• Tumor seeding after both, conventional biopsy and fine needle puncture does occur and can negate the benefits of subsequent surgery. A nice tabulation of case reports has recently been published (17).
• The incidence is approximately 0.5 % (6). However, in a recent retrospective review of cases of HCC, an incidence of 5.1 % - leading to major surgery - has been reported (18).
• Measures have been advocated to avoid tumor seeding (9) but most authors feel that neither biopsy nor FNP is warranted when the lesion is deemed to be resectable (7, 8, 11).
• Recently, tumor seeding has also been described after percutaneous ethanol injection (16, 18).
• My personal opinion is that biopsy or FNP should only be performed by radiologists or internists after discussion of the case with a hepatobiliary surgeon.

1. Abdelli N, Bouche O, Thiefin G, Renard P, Flament JB, and Zeitoun P. Subcutaneous Needle-Tract Seeding After Percutaneous Fine Needle Aspiration Biopsy of a Colonic Liver Metastasis. Gastroenterol.Clin.Biol. 1994; 18:652-656.
   Notes: Subcutaneous seeding after percutaneous ultrasonically guided fine needle aspiration of liver tumours is a rare complication and only a few cases have been reported. We report a new case of cutaneous implantation following a fine needle (21.5 gauge of external diameter) aspiration biopsy of a superficial colonic liver metastasis, as shown by a subcutaneous nodule and increased serum carcino-embryonnary-antigen. We discuss the risk factors of this rare complication, especially the thickness of the liver parenchyma along the needle tract and precautions which can be taken for prevention.
2. Cedrone A, Rapaccini GL, Pompili M, Grattagliano A, Aliotta A, and Trombino C. Neoplastic seeding complicating percutaneous ethanol injection for treatment of hepatocellular carcinoma. Radiology 1992; 183:787-788.
3. Dangou JM, Ka M, Fall B, Ndiaye MF, Diop TM, Bao O, and Ndiaye PD. Tumor seeding of the abdominal wall after fine needle aspiration of a hepatocellular carcinoma. Ann.Pathol. 1996; 16:227-228.
4. Evans GH, Harries SA, and Hobbs KE. Safety of and necessity for needle biopsy of liver tumours. Lancet 1987; 1:620
5. Goletti O, De Negri F, Pucciarelli M, Sidoti F, Bertolucci A, Chiarugi M, and Seccia M. Subcutaneous seeding after percutaneous ethanol injection of liver metastasis. Radiology 1992; 183:785-786.
6. Herszenyi L, Farinati F, Cecchetto A, Marafin C, de MN, Cardin R, and Naccarato R. Fine-needle biopsy in focal liver lesions: the usefulness of a screening programme and the role of cytology and microhistology. Ital.J.Gastroenterol. 1995; 27:473-478.
   Abstract: We evaluated the diagnostic usefulness of 244 ultrasound-guided fine-needle biopsies (FNB) in 226 patients with suspected liver malignancies. A malignancy was detected in 166 cases (73%) -145 hepatocellular carcinomas (HCC), 21 metastases; benign lesions were aspirated in 60 cases (27%). The sensitivity of FNB was 93%, with 100% specificity. In the FNB false-negative cirrhotic nodules, a final diagnosis of HCC was reached on repeating the biopsy 1-8 months later. When both cytological and microhistological examinations were performed, the positive correlation between the two techniques was 80%, with a slightly higher sensitivity for microhistology (93%). The malignancies diagnosed were potentially resectable in 26% of cases. We experienced 1 acute complication of FNB and 1 case of needle tract tumour seeding. These results confirm that FNB is useful in diagnosing malignant liver tumours. We believe that US-guided FNB is the first-choice invasive technique for assessing focal benign lesions and malignant tumors in the liver.
7. John TG and Garden OJ. Needle track seeding of primary and secondary liver carcinoma after percutaneous liver biopsy. HPB.Surg. 1993; 6:199-203.
   Abstract: Seeding of tumour in the needle track following percutaneous needle biopsy of liver neoplasms is rarely reported. We describe two such cases following the needle biopsy of an hepatocellular carcinoma and secondary colorectal carcinoma respectively. The risk of needle track recurrence of liver tumours should not be regarded as insignificant. The diagnosis of liver neoplasms may be achieved by non-invasive modalities, and their needle biopsy should be reserved for cases not amenable to surgical resection.
