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Copyright ©2009 Baishideng. All rights reserved.
World J Hepatol. Oct 31, 2009; 1(1): 48-61
Published online Oct 31, 2009. doi: 10.4254/wjh.v1.i1.48
Surveillance and diagnosis of hepatocellular carcinoma in patients with cirrhosis
Lorenzo Andreana, Graziella Isgrò, Maria Pleguezuelo, Giacomo Germani, Andrew K Burroughs, The Royal Free Sheila Sherlock Liver Center, Departement of Surgery, Royal Free Hospital, London, NW3 2QG, United Kingdom
Author contributions: Andreana L and Burroughs AK wrote the paper, Isgrò G conseived the figure, Pleguezuelo M and Germani G contributed equally on tables.
Correspondence to: Andrew K Burroughs, Professor, The Royal Free Sheila Sherlock Liver Center, Department of Surgery, Royal Free Hospital, Pond Street, London, NW3 2QG United Kingdom. andrew.burroughs@royalfree.nhs.uk
Telephone: +44-20-74726229 Fax: +44-20-74726226
Received: June 22, 2009
Revised: September 11, 2009
Accepted: September 18, 2009
Published online: October 31, 2009

Abstract

Early identification of hepatocellular carcinoma (HCC) is more frequent because of surveillance programs for HCC worldwide. The optimal strategy of surveillance in cirrhosis is a current topical issue. In terms of diagnosis, recent advances in non-invasive imaging technology, including various techniques of harmonic ultrasound, new ultrasound contrast agents, multi-slice helical computed tomography and rapid high quality magnetic resonance, have all improved the accuracy of diagnosis. Consequently the role of liver biopsy in diagnosis of HCC has declined. The imaging diagnosis relies on the hallmark of arterial hypervascularity with portal venous washout. However, with recent advances in genomics and proteomics a great number of potential serum and tissue markers have been identified and are being developed as new candidate markers for both diagnosis and prognosis of hepatocellular carcinoma, and may increase the need for liver biopsy.

Key Words: Hepatocellular carcinoma, Liver neoplasm, Screening, Diagnosis, Imaging, Liver biopsy, Molecular markers



INTRODUCTION

Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy worldwide and it represents the leading cause of death in patients with cirrhosis in Europe[1]. Malignant hepatic cell transformation is more frequent in cirrhotic livers, accounting for 80%-90% of overall autopsied series[2]. Between 59% and 94% of new diagnosed nodules in cirrhosis are histologically characterized as malignant[3,4] and about 50% of the hemangioma-like lesions in cirrhosis are shown to be HCC[5]. It is reasonable and common clinical practice to consider any lesions in a cirrhotic liver, as malignant until proven otherwise.

In developed countries there are surveillance programs for “at-risk” people, including those with cirrhosis, to identify the malignant lesions when they are small. For this purpose differentiating between early HCC and a dysplastic nodule is an important issue in a routine clinical setting.

Recent advances in non invasive imaging technology for the diagnosis of hepatocellular carcinoma include various techniques of tissue harmonic ultrasound (US) imaging, new US contrast agents, multi-slice helical computed tomography (CT) and rapid high quality magnetic resonance (MRI) with new, tissue-specific contrast agents.

Ultrasonography is the first line of investigation in the detection of focal liver lesions, particularly as it used for surveillance of HCC in patients with cirrhosis, as it has relatively low cost, is non invasive and has wide spread availability[6].

SURVEILLANCE AND SCREENING

Surveillance of HCC in patients with cirrhosis in most centres is performed using 6-monthly US and in some centres this is combined with α-fetoprotein (AFP).

Data to support the effectiveness of ultrasound surveillance are sparse because of ethical problems of not performing ultrasound as it is part of current clinical practise[7-10].

The value of using AFP for surveillance has not been validated but once a nodule has been detected is useful[11]. The AFP test, with a cut-off value of 20 ng/mL, has a sensitivity from 41% to 65%[11-16]: lowering the cut-off value and changing it for different etiologies of liver disease, such as in HBV carriers results in greatest sensitivity[17]. Currently, HCC screening with AFP alone is not recommended, except when US either is not available or of poor quality[18]. Moreover AFP measurement together with US screening, is not cost-effective[19], as it only increases sensitivity by about 10% compared to US screening alone[20].

However, high levels of AFP can identify an “at risk” category of patients with cirrhosis that require surveillance[21] (Table 1).

Table 1 At risk population for HCC surveillance: AASLD guide lines[21].
Hepatitis B carriers
Asian males 40 years or more
Asian females 50 years or more
All cirrhotic hepatitis B carriers
Family history of HCC
Africans over age 20
For non-cirrhotic hepatitis B carriers not listed above the risk of HCC varies depending on the severity of the underlying liver disease, and current and past hepatic inflammatory activity. Patients with high HBV DNA concentrations and those with ongoing hepatic inflammatory activity remain at risk for HCC
Non-hepatitis B cirrhosis
Hepatitis C
Alcoholic cirrhosis
Genetic hemochromatosis
Primary biliary cirrhosis
Group with lack of evidence. Although the following groups have an increased risk of HCC no recommendations for or against surveillance can be made because a lack of data precludes an assessment of whether surveillance would be beneficial: a1-antitrypsin deficiency, non-alcoholic steatohepatitis, autoimmune hepatitis

In the sole randomized controlled trial performed in China, which also included individuals without cirrhosis, the survival rate at five years after enrolment was 46.4% in the surveillance group (AFP plus US scan every 6 mo) against 0% in the control group[22].

Indirect proof of the utility of a surveillance strategy is the resulting change in presentation of HCC, with an increased rate of detection of tumors < 2 cm in diameter. In fact while tumors less then 2 cm in diameter represented less than 5% of the cases in the early nineties in Europe, now they represent up to at least 30% in Japan[23]. However, the increased diagnosis of HCC does not necessarily mean an improvement in survival[24], although a well documented cohort study does suggest this[10]. More data are need to substantiate the value of this strategy. Based on the estimated HCC doubling time and cost-effectiveness estimates, the recommended screening interval is 6 mo, although a 1 year interval seems to be as effective[25].

An additional consideration is the fact that ultrasound imaging requires good equipment and skilled operators. In a retrospective study in patients with cirrhosis five-year survival was better in the group screened in a specialized centre (52%) versus the group screened in non-specialized centres (40%)[26]. Surveillance programs for HCC would benefit from the same organizational setup as breast programs, with recall facilities and dedicated centres.

Ultrasound surveillance as it is currently practised has an acceptable sensitivity of 65%-80% and has a upper level of specificity of more than 90%[7,21,27]. Tumor size significantly affects the sensitivity of US in detecting HCC. Sensitivity ranges from 42% for lesions smaller than 1 cm[28,29] to 95% for tumors of larger size[30]. In pre-transplant screening, the US sensitivity is poor because of the coarse echotexture of the liver, the frequent presence of ascites and the high rate of malignant lesions present in end-stage liver disease[31]. In a retrospective study on 200 patients who underwent liver transplantation, within 3 mo of previous screening, the US scanning was correlated with explanted livers, and had a sensitivity of only 13.6% to 50% for lesions of 1-5 cm in diameter[32]. Therefore in liver transplant candidates, CT or MRI scanning should be performed[33].

Using grey-scale US more than 76% of hepatocellular cancers smaller than 2 cm appear as hypoechoic, with or without posterior enhancement[34]. About 17% of small HCC show an hyperechoic appearance[34,35], features related to the fatty changes occurring during the evolution of the borderline lesion. Fewer small HCC lesions appear isoechoic[34,35]. Lesions larger than 2 cm in diameter show a more heterogeneous pattern than smaller lesions because of the changes during the growth of the lesion (i.e. development of necrotic hypoechoic areas, calcifications and pseudocapsule). In these cases the presence of the “halo sign” and posterior enhancement increase the specificity of diagnosis[21,27,31].

The use of doppler US or power doppler US may help establish the nature of the lesion by detecting arterial vascularization. However, in small HCC and in lesions located deep within the liver parenchyma, the sensitivity of doppler is low and a typical arterial pulsatile flow arterial pattern is detected in only 50% of nodules [31,36]. Colour or power Doppler US of large HCC often demonstrate a basket pattern, with a fine blood network surrounding the nodule and flowing into it[37].

When new nodules are found in a cirrhotic liver, these must be characterized with a contrast-enhanced imaging technique. During surveillance using double harmonic-equipped US machine, the same operator can also diagnose an HCC with contrast-enhanced US (CEUS). This make CEUS more cost-effective[38]. However, MRI or CT are needed whenever a second technique of imaging is needed, particularly if the lesions is 1-2 cm in diameter, and to image the whole liver to ensure there are no other lesions. A chest CT can be done at the same time, to exclude the presence of metastases.

