Evaluation Of Transrectal Ultrasound Guided Biopsies In The Early Diagnosis Of Small Hepatocellular Carcinomas

The China health statistics indicated in 1995 that the liver cancer mortality was 20.40/100,000 in China. Since the 90's it has rise to the second position in the mortality of malignant tumor, and second only gastric carcinoma in countryside while second only lung cancer in city. In our country the deaths due to liver cancer occupy 45% of all deaths from liver cancer all over the world every year. Therefore, the early discovery, early diagnosis and early treatment of liver cancer possess very important significances. Ever since the modern interventional imageology was applied in the liver disease diagnosis, it has been possible to diagnose the small hepatocellular carcinomas and has founded approaches to diagnose earlier period liver cancer. Routine examinations such as tumor markers are not reliable in earlier period liver cancer diagnosis. The conventional ultrasonic image examination and radiological examination for instance CT, nuclear magnetic resonance, arteriography are limited in the diagnosis of small occupying lesions in liver and hyperplastic nodules appear in liver cirrhosis. For these reasons percutaneous puncture biopsy of these small occupying lesions under ultrasonic guidance is quite useful for giving the final diagnosis and selecting proper treatments. The histologic characteristics and standard histologic data of small hepatocellular carcinomas are very important. At present the final diagnosis rate of small hepatocellular carcinomas through liver puncture under ultrasonic guidance is about 90%. The author had summarized about 200 cases of percutaneous puncture biopsy to small occupying lesions in liver on 60 patients and the final diagnosis rate was 96.7%. In this article the author synthetically expounded the diagnostic significance of the percutaneous puncture biopsy to small hepatocellular carcinomas and the understanding on raising the final diagnosis rate.Data and Method:1. Clinical data: The hepatic solid lesions whose diameters were smaller than 3cm (the minimum was 1.5cm) were found on 60 patients through imageology examination (Ultrasound, CT, MRI and so on). Male 46 cases, female 14 cases, 34~66 years old, 48 cases with hepatitis history and 17 cases with liver cirrhosis. 45 patients complained with indisposition of different degree in right hypochondrium. 15 patients did not have any symptom but just found the lesions when did the health examination. Ultrasonic appearance:low level echo 29 cases (49%), equal echo 6 cases (10%), high level echo 19 cases (30%) and composite echo 6 cases (10%). 24 cases (40%) showed homogeneous internal echo and 36 cases (60%) showed inhomogeneous echo. 20 cases (30%) with acoustic halo, which more often appeared in hepatic occupying lesions of equal echo and high level echo. 12 cases (20%) with lateral shadow, 22 cases (37%) with blood flow signal, 10 cases (17%) showed artery-type low- resistance blood flow.2. Method and equipment: The percutaneous puncture biopsy under ultrasonic guidance were carried out on all the 60 patients after the detections of GGT, AKP, AFP, carcino-embryonic antigen and AFU, then did the histological section examinations and follow up longer than half a year, the longest lasted 2 years. We applied Siemens Sequoia 512 color diasonography with 3.5MHz small convex array probe and equipped puncturation trestle as well as adjustable automatic biopsy gun, hand-motion biopsy equipment, 16G-21G biopsy needle.3. The detailed puncturation procedures:(1) Preoperative preparations: Did the preoperative blood routine test and four- item blood clotting routine test then explained the patient's condition to the patient and his family members, let them sign and put on record.(2) The patient was generally in dorsal position, first swept and checked the patient with ordinary transducer to get the message of affection location in order to decide the puncturing position. If the affection was near to lateral, it was required to place a cushion which could raise the silk side properly or chose left-lateral position so as to vertically or nearly vertically needling.(3) Routinely sanitized the puncture area then spread and covered the sterile sheets, disinfect the transducer strictly and made sure the target again at same time chose proper needing site and needing pathway. Observed surrounding blood vessels'positional relations with color Doppler flow imaging (CDFI) in order to get out of the way of blood vessels.