aim: To investigate the diagnostic value for the diagnosis of small (1-2 cm) hepatic nodules detected by surveillance ultrasound in patients with cirrhosis using contrast-enhanced ultrasound (CEUS) compared with that of contrast-enhanced helical computed tomography (CECT). Methods: Seventy-two liver cirrhosis patients with 103 small hepatic nodules (1-2 cm) detected by surveillance ultrasound were enrolled in the present study. All patients underwent CEUS with SonoVue as well as CECT. Nodules which appeared by contrast enhancement during the arterial phase and contrast wash-out during the late phase on CEUS or CECT were diagnosed as malignant (hepatocellular carcinoma [HCC]). Histopathology obtained from biopsy or surgery served as the gold standard. Results: According to the above diagnostic criteria, the sensitivity (i.e. rate of correct diagnosis of HCC) was 91.1% (51/56 HCC) for CEUS and the specificity (i.e. the rate of correct exclusion of HCC) was 87.2% (41/47 regenerative nodules [RN]).Therefore, the diagnostic accuracy of CEUS was 89.3% (92/103 all nodules). Using the same diagnostic criteria, the sensitivity, specificity and accuracy of CECT were 80.4% (45/56 HCC), 97.9% (46/47 RN), and 88.4% (91/103 all nodules). Overall, there was no significant difference between CEUS and CECT in the diagnostic confidence of small hepatic nodules. Eighty-six nodules (45 HCC and 41 RN) were correctly diagnosed by both modalities and six (five HCC and one RN) were misdiagnosed by both. Conclusion: The ability of CEUS in the characterization of small nodules (1-2 cm) detected by surveillance US in patients with liver cirrhosis is similar to that of CECT.     

Space-occupying lesions of the liver detected by ultrasonography and their relation to hepatocellular carcinoma in cirrhosis

Abstract: Fifty-four patients with cirrhosis, found to have a space-occupying lesion in the liver by ultrasound (US), underwent US-assisted biopsy of the lesion and were then followed prospectively to define outcome and survival. Histologic examination revealed hepatocellular carcinoma in 26 patients, while five had liver cell dysplasia without hepatocellular carcinoma and 23 had no evidence of tumor or of dysplasia. All five patients with an initial diagnosis of dysplasia developed hepatocellular carcinoma during follow-up and their survival curve was similar to that of patients with liver cancer and significantly worse than that of patients without dysplasia or tumor. There were five false-negative cases of hepatocellular carcinoma among the patients with negative histology. Overall, US-assisted liver biopsy diagnosed malignancy with a sensitivity of 72%, which increased to 86% when dysplasia was considered a pre-neoplastic lesion.     

Portal vein thrombosis complicating hepatocellular carcinoma. Value of ultrasound-guided fine-needle biopsy of the thrombus in the therapeutic management

Abstract: During a 4-year period portal vein thrombosis was diagnosed in 20 Child class A patients with cirrhosis by means of ultrasound and ultrasound-Doppler study. Seventeen of them showed single or multiple focal liver lesions diagnosed as hepatocellular carcinoma by ultrasound-guided fine-needle biopsy and the remaining three a coarse liver echo-pattern without focal lesions. One patient was found to have developed portal vein thrombosis after the fifth ethanol injection of a single hepatocellular carcinoma lesion 17 mm in diameter. Ultrasound-guided fine-needle biopsy of the thrombus was performed on all the patients: portal vein thrombosis was neoplastic in 13 cases and non-neoplastic in seven cases (five patients with a single lesion; one with two lesions; one with coarse liver echo-pattern). Among the five patients with a single lesion, one had already been treated by percutaneous ethanol injection therapy. There were no complications related to the biopsy procedures. The diagnosis of non-neoplastic thrombosis allowed five new patients to be recruited for percutaneous ethanol injection treatment and allowed it to continue in the patient with portal vein thrombosis occurring after the fifth ethanol injection. The routine use of ultrasound-guided fine-needle biopsy of portal vein thrombosis yields an accurate diagnosis of the nature of the thrombus and can improve the selection for percutaneous ethanol injection treatment of patients with cirrhosis with hepatocellular carcinoma lesions.     

超声造影灌注时相分析在肝硬化背景下对肝脏增生结节的诊断价值

目的 探讨超声造影(CEUS)灌注时相分析在肝硬化背景下对肝脏增生结节的诊断价值.方法 2017年6月～2020年6月我院诊治的肝硬化患者100例,均接受CEUS检查,获得超声造影定量参数,包括造影峰值强度(Peak)、达峰时间(TTP)和平均度越时间(MTT),记录两组局部血容量(RBV)和局部血流量(RBF)水平....     