DIAGNOSIS-IMAGING BASED ON BLOOD SUPPLY AND TISSUE CHARACTERIZZATION

In 2001 the European Association for the Study of the Liver (EASL) published a consensus statement defining histological and radiological criteria for the identification of HCC, and categorizing patients with cirrhosis and HCC on the basis of the size of presumed nodule[18]. In 2005, practice guidelines deriving from EASL, American Association of Study for the Liver Diseases (AASLD) and Japanese Society of Hepatology (JSH) revised the 2001 statements[21], giving prime diagnostic importance to arterial hypervascularization together with portal venous washout, and adding CEUS as a non invasive diagnostic technique[21,39].

In the multistep process of hepatocarcinogenesis there is a progressive change in the vascular supply that consists of an increase in arterial blood supply and loss of portal blood. Contrast enhancing agents can characterize the vascular pattern of focal liver lesions secondary to hepatocellular transformation with a good correlation between grade of HCC malignancy and intranodular hemodynamics[40,41] (Figure 1).

Figure 1
Figure 1 The diagram shows the changes of intranodular blood supply that characterises HCC (A); The sampled small/well differentiated HCC shows in HE (B) compact carcinomatous tissue well circumscribed from dysplastic tissue; CD34 immunostain of the same nodule (C) demonstrates arteries not confined to portal tracts in HCC. diff.: Differentiated.

The typical feature of HCC, demonstrated by using intravenous contrast media that show extracellular-vascular distribution, consists of arterial enhancement with early portal and venous phase wash-out. Imaging techniques recommended in EASL/AASLD/JSH guidelines[21] are: triphasic CT with iodinated contrast media (but not lipiodol because of its low sensitivity), dynamic MRI enhanced by gadolinium or manganese based media (that have also a slightly hepatocellular uptake with biliary excretion) and CEUS with microbubble contrast agents[21]. Conventional angiography and CT hepatic arteriography-portography can be used, but are rarely necessary for diagnosis.

The average sensitivity, specificity and especially the predictive positive values of these techniques are currently comparable (Table 2).

Table 2 Overall sensitivity, specificity and predictive value of imaging technique for the diagnosis of hepatocellular carcinoma.
StudyNunber of patients (n)HCC patients/ HCC instancesGold standard referenceImaging techniqueSensitivity (%)Specificity (%)PPV (%)Ref.
Ward et al (2000)14525/76Explant/MR (SPIO)66NANA[72]
biopsyMR (Double)80NA93.5
Rode et al (2001)4318/13ExplantSDCT53.892.994.3[58]
MR (Gd)76.957.142.3
Krinsky et al (2001)7110/19ExplantMR (Gd)53NA96.9[69]
Krinsky et al (2002)2424/> 118ExplantMR (Gd)33NANA[70]
De Ledingen et al (2002)3421/54ExplantMDCT51.984.6 pts289.5[55]
MR (Gd)61.11002100
Libbrecht et al (2002)4917/77ExplantMDCT70 pts1822NA[57]
MR (Gd)501792NA
Zacherl et al (2002)2323/50ExplantMDCT75NA64[62]
Barthia et al (2003)3114/32ExplantMR (Double)78NANA[31]
Burrell et al (2003)5029/76ExplantMDCT61NA87[3]
MR (MRA)76NA90
Teefey et al (2003)3229/18ExplantMDCT57-67 pts169-752NA[60]
MR (Gd)50-56163-812NA
Battakiarjya et al (2004)3030/46ExplantMDCT67.478.9NA[53]
IOCT6888.6NA
Kim et al (2004)2727/50Biopsy/clinical/radiologicalMR (Gd)91.3NA92.6[68]
MR (SPIO)77.3NANA
Valls et al (2004)8551/85ExplantMDCT78.8 ptsNA88[61]
Kim et al (2006)4631/53Biopsy/clinical/radiologicalMDCT77.4-79.2NA95-97[56]
MR (Gd)92.5-94.3NA92-96
Hecht et al (2006)3818/19ExplantMR (Gd)68.465.7NA[67]
Ronzoni et al (2007)8848/139ExplantMDCT64NA66.9[59]
73.3NA79
Lauenstein et al (2007)11527/36ExplantMR (Gd)77.8NANA[71]
Forner et al (2008)8960/60BiopsyMR (Gd)61.796.6NA[42]
CEUS51.793.1NA
Dai et al (2008)498NA/56Biopsy/MDCT80.497.9NA[52]
resectionCEUS91.187.2NA
Choi et al (2008)47/41ExplantMDCT65NANA[54]
MR (Gd)83NANA

Part of the current recommendations[21], is that the diagnosis of hepatocellular carcinoma when the focal liver lesion is larger than 2 cm in diameter can be confidently made using one dynamic imaging technique which demonstrate the typical pattern of HCC (Table 3). Moreover if AFP serum level is > 200 ng/mL and the radiological appearance of the lesion is suggestive of HCC, the likelihood that the lesion is HCC is high, even without classical vascular enhancement and washout[21].

Table 3 Newly found focal liver lesion in patients with cirrhosis. Screening and diagnosis: AASLD guide lines[21].
Focal lesion < 1 cm diameter: screen every 3-4 mo
Focal lesion 1-2 cm diameter: HCC diagnosed when 2 dynamic imaging techniques are concordant for HCC feature
Focal lesion > 2 cm diameter: HCC diagnosed with feature of HCC on 1 dynamic imaging technique

When there are nodules between 1 and 2 cm in diameter two concordant dynamic imaging techniques are needed to confirm HCC[21] (Table 3).

Only one prospective study has been published validating the international guidelines for nodules smaller than 20 mm in diameter[42]. In this study, MRI and CEUS were concordant for HCC in only 33.3% of cases, showing a poor predictive negative value of 42% (slightly higher if only considering lesions of more than 1 cm in diameter). In addition, commenting on the above-quoted study, Caturelli et al[43] suggest that the first diagnostic approach to a newly found liver lesion smaller than 20 mm in diameter should be a fine-needle aspiration, as this technique reaches a higher diagnostic accuracy than that reported for the two concordant imaging techniques[42,43]. Otherwise these lesions should not be treated as HCC, without histological evidence, as the false positive rate is about 20%[44]. Thus a biopsy of the lesion is required if confirmation of diagnosis of HCC is needed. Alternatively repeat imaging in 2-3 mo may resolve the issue.

Lesions < 1 cm in diameter may be especially difficult to characterize, even with the best imaging techniques. These small nodules are less likely to be HCC, even if they show hypervascularity with imaging techniques. These nodules need to be followed-up with US every 3-4 mo in order to determine if there is growth suggestive of malignant transformation (Table 3). If the nodule enlarges during follow-up, the criteria related to the particular size reached, pertain[21]. For this size of lesion, histology may not able to confirm the diagnosis.

Regenerative nodules and borderline lesions, such as dysplastic nodules and early HCC, show an inconsistent pattern of vascular enhancement. Benign regenerative nodules can also be hypervascular and if their diameter is between 1 and 2 cm, they should biopsied to resolve the diagnosis.

In addition, in smaller lesions the amount of Kupffer cells and fatty changes can be very variable, in comparison to overt HCC[45]. MRI with the use of super paramagnetic iron oxide (SPIO) enhancement, can be useful to characterize these lesions.

Characterisation of these smaller nodules poses a diagnostic challenge as they are more difficult to characterize even with pathological examination[23], although stromal invasion by “carcinomatous” cells, is associated with malignancy.

DIAGNOSIS - CEUS, CT AND MRI AS SINGLE TECHNIQUES: ADVANTAGES AND LIMITS
CEUS

In ultrasonography the main advance has been contrast-enhanced ultrasonography, which has improved the accuracy of ultrasound in detecting focal lesions, combining morphological aspects with functional perfusion ones[46]. CEUS is also very useful for assessment of HCC after treatment and has a good correlation with CT findings[47]. After trans-arterial embolization using lipiodol-based compounds that leave a radio-opaque shadow, only CEUS or dynamic MRI can detect residual vascularity.

Several reports have shown that CEUS is a good tool to show arterial hypervascularity of HCC. Two studies showed that CEUS has a higher detection rate compared to CT for lesions ≤ 2 cm (53.6% vs 42.9% and 61% vs 49%)[48,49]. However, a more recent study, comparing CEUS with MRI, found that CEUS was slightly inferior to dynamic MR imaging in showing the presence of arterial hypervascularity (78% vs 85%)[42]. The sole detection of arterial hypervascularity without contrast wash-out in a small solitary lesion of ≤ 2 cm in the setting of cirrhosis has a specificity of 86.2% and a positive predictive value of 92.2% for the diagnosis of HCC and thus cannot be considered as a conclusive finding[42]. Therefore, to increase the specificity of diagnosis it is necessary to evaluate contrast wash-out during the portal venous and the late phase as is currently recommended. Wang et al[50] found that the combination of arterial phase enhancement and the contrast wash-out during the portal venous and the late phase determined by CEUS are more specific for HCC if nodules < 2 cm, compared with the use of either arterial phase enhancement or the absence of delayed phase enhancement considered separately (91.7% vs 66.7%).

