Fine-needle biopsy of hepatic hemangioma with sonographic guidance

A new predictor of bleeding based on ultrasonographic features in percutaneous liver mass biopsy

Background/aim

An ultrasound-guided liver mass biopsy is a method frequently used in determining the diagnosis and treatment plan.The aim of this study was to evaluate the potential new predictors of bleedingbased on ultrasonographic features in liver mass biopsies, which are frequently applied in routine clinical practice.

Materials and methods

The images and data of patients aged over 18years,who underwent an imaging-guided percutaneous liver mass biopsy between January 2018 and December 2019 with various indications, were retrospectively reviewed. Liver size, liver steatosis status, parenchyma appearance, and mass vascularity on Doppler ultrasonography before the procedure, and hemoglobin (Hb) values before and after the procedure were recorded.

Results

A total of 176 patients were included in the study. Ninety-six patients were male (54.5%) and 80 were female (45.5%). The mean age of the patients was 64 ± 12.3 years. The mean hemoglobin values of the patients were 11.5 ± 1.9 gr/dL before the procedure and 11.4 ± 1.5 gr/dL after the procedure. While 144 of the patients had less than 10% hemoglobin decrease (81.8%), 32 had more than 10% decrease (8.2%). In 56 patients, a heterogeneous and coarse granular pattern was observed in the liver parenchyma (31.8%). The decrease in the Hb rate was significantly higher in patients with heterogeneous and coarse granular liver parenchyma (8.7%) than in patients with normal parenchyma (6.6%) (P = 0.036).

Conclusion

In our study, it was shown for the first time in the literature that the ultrasonographic appearance of the liver (heterogeneous and coarse granular parenchyma) may also be one of the parameters that can help to predict the risk of bleeding.

« Cyto-Assisted », Ultrasound-Guided Biopsy in the Diagnosis of Focal Disease of the Abdomen

From May 1988 to June 1990, 260 patients with abdominal focal disease underwent ultrasonically guided percutaneous fine needle biopsy. The technique of so-called « FNAB-CYT » is described. The procedure entailed very few complications: the mortality rate was 0% and the morbidity rate was 1.5%. The specificity of the technique was 100%, and sensitivity was 93.43%. False-negative diagnoses were made in 8 cases, and in 5 patients the cytologic diagnoses were uncertain. There were no false-positives. The possibility of an immediate control of the collected material by the pathologist avoids the risk of inadequate samples and reduces the number of biopsies for the patient. Comparison among diagnoses on rapid and definitive preparations and histologic ones was carried out to evaluate the diagnostic efficiency of the cytologic procedure. In our experience, a rapid staining of the smears allowed a correct cytologic diagnosis in 87.7% of the cases within approximately 5 min of the biopsy. On the basis of our experience, the authors recommend FNAB-CYT as a routine first-level (less invasive) procedure for diagnosis of abdominal focal disease.

Hepatic Cavernous Hemangioma in Patients at High Risk for Liver Cancer

Cavernous hemangioma of the liver occurring in patients at high risk for liver cancer has been reviewed. Twenty-four patients with hemangioma were encountered during the past 4 years. Five lesions over 3 cm in diameter were correctly diagnosed with enhanced CT alone. Definite CT findings were however obtained in only 6 out of 19 lesions smaller than 3 cm in diameter. Ultrasonography was the most sensitive method for picking up small liver tumors even when compared with angiography, but the findings were non-specific (an echogenic mass was noted in 14 of the 19 lesions). Magnetic resonance imaging (MRI) had almost the same sensitivity as ultrasound in detecting small hemangiomas, and a prolonged T2 was highly suggestive of the diagnosis (T2 over 80 ms in 8 of 11 lesions). The results suggest that combined use of non-invasive diagnostic modalities has sufficient reliability to make a diagnosis of cavernous hemangioma even in small hepatic lesions, in patients at high risk for liver cancer.