Guidelines for imaging focal lesions in liver cirrhosis

Imaging cirrhotic patients for early detection of hepatocellular carcinoma remains a challenging issue despite many technological advances. In fact, nonmalignant hepatocellular lesions, such as regenerative or dysplastic nodules, may mimic a small tumor. Imaging protocols are aimed at showing the different vascular supply to the lesion. It is accepted that dynamic contrast-enhanced imaging techniques, including contrast ultrasound, multidetector computed tomography and magnetic resonance imaging, can establish the diagnosis of hepatocellular carcinoma in nodular lesions larger than 1 cm showing arterial hypervascularization with venous washout. Magnetic resonance imaging in combination with liver-specific contrast agents, including hepatocyte-targeted and reticuloendothelial system-targeted agents, may be useful to clarify questionable cases, due to its ability to show changes in hepatobiliary function or Kuppfer cell content associated with malignancy. However, even optimized imaging techniques remain relatively insensitive for the detection of tiny satellite nodules associated with the main tumor.     

老年甲状腺结节382例细针穿刺活检临床病理分析

目的 分析老年甲状腺结节细针穿刺活检（FNAB）临床病理特点。方法 回顾性分析2005年5月至2011年10月于中日友好医院行FNAB的382例老年患者的临床病理资料。细胞病理诊断按美国甲状腺细胞病理学贝塞斯达报告系统6（BSTC6）分类标准进行归类统计。临床资料包括患者年龄、性别、甲状腺功能检查以及甲状腺超声检查结果等。结果 382例行FNAB的患者中无法诊断占14.7%（56/382）,良性病变占71.7%（274/382）,意义不明确的非典型病变/滤泡性病变占3.4%（13/382）,滤泡性肿瘤占4.7%（18/382）,可疑恶性肿瘤占2.1%（8/382）,恶性肿瘤占3.4%（13/382）。382例FNAB患者中有355例检查甲状腺功能,甲状腺功能正常占70.1%（249/355）,甲状腺功能异常占29.9%（106/355）。结论 老年甲状腺结节患者以良性病变为主,术前行FNAB可避免良性结节的手术治疗。老年甲状腺结节患者甲状腺功能异常比例高,对老年甲状腺结节患者检测甲状腺功能非常重要。     

Juvenile hepatocellular carcinoma with congestive liver cirrhosis

A case of juvenile hepatocellular carcinoma (HCC) with congestive liver cirrhosis is reported. The patient was a 21-year-old woman. She had been diagnosed as having transposition of the great arteries, type 2, in 1978. She underwent the Mustard operation, but suffered from chronic heart failure. In 1995, she experienced abdominal pain and underwent examination. The laboratory data were normal, except for elevated total bilirubin (5.2mg/dl). Blood examinations were performed at frequent intervals, and the total bilirubin level fluctuated between 0.9 and 8.1mg/dl over the next 4 years, but the transaminase level remained normal. In 1999, she experienced abdominal pain again and was admitted to our hospital. Computed tomography showed four space-occupying lesions in the liver; 45mm, 20mm, 12mm, and 10mm in size. She was diagnosed as having HCC, and transcatheter arterial chemoembolization and percutaneous ethanol injection therapy were performed. Histology of the cancerous and the noncancerous liver tissue revealed HCC, moderately differentiated type, in cirrhotic liver with congestion. This patient had no background factors of liver disease, except for liver congestion, associated with the chronic heart failure. Because most patients with cardiac cirrhosis die of cardiac disease, only a small number of these patients develop liver failure. However, the incidence of HCC in patients with congestive liver disease is likely to increase in the future, as survival time is prolonged with the advances in treatment for chronic heart failure. Therefore, patients with congestive liver disease should be followed, taking into account the possibility of HCC.     