Considering CT as the gold standard, the sensitivity of CEUS in detecting HCC decreases with smaller tumoral lesions. Two studies have found that lesion base sensitivity was 89.3% for nodules < 2 cm and 67% for nodules < 1 cm[51]. In a recent study, 72 patients with cirrhosis with 103 small hepatic nodules (1-2 cm) detected on US, underwent CEUS and CT. Nodules which had contrast enhancement during the arterial phase and contrast wash-out during the late phase on CEUS or CT were diagnosed as HCC. According on these diagnostic criteria the sensitivity of CEUS was 91.1% and specificity 87.2%[52].

CT

Helical CT and more recently multi-detector helical CT (MDCT), which has improved spatial and temporal resolution, has increased the accuracy of CT in diagnosis of HCC[47]. Several studies, most using correlation with explanted liver after transplantation, show that the overall sensitivity, specificity and positive predictive value of CT in diagnosis of HCC ranges from 51.9%-80.4%, 78.9%-97.9% and 88.6%-92.9% respectively[52-62].

Among studies that have assessed the sensitivity of CT in diagnosis of HCC and stratified for tumor size, the sensitivity for HCC < 2 cm in diameter was 61%, for HCC of 1-2 cm it ranged from 53.3% to 76%[3,53,58,59,61], and for HCC <1 cm in diameter it ranged from 10% to 57%[3,53-56,58,59].

CT requires intravenous iodinated contrast material and exposes patients to ionizing radiation. Although induction of renal failure by contrast is low, patients with liver cirrhosis frequently have renal dysfunction limiting its use[63], and the efficacy of N-acetylcysteine for preventing contrast induced-nephrotoxicity is not substantiated[64].

MRI

The application of MRI for liver imaging continues to expand with the recent progress of rapid, high-quality scanning techniques and the development of new tissue-specific contrast agents. Although initially used to complement CT in selective applications, MRI now plays an important primary role (after US) for the detection and characterization of liver tumors[65]. Extracellular intravenous contrast agents and novel tissue specific contrast agents are used to assess patterns of enhancement. Mostly, gadolinium-chelates are used for MRI, but hepatocyte-targeted and reticolo-endothelial system-targeted compounds are also used. Many studies have been published on the sensitivity and specificity of MRI imaging for diagnosis of HCC[3,42,54,55,57,58,60,66-72]. Among studies with liver explant correlation, the sensitivity, specificity and positive predictive value ranged from 33% to 83%, from 57.1% to 100% and from 42.3% to 100% respectively[3,54,55,57,58,60,66,67,69-72]. Studies which evaluated the sensitivity of MRI in detecting HCC, using only liver biopsy or clinical and radiological findings as gold standard, have shown an overall sensitivity, specificity and positive predictive value of 77.3% to 94.3%, 96.6% and of 92.6% to 97% respectively[42,56,68].

For MRI, the lesion-based sensitivity stratified for tumor size was 55.6% for < 2 cm in diameter; for HCC 1-2 cm in diameter it ranged from 52% to 89%[3,58,69,70], and for HCC <1cm in diameter it ranged from 4% to 88.2%[3,54-56,58,66,69,70,72].Super paramagnetic iron oxide particles used alone[56] or combined with gadolinium-based contrast agents[66,2] are highly sensitive for the diagnosis of small HCC. Ward et al[72] found a sensitivity of 91% for HCC ≥ 1 cm and of 46% for HCC ≤ 1 cm with double-contrast MRI. Another study [66] showed a sensitivity of 92% for HCC between 1 and 2 cm and 38% for HCC ≤ 1 cm. The sensitivity of MRA was shown to be superior to CT, but it also decreased with size of tumor (84% for nodules between 1 and 2 cm; 32% for nodules < 1 cm) [3]. In contrast when gadolinium-enhanced multiphase dynamic MRI was compared with MDCT scanning, for detecting small HCC, the sensitivity of detection for HCC <1 cm was higher with MDCT than with MRI (90%-95% vs 70%-85%)[73].

Whether MRI or CT should be the first imaging technique to characterise a nodule after ultrasound depends on the availability and characteristics of either technology in any one centre. Comparison of these is complicated by comparison of different generation machines[74] and different types of tumor. In general modern MRI appears more sensitive for the diagnosis of smaller nodules < 1.5 cm in a cirrhotic liver and in distinguishing regenerative/dysplastic nodules versus malignant ones. The importance of the experience of the reporting radiologist should not be underestimated here. Moreover every diagnostic imaging tool has some specific advantage and combination of more than one imaging technique, for difficult focal liver lesions, often increases diagnostic yield.

DIAGNOSIS-LIVER LESION BIOPSY AND TISSUE MARKERS

Many variables affect the accuracy of pathological diagnosis, with sampling being the most important. Many studies evaluating and/or validating immunostaining techniques, have used specimens obtained from resected or explanted livers. However, in clinical practice it is percutaneous biopsy specimens that are available. Biopsy specimens often are small, and represent a fraction of the tumor, so that a lack of immunostaining may simply be the result of inadequate sampling. Using standardized panels with more than one immunostaining method, may result in more confident histological diagnosis of HCC, with a better reproducibility and accuracy, but this needs to be evaluated formally using biopsy specimens.

The role of liver biopsy, in diagnosis of HCC in patients with cirrhosis, has declined during the past few years because better radiological techniques have enormously improved the accuracy of diagnosis. However, when the imaging characteristics are not typical together with AFP < 200 ng/mL, the diagnosis is not reliable without a biopsy sample, as recommended in the joint EASL/AASLD/JSH guidelines[21].

Even though the specificity and positive predictive value of nodule biopsy is high, its negative predictive value is low. Considering that there is a 10% risk of false negativity, the presence of HCC cannot be excluded when a biopsy is negative for HCC. Moreover, it has been suggested that a second biopsy performed immediately after the first one has a limited chance of success, with a gain in diagnosis of HCC of only approximately 5%[44,48,75]. In patients with HCC < 2 cm in whom the first nodule biopsy is negative, repeated imaging is preferred to performing a second biopsy. Whether the risk of false-negative findings is far higher in patients with small nodules (< 2 cm in size), compared with larger nodules, has not been yet clearly demonstrated. However, this is likely, as optimal placement of the needle in smaller nodules is more difficult. Indeed a study of the technical aspects of biopsying nodules ≤ 1 cm has not been published. However, independent of the size of nodules, the risk of false-negative is higher for those located on the posterior and superior segments of the liver[76].

Percutaneous biopsy of HCC carries a potential risk of tumor seeding along the needle tract. The median risk of seeding is 1%-2%, and is higher if performed alone, compared to combining biopsy with percutaneous ablative techniques[77,78]. Seeding can become manifest after liver transplantation[77,78]. However, if biopsy is necessary, with an indeterminate lesion, it should be combined with percutaneous ablation[77,78]. Another technical variant that may help prevent seeding is the use of a coaxial 17-gauge introducer needle before a 18-gauge biopsy needle, to isolate liver parenchyma during the run of biopsy needle[79]. This should be subject to a comparative study.

Ultrasound-guided fine-needle aspiration (FNA) cytology has been used as an alternative to biopsy because samples can be obtained with smaller needles (23 gauge). Although the specificity and positive predictive value of FNA examination for focal liver lesions is reasonable, the sensitivity ranges between 67% and 93% and thus diagnostic accuracy is less than for histology[77], and risk of seeding is not reduced. Fine-needle aspiration cytology is not recommended for diagnosis.

Histologically diagnosing borderline lesions represents the “Gordian knot” in HCC diagnostics. The three criteria listed from the International Working Party to differentiate HCC from an high grade dysplastic nodule and well-differentiated HCC are: cellular density more than twice normal, irregular nuclear contour of lesion cells and invasion of stroma or portal tract[80]. Tissue markers of HCC might provide a more standardized diagnosis especially for early/well-differentiated HCC and may give information about the probable phenotypic behaviour and thus guide therapy.

Tissue markers

Studies using genome-wide DNA microarray or quantitative real time reverse transcriptase polymerase chain reactions have been done to identify tissue markers of early HCC, in particular to distinguish HCC from dysplastic nodules: Glypican-3 (GPC-3)[81], TGF-b1[82,83], heat shock proteins (HSP) HSP-70 and HSP-27 are the most studied as they inhibit apoptosis[84].

Proteomic studies on liver tissue have traditionally utilized a combination of two-dimensional gel electrophoresis and mass spectrometry analysis[85]. Zeindl-Eberhart et al[86] demonstrated the immunoreactivity of aldose reductase-like protein variants (h-ARLP) in cells of HCC and their absence or low signal in normal and cirrhotic livers, fibrolamellar carcinoma or hepatic adenomas. In a more recent study Li et al[87] evaluated patients with HCC in HBV-related liver cirrhosis and found 80 proteins with differential expression in HCC. Among these, only two proteins (proliferating cell antigen and stathmin 1) were confirmed by Western blotting analysis.