Fine-Needle Aspiration Biopsy of Liver Hemangioma

The results of 36 consecutive fine-needle aspiration biopsies of liver hemangiomas at two University Hospitals from the years 1981–1988 are described. The sizes of the lesions were 1 to 15 cm. Six patients had malignant disease, and liver metastasis was considered possible. In 2 cases the chief complaint was related to liver enlargement, and 28 patients had other abdominal symptoms. The aspiration was performed to confirm a suggested hemangioma in 18 and because of inconclusive findings at imaging in 18 cases. The aspirations were performed with sonographic guidance using 0.7 to 0.8 mm outer diameter needles. Cellular material from a hemangioma was obtained in 21 cases; only blood was aspirated in 5 cases. Hepatocytes were seen among abundant blood cells in 10, and some fibroblasts in 5 cases. One patient had significant bleeding that was treated with a transfusion of two units of blood. Nine patients were treated surgically, and histologic samples confirmed the diagnosis of hemangioma. None of the 27 non-operated patients showed progression of the liver lesion at 3 to 48 months follow-up. Fine-needle aspiration biopsy is helpful in the diagnosis of liver hemangioma. Confusion with malignancy is unlikely. Further experience will show the frequency of complications.

Reliability of Ultrasound-Guided Fine-Needle Biopsy of Pancreatic Masses

Fine-needle aspiration biopsy (FNB) was performed with ultrasound guidance in 79 patients in whom sonography had revealed a mass suggesting pancreatic malignancy. The final diagnosis (surgery, autopsy and clinical course) in 69 of these 79 patients was a malignancy closely related to the pancreas while in the remaining 10 patients benign disease was confirmed. A correct diagnosis of malignancy was attained by FNB in 59 of the 69 patients with a malignant tumour while in 10 it failed to confirm the diagnosis. FNB yielded a true negative result in 10 patients with benign disease. The accuracy of sonographically guided FNB in the present investigation was 87 per cent. Ultrasound-guided fine-needle biopsy is considered the method of choice for further evaluation of pancreatic masses.

Major bleeding after percutaneous image-guided biopsies: frequency, predictors, and periprocedural management

Major bleeding remains an uncommon yet potentially devastating complication following percutaneous image-guided biopsy. This article reviews two cases of major bleeding after percutaneous biopsy and discusses the frequency, predictors, and periprocedural management of major postprocedural bleeding.

Transhemangioma ablation of hepatocellular carcinoma

Radiofrequency ablation (RFA) is a well-established treatment modality in the treatment of early hepatocellular carcinoma (HCC) [1]. Safe trajectory of the RFA probe is crucial in decreasing collateral tissue damage and unwarranted probe transgression. As a percutaneous technique, however, the trajectory of the needle is sometimes constrained by the available imaging plane. The presence of a hemangioma beside an HCC is uncommon but poses the question of safety related to probe transgression. We hereby describe a case of transhemangioma ablation of a dome HCC.

Review article: the evaluation of solitary liver masses

BACKGROUND

The increasing use of imaging modalities has led to the detection of more liver masses. The differential diagnosis of a focal liver mass includes a host of benign as well as malignant conditions.

AIM

To provide a comprehensive review on the commonly encountered liver masses, and to help guide an approach to their evaluation and management.

METHODS

Pertinent literature that was identified through PubMed search and senior author's experience formed the basis of this review.

RESULTS

While most incidentally noted liver masses are benign, it may be difficult to differentiate them from those that are malignant. Furthermore, some benign lesions have malignant potential. Certain lesions such as focal nodular hyperplasia, haemangiomas and focal steatosis are often distinctly diagnosed by an imaging modality alone. The less frequently encountered hepatic adenomas are diagnosed radiologically in those with the appropriate clinical background and the absence of radiological features to suggest haemangioma or focal nodular hyperplasia.

CONCLUSIONS

A reasonable approach to the diagnosis, follow-up and management of liver masses is based on a rudimentary knowledge of their presentation, associated clinical and laboratory features, natural history and available treatment options. Most often, the so called 'incidentalomas' are benign and require patient reassurance.