Differential diagnosis of nodular lesions in cirrhotic liver by post-vascular phase contrast-enhanced US with Levovist: comparison with superparamagnetic iron oxide magnetic resonance images

Background We investigated the diagnostic utility of post-vascular phase contrast-enhanced ultrasonography (US) and superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance imaging (MRI) as compared to the histological diagnosis of differential grades of hepatocellular carcinomas (HCCs). Methods Forty-nine patients with histologically characterized liver nodules (well-differentiated HCC, n = 20; moderately differentiated HCC, n = 19; poorly differentiated HCC, n = 1; dysplastic nodule, n = 9) received contrast-enhanced US and SPIO-MRI. Subsequently, we quantitatively evaluated the relationships between the images of the nodules and their histological diagnosis and differential grades. Results The ratio of the echogenicity of the tumorous area to that of the nontumorous area with post-vascular phase contrast-enhanced US (post-vascular phase ratio) decreased as nodules became less differentiated (P < 0.05; Kruskal-Wallis test). The ratio of the intensity of the nontumorous area to that of the tumorous area on SPIO-enhanced MR images (SPIO intensity index) also decreased as nodules became less differentiated (P < 0.01). The post-vascular phase ratio correlated with the SPIO intensity index for HCCs and dysplastic nodules (r = 0.76). The conformity of the result from the post-vascular phase contrast-enhanced US and SPIO-MRI was 96%. Conclusions Contrast-enhanced US is a valuable method for predicting the histological grade of HCCs in cirrhotic patients, and may be a good alternative to SPIO-enhanced MRI.     

Ultrasonography and alpha-fetoprotein in diagnosis of hepatocellular carcinoma in cirrhosis

The accuracy of ultrasound (US) and alpha-fetoprotein (AFP) in the diagnosis of hepatocellular carcinoma (HCC) in 363 patients with cirrhosis (C) and a clinical suspicion of HCC was assessed. The ultrasonographic patterns of HCC and their relationship with AFP values were analyzed. Echographic patterns were distributed as follows: 47 patients had sonodense lesions; 30 patients had hypoechoic lesions; 47 had mixed-pattern lesions, and in four patients focal dilated intrahepatic bile ducts were demonstrated. The sensitivity of US was 90%; specificity was 93.3%. Serum AFP level 500 ng/ml (RIA) was the first clue to the diagnosis in 71 patients (48.6%); specificity was 100%. In 28 patients AFP levels became significantly elevated during follow-up after US detection of HCC. No relationship between echo pattern and serum AFP levels was demonstrated. An algorithm for diagnosis of HCC is proposed.     

Diaphragmatic and subcutaneous seeding of hepatocellular carcinoma following fine-needle aspiration biopsy

ABSTRACT— Aims/Background: We report the discovery of associated metastatic subcutaneous and metastatic diaphragmatic nodules on the needle track after fine-needle biopsy aspiration under echography, which has not yet been reported in the literature. Methods: A 35-year-old man with non-replicating hepatitis B virus presented with a tumor that suggested hepatocarcinoma with cirrhosis. A diagnostic needle biopsy was carried out before surgery. Twelve months later, he presented with a series of four continuous metastatic diaphragmatic nodules on the inner wall lining the needle track. Surgery was performed, followed by external radiation (40 Gy). Conclusions: The risk of seeding following fine-needle biopsy aspiration of hepatocellular carcinoma can no longer be considered negligable. The real risk is probably underestimated. Even for biopsy of lesions localized to the inferior part of the liver, diaphragmatic seeding is possible. This seeding necessitates surgical resection, increasing the therapeutic morbidity of hepatocellular carcinomas. We believe that in cases where investigation of a small hepatic tumor suggests a hepatocellular carcinoma that could be resected, or for candidate patients for liver transplantation, one should not puncture the tumor. If this diagnostic biopsy is essential, then the needle track could be resected upon surgery, after cutaneous external tattooing.     

Surecut® 0.6 mm liver biopsy in the diagnosis of cirrhosis

Abstract— Liver biopsy with the 0.6 mm (23 gauge) Surecut® needle was compared to conventional Menghini biopsy in the diagnosis of cirrhosis. Seventy-seven consecutive patients (mainly alcoholics) with a clinical indication for liver biopsy had both biopsies performed simultaneously. In 71 patients sufficient material for a morphological diagnosis concerning liver architecture was obtained with both biopsy techniques (Surecut insufficient in 5 cases and Menghini insufficient in 2 cases). The biopsies were classified as cirrhosis or non-cirrhosis. There was agreement in 69 cases (97%, confidence limits 90–100%). Using the result of the Menghini biopsy as the final diagnosis, the predictive values for a positive and negative diagnosis for the Surecut needle were 96% and 98%, respectively. There were no complications to either of the biopsies. It is suggested that the 0.6 mm Surecut biopsy may be used in the diagnosis of cirrhosis in cases where conventional Menghini needle biopsy is contraindicated.     