A 3-gene set (GP3, LYVE1 and survivin) has been proposed as molecular diagnosis of early HCC with accuracy rates of 85%-95% in training and validation sets of more than 70 samples[88].

Current markers available for routine immunochemistry, show different ranges of sensitivity, and few of these are specific to HCC (as are AFP and GP-3). Although there are always false positives and negatives, other markers can be useful for differential diagnosis of HCC versus benign nodule or non-HCC cancers, if the specific HCC markers are negative and/or the experience of the pathologist suggests their use. Trying to classify these immunostaining patterns which are useful to build an HCC diagnostic panel, there are five groups of markers (Table 4): 1. specific HCC products, including, AFP and GP-3; 2. vascular pattern markers, such as CD34; 3. canalicular pattern markers, including polyclonal carcinoembryonic antigen (p-CEA) and CD10; 4. markers of cell proliferation such as Ki67; 5. other hepatocellular products as HepPar1 and cytokeratins.

Table 4 Immunohistochemistry for HCC.
MarkerStaining patternDiagnostic useDiagnostic valueRef.
AFPSpecific for HCC CytoplasmExpressed in HCC cells cytoplasm but also in: fetal liver, hepatoid tumors, germ cells tumorsSensitivity 17%-68%[89-104]
Specificity 97%
For HCC
GP-3Specific for HCC CytoplasmExpressed in HCC cell cytoplasm (less so if fibrolamellar or sarcomatoid variants) but also in: fetal liver, hepatoblastoma, melanomaSensitivity 49%-91%[81,109-115]
Specificity 89%-100%
For HCC
CD-34EndotheliumSurface of normal endothelium and HCC trabeculae or acini but also in: myelodysplasia in transformation, GI stromal tumors (high coexpression with bcl-2)HCC positivity 82%[117]
p-CEABiliary canaliculaIdentifies biliary glycoprotein 1 on hepatocyte canalicular pole and cholangiocyte. Useful for differential diagnosis vs cholangiocarcinoma, other adenocarcinomaHCC positivity 24%-90%[94,98,100,118-128]
CD-10Biliary canaliculaSurface of biliary tract cells and in HCC, but also positive in: B cell lymphomas, renal cells carcinoma, melanoma, prostate and pancreas adenocarcinoma. Useful for differential diagnosis vs cholangiocarcinoma, other adenocarcinomasHCC positivity 28%-86%[94,98,100,119,120,122-124,126,128]
Ki67 HepPar1Cell proliferation marker HCC & normal Hepatocyte citoplasmAssessing cell proliferation rate, correlates with tumor grade and clinical course. Useful to differentiate between HCC and hepatic adenomaHCC positivity rate 10%-50%[129]
Expressed in HCC and in normal liver cells, but also in hepatoblastoma. useful for differential diagnosis vs cholangiocarcinoma and metastasesHCC positivity 66%-100%[130-136]
CytokeratinsEpithelial cellsUseful for differential diagnosis vs cholangiocarcinoma. HCC profile: CK7/CK19/CK8/CK18 = - / - / + / +HCC positivity 76%-96%[97,101,104,137-140]
AFP

AFP is a fetal-specific glycoprotein with a molecular weight of 70 kDa, whose synthesis declines rapidly after birth. The immunohistochemical use of AFP staining has very low sensitivity as it detects just 17%-68% of malignant hepatocellular lesions when used alone[89-103]. In a study by Murakata et al[104] there was no staining of clear-cell HCC. However, the specificity of AFP is high with an average value of 97%[89,92,93,95,96,99,101,104].

GP-3

GP-3 is a member of the heparan sulfate proteoglycan family, linked to the cell surface through glycosylphosphatidyl inositol, which may also be found in a secreted form. In patients with HCC, GP-3 is over expressed in neoplastic liver tissue and elevated in the serum but is undetectable in normal liver. Melanoma[105], testicular germ cell tumors[106], Wilms tumor, hepatoblastoma[107], among non-HCC malignant neoplasms, and focal nodular hyperplasia, regenerative and dysplastic cirrhotic nodules, among liver benign and pre-malignant lesions, may be positive for GPC-3[108-110].

Immunostaining for GP-3 can be focal and so it not surprising that there is a lower sensitivity in studies using needle core biopsy[111,112] and FNA[113]. Wang et al[109] using 1-mm tissue microarray also demonstrated a sub-optimal sensitivity of GP-3 (70%). In a recent study using a fine-needle aspiration specimen GP-3 had a sensitivity of only 56.8%. The author suggested that the HCC specimen fixation in alcohol rather than in formalin reduced the positivity rate for GP-3[113], although this has not been confirmed. In the literature the GPC-3 sensitivity and specificity ranges from 49% to 90.5% and from 88.5% to 100% respectively[81,109-115]. Dysplastic nodules show a weak positivity of 0%-25% when low grade[109,110,114] and of 20%-75% when high grade[109,110,114].

CD34

CD34 is a 110 kDa transmembrane glycoprotein founded on normal endothelium. It is absent in normal liver sinusoids. The immunostain highlights regions of sinusoids, both in the vicinity of portal tracts in normal liver, and in areas of capillarization such as occur in the periphery of cirrhotic regenerative nodules[116]. In HCC samples an encircling pattern showing the endothelial cells investing the trabeculae and acini or a fine sinusoidal pattern, may be present in 82.5% of cases[117]. Overall specificity of this immunostaining is poor. However, the gradual increase in CD34 expression in HCC, reflecting the progressive arterialization due to hepatocarcinogenesis, eventually results in a complete CD34 immunostaining pattern, so that specificity becomes acceptable[115].

p-CEA

Polyclonal antibodies against carcinoembryonic antigen cross-react with biliary glycoprotein 1 expressed on cholangiocyte surfaces and on hepatocyte canalicular poles. In HCC, biliary glycoprotein 1 co-localisation may show a typical canalicular pattern. This is useful immunostaining for the differential diagnosis of HCC when it is a sclerosing or acinar variant (versus cholangiocarcinoma) or where there is pseudoglandular formation and/or clear cell changes in HCC (usually poorly differentiated HCC which is useful versus the differential of epithelial metastases). Immunostaining for p-CEA is reported positive in 24%-90% of HCC[94,98,100,118-128].

CD10

The diagnostic usefulness of CD10 immunostaining is analogous of that of p-CEA, with a lower sensitivity (28%-86%)[94,98,100,119,120,122-124,126,128], but with a specificity of 100%[119,122,123,126,128].

Ki67

Ki67 is a monoclonal antibody which reacts with nuclear proteins expressed in the G1, G2, M and S phases of cell cycle[129]. Evaluating the rate of proliferation is particularly useful for evaluating HCC grade and in differentiating between liver cell adenoma and HCC.

HepPar1

HepPar1 is an antibody which, on paraffin-embedded tissue, links mitochondrial antigens from both malignant and non-malignant hepatic cells, giving a granular cytoplasmic pattern on immunostaining. Is an excellent marker for HCC diagnosis, distinguishing between HCC and liver metastasis or cholangiocarcinoma. It has a similar accuracy to core needle biopsy and in FNA sampling, with a sensitivity of 66%-100% and a specificity of 70.8%-100%[130-136].

Cytokeratins

A subclass of the intermediate filaments family, the cytokeratins (CKs) are expressed in human liver with a characteristic distribution. CK8 and CK18 stain hepatocytes, CK8, CK7, CK18, and CK19 are present in bile duct cells. CK7 and CK19 are not usually present in HCC (76%-96% immunonegative)[97,101,104,137-140], but they exist in many adenocarcinomas, including, cholangiocarcinoma.

DIAGNOSIS-SERUM MOLECULAR MARKERS

Serum tumor markers have several potential uses: for early diagnosis of HCC in high risk patients, in determining prognosis, to estimate tumor volume as well as to monitor therapeutic response and detect recurrence[141].

AFP

The increase of serum AFP may relate to hepatocarcinogenesis but also to hepatic regeneration in chronic liver disease, and may also occur in embryonic carcinomas, gastric and lung cancers[142-147]. Moreover the positive predictive value for the diagnosis of HCC varies with the cut-off value used, ethnicity of the patients, treatment and tumor stage. An AFP with a cut off value of 20 ng/mL has a sensitivity and specificity for HCC diagnosis of 41%-65% and 80%-94% respectively[146]. About 42% of HCC are diagnosed in the absence of a raised AFP[29]. However, AFP confirms the diagnosis of HCC in cirrhosis when the value is over 200 ng/mL when the suspected nodule is larger than 2 cm[21]. A value of ≥ 400 ng/mL is often associated with the large volume of the tumor mass and/or the carcinomatous involvement of the portal vein, and with a poor median survival rate[145]. In a recent study about 61% of patients with AFP level of > 1000 ng/mL presented with vascular invasion[148].