Sclerosed hemangioma of the liver: Report of a case and review of the literature

A sclerosed hemangioma of the liver is an extremely rare type of benign hepatic tumor. A 77-year-old female was referred to Tokushima University Hospital with fever, abnormal liver function tests and a large liver mass. The tumor, 10 x 5 cm in size and located in segment 5-6 of the liver, was depicted as a low density tumor with enhancement by computed tomography (CT). Magnetic resonance imaging (MRI) showed it to be a tumor with a low signal on T1-weighted and a high signal on T2-weighted images. The patient was negative for hepatitis B surface antigen and hepatitis C antibody. She underwent a right hepatectomy for possible malignant liver tumors, including intrahepatic cholangiocarcinoma or fibrolamellar hepatocellular carcinoma. The following histological examination of the surgical specimen revealed the tumor to be a hepatic sclerosed hemangioma with characteristic dense collagenous tissues. We report here on the case of this unusual tumor and review the relevant literature.

Ultrasonography guided percutaneous radiofrequency ablation for hepatic cavernous hemangioma

AIM: Hepatic cavernous hemangioma (HCH) is the most common benign tumor of the liver and its management is still controversial. Recent success in situ radiofrequency ablation of hepatic malignancies has led us to consider using this technique in patients with HCH. This study was to assess the efficacy, safety, and complications of percutaneous radiofrequency ablation (PRFA) under ultrasonography guidance in patients with HCH.

METHODS: Twelve patients (four men and eight women, age ranged 33-56 years, mean age was 41.7 years) with 15 hepatic cavernous hemangiomas (2.5 cm to 9.5 cm) were treated using the RF-2000 generator and 10-needle LeVeen electrode percutaneously guided by B-ultrasound. Lesions larger than 3 cm were treated by multiple overlapping ablations that encompass the entire lesion as well as a rim of normal liver tissue (approximately 0.5 cm).

RESULTS: All the patients who received PRFA therapy had no severe pain, bleeding or bile leakage during and after the procedures. Nine to 34 months’ follow-up (mean, 21 months) by ultrasound and/or spiral CT scan demonstrated that the ablated lesions in this group were shrunk remarkably, and the shrunken range was 38%-79% (mean, 67% per 21 months). The contrast enhancement was disappeared within the tumor or at its periphery in all cases on spiral CT scans obtained 3 to 6 months after treatment.

CONCLUSION: The results of this study suggest that PRFA therapy is a mini-invasive, simple, safe, and effective method for the treatment of selected patients with HCH.

Reliability of fine-needle aspiration biopsy in the initial diagnosis of soft-tissue lesions

We retrospectively reviewed fine-needle aspiration biopsy (FNAB) specimens of 301 soft tissue lesions of the extremities and trunk. Final diagnoses were 137 benign and 86 malignant neoplasms and 78 nonneoplastic lesions. Of the 301 FNAB samples, 279 (93%) were adequate for cytologic diagnosis. The adequate FNAB specimens were initially grouped into three broad categories: benign (197 cases), malignant (57 cases), and suspicious for malignancy (25 cases). Sensitivity and specificity for diagnosis of a malignant lesion were 92% and 97%, respectively. The specimens were cytomorphologically classified into nine categories: small round (14 cases), spindle cell (77 cases), epithelioid/polygonal (16 cases), pleomorphic (29 cases), myxoid (19 cases), lipomatous (37 cases), epithelial (23 cases), inflammatory lesions (28 cases), and others (36 cases). Specific FNAB diagnoses were correct in 151 of 279 cases (54%) in combination with clinical and radiologic findings. FNAB is a valuable technique for the primary diagnosis of soft-tissue lesions.

Gray-scale ultrasound in hepatic cirrhosis and chronic hepatitis: diagnosis, screening, and intervention

Chronic hepatitis and hepatic cirrhosis are pathologies with high prevalence in the world population. Ultrasound (US) allows for a quick and precise examination of the liver parenchyma, the vascular structures, the biliary tract, and the abdominal cavity. Changes can be detected in the pattern of liver echostructure that suggest the presence of chronic liver disease, portal hypertension, and the presence of liver tumors. Moreover, US guidance provides an easy way for performing interventional procedures, such as biopsies for classifying the degree and type of liver disease, biopsies of focal liver lesions, and the application of percutaneous treatments for hepatocellular carcinoma (HCC). In this article we discuss the multiple applications of US in the management of patients with chronic liver disease.

