Distinguishing well-differentiated hepatocellular carcinoma from benign liver by the physical features of fine-needle aspirates

Distinguishing well-differentiated hepatocellular carcinoma (HCC) from benign hepatic lesions is challenging for pathologists in limited diagnostic material such as needle-core tissue biopsy and fine-needle aspiration (FNA) biopsy. The objective of this study is to test a hypothesis that the fortification of liver by reticulin along single cell plates should protect benign hepatic lesions from breakdown by the force of aspiration and smearing, whereas the decreased reticulin in well-differentiated HCC would result in finely granular FNA smear. The study involved FNA biopsies of 67 cases of well-differentiated HCC and 109 cases of benign hepatic lesions, including cirrhosis (22), liver cell adenoma (8), steatosis (7), focal nodular hyperplasia (6), liver with cholestasis (6), and unremarkable liver sampled from nodular hepatic lesions consistent with the regenerative nodules (60). A slide with the most sample from each case by gross inspection was mixed together. Two observers blinded to the diagnoses were asked to separate the slides into two groups based on smear characteristics by gross inspection. Fragments of rigid fine-needle cores was present in 109 out of 109 cases of benign hepatic lesions but absent in 61 out of 67 cases of well-differentiated HCC, which presented as finely granular smears. The difference is statistically significant. (P< 0.001, df = 1, χ(2) = 149.3). Using the physical characteristic of liver aspirates as the screening test for malignancy, the sensitivity is 91%, specificity is 100%, positive predictive value is 100%, negative predictive value is 94.8%, and efficiency is 96.6%. In conclusion, the smear characteristics of liver samples in FNA biopsy correlate to their reticulin status on histology. This physical characteristic can be used as the first clue to distinguish malignant and benign liver aspirates prior to microscopic examination.