Alpha-Fetoprotein-L3 (AFP-L3)

Studies on a fucosylated variant of the AFP glycoprotein which has a high affinity to the sugar chain of Lens culinaris showed increased activities in patients with chronic liver disease and HCC. However, sensitivity and specificity range from 36.5% to 71% and from 63% to 91.6%, respectively[149,150]. When compared with AFP, AFP-L3 showed a higher specificity but similar sensitivity. The disease specificity of this marker is limited as non-tumoral, extrahepatic disease (diabetes, pancreatitis and hypothyroidism) are associated with increased serum levels.

Des-g-carboxy prothrombin (DCP)

DCP also known as a protein induced by the absence of vitamin K or antagonist II (PIVKA-II) was reported firstly by Liebman et al[151] as a candidate biomarker for the diagnosis of HCC. Recent case-control studies documented a sensitivity and specificity ranging from 58% to 89% and 93% to 97% respectively[152-154],and one of these studies found that DCP had a higher sensitivity in the diagnosis of small HCC when compared to AFP and AFP-L3[154].

GPC-3

GPC-3 has been mainly evaluated at the tissue level, although some studies report that GPC-3 can be found in the serum in about 55% of patients with HCC. On the other hand GPC-3 is not detectable in healthy subjects and in patients with liver cirrhosis without HCC[114]. The sensitivity and specificity of serum GPC-3 in diagnosing HCC was reported to be 51% and 90% respectively[155].

GP73

GP73, a Golgi glycoprotein is overexpressed in viral-related HCC[156,157]. Total circulating GP73 can be positive in AFP negative cancer[158].

Other studies have evaluated hepatocyte growth factor[85,159], insulin growth factor[160,161], vascular endothelial growth factor[162] (which correlates with venous invasion), transforming growth factor TGFb1[163-165], IL-6 and IL-10[166,167], hepatoma-specific g-glutamyl-transferase GGTII[168], human cervical cancer oncogene (HCCR)[169] (HCC < 2 cm the positive predictive rate in HCC was 69.2%) and tumor-derived autoantibodies (TAA)[170,171].

Although numerous biomarkers with potential diagnostic or prognostic significance for HCC have been identified there are currently only two FDA-approved tumor markers (AFP and AFP-L3). It is likely that panels of 2 or 3 serum and tissue tumor markers will be used in routine clinical practice in the near future. A standardized approach is required to assess panels of tumor markers and validation is needed in large patient cohorts preferably from multiple centres. In the future, new markers may help not only to diagnose indeterminate lesions based on today’s criteria but also to distinguish between HCC with worse or better prognosis.

Diagnosis of HCC lesions in patients with cirrhosis requires a multidisciplinary approach. It follows that specialized centres in which patients may find skilled operators and the most recent diagnostic tools are necessary to optimise diagnosis, particularly with smaller lesions.

Footnotes

Peer reviewer: Donald Peter McManus, Professor and Head, Molecular Parasitology Laboratory, Division of Infectious Diseases, Queensland Institute of Medical Research, 300 Herston Road, Brisbane, Queensland 4006, Australia