Hemangioma-like lesions in chronic liver disease: diagnostic evaluation in patients

PURPOSE

To quantify the risk of misdiagnosis of focal hepatic lesions manifesting at ultrasonography (US) as typical hemangiomas in a population at high risk for hepatocellular carcinoma (HCC) and to identify the most effective approach to their diagnostic evaluation.

MATERIALS AND METHODS

A total of 1,982 patients with newly diagnosed cirrhosis underwent US and serum alpha-fetoprotein determinations for early detection of HCC. Focal lesions with typical features of hemangioma were evaluated with confirmatory findings of contrast material-enhanced dynamic or spiral computed tomography (CT) and/or single photon emission CT with technetium 99m-labeled red blood cells and, in the absence of confirmatory imaging findings, US-guided fine-needle biopsy. Patients whose initial US scan depicted no lesions or hemangiomas were enrolled in a US follow-up program. All hemangioma-like lesions detected during follow-up were evaluated, or biopsy was performed.

RESULTS

US depicted hemangioma-like lesions in 44 of 1,982 patients: 22 hemangiomas and 22 HCCs. Hemangioma-like lesions detected during follow-up in 1,648 patients were HCCs (n = 22) or dysplastic nodules (n = 4). Only 85 (22%) of 383 patients with HCC had alpha-fetoprotein levels suggestive of the diagnosis. The probability of a diagnosis of HCC (or preneoplastic lesion) is 100% for hemangioma-like lesions depicted on subsequent US scans.

CONCLUSION

If initial US examination of a cirrhotic liver depicts a hemangioma, confirmatory findings of imaging studies are necessary since 50% of hemangiomas in this study were hyperechogenic HCCs. US-guided biopsy can be safely performed, and its findings can be used to confirm the diagnosis.

Follow-up of patients at low risk for hepatic malignancy with a characteristic hemangioma at US

PURPOSE

To determine the need for follow-up imaging in patients with a low risk of malignancy and with ultrasonographic (US) findings typical of hepatic hemangioma.

MATERIALS AND METHODS

A computer search of US reports completed between 1991 and 1994 helped identify 383 patients whose reports contained the word "hemangioma." One hundred eleven patients were excluded because the lesion's appearance was atypical (n = 16) or because the patients had a high risk of malignancy (prior history or current evidence of extrahepatic malignancy or chronic hepatic disease [n = 95]). Fifty-nine patients were excluded because they were lost to follow-up (n = 41) or had clinical follow-up of less than 2 years (n = 18). The conditions of the remaining 213 patients with typical-appearing hemangiomas and a low risk of malignancy were analyzed. One hundred twenty-one patients underwent imaging follow-up or histopathologic confirmation. Ninety-two had clinical follow-up of more than 2 years (mean, 46 months).

RESULTS

Of the 213 patients, four had benign lesions other than hemangiomas. One patient who subsequently developed a malignancy (neuroendocrine metastases from primary colonic carcinoma diagnosed 22 months after initial US) potentially had an early metastasis that was misdiagnosed as a hemangioma.

CONCLUSION

On the basis of these results, the authors no longer recommend follow-up studies in their patients with a low risk of malignancy and a typical-appearing hemangioma at US.

Interventional ultrasound in Europe

"Interventional ultrasound," defined as any diagnostic and therapeutic procedure performed under ultrasound guidance was first introduced in Europe, where its early development took place in Vienna, in Copenhagen, in Italy and in Switzerland. However, many of the applications of interventional ultrasound have been based on important pioneer work using other less-suitable needle guiding methods from the pre-ultrasound era. The European contributions to "interventional ultrasound" have especially been in the development of new puncture equipment, in the dissemination of various biopsy techniques, and draining procedures and, more recently, in the development of many different tissue-ablation techniques. The above contributions, which are outlined in this historical review, have, together with significant contributions from the rest of the world-not least from the United States and Japan-created a most efficient diagnostic as well as therapeutic tool for the benefit of our patients.

