Diagnosis of hepatocellular carcinoma - Fine needle aspiration cytology or needle core biopsy

Needle core biopsy (NCB) has been the standard procedure for histopathologic diagnosis of hepatic lesions for more than 50 years. In recent years fine needle aspiration cytology (FNAC) has emerged as a minimally invasive, relatively inexpensive and a rapid method of pathologic evaluation of primary or metastatic hepatic masses. The specificity and the positive predictive value of FNAC is very high however, the sensitivity of the procedure widely ranges between 67% to 93%. The two major areas of diagnostic difficulties are differentiation of benign and nonneoplastic hepatic nodules from well differentiated HCC and identification of obviously malignant cells as HCC, cholangiocarcinoma, or metastasis. Preparation of cell blocks, immunohistochemical stains and application of other ancillary techniques are often helpful in difficult cases. In presence of characteristic features a diagnosis of HCC can be established on FNAC however, a negative result does not exclude malignancy. The role of pathologic diagnosis in the assessment of large hepatic masses is well established however, its role in the evaluation of small hepatic nodules (<3 cm) detected during surveillance of high risk patients is still evolving. Considering the overall advantages and cost-analysis, FNAC can be suggested as the initial method of choice for evaluation of hepatic masses in most clinical settings. However, the final choice of the diagnostic procedure should be decided on the basis of working clinical diagnosis and the institutional experience.