S- Editor Zhang HN L- Editor Hughes D E- Editor Ma WH

References
1.  Bosch FX, Ribes J, Diaz M, Cleries R. Primary liver cancer: worldwide incidence and trends. Gastroenterology. 2004;127:S5-S16.  [PubMed]  [DOI]  [Cited in This Article: ]
2.  Fattovich G, Stroffolini T, Zagni I, Donato F. Hepatocellular carcinoma in cirrhosis: incidence and risk factors. Gastroenterology. 2004;127:S35-S50.  [PubMed]  [DOI]  [Cited in This Article: ]
3.  Burrel M, Llovet JM, Ayuso C, Iglesias C, Sala M, Miquel R, Caralt T, Ayuso JR, Sole M, Sanchez M. MRI angiography is superior to helical CT for detection of HCC prior to liver transplantation: an explant correlation. Hepatology. 2003;38:1034-1042.  [PubMed]  [DOI]  [Cited in This Article: ]
4.  Caturelli E, Bartolucci F, Biasini E, Vigliotti ML, Andriulli A, Siena DA, Attino V, Bisceglia M. Diagnosis of liver nodules observed in chronic liver disease patients during ultrasound screening for early detection of hepatocellular carcinoma. Am J Gastroenterol. 2002;97:397-405.  [PubMed]  [DOI]  [Cited in This Article: ]
5.  Caturelli E, Pompili M, Bartolucci F, Siena DA, Sperandeo M, Andriulli A, Bisceglia M. Hemangioma-like lesions in chronic liver disease: diagnostic evaluation in patients. Radiology. 2001;220:337-342.  [PubMed]  [DOI]  [Cited in This Article: ]
6.  Maruyama H, Yoshikawa M, Yokosuka O. Current role of ultrasound for the management of hepatocellular carcinoma. World J Gastroenterol. 2008;14:1710-1719.  [PubMed]  [DOI]  [Cited in This Article: ]
7.  Bolondi L, Sofia S, Siringo S, Gaiani S, Casali A, Zironi G, Piscaglia F, Gramantieri L, Zanetti M, Sherman M. Surveillance programme of cirrhotic patients for early diagnosis and treatment of hepatocellular carcinoma: a cost effectiveness analysis. Gut. 2001;48:251-259.  [PubMed]  [DOI]  [Cited in This Article: ]
8.  Kemp W, Pianko S, Nguyen S, Bailey MJ, Roberts SK. Survival in hepatocellular carcinoma: impact of screening and etiology of liver disease. J Gastroenterol Hepatol. 2005;20:873-881.  [PubMed]  [DOI]  [Cited in This Article: ]
9.  McMahon BJ, Bulkow L, Harpster A, Snowball M, Lanier A, Sacco F, Dunaway E, Williams J. Screening for hepatocellular carcinoma in Alaska natives infected with chronic hepatitis B: a 16-year population-based study. Hepatology. 2000;32:842-846.  [PubMed]  [DOI]  [Cited in This Article: ]
10.  Sangiovanni A, Del Ninno E, Fasani P, De Fazio C, Ronchi G, Romeo R, Morabito A, De Franchis R, Colombo M. Increased survival of cirrhotic patients with a hepatocellular carcinoma detected during surveillance. Gastroenterology. 2004;126:1005-1014.  [PubMed]  [DOI]  [Cited in This Article: ]
11.  Sherman M. Alphafetoprotein: an obituary. J Hepatol. 2001;34:603-605.  [PubMed]  [DOI]  [Cited in This Article: ]
12.  Cedrone A, Covino M, Caturelli E, Pompili M, Lorenzelli G, Villani MR, Valle D, Sperandeo M, Rapaccini GL, Gasbarrini G. Utility of alpha-fetoprotein (AFP) in the screening of patients with virus-related chronic liver disease: does different viral etiology influence AFP levels in HCC? A study in 350 western patients. Hepatogastroenterology. 2000;47:1654-1658.  [PubMed]  [DOI]  [Cited in This Article: ]
13.  Nguyen MH, Garcia RT, Simpson PW, Wright TL, Keeffe EB. Racial differences in effectiveness of alpha-fetoprotein for diagnosis of hepatocellular carcinoma in hepatitis C virus cirrhosis. Hepatology. 2002;36:410-417.  [PubMed]  [DOI]  [Cited in This Article: ]
14.  Peng YC, Chan CS, Chen GH. The effectiveness of serum alpha-fetoprotein level in anti-HCV positive patients for screening hepatocellular carcinoma. Hepatogastroenterology. 1999;46:3208-3211.  [PubMed]  [DOI]  [Cited in This Article: ]
15.  Tong MJ, Blatt LM, Kao VW. Surveillance for hepatocellular carcinoma in patients with chronic viral hepatitis in the United States of America. J Gastroenterol Hepatol. 2001;16:553-559.  [PubMed]  [DOI]  [Cited in This Article: ]
16.  Trevisani F, D'Intino PE, Morselli-Labate AM, Mazzella G, Accogli E, Caraceni P, Domenicali M, De Notariis S, Roda E, Bernardi M. Serum alpha-fetoprotein for diagnosis of hepatocellular carcinoma in patients with chronic liver disease: influence of HBsAg and anti-HCV status. J Hepatol. 2001;34:570-575.  [PubMed]  [DOI]  [Cited in This Article: ]
17.  Mok TS, Yeo W, Yu S, Lai P, Chan HL, Chan AT, Lau JW, Wong H, Leung N, Hui EP. An intensive surveillance program detected a high incidence of hepatocellular carcinoma among hepatitis B virus carriers with abnormal alpha-fetoprotein levels or abdominal ultrasonography results. J Clin Oncol. 2005;23:8041-8047.  [PubMed]  [DOI]  [Cited in This Article: ]
18.  Bruix J, Sherman M, Llovet JM, Beaugrand M, Lencioni R, Burroughs AK, Christensen E, Pagliaro L, Colombo M, Rodes J. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver. J Hepatol. 2001;35:421-430.  [PubMed]  [DOI]  [Cited in This Article: ]
19.  Thompson Coon J, Rogers G, Hewson P, Wright D, Anderson R, Jackson S, Ryder S, Cramp M, Stein K. Surveillance of cirrhosis for hepatocellular carcinoma: a cost-utility analysis. Br J Cancer. 2008;98:1166-1175.  [PubMed]  [DOI]  [Cited in This Article: ]
20.  Kang JY, Lee TP, Yap I, Lun KC. Analysis of cost-effectiveness of different strategies for hepatocellular carcinoma screening in hepatitis B virus carriers. J Gastroenterol Hepatol. 1992;7:463-468.  [PubMed]  [DOI]  [Cited in This Article: ]
21.  Bruix J, Sherman M. Management of hepatocellular carcinoma. Hepatology. 2005;42:1208-1236.  [PubMed]  [DOI]  [Cited in This Article: ]
22.  Zhang BH, Yang BH, Tang ZY. Randomized controlled trial of screening for hepatocellular carcinoma. J Cancer Res Clin Oncol. 2004;130:417-422.  [PubMed]  [DOI]  [Cited in This Article: ]
23.  Llovet JM, Bruix J. Novel advancements in the management of hepatocellular carcinoma in 2008. J Hepatol. 2008;48 Suppl 1:S20-S37.  [PubMed]  [DOI]  [Cited in This Article: ]
24.  Patz EF Jr, Goodman PC, Bepler G. Screening for lung cancer. N Engl J Med. 2000;343:1627-1633.  [PubMed]  [DOI]  [Cited in This Article: ]
25.  Trevisani F, De NS, Rapaccini G, Farinati F, Benvegnu L, Zoli M, Grazi GL, Del PP, Di N, Bernardi M. Semiannual and annual surveillance of cirrhotic patients for hepatocellular carcinoma: effects on cancer stage and patient survival (Italian experience). Am J Gastroenterol. 2002;97:734-744.  [PubMed]  [DOI]  [Cited in This Article: ]
26.  Ando E, Kuromatsu R, Tanaka M, Takada A, Fukushima N, Sumie S, Nagaoka S, Akiyoshi J, Inoue K, Torimura T. Surveillance program for early detection of hepatocellular carcinoma in Japan: results of specialized department of liver disease. J Clin Gastroenterol. 2006;40:942-948.  [PubMed]  [DOI]  [Cited in This Article: ]
27.  Bruix J, Hessheimer AJ, Forner A, Boix L, Vilana R, Llovet JM. New aspects of diagnosis and therapy of hepatocellular carcinoma. Oncogene. 2006;25:3848-3856.  [PubMed]  [DOI]  [Cited in This Article: ]
28.  Dodd GD 3rd, Miller WJ, Baron RL, Skolnick ML, Campbell WL. Detection of malignant tumors in end-stage cirrhotic livers: efficacy of sonography as a screening technique. AJR Am J Roentgenol. 1992;159:727-733.  [PubMed]  [DOI]  [Cited in This Article: ]
29.  Franca AV, Elias Junior J, Lima BL, Martinelli AL, Carrilho FJ. Diagnosis, staging and treatment of hepatocellular carcinoma. Braz J Med Biol Res. 2004;37:1689-1705.  [PubMed]  [DOI]  [Cited in This Article: ]
30.  Colli A, Fraquelli M, Casazza G, Massironi S, Colucci A, Conte D, Duca P. Accuracy of ultrasonography, spiral CT, magnetic resonance, and alpha-fetoprotein in diagnosing hepatocellular carcinoma: a systematic review. Am J Gastroenterol. 2006;101:513-523.  [PubMed]  [DOI]  [Cited in This Article: ]
31.  Saar B, Kellner-Weldon F. Radiological diagnosis of hepatocellular carcinoma. Liver Int. 2008;28:189-199.  [PubMed]  [DOI]  [Cited in This Article: ]
32.  Bennett GL, Krinsky GA, Abitbol RJ, Kim SY, Theise ND, Teperman LW. Sonographic detection of hepatocellular carcinoma and dysplastic nodules in cirrhosis: correlation of pretransplantation sonography and liver explant pathology in 200 patients. AJR Am J Roentgenol. 2002;179:75-80.  [PubMed]  [DOI]  [Cited in This Article: ]
33.  Saab S, Ly D, Nieto J, Kanwal F, Lu D, Raman S, Amado R, Nuesse B, Durazo F, Han S. Hepatocellular carcinoma screening in patients waiting for liver transplantation: a decision analytic model. Liver Transpl. 2003;9:672-681.  [PubMed]  [DOI]  [Cited in This Article: ]
34.  Rapaccini GL, Pompili M, Caturelli E, Covino M, Lippi ME, Beccaria S, Cedrone A, Riccardi L, Siena DA, Gasbarrini G. Hepatocellular carcinomas <2 cm in diameter complicating cirrhosis: ultrasound and clinical features in 153 consecutive patients. Liver Int. 2004;24:124-130.  [PubMed]  [DOI]  [Cited in This Article: ]