Nuclear imaging of solid hepatic masses

This review has focused on the unique role of radionuclide scintigraphy in characterization of hepatic mass lesions. Radionuclide scintigraphy, unlike most other imaging modalities, is based on specific physiological and biochemical properties of each pathological entity that affects the liver. Hepatic scintigraphy, with its widespread availability, noninvasive nature, and relatively low cost is a powerful adjunct to other imaging techniques in the investigation of hepatic mass lesions. We have reviewed clinical presentation and characteristic findings of most hepatic lesions and have described reported findings with all available imaging modalities with particular emphasis on hepatic scintigraphy (Table 1) as well as a suggested algorithm for workup of solid hepatic masses (Fig 6). Additionally, the role of newer, more specialized techniques including PET scanning, 123I-labeled VIP, and 111In-labeled DTPA-D-Phe-octreotide scanning are reviewed. Hepatic nuclear scintigraphy continues to play an important role in the management of patients with solid hepatic masses.

Small (< or = 3 cm) hepatic lesions. Results of sonographically guided fine-needle biopsy in 385 patients

Three hundred ninety-five consecutive patients with sonographically detected hepatic lesions < or = 3 cm in diameter were submitted to ultrasonically guided fine-needle biopsy: 24 (6.1%) were < or = 1 cm in diameter; 142 (36%) were between 1.1 and 2 cm, and 229 (57.9%) were between 2.1 and 3 cm in diameter. In the 385 controlled cases, we obtained a cytohistological diagnosis of malignancy in 243 (63.1%): 135 hepatocellular carcinomas, 97 metastases, and 11 hepatic lymphomas. There were 104 true negatives (27%) and 38 false negatives (9.9%). The sensitivity of ultrasonically guided fine needle biopsy in the total series was 86.5%, the specificity 100%, with an overall accuracy of 90.1%. The overall accuracy was higher for lesions between 2.1 and 3 cm in diameter (90%) and was lower for lesions located in the sixth segment (84.6%). The correct diagnosis was obtained in the 83.3% (135/162) of small hepatocellular carcinomas versus 89.8% (97/108) in cases of small metastatic lesions.

Radiation therapy in the unresectable cavernous hemangioma of the liver

Hemangioma is the most common benign neoplasm of the liver, for which a 'wait and see' policy has been advised when it is small or without symptoms. Surgery is the treatment of choice of these tumors when marked symptomatology is present. However, some of these lesions cannot be excised due to their size, multiplicity, location or medical conditions. In these patients, radiotherapy has been reported to give good results with minor morbidity, suspending the tumor growth and decreasing the symptomatology. Seven symptomatic patients were treated with radiotherapy with a dose of 15-30 Gray in 15-22 fractions. Improvement of the quality of life was observed in all patients and the regression of the tumor volume was confirmed by computed tomography in five, with a follow-up ranging from 40 to 67 months.

Fine-needle aspiration biopsy of hepatic angiosarcoma: report of a case with immunocytochemical findings

Hepatic angiosarcoma (Kupffer cell sarcoma) is a very rare but ominous malignancy. We report a case diagnosed by fine-needle aspiration biopsy (FNAB). The smear showed malignant spindle cells and a few rounded cells. The diagnosis was made on the cell block by the characteristic scaffolding arrangement of malignant cells along preexisting hepatocytes. This is the first report with immunocytochemical findings. The tumour cells stained positively for vimentin and negatively for keratin, factor VIII, Ulex europaeus agglutinin I (UEA-1), carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), and lysozyme. This case demonstrates the possibility of a definitive diagnosis by FNAB prior to death without inflicting serious complications.

Percutaneous abdominal biopsy

The radiologically guided percutaneous needle biopsy is of proven value for evaluating intra-abdominal disease. Every region of the abdomen and pelvis is amenable to fine-needle biopsy. Accuracy rates are high with minimal risk to the patient. Current trends in biopsies tend to favour the use of larger core biopsy needles (18-gauge Biopty), and preliminary reports suggest that this is safe and may increase the diagnostic accuracy. Clinicians need not hesitate to call on their radiological colleagues to perform this most important procedure.

