| Abstract|| |
This is a retrospective study of 40 patients clinically suspected of having hepatocellular carcinoma. Group 1 (20) patients underwent laparoscopic Tru-cut needle liver biopsy and Group II (20 patients) underwent percutaneous blind needle liver biopsy. In the first group, in 17 (85%) of the patients, the diagnosis of hepatocellular carcinoma was confirmed by histopathology, direct observation of cirrhosis was seen in 8 (40%) patients, histopathology confirmation of cirrhosis was documented in 6 (35%) patients. In the second group, 14 (70%) of the patients were confirmed to have hepatocellular carcinoma histopathologically and no patients confirmed to have cirrhosis. Both procedures were safe. While ascitic leak from the infraumbilical incision was the only complication encountered in the 1st group, no complications were encountered in the 2nd group. The results support the premise that laparoscopy directed cutting needle biopsy is superior over other techniques in fulfilling all the diagnostic requirements for hepatocelullar carcinoma and associated liver cirrhosis which is important for surgical liver resection.
|How to cite this article:|
Al-Saigh AH. Superiority of laparoscopic guided needle biopsy over percutaneous blind needle biopsy in diagnosing hepatocellular carcinoma associated with cirrhosis. Saudi J Gastroenterol 1998;4:96-100
|How to cite this URL:|
Al-Saigh AH. Superiority of laparoscopic guided needle biopsy over percutaneous blind needle biopsy in diagnosing hepatocellular carcinoma associated with cirrhosis. Saudi J Gastroenterol [serial online] 1998 [cited 2020 Jul 15];4:96-100. Available from: http://www.saudijgastro.com/text.asp?1998/4/2/96/33897
Histopathological diagnosis of hepatocellular carcinoma is not complete unless presence or absence of associated cirrhosis is established to evaluate prognosis and treatment, especially surgical resection  . This requires obtaining histologic specimen not only from the tumor but also from liver tissue away from the tumor. This is not possible by percutaneous "blind" needle biopsy. Use of ultrasound or CT scans "guided" techniques using the fine needle aspiration can yield diagnostic malignant cells but not enough tissue to diagnose cirrhosis , . This prompted us to review our experience with diagnostic laparoscopy using a large bore cutting needle (TRU-CUT R ).
| Patients and methods|| |
Twenty consecutive patients clinically suspected of hepatocellular carcinoma were studied restrospectively. All the laparoscopies were conducted by the author.
Technique of laparoscopy
Generally 1 cm. infraumbilical incision is chosen for the laparoscopic procedure. Laparoscopy has been carried out under local anesthesia in 12 patients who were expected to be cooperative and not very apprehensive and under general anesthesia in eight patients.
The insufflating veress needle was introduced through the infraumbilical incision. CO 2 is used to insufflate the abdomen to 12-15 rmnHg pressure. Standard laparoscopy was carried out using 30° telescope. The liver, the spleen and peritoneal surfaces were inspected for any lesions. Morphologic features of cirrhosis of liver were documented in the presence of nodularity of the surface and distended veins in the falciform ligament and around the stomach.
The lesion in the liver was localized (if apparent or as estimated by previous knowledge of ultrasonography or CT scan). A Tru-cut R needle was selectively introduced percutaneously to reach the lesion under direct laparoscopic observation. The location of the needle entry into the liver, the depth of the entry were judged by laparoscopic vision. The needle is withdrawn with a core of biopsy specimen.
Multiple biopsies were taken as needed from the tumor as well as tissue away from the tumor for assessment of cirrhosis of liver by the pathologist. Any other suspicious lesion outside the liver can also be biopsied through laparoscope.
The biopsy sites were carefully watched for twothree minutes after the needle was withdrawn each time. In case of excessive bleeding, cauterization and hemostasis was possible.
