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Authors’ response
  1. M A Silva1,
  2. B Hegab1,
  3. C Hyde2,
  4. B Guo2,
  5. J A C Buckels1,
  6. D F Mirza1
  1. 1
    University Hospital Birmingham Foundation Trust, Birmingham, UK
  2. 2
    University of Birmingham, UK
  1. Mr D F Mirza, University Hospital Birmingham Foundation Trust, Birmingham B15 2TH, UK; darius.mirza{at}

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We thank Germani et al for their comments in response to our paper. In the absence of randomised controlled studies, we based our review on the guidelines set out by the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group, as a systematic review and meta-analysis of observational studies.1 On the basis of these guidelines using robust search strategies, only eight studies fulfilled inclusion and exclusion criteria making them eligible for meta-analysis. This methodology helps address some of the shortcomings of cross-sectional observational studies.

Our systematic review and meta-analysis was primarily on needle track seeding following diagnostic needle biopsies of lesions believed to be hepatocellular cancer. Percutaneous ablative therapies are accepted treatment for hepatocellular cancer but there have been no randomised controlled trials on the incidence of seeding following these procedures. Percutaneous needle biopsies, on the other hand, are not recommended in the diagnostic work-up of patients suspected of having hepatocellular cancer if surgery is being considered. In certain circumstances, however, a biopsy could be helpful in situations where imaging and α-fetoprotein levels are equivocal. The differentiation between a hyperplastic nodule and a hepatocellular cancer could decide whether a patient should be listed for a liver transplant or not.

In this setting, a diagnostic needle biopsy done at a specialist liver centre following multi-disciplinary consideration, according to our analysis, has a 2.7% risk of seeding. A biopsy could avert an unnecessary liver transplant in the event of a negative result and may help in prognostication with details of tumour biology in the event it is positive. This should be considered in the knowledge that a liver transplant carries a 10% risk of mortality at 1 year.

In conclusion, we have recommended that percutaneous image guided biopsies of liver lesions suspected to be hepatocellular cancers should not be done indiscriminately. Such a procedure should be undertaken only in specialised liver centres on a case by case basis following multi-disciplinary review.


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  • Competing interests: None.

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