Giant cavernous hemangiomas: diagnosis and surgical strategies

From January, 1972 to June, 1989, 51 patients with liver hemangiomas (32 females and 19 males, mean age 35 years) were evaluated for surgical treatment. Diameters of the masses were 5 cm to 20 cm (median 8.5 cm). Nine of the patients had already been treated for cancer. Twenty-two (43.1%) of the 51 patients were symptomatic and 29 (56.9%) patients were asymptomatic. In 34 patients (66.7%) a definite diagnosis of hemangioma was made by scintiscan and/or ultrasound and/or computed tomography and/or angiography while in the remaining 17 (33.3%) patients the diagnosis was uncertain. The most common indications for resection were the presence of a symptomatic angioma, a symptomatic mass with an uncertain diagnosis, and/or lack of a definite pre-operative diagnosis. Surgery was performed on 25 patients. Ten anatomic and 15 atypical resections or enucleations were performed. There were no postoperative deaths. Two further patients, operated for probable hemangioma, were found to have primary hepatic malignancies. In the 26 unresected patients, no complications were observed during follow-up. In 3 patients, hemangioma enlargement was detected by ultrasound, but there were no symptoms. As cavernous liver hemangiomas are now more reliably diagnosed and their natural history is usually uneventful, surgery can be avoided in most cases. However, when a non-resection policy is adopted, an exact diagnosis is essential in order to rule out primary or metastatic cancer. Surgical exploration and treatment should be limited to symptomatic or complicated cases as well as to patients with an uncertain diagnosis.

Unexpected findings in gastrointestinal tract surgery

We discussed the proper management of patients with asymptomatic lesions incidentally found during laparotomy for other problems. For common or important lesions, information about the natural history, significance, treatment guidelines, and possible risks or complications related to operations on such incidentalomas were given. Thus, we discussed gallstones, masses of the upper and lower gastrointestinal tract, and masses in solid organs, such as liver, ovaries, and pancreas.

Imaging-guided and nonimaging-guided fine needle aspiration of liver lesions: experience with 406 patients

The aim of the present study was to determine the diagnostic accuracy of different modes of fine needle aspiration (FNA) of liver lesions. A total of 492 FNAs were performed on 406 patients in order to confirm or to rule out focal or multifocal neoplastic disease: 29% under ultrasound (US) guidance, 3% with computed tomographic (CT) guidance, 67% preoperatively, and 1% intraoperatively without imaging guidance. Based on histologic, cytologic, and clinical findings, final diagnoses were reached in 387 patients, of whom 264 had malignant liver disease and 123 had benign liver disease. Of 321 aspirations performed in patients with malignant liver disease, the cytologic findings suggested malignancy in 225 (70.1%), suspected malignancy in 25 (7.8%), and did not reveal malignancy in 71 aspirations (22.1%). Among the 123 patients with benign liver disease, the cytologic findings were reported as benign in all but two patients, who had false-positive cytologic findings. The overall sensitivity, specificity, positive, and negative predictive values for cytologic findings were 85.6, 98.4, 99.1, and 76.1%, respectively. The overall diagnostic accuracy was 89.7%. In one patient, fatal intraperitoneal bleeding due to chronic intravascular coagulation complicated the FNA procedure. We conclude that imaging-guided FNA as well as nonguided FNA for cytologic diagnosis of liver lesions are highly accurate and only rarely may be associated with a fatal complication.

Massive bleeding after fine needle aspiration of liver angiosarcoma

Open or closed biopsy of liver angiosarcoma is a life-threatening procedure. A case of massive bleeding after fine needle aspiration of the liver is reported in a patient having an angiosarcoma of the liver and spleen. Fine needle aspiration seems a hazardous procedure in this disease.