Percutaneous blind needle biopsy
Twenty consecutive patients clinically suspected of hepatocellular carcinoma were studied restrospectively. Biopsies were conducted by experienced gastroenterologists or senior physicians. All the biopsies were conducted using the blind technique at bedside with local anesthesia using Menghini R needle.
| Results|| |
Among the 20 patients who had undergone laparoscopy for clinical suspicion of hepatocellular carcinoma, 17 (85%) were confirmed by histopathology. Two others proved to be hemangiomas and one hydatid cyst. Clinically it was not possible to diagnose cirrhosis. However, eight of the 17 patients (40%) showed cirrhosis by morphologic features on the surface of the liver under vision. Six of them were proved by histopathology (35%).
Out of the 20 patients who had undergone percutaneous blind needle biopsy, hepatocellular carcinoma were confirmed in 14 (70%) patients. The six others underwent laparoscopy and were confirmed to have hepatocellular carcinoma [Table - 1]. None of the patients with hepatocellular carcinoma could be proven to have cirrhosis in the specimens taken from the tumor.
Laparoscopic liver biopsy specimens reported by pathologist were bigger in size, more complete, and less fragmented compared to percutaneous blind needle biopsy specimens, which is statistically significant [Table - 2].
| Discussion|| |
Laparoscopy has emerged as a highly accurate diagnostic tool for intraabdominal pathology ,, . Its use in the diagnosis of suspected intraabdominal tumor is well defined ,, . Laparoscopically guided fine needle aspiration for the diagnosis of hepatocellular carcinoma is considered safe and accurate  . The sensitivity, specificity and predictive values of these procedures are available in the literature , .
There is high incidence of hepatocelullar carcinoma in Saudi Arabia ,, . The prevalence of HbsAg is 8.3% in the Saudi population  . However, hepatocellular carcinoma occurs primarily in patients with chronic hepatitis B infection and cirrhosis. Chronic hepatitis C infections has also been recognized as a risk factor , . Traditional percutaneous blind needle biopsy and fine needle biopsy guided by ultrasound or CT readily yielded the diagnosis of hepatocellular carcinoma. However, these procedures failed to diagnose associated cirrhosis of the liver which is a major factor in the evaluation of prognosis and hepatic resections  .
The high yield of diagnosis of hepatocellular carcinoma per se, in this study is 85% for laparoscopy and 70% percutaneous blind needle biopsy is not surprising and not statistically significant (P=0.44). The major difference between these procedures is in the diagnosis of associated cirrhosis. Laparoscopy could visually diagnose cirrhosis in 40% of the patients, this was confirmed by histopathology in 35% of the cases, whereas percutaneous needle biopsy failed to prove in the 14 cases [Table - 1]. We consider this is due to the difficulty in obtaining adequate specimens from proper locations. While obtaining specimen easily from a large tumor, it was not possible to get liver tissue surrounding the tumor or away from the tumor which is needed for the diagnosis of cirrhosis. It is dangerous to go for a second specimen blindly. Besides, fragmentation of biopsy specimens occurred frequently [Table - 2]. This may indicate associated cirrhosis but loss of architecture due to fragmentation makes it difficult to diagnose cirrhosis. The success of laparoscopy in obtaining the diagnosis of associated cirrhosis is easily explained. The changes seen on hepatic surface with nodularity and distended veins easily gives away the macroscopic diagnosis of cirrhosis. It is also easy to get biopsy of the liver away from the tumor to prove cirrhosis. Pathologists were easily convinced of the diagnosis because they received larger and multiple specimens, however the disadvantages of the laparoscopic biopsy are that it is an invasive procedure, needs general anesthesia in some patients and expensive compared to the precutaneous blind needle biopsy.
Clinical suspicion of cirrhosis alone was adequately diagnosed by percutaneous blind needle biopsy when the biopsy specimen was adequate. In one study, using a large number of patients, percutaneous blind biopsy missed cirrhosis in 20% of patients  . The same study recommended laparoscopic biopsy to diagnose cirrhosis of liver without esophageal varices. In 1989 Herrera et al reported a series of 100 laparoscopies which showed 100% sensitivity and 91% specificity for the diagnosis of cirrhosis  .
Laparoscopy not only allows for more careful evaluation for cirrhosis but also identifies hypervascular tumors. Interestingly, two of the tumors in this series proved to be hemangiomas. There were no hemorrhagic complications.