肝癌、肝硬化患者淋巴细胞染色体着丝粒点结构的变化

目的 探讨染色体着丝粒点结构（Ｃｄ）的变化在肝癌发生过程的意义。方法 采用染色体Ｃｄ带技术检测２８例肝癌、２５例肝硬化及２６例正常人染色体Ｃｄ结构丢 失频率。结果 肝癌组Ｃｄ结构在总消失率、Ａ和Ｃ组染色体中明显高于肝硬化和正常对组（Ｐ〈０．０１）,在Ｄ、Ｅ组染色体中亦高于正常组（Ｐ〈０．０５）。结论 肝癌患者外周血细胞染色体Ｃｄ结构丢失在增高趋势,提示Ｃｄ结构消失率增加是引起肝癌细胞染色体非整倍性     

B超引导下自动活检枪肝穿对AFP阴性肝占位性病变的诊断

为了评价B超引导下自动活检枪肝穿对AFP阴性肝占位性病变的定性诊断价值,作者对52例AFP阴性肝占位性病变患者行B超引导下自动活检枪肝穿,组织病理学检查。结果,52例AFP阴性肝占位性病变中,经病理学证实,原发性肝癌23例(44.2%),其余病例亦各获得正确诊断。超声引导下自动活检枪肝穿刺对肝脏占位病变定性诊断安全、准确,具有很高的临床应用价值,可作为肝占位性病变的确诊技术。     

Small hepatic nodules (< or =2 cm) in cirrhosis patients: characterization with contrast-enhanced ultrasonography.

AIM: We evaluated the efficacy of contrast-enhanced ultrasonography (CEUS) for the characterization of small hepatic nodules (< or =2 cm) in cirrhosis patients. PATIENTS AND METHODS: Thirty cirrhosis patients with 30 hepatic nodules (1-2 cm) were enrolled in this study. Eighteen hepatic nodules were hepatocellular carcinomas (HCC) and 12 were benign lesions. CEUS was performed using microbubble contrast (Levovist). With surrounding hepatic parenchyma as a reference, two characteristics of hepatic nodules, including arterial phase enhancement (AE) and the absence of delayed phase enhancement (ADE), were evaluated as criteria for the diagnosis of HCC. A radiologist independently reviewed the dynamic computed tomographies (CT) of 26 hepatic nodules. RESULTS: CEUS showed AE in 15 nodules (13 HCC and two benign) and ADE in 17 lesions (14 HCC and three benign). For HCC, the coincidental AE of both CEUS and dynamic CT was 40%. Using both AE and ADE for HCC diagnosis, the sensitivity, specificity, accuracy, positive predictive value and negative predictive values were 55.6%, 91.7%, 70%, 90.9% and 57.9%, respectively. When using either AE or ADE for HCC diagnosis, the same parameters were 94.4%, 66.7%, 83.3%, 81% and 88.9%, respectively. One benign hepatic nodule with both AE and ADE was diagnosed as HCC 29 months after the CEUS study. CONCLUSIONS: A combination of characteristics of AE and ADE as determined by CEUS was highly specific for small HCCs in cirrhosis patients. Concurrent delayed phase imaging is useful in the diagnosis of small hypovascular HCCs.     

Multistep hepatocarcinogenesis from a dysplastic nodule to well-differentiated hepatocellular carcinoma in a patient with alcohol-related liver cirrhosis

We describe a rare case of the transformation of a dysplastic nodule into well-differentiated hepato- cellular carcinoma (HCC) in a 56-year-old man with alcoholrelated liver cirrhosis. Ultrasound (US) disclosed a 10 mm hypoechoic nodule and contrast enhanced US revealed a hypovascular nodule, both in segment seven. US-guided biopsy revealed a high-grade dysplastic nodule characterized by enhanced cellularity with a high N/C ratio, increased cytoplasmic eosinophilia, and slight cell atypia. One year later, the US pattern of the nodule changed from hypoechoic to hyperechoic without any change in size or hypovascularity. US-guided biopsy revealed well-differentiated HCC of the same features as shown in the first biopsy, but with additional pseudoglandular formation and moderate cell atypia. Moreover, immunohistochemical staining of cyclase- associated protein 2, a new molecular marker of well- differentiated HCC, turned positive. This is the first case of multistep hepatocarcinogenesis from a dysplastic nodule to well-differentiated HCC within one year in alcohol-related liver cirrhosis.