Wee A
Department of Pathology, Yong Loo Lin School of Medicine, National University of Singapore, National University Hospital, Singapore.
Cytopathology. 2011 Oct;22(5):287-305. doi: 10.1111/j.1365-2303.2011.00882.x. Epub 2011 Jul 18.
The role of fine needle aspiration (FNA) biopsy of the liver has evolved. Advances in imaging modalities have obviated the need for tissue confirmation in clinically classic hepatocellular carcinoma (HCC). The risks of needle tract seeding and haematogenous dissemination have been actively debated. Nowadays, cytopathologists are confronted by smaller and smaller nodules, detected due to increased surveillance of high-risk cirrhotic patients. Tissue characterization of small well-differentiated hepatocellular nodular lesions (size less than and equal to 2 cm) is extremely challenging and has therapeutic implications. Major issues in the cytodiagnosis of HCC include: (i) distinguishing benign hepatocellular nodular lesions, namely, large regenerative nodules, dysplastic nodules, focal nodular hyperplasia and hepatocellular adenoma from reactive hepatocytes; (ii) distinguishing well-differentiated HCC from benign hepatocellular nodular lesions; (iii) distinguishing poorly differentiated HCC from intrahepatic cholangiocarcinoma and metastatic carcinomas; (iv) determining the histogenesis of a malignant tumour; and (v) determining the site of origin of a malignant tumour. An overview of the biological evolution and histopathological aspects of dysplastic nodules, small HCCs and 'nodule-in-nodule' lesions is presented in tandem with clinically relevant nomenclature. An algorithmic approach to FNA diagnosis of HCC and hepatocellular nodular lesions is outlined. Optimal results depend on (i) a dedicated radiologist-cytopathologist team; (ii) an on-site cytology service, (iii) a combined cytohistological approach, (iv) immunohistochemistry, and (v) clinicopathological correlation. As we move towards personalized medicine, it is envisaged that hepatic FNA is likely to become a point of care in the management protocol as it takes on the additional role of procurement of tumour and peritumoural tissues for genomic and proteomic profiling to enable targeted molecular therapy.
肝脏细针穿刺抽吸活检（FNA）的作用已经发生了演变。成像技术的进步使得在临床典型的肝细胞癌（HCC）中无需进行组织确诊。针道种植和血行播散的风险一直存在激烈争论。如今，由于对高危肝硬化患者的监测增加，细胞病理学家面临着越来越小的结节。小的高分化肝细胞结节性病变（大小小于或等于2cm）的组织特征极具挑战性且具有治疗意义。HCC细胞诊断中的主要问题包括：（i）将良性肝细胞结节性病变，即大再生结节、发育异常结节、局灶性结节性增生和肝细胞腺瘤与反应性肝细胞区分开来；（ii）将高分化HCC与良性肝细胞结节性病变区分开来；（iii）将低分化HCC与肝内胆管癌和转移癌区分开来；（iv）确定恶性肿瘤的组织发生；以及（v）确定恶性肿瘤的起源部位。同时介绍了发育异常结节、小HCC和“结节内结节”病变的生物学演变和组织病理学方面，并给出了临床相关的命名法。概述了FNA诊断HCC和肝细胞结节性病变的算法方法。最佳结果取决于：（i）专业的放射科医生 - 细胞病理学家团队；（ii）现场细胞学服务；（iii）细胞组织学联合方法；（iv）免疫组织化学；以及（v）临床病理相关性。随着我们向个性化医疗迈进，可以设想肝脏FNA可能会成为管理方案中的一个即时护理点，因为它承担了获取肿瘤和肿瘤周围组织用于基因组和蛋白质组分析以实现靶向分子治疗的额外作用。