We proved the pathologists' satisfaction of laparoscopic tissue compared to blind needle biopsy by analyzing their reports. Laparoscopic specimens were large, more complete and in multiple [Table - 2].
Comparative studies between ultrasonography, CT scans, and laparoscopy are available  . However, none of the radiographic studies were useful in predicting cirrhosis of the liver. They may also miss surface lesions while laparoscopy offers a panoramic view of the liver, 70-80% of the liver surface can be visualized and even minute lesions only a few millimeters in size can be biopsied .
We have not encountered any major complications in this series of patients by laparoscopy. Rare complications of cardiovascular collapse and cardiac arrhythmias have been reported , . We have encountered some minor complications such as leak of ascitic fluid from the incision.
It may be argued that the laparoscopic procedure is invasive, time consuming and expensive. There are advocates for percutaneous fine needle aspiration claiming its safety  . Fine needle liver biopsies are increasingly being conducted guided by ultrasonography  . However, the diagnosis of cirrhosis is not possible with fine needle. Some investigators have ventured into using large bore cutting needle under CT guidance  . Most experienced hepatologists firmly discourage CT guided large bore cutting needle biopsies because their complications may equal to percutaneous blind biopsy  .
Percutaneous blind needle biopsies have shown to be useful in diagnosing diffuse disease such as hepatitis, tuberculosis, and schistosomiasis. For localized liver diseases such as primary hepatocellular carcinoma associated with cirrhosis, laparoscopy is the procedure of choice. The advantages are summarized in [Table - 3]. As a matter of fact, the indications of laparoscopy are expanding with increased experience. Laparoscopy is being used to diagnose retroperitoneal pathology more frequently  . More and more gastroenterology training programs are including laparoscopy in their curriculum without compromising safety  .
There are some limitations of laparoscopy which include lesions in the most superior or posterior surface of the liver, small intrahepatic lesions and vascular invasion cannot be visualized by laparoscopy , . However, with the introduction, of sonolaparoscope with 180 0 sector scan, its sensitivity to detect some of these lesions can be determined
In conclusion, laparoscopy is a superior procedure over percutaneous blind needle biopsy in the diagnosis of hepatocellular carcinoma and associated cirrhosis of the liver [Table - 3]. First, laparoscopy can visualize accurately the liver surface for morphology of cirrhosis. Second, a large bore cutting needle can be directed under vision to obtain biopsy from the most appropriate sites. Third, laparoscopic biopsies achieve complete satisfaction of the pathologist for a descriptive report. Fourth, other liver pathology can be identified, e.g. hydatid cysts and hemangioma.
| References|| |
|1.||Joishy SK, Balasegaram M. Hepatic resection for malignant tumors of the liver. Essentials for a unified surgical approach. Am J Surg 1980; 139:360-9. |
|2.||Fomari F, Rapaccini GL, Cavanna et al. Diagnosis of hepatic lesions: Ultrasonographically guided fine needle biopsy or laparoscopy. Gastrointest Endoscopy, 1988;34:32-4. |
|3.||Martino KR, Haaga JR, Bryan PJ, et al. CT guided liver biopsies: Eight years experience. Radiology, 1984; 152:755-7. |
|4.||Nagy AG, James D. Diagnostic laparoscopy. Am J Surg 1989; 157:490-3. [PUBMED] [FULLTEXT]|
|5.||Jalan R, Hayes PC. Laparoscopy in the diagnosis of chronic liver disease. Brit J of Hospt Med 1995;53:81-6. |
