Large hepatocellular carcinoma: time to stop preoperative biopsy

In Western countries, hepatocellular carcinoma (HCC) often presents at a large size, which is seen as a contraindication to transplantation and often resection. Although diagnosis by imaging and alpha-fetoprotein is usually straightforward, nonspecialist units continue to use biopsy to prove the diagnosis before transfer for specialist surgical opinion. We have looked at the impact of this on our practice.

We retrospectively analyzed all large HCCs resected in our unit during the last 12 years. Survival data were calculated according to size and univariate and multivariate analyses were carried out to determine impact of preoperative, operative, and histologic factors affecting outcomes.

We identified 85 large HCCs (> 3 cm) and classified 42 as giant (> 10 cm). Overall survival at 1, 3, and 5 years was 76%, 54%, and 51%. Size did not influence survival, although more complex surgical techniques were required for giant tumors. Predictors of poorer disease-free survival were positive resection margin (p < 0.001), multiple tumors (p = 0.003), macroscopic vascular invasion (p = 0.015), and preoperative lesion biopsy (p = 0.027).

Our data shows excellent outcomes after resection for large HCC. This supports the management of such patients in large-volume units that are fully equipped and experienced in the management of these patients. Preoperative biopsy should be avoided, as this unnecessary maneuver appears to have worsened our longterm results.