Diagnosis of hepatic cavernous hemangioma by fine needle aspiration biopsy under ultrasonic guidance

Percutaneous aspiration biopsy of the liver using a heparinized 22-gauge needle was performed under ultrasonic guidance in 11 patients with hepatic cavernous hemangioma. Ten (91%) of 11 biopsy specimens obtained were cytologically diagnostic for hemangioma. No indications of malignancy were found. There was no relation between the cytological diagnosis and the location, size, or ultrasonographic findings. No complications were encountered. These findings indicate that cytological examination of the liver by fine needle aspiration biopsy is useful in diagnosing hepatic cavernous hemangioma of any size and in any location, provided optimal route to the lesions is chosen.

Hepatic hemangioma in the presence of fatty infiltration: an atypical sonographic appearance

The typical hepatic cavernous hemangioma presents no diagnostic difficulty at sonography. In contrast, an atypical hemangioma may cause great concern and result in costly and time-consuming investigations. The presence of diffuse fatty infiltration may result in an atypical echo-poor appearance of the hemangioma. Under such circumstances, computed tomography (CT) may not allow definitive diagnosis and magnetic resonance imaging (MRI) may be necessary.

Complications of ultrasonically guided fine-needle abdominal biopsy. Results of a multicenter Italian study and review of the literature. The Cooperative Italian Study Group

This report describes the complications following 10,766 ultrasonically guided fine-needle biopsies performed from 1979 to 1987 in 33 Italian echographic units. The mortality was 0.018%: the two reported deaths were due to hemoperitoneum and occurred in patients with hepatocellular carcinoma arising in a cirrhotic liver. Twenty patients (0.18%) had major complications. This series confirms that abdominal biopsy with fine needles is safe, even though our death rate was higher than in previous reports. Among the other nine fatalities following fine-needle abdominal biopsy reported in the literature, seven were secondary to hemorrhage. The biopsy of pancreatic carcinoma was more dangerous for needle-tract seeding (five of eight reported cases, including one in our series).

Imaging-guided biopsy

In the past 10 years, imaging-guided biopsy has become an accepted technique of tissue retrieval for pathologic analysis. Fluoroscopy, ultrasonography, computed tomography, and magnetic resonance imaging are the current methods of guiding biopsy procedures. Each modality has advantages and disadvantages for various organ systems. High accuracy rates and low complication rates can be expected. Cost savings and rapid reporting of results add to the value of these procedures.

Technetium-99m radiocolloid scintigraphy, planar and SPECT red blood cell imaging and ultrasonography in diagnosis of hepatic hemangioma

Technetium-99m planar sulfur colloid scintigraphy, red blood cell imaging and ultrasonography were performed in eighteen patients of hepatic hemangioma to evaluate their diagnostic utility. Radiocolloid scans detected fourteen hemangiomas in 12 patients as focal hepatic defects but missed 9 lesions smaller than 2.5 cm in the other 6 patients, accounting for a 61% sensitivity. All 23 lesions were avascular or normovascular on radionuclide flow study. Serial planar red blood cell scintigraphy showed characteristic gradually increasing focal isotopic accumulation in the 14 hemangiomas which had identifiable cold areas on the radiocolloid study. One of 6 patients with normal radiocolloid scan also showed the typical increasing blood pool pattern of hemangioma, five had normal planar scans till 1 1/2 hours. SPECT red blood cell imaging in these 5 patients detected an additional seven hemangiomas. All 7 lesions were smaller than 2.5 cm. One 1.5 cm hemangioma was missed on both planar and SPECT red blood cell imaging. Region of interest ratios in SPECT transaxial images confirmed gradually increasing concentration of labeled red blood cells in the lesions. Ultrasonography detected 22 of the 23 hemangiomas. Ten were hyperechoic, average size 2.25 cm. Twelve were of mixed pattern, generally larger, average size 7.2 cm. Sonography is useful in the detection of hepatic hemangiomas as a focal mass lesion, but the variable sonographic appearance precludes a definite pathological diagnosis. Technetium-99m red blood cell imaging appears a sensitive technique in detection of hepatic hemangioma, with SPECT being especially useful in locating smaller lesions. The addition of useful in locating smaller lesions.(ABSTRACT TRUNCATED AT 250 WORDS)