|6.||Yoshio Kameda, Shinji Y. Early detection of hepatocellular carcinoma by laparoscopy: Yellow nodules as diagnostic indicators. Gastrointest Endoscopy, 1992;38:554-9. |
|7.||Ishida H, Dohzono T, Furukawa T, et al. Laparoscopy and biopsy in the diagnosis of malignant intraabdominal tumors. Endoscopy 1984;16:140-2. |
|8.||Nord HJ, Brady PG. Endoscopic diagnosis and therapy of hepatocellular carcinoma. Endoscopy 1993;25:126-30. [PUBMED] |
|9.||Cushieri A. Laparoscopic management of cancer patients. J. R. Coll Surg Edinb 1995;40:1-9. |
|10.||Jeffers L, Spieglman G, Reddy R, et al. Laparoscopically directed fine needle aspiration for the diagnosis of hepatocellular carcinoma: A safe and accurate technique. Gastrointest Endoscopy 1988;34:235-7. |
|11.||Possik RA, Franco EL, Pires DR et al. Sensitivity, specificity, and predictive value of laparoscopy for the staging of gastric cancer and for detection of liver metastases. Cancer 1986;58:1-6. |
|12.||Lightdale CJ, Winawer SJ, Kurtz RC, Knapper WH. Laparoscopic diagnosis of suspected liver neoplasms. Value of prior liver scans. Dig. Dis. Sci, 1979;24:588-93. |
|13.||Abdulaziz H. Al-Saigh, Allam M, Khan K, and Hawsawi Z. Pattern of cancer in Al-Madinah Al-Munawarrah Region. Ann Saudi Med 1995;15:350-3. |
|14.||Morad Nader, Khan AR, Al-Saigh AH, et al. Pattern of primary gastrointestinal tract cancer in the southern province. Ann Saudi Med 1992;12:259-63. |
|15.||Abdu Rauf Khan, Hussain N, Al-Saigh A, et al. Pattern of cancer at Asir Central Hospital, Abha, Saudi Arabia. Ann Saudi Med, 1991;11:285-8. |
|16.||Al-Faleh FZ. Hepatitis B infection in Saudi Arabia. Ann Saudi Med 1988;8:474-80. |
|17.||Hasan F, Jeffers LJ, Medina MD, et al. Hepatitis C - associated hepatocellular carcinoma. Hepatology 1990;12:589-91. |
|18.||Geoffrey H, Haydon, Hayes PC. Hepatocellular carcinoma. Brit J of Hospt Med, 1995;53:74-80. |
|19.||Pagliaro L, Rinaldi F, Craxi A, et al. Percutaneous blind biopsy versus laparoscopy guided biopsy in diagnosis of cirrhosis. A prospective randomized trial. Dig Dis Sci 1983;28:39-43. |
|20.||Mansi C, Savarino V, Picciotto A, et al. Comparison between laparoscopy, ultrasonography and computed tomography in widespread and localized liver diseases. Gastrointest Endoscopy 1982;28:83-5. |
|21.||Brantley JC, Riely PM. Cardiovascular collapse during laparoscopy: A report of two cases. Am J Obstet Gyn, 1988;159:735-7. |
|22.||Bums JMA, Kelman AW, Hillis WS. Effects of Nadolol on arrythmias during laparoscopy performed under general anesthesia. Br J Anesth, 1988;61:345-6. |
|23.||Bottles K, Miller TR, Cohen MB, Jung BL. Fine needle aspiration. Has its time come? Am J Med, 1986;81:525-31. |
|24.||Lightdale CJ. Laparoscopy in the age of imaging. Editorials. Gastrointest Endoscopy, 1985;31:47-8. |
|25.||Salky BA, Bauer JJ, Gellernt IM, Kreel I. The use of laparoscopy in retroperitoneal pathology. Gastrointest Endoscopy, 1988;34:227-30. |
|26.||Phillips RS, Reddy KR, Jeffers LJ, Schiff ER. Experience with diagnostic laparoscopy in a hepatology training program. Gastrointest Endoscopy, 1987;33:417-20. |
|27.||Gandolfi L, Muratori R, Solmi L, et al. Laparoscopy compared with ultrasonography in the diagnosis of hepatocellular carcinoma. Gastrointest Endosc, 1989;35:508-11. |
|28.||Fornari A, Civardi A, Cavanna L, et al. Laparoscopic ultrasonography in the study of liver diseases. Preliminary results. Surg Endosc, 1989;3:33-7. |
Abdulaziz Hassan Al-Saigh
Department of Surgery, College of Medicine, King Saud University, P.O. Box 7805, Riyadh 11472
Source of Support: None, Conflict of Interest: None
[Table - 1], [Table - 2], [Table - 3]