35.  Sheu JC, Chen DS, Sung JL, Chuang CN, Yang PM, Lin JT, Yang PC. Hepatocellular carcinoma: US evolution in the early stage. Radiology. 1985;155:463-467.  [PubMed]  [DOI]  [Cited in This Article: ]
36.  Lencioni R, Cioni D, Crocetti L, Donati F, Franchini C, Giusti S, Bartolozzi C. Ultrasound imaging of focal liver lesions with a second-generation contrast agent. Acad Radiol. 2002;9 Suppl 2:S371-S374.  [PubMed]  [DOI]  [Cited in This Article: ]
37.  Lencioni R, Piscaglia F, Bolondi L. Contrast-enhanced ultrasound in the diagnosis of hepatocellular carcinoma. J Hepatol. 2008;48:848-857.  [PubMed]  [DOI]  [Cited in This Article: ]
38.  Giesel FL, Delorme S, Sibbel R, Kauczor HU, Krix M. [Contrast-enhanced ultrasound for the characterization of incidental liver lesions - an economical evaluation in comparison with multi-phase computed tomography]. Ultraschall Med. 2009;30:259-268.  [PubMed]  [DOI]  [Cited in This Article: ]
39.  Makuuchi M, Kokudo N. Clinical practice guidelines for hepatocellular carcinoma: the first evidence based guidelines from Japan. World J Gastroenterol. 2006;12:828-829.  [PubMed]  [DOI]  [Cited in This Article: ]
40.  Hayashi M, Matsui O, Ueda K, Kawamori Y, Kadoya M, Yoshikawa J, Gabata T, Takashima T, Nonomura A, Nakanuma Y. Correlation between the blood supply and grade of malignancy of hepatocellular nodules associated with liver cirrhosis: evaluation by CT during intraarterial injection of contrast medium. AJR Am J Roentgenol. 1999;172:969-976.  [PubMed]  [DOI]  [Cited in This Article: ]
41.  Kim YI, Chung JW, Park JH, Kang GH, Lee M, Suh KS, Kim KG. Multiphase contrast-enhanced CT imaging in hepatocellular carcinoma correlation with immunohistochemical angiogenic activities. Acad Radiol. 2007;14:1084-1091.  [PubMed]  [DOI]  [Cited in This Article: ]
42.  Forner A, Vilana R, Ayuso C, Bianchi L, Sole M, Ayuso JR, Boix L, Sala M, Varela M, Llovet JM. Diagnosis of hepatic nodules 20 mm or smaller in cirrhosis: Prospective validation of the noninvasive diagnostic criteria for hepatocellular carcinoma. Hepatology. 2008;47:97-104.  [PubMed]  [DOI]  [Cited in This Article: ]
43.  Caturelli E, de Sio I. Biopsy diagnosis of hepatocellular carcinoma. Hepatology. 2008;47:2145; author reply 2146-2147.  [PubMed]  [DOI]  [Cited in This Article: ]
44.  Caturelli E, Biasini E, Bartolucci F, Facciorusso D, Decembrino F, Attino V, Bisceglia M. Diagnosis of hepatocellular carcinoma complicating liver cirrhosis: utility of repeat ultrasound-guided biopsy after unsuccessful first sampling. Cardiovasc Intervent Radiol. 2002;25:295-299.  [PubMed]  [DOI]  [Cited in This Article: ]
45.  Tanaka M, Nakashima O, Wada Y, Kage M, Kojiro M. Pathomorphological study of Kupffer cells in hepatocellular carcinoma and hyperplastic nodular lesions in the liver. Hepatology. 1996;24:807-812.  [PubMed]  [DOI]  [Cited in This Article: ]
46.  Konopke R, Bunk A, Kersting S. The role of contrast-enhanced ultrasound for focal liver lesion detection: an overview. Ultrasound Med Biol. 2007;33:1515-1526.  [PubMed]  [DOI]  [Cited in This Article: ]
47.  Lu MD, Yu XL, Li AH, Jiang TA, Chen MH, Zhao BZ, Zhou XD, Wang JR. Comparison of contrast enhanced ultrasound and contrast enhanced CT or MRI in monitoring percutaneous thermal ablation procedure in patients with hepatocellular carcinoma: a multi-center study in China. Ultrasound Med Biol. 2007;33:1736-1749.  [PubMed]  [DOI]  [Cited in This Article: ]
48.  Bolondi L, Gaiani S, Celli N, Golfieri R, Grigioni WF, Leoni S, Venturi AM, Piscaglia F. Characterization of small nodules in cirrhosis by assessment of vascularity: the problem of hypovascular hepatocellular carcinoma. Hepatology. 2005;42:27-34.  [PubMed]  [DOI]  [Cited in This Article: ]
49.  Giorgio A, Ferraioli G, Tarantino L, de Stefano G, Scala V, Scarano F, Coppola C, Del Viscovo L. Contrast-enhanced sonographic appearance of hepatocellular carcinoma in patients with cirrhosis: comparison with contrast-enhanced helical CT appearance. AJR Am J Roentgenol. 2004;183:1319-1326.  [PubMed]  [DOI]  [Cited in This Article: ]
50.  Wang JH, Lu SN, Hung CH, Chen TY, Chen CH, Changchien CS, Lee CM. Small hepatic nodules (< or =2 cm) in cirrhosis patients: characterization with contrast-enhanced ultrasonography. Liver Int. 2006;26:928-934.  [PubMed]  [DOI]  [Cited in This Article: ]
51.  Gaiani S, Celli N, Piscaglia F, Cecilioni L, Losinno F, Giangregorio F, Mancini M, Pini P, Fornari F, Bolondi L. Usefulness of contrast-enhanced perfusional sonography in the assessment of hepatocellular carcinoma hypervascular at spiral computed tomography. J Hepatol. 2004;41:421-426.  [PubMed]  [DOI]  [Cited in This Article: ]
52.  Dai Y, Chen MH, Fan ZH, Yan K, Yin SS, Zhang XP. Diagnosis of small hepatic nodules detected by surveillance ultrasound in patients with cirrhosis: Comparison between contrast-enhanced ultrasound and contrast-enhanced helical computed tomography. Hepatol Res. 2008;38:281-290.  [PubMed]  [DOI]  [Cited in This Article: ]
53.  Bhattacharjya S, Bhattacharjya T, Quaglia A, Dhillon AP, Burroughs AK, Patch DW, Tibballs JM, Watkinson AF, Rolles K, Davidson BR. Liver transplantation in cirrhotic patients with small hepatocellular carcinoma: an analysis of pre-operative imaging, explant histology and prognostic histologic indicators. Dig Surg. 2004;21:152-159; discussion 159-160.  [PubMed]  [DOI]  [Cited in This Article: ]
54.  Choi SH, Lee JM, Yu NC, Suh KS, Jang JJ, Kim SH, Choi BI. Hepatocellular carcinoma in liver transplantation candidates: detection with gadobenate dimeglumine-enhanced MRI. AJR Am J Roentgenol. 2008;191:529-536.  [PubMed]  [DOI]  [Cited in This Article: ]
55.  de Ledinghen V, Laharie D, Lecesne R, Le Bail B, Winnock M, Bernard PH, Saric J, Couzigou P, Balabaud C, Bioulac-Sage P. Detection of nodules in liver cirrhosis: spiral computed tomography or magnetic resonance imaging? A prospective study of 88 nodules in 34 patients. Eur J Gastroenterol Hepatol. 2002;14:159-165.  [PubMed]  [DOI]  [Cited in This Article: ]
56.  Kim YK, Kwak HS, Kim CS, Chung GH, Han YM, Lee JM. Hepatocellular carcinoma in patients with chronic liver disease: comparison of SPIO-enhanced MR imaging and 16-detector row CT. Radiology. 2006;238:531-541.  [PubMed]  [DOI]  [Cited in This Article: ]
57.  Libbrecht L, Bielen D, Verslype C, Vanbeckevoort D, Pirenne J, Nevens F, Desmet V, Roskams T. Focal lesions in cirrhotic explant livers: pathological evaluation and accuracy of pretransplantation imaging examinations. Liver Transpl. 2002;8:749-761.  [PubMed]  [DOI]  [Cited in This Article: ]
58.  Rode A, Bancel B, Douek P, Chevallier M, Vilgrain V, Picaud G, Henry L, Berger F, Bizollon T, Gaudin JL. Small nodule detection in cirrhotic livers: evaluation with US, spiral CT, and MRI and correlation with pathologic examination of explanted liver. J Comput Assist Tomogr. 2001;25:327-336.  [PubMed]  [DOI]  [Cited in This Article: ]
59.  Ronzoni A, Artioli D, Scardina R, Battistig L, Minola E, Sironi S, Vanzulli A. Role of MDCT in the diagnosis of hepatocellular carcinoma in patients with cirrhosis undergoing orthotopic liver transplantation. AJR Am J Roentgenol. 2007;189:792-798.  [PubMed]  [DOI]  [Cited in This Article: ]
60.  Teefey SA, Hildeboldt CC, Dehdashti F, Siegel BA, Peters MG, Heiken JP, Brown JJ, McFarland EG, Middleton WD, Balfe DM. Detection of primary hepatic malignancy in liver transplant candidates: prospective comparison of CT, MR imaging, US, and PET. Radiology. 2003;226:533-542.  [PubMed]  [DOI]  [Cited in This Article: ]
61.  Valls C, Cos M, Figueras J, Andia E, Ramos E, Sanchez A, Serrano T, Torras J. Pretransplantation diagnosis and staging of hepatocellular carcinoma in patients with cirrhosis: value of dual-phase helical CT. AJR Am J Roentgenol. 2004;182:1011-1017.  [PubMed]  [DOI]  [Cited in This Article: ]
62.  Zacherl J, Pokieser P, Wrba F, Scheuba C, Prokesch R, Zacherl M, Langle F, Berlakovich GA, Muhlbacher F, Steininger R. Accuracy of multiphasic helical computed tomography and intraoperative sonography in patients undergoing orthotopic liver transplantation for hepatoma: what is the truth? Ann Surg. 2002;235:528-532.  [PubMed]  [DOI]  [Cited in This Article: ]
63.  Guevara M, Fernandez-Esparrach G, Alessandria C, Torre A, Terra C, Montana X, Piera C, Alvarez ML, Jimenez W, Gines P. Effects of contrast media on renal function in patients with cirrhosis: a prospective study. Hepatology. 2004;40:646-651.  [PubMed]  [DOI]  [Cited in This Article: ]
64.  Gonzales DA, Norsworthy KJ, Kern SJ, Banks S, Sieving PC, Star RA, Natanson C, Danner RL. A meta-analysis of N-acetylcysteine in contrast-induced nephrotoxicity: unsupervised clustering to resolve heterogeneity. BMC Med. 2007;5:32.  [PubMed]  [DOI]  [Cited in This Article: ]