8. Jourdan JL and Stubbs RS. Percutaneous biopsy of operable liver lesions: is it necessary or advisable? N.Z.Med.J. 1996; 109:469-470.
   Abstract: AIM: The necessity and desirability of performing percutaneous biopsy of potentially resectable liver tumours is called into question. METHODS: Two cases are reported in which percutaneous biopsy of resectable liver tumours was performed unnecessarily and resulted in needle track seeding. RESULTS: In both instances patients who underwent potentially curative liver resection were rendered incurable because of biopsy track recurrence. CONCLUSION: The common practice of performing percutaneous ultrasound or CT guided biopsy of potentially resectable lesions in the liver is generally neither necessary nor desirable.
9. Ka MM, Dangou JM, Fall B, Pouye A, Ndiaye MF, Diop TM, Ndiaye PD, and Bao O. Tumor seeding of the abdominal wall after fine needle cytologic puncture of the liver. Apropos of a case. Ann.Gastroenterol.Hepatol. 1995; 31:221-225.
   Abstract: Tumor seeding of the abdominal wall during fine needle puncture-aspiration of the liver is a very rare complication. The authors report a case of this complication affecting a 50-year-old Senegalese woman. She underwent echo-guided fine needle cyto-puncture of a hepatocellular carcinoma arising from the left lobe, followed by left lobectomy. The subcutaneous nodule was discovered 42 months after cyto-puncture. Histology following its excision revealed infiltration of carcinomatous hepatocytes between the fibers of rectus abdominis. There was no recurrence and the patient was well 10 months after excision of the subcutaneous nodule. With a review of 10 others cases reported in the literature, the authors feel that, although rare, this complication must be avoided and suggest a system for the protection of structures through which the needle passes.
10. Kanematsu M, Hoshi H, Takao H, and Sugiyama Y. Abdominal wall tumor seeding at sonographically guided needle-core aspiration biopsy of hepatocellular carcinoma. AJR.Am.J.Roentgenol. 1997; 169:1198-1199.
11. Russi EG, Pergolizzi S, Mesiti M, Rizzo M, d'Aquino A, Altavilla G, and Adamo V. Unusual relapse of hepatocellular carcinoma. Cancer 1992; 70:1483-1487.
    Abstract: The authors report a patient with iatrogenic dissemination of hepatocellular carcinoma (HCC). A 65-year-old Caucasian man was found to have a moderately well-differentiated HCC diagnosed by laparoscopy and biopsy; the patient had atypical left liver lobe resection. Thirty-three months after definitive surgery a double relapse was found at the site of the previous laparoscopy and at the surgical scar; no other metastases were found. Surgical procedure for removal of these lesions was performed, and the patient received complementary radiation therapy. At 30 months of follow-up, the patient is alive and disease free. The risk of neoplastic seeding through biopsy and improved safety in surgical techniques justify the omission of diagnostic biopsy in patients who have surgical procedures.
12. Sakurai M, Okamura J, Seki K, and Kuroda C. Needle tract implantation of hepatocellular carcinoma after percutaneous liver biopsy. Am.J.Surg.Pathol. 1983; 7:191-195.
    Abstract: The authors report a case of needle tract implantation of hepatocellular carcinoma following percutaneous biopsy of the liver. The patient, a 62-year-old Japanese male, was found to have a small hepatocellular carcinoma diagnosed by needle biopsy; this was followed by transcatheter chemoembolization, a combination of transcatheter arterial infusion of adriamycin and transcatheter arterial embolization of Gelfoam, and right lobectomy. Eight months after the biopsy and the lobectomy, a nodule of hepatocellular carcinoma, measuring 3.5 cm in diameter, was found at the site of the previous biopsy and excised. The patient is doing well without further recurrence of tumor 23 months after the lobectomy and 15 months after the excision of the implanted tumor in the subcutis.
13. Vergara V, Garripoli A, Marucci MM, Bonino F, and Capussotti L. Colon cancer seeding after percutaneous fine needle aspiration of liver metastasis. J.Hepatol. 1993; 18:276-278.
    Abstract: Fine needle aspiration or biopsy is used for cytologic diagnosis of many intra-abdominal tumors including focal liver lesions. The incidence of needle tract seeding is quite low. In this paper the first case of cutaneous seeding after percutaneous fine needle aspiration of liver metastasis is reported in a case of colon cancer. We suggest using this method for cytologic diagnosis in hepatic tumors when surgical resection is not possible and when patients will be treated with invasive therapies and to avoid fine needle aspiration biopsy in patients undergoing surgical resection or when there is a confident diagnosis of HCC by non-invasive procedures.
