A diagnostic paradigm for resectable liver lesions: to biopsy or not to biopsy?

Abstract

Background: Despite a growing body of evidence reporting the deleterious mechanical and oncological complications of biopsy of hepatic malignancy, a small but significant number of patients undergo the procedure prior to specialist surgical referral. Biopsy has been shown to result in poorer longterm survival following resection and advances in modern imaging modalities provide equivalent, or better, diagnostic accuracy.

Methods: The literature relating to needle-tract seeding of primary and secondary liver cancers was reviewed. MEDLINE, EMBASE and the Cochrane Library were searched for case reports and series relating to the oncological complications of biopsy of liver malignancies. Current non-invasive diagnostic modalities are reviewed and their diagnostic accuracy presented.

Results: Biopsy of malignant liver lesions has been shown to result in poorer longterm survival following resection and does not confer any diagnostic advantage over a combination of non-invasive imaging techniques and serum tumour markers.

Conclusions: Given that chemotherapeutic advances now often permit downstaging and subsequent resection of 'unresectable' disease, the time has come to abandon biopsy of solid lesions outside the setting of a specialist multi-disciplinary team meeting (MDT).

Figure 1

Kaplan–Meier survival curve comparing survival after liver resection in patients who underwent biopsy of suspected colorectal metastases (Group 1, biopsy) and those who did not (Group 2, no biopsy) (Jones et al. 20053)

Figure 2

Images obtained by computed tomography (CT) with venous contrast, T2-weighted HASTE magnetic resonance imaging (MRI), gadolinium-enhanced MRI and resovist-enhanced MRI. The comparative images show a simple cyst in segment 4b (CT and GAD images), displaying a typically high signal on T2 images and a metastasis in segment 2 (HASTE and resovist images). Gadolinium, which is an extracellular contrast agent, produces a typical ‘ring-enhancement’ of metastases, whereas resovist, which is a liver-specific agent, reduces the signal from normal parenchyma, which leads to a relatively increased signal from the metastasis