Benign liver tumors

This article discusses the most important benign liver tumors, both in adult and pediatric patients. A pathologic discussion of each neoplasm is included to provide a basis for understanding the radiologic-pathologic correlation that is used throughout the monograph. The benign liver tumors are presented according to their frequency. Therefore, hemangioma, the most common primary benign liver neoplasm, is discussed first, followed by focal nodular hyperplasia, hepatocellular adenoma, and the benign primary pediatric tumors--infantile hemangioendothelioma and mesenchymal hamartoma. Finally, a brief discussion of nodular regenerative hyperplasia and other rare hepatic masses is included. Bile duct cyst (simple, non-parasitic cyst of the liver) is not included since it is not a neoplasm. Likewise, cystadenoma is not discussed since it originates from the biliary duct cell and is appropriately included in the biliary neoplasms category.

Management of cavernous hemangioma of the liver

Cavernous hemangioma of the liver was diagnosed in 12 of 60 patients (20 percent) evaluated for surgery of neoplastic liver disease. All were female, from 29 to 77 years old. Six patients presented with abdominal pain and seven had taken estrogens. Indications for surgery included uncertain diagnosis, symptoms, large lesion greater than or equal to 6 cm, and hypoproliferative anemia. Three right lobectomies, one left lateral segmentectomy, one open biopsy, and one right trisegmentectomy were performed. There were no deaths, one subphrenic abscess, and one bile leak. The remaining seven patients were observed and at 2 to 6 years post operatively had followed a benign course. Resectional therapy may be considered for superficial large or symptomatic lesions in the appropriate patient, but most hepatic hemangiomas follow a benign course.

Laparoscopic ultrasonography in the study of liver diseases. Preliminary results

In this report we present our preliminary experience using a recently developed sonolaparoscope. The 7.5 MHz rotating transducer, fixed to the tip of the laparoscope, produces a sector scan display of 180 degrees. We have used this technique in nine patients: five with cirrhosis and four with focal lesions of the liver. Laparoscopic sonography (LS) visualized two small nodular lesions in two cases of cirrhosis that did not show up with conventional ultrasonography (US). In one case of small hepatocellular carcinoma (HCC) located in the seventh hepatic segment, the lesion was not revealed. The ultrasound patterns of cirrhosis, hepatic cyst, and hemangioma were typical. We also performed ultrasonically guided biopsies. We concluded that laparoscopic sonography may be useful in the study of cirrhosis and in oncological patients for the screening of small hepatic lesions and that it could, in future, represent a preoperative step for liver surgery.

Diagnosis of hepatic lesions: ultrasonically guided fine needle biopsy or laparoscopy?

We compared the results of ultrasonically guided fine needle aspiration biopsy and laparoscopy in 63 patients who underwent both procedures. In this series, fine needle biopsy showed a sensitivity of 75.6% with a 84.1% overall accuracy. Laparoscopy demonstrated a 74.3% sensitivity with an overall accuracy of 82.7%. The combination of both procedures achieved an overall accuracy of 98.4% with a sensitivity of 97.5%. In one case only (hepatic involvement by Hodgkin's lymphoma), both laparoscopy and ultrasonically guided fine needle biopsy failed to establish the diagnosis. In small and deeply located lesions, ultrasonography is the most useful guide for biopsy. Laparoscopy is irreplaceable in the diagnosis of cirrhosis and in hepatic biopsies requiring larger bore needles. With the increasing use of ultrasonically guided fine needle biopsy, laparoscopy finds new indications, particularly in the preoperative staging of small hepatocellular carcinoma.

Ultrasound-guided fine-needle aspiration biopsy in the diagnosis of hepatic hemangioma

Fine-needle biopsy of hepatic hemangioma is discussed on the basis of a series of 10 biopsies performed on eight patients. The fine needle biopsies were executed because of the atypical sonographic pattern of some lesions, or in order to exclude malignancy for others (five patients were known to have neoplasms). No complication presented during or after the punctures. In six cases cytologic samples included capillary vessels or endothelial cells, supplying the diagnosis of hemangioma. It is concluded that fine-needle biopsy of a hepatic hemangioma is not loaded with complications, and moreover can yield true positive information in 60% of cases.