(4) Took local anesthesia with 1% lidocaine and made sure that had reached to Glisson capsule then moved the transducer just a little or moved it laterad, fixed the transducer immediately when the affection was most clear and puncture guideline was just passed through biopsy position.(5) Inserted the biopsy needle along the puncture guideline, stopped inserting when got to the liver surface. Tell the patient to hold his breath and not to move the body. Pricked the biopsy needle into the liver along the puncture guideline, reached to the verge of the lump and then opened thebiopsy gun insurance, got the lump tissue.(6) Took 2 ~3 samples from every case, put the samples into formalin liquid to fix them and then did the pathological examination.(7) Observed 3 hours after operation, pay attention to patient's arterial pulse, blood pressure and abdomenal condition. If there were no abnormality the patient could leave.Results:165 times puncturations on 60 cases were all succeed without complication. The majority only had light gas pains in hepatic region and 3 of them who had obvious pains were given bucinperazine 100 mg by intramuscular injection then the pains disappeared. The results of pathological examination: Hepatic cell carcinoma 25 cases (41.7%), cholangiole carcinoma 3 cases (5%), metastatic carcinoma 4 cases (6.7%), liver cirrhosis nodus 6 cases (10%), hepatitis nodus 5 cases (8.3%), focal adiposis hepatica 7 cases (11.1%), hemangiomas of liver 6 cases (10%) and hepatic phthisis 2 cases (3.3%). 2 cases (3.3%) got the negative results on pathological examination and one of them was small liver cancer, the other one was liver cirrhosis nodus which be confirmed by follow–up visit. All the results of pathological examination were accurate. The final diagnosis rate reached to 96.7% and there was significant variance (p<0.05) compared with the combination of imageology and tumor markers (60%).Discussion:At present, the detection rate of hepatic small occupying lesions through imageology methods can be above 90%, but it is still difficult to give final diagnosis for the parenchymatous lesser tubercle affections clinically. The specific signs of small affections with different characters are not obvious in imageology examination so that they are difficult to discriminate, accordingly imageology examination is only able to achieve positioning examination but unable to determine the quality of these small affections. Serum tumor markers lacked specificity, so we only could get the final diagnosis depending on pathological biopsy. Pathological biopsy after the exairesis is often blind because there is no definite affection'quality given before the operation and it has increased the patients'distresses. If the lump was malignant, we afraid that the ablation is so slight that has not ablated the lump clearly and the tumor is possible to relapse, while if the lump was benign, the operation is aheavy mental burden and stress for the patient as well as results in unnecessary suffering. Puncture biopsy under ultrasonic guidance to the hepatic small occupying lesions possesses important significance on finding out the quality of the lump and making the early diagnosis of malignant tumors. It also provides reliable evidence to the surgical intervention therapy and the choice of the modus operandi, avoids the pretherapeutic blind. It can not be displaced by all the imageology diagnosis or tumor makers but makes up their shortages on the contrary, reduces the patients'unnecessary suffering. Although this method is traumatogenic, the wound is less and it has the merits of quick, safe, less complication and high final diagnosis rate. The whole procedure is under the ultrasonic guidance and the ultrasonic observation. The processes of pricking into liver parenchyma and the lump are clear displayed. The manipulations are direct-viewing, samples derived from Puncture biopsy are very satisfactory, and it is convenient and takes less time to get the samples. The color Doppler ultrasound techniques are capable of avoiding the injury of great vessels and it is benefit to monitor the needle tip to get accurate samples so that raise the final diagnosis rate.Conclusion:Percutaneous puncture biopsy under ultrasonic guidance is an ideal diagnostic method for the small hepatocellular carcinomas and has very important significance in the early diagnosis, early treatment of small hepatocellular carcinomas. The color Doppler ultrasound techniques ensures the safe, accurate for the new method, has raise the final diagnosis rate and provided original platform and idea for Percutaneous puncture biopsy under ultrasonic guidance.