Outcome of patients with hepatocellular carcinoma listed for liver transplantation within the Eurotransplant allocation system.

Although hepatocellular carcinoma (HCC) has become a recognized indication for liver transplantation, the rules governing priority and access to the waiting list are not well defined. Patient- and tumor-related variables were evaluated in 226 patients listed primarily for HCC in Belgium, a region where the allocation system is patient-driven, priority being given to sicker patients, based on the Child-Turcotte-Pugh (CTP) score. Intention-to-treat and posttransplantation survival rates at 4 years were 56.5 and 66%, respectively, and overall HCC recurrence rate was 10%. The most significant predictors of failure to receive a transplant in due time were baseline CTP score equal to or above 9 (relative risk [RR] 4.1; confidence interval [CI]: 1.7-9.9) and alpha fetoprotein above 100 ng/mL (RR 3.0; CI: 1.2-7.1). Independent predictors of posttransplantation mortality were age equal to or above 50 years (RR 2.5; CI: 1.0-3.7) and United Network for Organ Sharing pathological tumor nodule metastasis above the Milan criteria (RR 2.1; CI: 1.0-5.9). Predictors of recurrence (10%) were alpha fetoprotein above 100 ng/mL (RR 3.2; CI:1.1-10) and vascular involvement of the tumor on the explant (RR 3.6; CI: 1.1-11.3). Assessing the value of the pretransplantation staging by imaging compared to explant pathology revealed 34% accuracy, absence of carcinoma in 8.3%, overstaging in 36.2%, and understaging in 10.4%. Allocation rules for HCC should consider not only tumor characteristics but also the degree of liver impairment. Patients older than 50 years with a stage above the Milan criteria at transplantation have a poorer prognosis after transplantation.

Fine needle trucut biopsy in focal liver lesions: a reliable and safe method in identifying the malignant nature of liver lesions.

BACKGROUND AND STUDY AIMS: The correct management of a focal liver lesion, suspected of being malignant, requires tissue for histopathological examination. To this purpose an ultrasonically guided fine needle trucut biopsy technique (FNTCB) can be used, to allow obtaining large tissue samples. The aim of the study is to see that FNTCB is a reliable method in identifying the malignant or benign character of a focal liver lesion. PATIENTS AND METHODS: We retrospectively compared the results of 231 FNTCB of focal liver lesions with the final diagnosis. RESULTS: In 191 lesions a final diagnosis was obtained (164 were malignant, 27 were benign). In our series FNTCB has a sensitivity of 86.6% (142/164), a specificity of 100% (27/27) and an overall accuracy of 88.5% (169/191) in identifying malignancy. There was a correct identification in 79.4% (27/34) of primary liver tumours and 88.5% (115/130) of liver metastases. In 52% (60/115) of liver metastases the primary site was accurately suggested by the pathologist. Correct characterization of benign liver lesions was obtained in 63% (17/27) of the cases. The insufficient sample rate was 3.1% (6/191). In one patient with thrombocytopenia an intraabdominal haemorrhage occurred. CONCLUSIONS: FNTCB is a reliable and safe method in identifying the malignant nature of liver lesions. Due to the large tissue sample, insufficient sample rate is low and an accurate histological identification of benign lesions, primary liver malignancies and metastases can be made. In case of metastases it is often possible to determine the site of the primary tumour.

Bacillus Calmette-Guérin-induced granulomatous hepatitis in a patient with a superficial bladder carcinoma.

A 71-year-old male patient with a superficial transitional cell carcinoma of the urinary bladder developed high fever and jaundice, accompanied by progressively increasing serum aminotransferase activities, 2 weeks after the fourth local instillation with an attenuated live strain of Mycobacterium bovis [bacillus Calmette-Guérin (BCG)]. A liver biopsy showed non-caseating granulomatous hepatitis. Cultures for mycobacteria were negative. Mycobacterial DNA was not detected in liver tissue using the polymerase chain reaction. Empirical treatment with rifampicin and isoniazid was started, resulting in partial recovery. After 6 months of therapy, however, serum aminotransferase activities were still twice the upper limit of normal. A second liver biopsy still demonstrated several granulomas. Only after addition of prednisolone, liver tests completely normalized. Also histologically the lesions improved dramatically. This suggests that the BCG hepatitis was at least partially caused by a hypersensitivity reaction. Our patient is the first reported case of BCG hepatitis with histological follow-up under therapy.