14. Yamada N, Shinzawa H, Ukai K, Wakabayashi H, Togashi H, Takahashi T, Seo N, Ishiyama S, Tsukamoto M, and Fuyama S. Subcutaneous seeding of small hepatocellular carcinoma after fine needle aspiration biopsy. J.Gastroenterol.Hepatol. 1993; 8:195-198.
    Abstract: Ultrasonically guided fine needle (21 gauge) aspiration biopsy (FNAB) was performed on a patient with a hepatocellular carcinoma (HCC) measuring 1.5 x 1.5 cm in segment VI of the liver. The tumour was located just beneath the liver surface. Subsegmentectomy of segment VI was performed. Twelve months after the biopsy and 10 months after the operation, levels of alpha-fetoprotein (AFP) and protein induced by Vitamin K absence or antagonist-II (PIVKA-II) increased gradually without any evidence of recurrence of HCC in the liver. Thirteen months after the biopsy, the patient palpated a hard subcutaneous nodule 1.5 cm in diameter in the right lower anterior chest wall at the insertion site of the biopsy needle. A subcutaneous tumour was excised and histological examination revealed moderately differentiated HCC. The levels of AFP and PIVKA-II normalized thereafter. These tumour markers were therefore useful for diagnosing the subcutaneous nodule as a metastatic HCC. The patient is currently doing well without further recurrence of HCC or needle-tract seeding 23 months after subsegmentectomy and 11 months after excision of the subcutaneous tumour.
15. Zerbey AL, Mueller PR, Dawson SL, and Hoover HCJ. Pleural seeding from hepatocellular carcinoma: a complication of percutaneous alcohol ablation. Radiology 1994; 193:81-82.
    Abstract: The authors present a case of proved seeding of the pleural space secondary to alcohol ablation of a primary hepatocellular carcinoma. The patient underwent alcohol ablation for a 6.5-cm-diameter tumor in the right lobe of the liver; approximately 20 needle punctures were required to ensure complete or almost complete destruction of the tumor. Six months after the original ablation, a hypervascular pleural metastasis was noted adjacent to the original lesion at computed tomography. Percutaneous biopsy of the pleural lesion showed hepatocellular carcinoma.
16. Ishii H, Okada S, Okusaka T et al. Needle tract implantation of hepatocellular carcinoma after percutaneous ethanol injection. Cancer 1998; 82:1638-42.
    Abstract: BACKGROUND. Percutaneous ethanol injection (PEI) therapy currently is widely used for small hepatocellular carcinoma (HCC). However, only limited information is available regarding needle tract implantation after PEI treatment. METHODS. Records of HCC patients who underwent PEI between March 1990 and April 1997 at the National Cancer Center Hospital (n = 177) were reviewed to clarify the incidence, risk factors, and outcome of needle tract implantation of HCC. RESULTS. PEI was performed for 348 HCC patients with a median tumor size of 20 mm. Needle tract implantation was found in 4 patients (10, 13, 15, and 46 months, respectively, after PEI). The size of the PEI-treated HCC tumors in these patients was 20, 27, 28, and 30 mm, respectively, in greatest dimension. All tumors were enhanced in the early phase on dynamic computed tomography (CT), and were found to have moderate tumor cell differentiation on biopsied specimens. Of the four implanted tumors, three were resected and the remaining tumor was treated with extrabeam radiotherapy. At last follow-up, 2 of the 4 patients had died (1 of variceal bleeding 60 months after PEI and the other from cancer 61 months after PEI) and 2 were still alive (14 and 20 months, respectively, after PEI) with no evidence of active tumor. CONCLUSIONS. Needle tract implantation after PEI is not unusual, especially when HCC tumors are greater than or equal to 2 cm in greatest dimension, enhanced in the early phase on dynamic CT, and/or moderately differentiated on biopsied specimens. (C) 1998 American Cancer Society.
17. Schotman SN, De Man R, Stoker J et al. (1999).  Subcutaneous seeding of hepatocellular carcinoma after percutaneous needle biopsy. Gut 45: 626-627.
18. Takamori R, Wong LL, Dang C, Wong L (2000). Needle tract implantation from hepatocellular cancer: Is needle biopsy of the liver always necessary? Liver Transpl Surg 6: 67-72.
     

     
     

   Back to topics in postgraduate education

   Back to homepage