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Editor,—Schotman and colleagues (
) reported a patient with subcutaneous seeding of hepatocellular carcinoma (HCC) after percutaneous needle biopsy together with a review of 14 similar cases and correctly outlined the necessity for a critical evaluation of the role of needle biopsy in resectable HCC.1-4
We agree with their conclusion, namely that: (i) a needle biopsy may be indicated only if it is not possible to diagnose HCC by other means (namely increased α fetoprotein (AFP) concentrations, spiral computed tomography (CT), magnetic resonance imaging); in these cases, a single pass with a large needle (18 gauge) may be preferable to multiple passes with smaller calibre needles; (ii) needle biopsies are not indicated to confirm HCC in patients suitable for liver transplantation; and (iii) the entire needle tract should be resected at surgery for the primary tumour. This has been important in other skin recurrences, namely those after laparoscopic cholecystectomy for undiagnosed gall bladder carcinoma.5 6
However, we have some questions and comments concerning the reported case. Firstly, why did the authors perform tumour biopsy in a 30 year old woman with hepatitis B liver cirrhosis and raised serum AFP, showing a 2 cm diameter subcapsular nodule in segment V and two additional satellite lesions in the same segment? Adequate imaging procedures were already available four years ago. In fact, the patient had percutaneous liver biopsy together with an informative diagnostic procedure such as spiral CT. In addition, subcapsular liver lesions are known to give a high rate of both subcutaneous recurrence and intraperitoneal subdiaphragmatic seeding.1 Therefore, in contrast with recurrence after laparoscopic surgery which mostly cluster around abdominal port tracts,5 6 simple removal of the needle tract could not be sufficient to prevent the side effects of percutaneous liver biopsy. Secondly, why did they perform right hemihepatectomy in a cirrhotic liver rather than segment V segmentectomy? The latter could be a similarly adequate procedure while preserving better residual liver function.
The authors should be congratulated for focusing once again on a very important question (to biopsy or not to biopsy liver nodules in suspected HCC in the present era of highly effective imaging) and for their collection of 15 cases, which is obviously an underestimation of what occurs in practice and is currently observed in many transplantation centres. However, their message for the reader should be clearer as there is an apparent contradiction between what they state and what they actually did.
The study was supported in part by: National Research Institute (CNR) (grant No 93.00239.CT04; No 94.02376.CT04; No 95.00897.CT04); Regione Toscana (grant No 358/C, 1995); MURST 40%–MURST 60%; and TELETHON (grant E611).
Editor,—We read with interest the letter of Cettaet al in which they discussed our case (
) of subcutaneous seeding of a hepatocellular carcinoma (HCC) after percutaneous needle biopsy.
Firstly, they state that a needle biopsy was not indicated in the case presented. It must be stated that the biopsy was performed elsewhere before the patient was admitted to our hospital. Secondly, they suggest that a smaller partial hepatectomy might have been sufficient to treat the HCC in this 30 year old woman with hepatitis B liver cirrhosis.
In the case presented there was no deterioration in liver function or impaired functional reserve after resection. The postoperative course was uneventful.
In general, we agree with the opinion to limit resection as far as possible and presently we would perform a segmentectomy.
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