BACKGROUND Hepatocellular carcinoma (HCC) complicating cirrhosis has a high intrahepatic recurrence rate after treatment by surgical resection or percutaneous ethanol injection (PEI). In this study, certain clinical, biochemical, and pathologic parameters were evaluated as risk factors for intrahepatic tumor recurrence in liver segments different from that of the first neoplasm in a group of 57 cirrhotic patients with single HCC < 5 cm treated by PEI. METHODS After PEI treatment of HCC, the patients were followed for a mean period of 33 ± 16 months. The following pretreatment parameters were evaluated as predictors of tumor recurrence: age, gender, Child‐Pugh score, hepatitis B virus surface antigen, hepatitis C virus antibodies, alanine aminotransferase, aspartate aminotransferase, alpha‐fetoprotein (AFP) level before PEI, alcohol abuse, HCC size, HCC ultrasound pattern, HCC histologic grade, HCC capsule, and time from cirrhosis diagnosis. Furthermore, the posttreatment parameters of the AFP level 1 month after PEI and recurrence of HCC in the same liver segment were also evaluated. RESULTS The cumulative 4‐year intrahepatic recurrence rate of HCC was 62%. The log rank test indicated that, among pretreatment parameters, time from cirrhosis diagnosis >6 years (P = 0.05) and AFP level before PEI of >25 ng/mL (P = 0.00005) were significantly linked to tumor recurrence. Cox's proportional hazards model showed that only AFP level before PEI was independently associated with recurrence (P < 0.002). With regard to posttreatment parameters, an AFP level 1 month after PEI of >13 ng/mL was shown to be significantly related to tumor recurrence by the log rank test (P < 0.0001). CONCLUSIONS Cirrhotic patients with single HCC treated by PEI who have slightly increased serum levels of AFP before and/or after PEI treatment are at increased risk of intrahepatic tumor recurrence and should undergo a close follow‐up program. Cancer 1997; 79:1501‐8. © 1997 American Cancer Society.

ABSTRACT— Severe coagulation defects, as reflected by platelet count and prothrombin time, have always been considered a contraindication to needle biopsy of the liver, but there are very limited data on the actual rate of bleeding in patients with such severe alterations and none whatsoever on the bleeding risk associated with newer, fine‐gauge needles that produce less trauma to the liver tissue. In addition, there has never been any evidence that platelet count and/or prothrombin time are the most sensitive indices of bleeding risk. This retrospective study of 85 patients, with platelet counts less than 50 000/mm3 and/or prothrombin times less than 50% of controls, subjected to ultrasound‐guided fine‐needle liver punctures for diagnostic or therapeutic (percutaneous ethanol injection) purposes showed no bleeding episodes after any of the 229 punctures performed. No type of replacement therapy was administered to correct clotting defects prior to the procedure. Correct pathologic diagnoses were obtained in 81.2% of all patients. Ultrasound‐guided fine needle puncture appears to be safer than currently believed in patients with severe clotting defects and deserves further evaluation as an alternative to surgical procedures to diagnose and treat liver lesions, even when severe coagulation impairment is present.

During a 4‐year period portal vein thrombosis was diagnosed in 20 Child class A patients with cirrhosis by means of ultrasound and ultrasound‐Doppler study. Seventeen of them showed single or multiple focal liver lesions diagnosed as hepatocellular carcinoma by ultrasound‐guided fine‐needle biopsy and the remaining three a coarse liver echo‐pattern without focal lesions. One patient was found to have developed portal vein thrombosis after the fifth ethanol injection of a single hepatocellular carcinoma lesion 17 mm in diameter. Ultrasound‐guided fine‐needle biopsy of the thrombus was performed on all the patients: portal vein thrombosis was neoplastic in 13 cases and non‐neoplastic in seven cases (five patients with a single lesion; one with two lesions; one with coarse liver echo‐pattern). Among the five patients with a single lesion, one had already been treated by percutaneous ethanol injection therapy. There were no complications related to the biopsy procedures. The diagnosis of non‐neoplastic thrombosis allowed five new patients to be recruited for percutaneous ethanol injection treatment and allowed it to continue in the patient with portal vein thrombosis occurring after the fifth ethanol injection. The routine use of ultrasound‐guided fine‐needle biopsy of portal vein thrombosis yields an accurate diagnosis of the nature of the thrombus and can improve the selection for percutaneous ethanol injection treatment of patients with cirrhosis with hepatocellular carcinoma lesions.

Renal vasoconstriction commonly occurs in decompensated liver cirrhosis and is entirely reversible after hepatic transplantation. In this study we evaluated by Doppler ultrasonography the changes of renal vascular resistance occurring during the first month after transplantation. In 16 cirrhotic patients the intrarenal resistive index at the level of interlobar arteries and the blood urea nitrogen and serum creatinine levels were measured before (range, 1 to 34 days) and after transplantation (days 1, 3, 7, 14, 30). Before transplantation the median resistive index value was 0.69 (95% CI, 0.65 to 0.71) and eight of 16 patients showed abnormal values (0.70 or more). After transplantation, the median resistive index was significantly decreased on all the evaluation days, and no patient had abnormal values on posttransplantation day 7. No significant correlation was found between resistive index and serum creatinine or blood urea nitrogen levels. Doppler ultrasonography is a simple tool to evaluate the recovery of normal intrarenal arterial resistance levels after liver transplantation. One week appears to be the optimal timing to evaluate the renal resistive index in the posttransplantation period.

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