65.  Willatt JM, Hussain HK, Adusumilli S, Marrero JA. MR Imaging of hepatocellular carcinoma in the cirrhotic liver: challenges and controversies. Radiology. 2008;247:311-330.  [PubMed]  [DOI]  [Cited in This Article: ]
66.  Bhartia B, Ward J, Guthrie JA, Robinson PJ. Hepatocellular carcinoma in cirrhotic livers: double-contrast thin-section MR imaging with pathologic correlation of explanted tissue. AJR Am J Roentgenol. 2003;180:577-584.  [PubMed]  [DOI]  [Cited in This Article: ]
67.  Hecht EM, Holland AE, Israel GM, Hahn WY, Kim DC, West AB, Babb JS, Taouli B, Lee VS, Krinsky GA. Hepatocellular carcinoma in the cirrhotic liver: gadolinium-enhanced 3D T1-weighted MR imaging as a stand-alone sequence for diagnosis. Radiology. 2006;239:438-447.  [PubMed]  [DOI]  [Cited in This Article: ]
68.  Kim YK, Kim CS, Kwak HS, Lee JM. Three-dimensional dynamic liver MR imaging using sensitivity encoding for detection of hepatocellular carcinomas: comparison with superparamagnetic iron oxide-enhanced mr imaging. J Magn Reson Imaging. 2004;20:826-837.  [PubMed]  [DOI]  [Cited in This Article: ]
69.  Krinsky GA, Lee VS, Theise ND, Weinreb JC, Rofsky NM, Diflo T, Teperman LW. Hepatocellular carcinoma and dysplastic nodules in patients with cirrhosis: prospective diagnosis with MR imaging and explantation correlation. Radiology. 2001;219:445-454.  [PubMed]  [DOI]  [Cited in This Article: ]
70.  Krinsky GA, Lee VS, Theise ND, Weinreb JC, Morgan GR, Diflo T, John D, Teperman LW, Goldenberg AS. Transplantation for hepatocellular carcinoma and cirrhosis: sensitivity of magnetic resonance imaging. Liver Transpl. 2002;8:1156-1164.  [PubMed]  [DOI]  [Cited in This Article: ]
71.  Lauenstein TC, Salman K, Morreira R, Heffron T, Spivey JR, Martinez E, Sharma P, Martin DR. Gadolinium-enhanced MRI for tumor surveillance before liver transplantation: center-based experience. AJR Am J Roentgenol. 2007;189:663-670.  [PubMed]  [DOI]  [Cited in This Article: ]
72.  Ward J, Guthrie JA, Scott DJ, Atchley J, Wilson D, Davies MH, Wyatt JI, Robinson PJ. Hepatocellular carcinoma in the cirrhotic liver: double-contrast MR imaging for diagnosis. Radiology. 2000;216:154-162.  [PubMed]  [DOI]  [Cited in This Article: ]
73.  Zhao H, Yao JL, Wang Y, Zhou KR. Detection of small hepatocellular carcinoma: comparison of dynamic enhancement magnetic resonance imaging and multiphase multirow-detector helical CT scanning. World J Gastroenterol. 2007;13:1252-1256.  [PubMed]  [DOI]  [Cited in This Article: ]
74.  Fung KT, Li FT, Raimondo ML, Maudgil D, Mancuso A, Tibballs JM, Watkinson AA, Patch D, Burroughs AK. Systematic review of radiological imaging for hepatocellular carcinoma in cirrhotic patients. Br J Radiol. 2004;77:633-640.  [PubMed]  [DOI]  [Cited in This Article: ]
75.  Durand F, Regimbeau JM, Belghiti J, Sauvanet A, Vilgrain V, Terris B, Moutardier V, Farges O, Valla D. Assessment of the benefits and risks of percutaneous biopsy before surgical resection of hepatocellular carcinoma. J Hepatol. 2001;35:254-258.  [PubMed]  [DOI]  [Cited in This Article: ]
76.  Durand F, Belghiti J, Paradis V. Liver transplantation for hepatocellular carcinoma: role of biopsy. Liver Transpl. 2007;13:S17-S23.  [PubMed]  [DOI]  [Cited in This Article: ]
77.  Stigliano R, Burroughs AK. Should we biopsy each liver mass suspicious for HCC before liver transplantation?--no, please don’t. J Hepatol. 2005;43:563-568.  [PubMed]  [DOI]  [Cited in This Article: ]
78.  Stigliano R, Marelli L, Yu D, Davies N, Patch D, Burroughs AK. Seeding following percutaneous diagnostic and therapeutic approaches for hepatocellular carcinoma. What is the risk and the outcome? Seeding risk for percutaneous approach of HCC. Cancer Treat Rev. 2007;33:437-447.  [PubMed]  [DOI]  [Cited in This Article: ]
79.  Maturen KE, Nghiem HV, Marrero JA, Hussain HK, Higgins EG, Fox GA, Francis IR. Lack of tumor seeding of hepatocellular carcinoma after percutaneous needle biopsy using coaxial cutting needle technique. AJR Am J Roentgenol. 2006;187:1184-187.  [PubMed]  [DOI]  [Cited in This Article: ]
80.  Wanless IR. International consensus on histologic diagnosis of early hepatocellular neoplasia. Hepatol Res. 2007;37 Suppl 2:S139-S141.  [PubMed]  [DOI]  [Cited in This Article: ]
81.  Di Tommaso L, Franchi G, Park YN, Fiamengo B, Destro A, Morenghi E, Montorsi M, Torzilli G, Tommasini M, Terracciano L. Diagnostic value of HSP70, glypican 3, and glutamine synthetase in hepatocellular nodules in cirrhosis. Hepatology. 2007;45:725-734.  [PubMed]  [DOI]  [Cited in This Article: ]
82.  Kim YJ, Lee HS, Im JP, Min BH, Kim HD, Jeong JB, Yoon JH, Kim CY, Kim MS, Kim JY. Association of transforming growth factor-beta1 gene polymorphisms with a hepatocellular carcinoma risk in patients with chronic hepatitis B virus infection. Exp Mol Med. 2003;35:196-202.  [PubMed]  [DOI]  [Cited in This Article: ]
83.  Okumoto K, Hattori E, Tamura K, Kiso S, Watanabe H, Saito K, Saito T, Togashi H, Kawata S. Possible contribution of circulating transforming growth factor-beta1 to immunity and prognosis in unresectable hepatocellular carcinoma. Liver Int. 2004;24:21-28.  [PubMed]  [DOI]  [Cited in This Article: ]
84.  Joo M, Chi JG, Lee H. Expressions of HSP70 and HSP27 in hepatocellular carcinoma. J Korean Med Sci. 2005;20:829-834.  [PubMed]  [DOI]  [Cited in This Article: ]
85.  Wright LM, Kreikemeier JT, Fimmel CJ. A concise review of serum markers for hepatocellular cancer. Cancer Detect Prev. 2007;31:35-44.  [PubMed]  [DOI]  [Cited in This Article: ]
86.  Zeindl-Eberhart E, Haraida S, Liebmann S, Jungblut PR, Lamer S, Mayer D, Jager G, Chung S, Rabes HM. Detection and identification of tumor-associated protein variants in human hepatocellular carcinomas. Hepatology. 2004;39:540-549.  [PubMed]  [DOI]  [Cited in This Article: ]
87.  Li C, Tan YX, Zhou H, Ding SJ, Li SJ, Ma DJ, Man XB, Hong Y, Zhang L, Li L. Proteomic analysis of hepatitis B virus-associated hepatocellular carcinoma: Identification of potential tumor markers. Proteomics. 2005;5:1125-1139.  [PubMed]  [DOI]  [Cited in This Article: ]
88.  Llovet JM, Chen Y, Wurmbach E, Roayaie S, Fiel MI, Schwartz M, Thung SN, Khitrov G, Zhang W, Villanueva A. A molecular signature to discriminate dysplastic nodules from early hepatocellular carcinoma in HCV cirrhosis. Gastroenterology. 2006;131:1758-1767.  [PubMed]  [DOI]  [Cited in This Article: ]
89.  Bedrossian CW, Davila RM, Merenda G. Immunocytochemical evaluation of liver fine-needle aspirations. Arch Pathol Lab Med. 1989;113:1225-1230.  [PubMed]  [DOI]  [Cited in This Article: ]
90.  Brumm C, Schulze C, Charels K, Morohoshi T, Kloppel G. The significance of alpha-fetoprotein and other tumour markers in differential immunocytochemistry of primary liver tumours. Histopathology. 1989;14:503-513.  [PubMed]  [DOI]  [Cited in This Article: ]
91.  Chedid A, Chejfec G, Eichorst M, Villamil F, Terg R, Telenta M, Hojman R. Antigenic markers of hepatocellular carcinoma. Cancer. 1990;65:84-87.  [PubMed]  [DOI]  [Cited in This Article: ]
92.  Fucich LF, Cheles MK, Thung SN, Gerber MA, Marrogi AJ. Primary vs metastatic hepatic carcinoma. An immunohistochemical study of 34 cases. Arch Pathol Lab Med. 1994;118:927-930.  [PubMed]  [DOI]  [Cited in This Article: ]
93.  Ganjei P, Nadji M, Albores-Saavedra J, Morales AR. Histologic markers in primary and metastatic tumors of the liver. Cancer. 1988;62:1994-1998.  [PubMed]  [DOI]  [Cited in This Article: ]
94.  Hurlimann J, Gardiol D. Immunohistochemistry in the differential diagnosis of liver carcinomas. Am J Surg Pathol. 1991;15:280-288.  [PubMed]  [DOI]  [Cited in This Article: ]
95.  Imoto M, Nishimura D, Fukuda Y, Sugiyama K, Kumada T, Nakano S. Immunohistochemical detection of alpha-fetoprotein, carcinoembryonic antigen, and ferritin in formalin-paraffin sections from hepatocellular carcinoma. Am J Gastroenterol. 1985;80:902-906.  [PubMed]  [DOI]  [Cited in This Article: ]
96.  Johnson DE, Powers CN, Rupp G, Frable WJ. Immunocytochemical staining of fine-needle aspiration biopsies of the liver as a diagnostic tool for hepatocellular carcinoma. Mod Pathol. 1992;5:117-123.  [PubMed]  [DOI]  [Cited in This Article: ]
97.  Leong AS, Sormunen RT, Tsui WM, Liew CT. Hep Par 1 and selected antibodies in the immunohistological distinction of hepatocellular carcinoma from cholangiocarcinoma, combined tumours and metastatic carcinoma. Histopathology. 1998;33:318-324.  [PubMed]  [DOI]  [Cited in This Article: ]
98.  Ma CK, Zarbo RJ, Frierson HF Jr, Lee MW. Comparative immunohistochemical study of primary and metastatic carcinomas of the liver. Am J Clin Pathol. 1993;99:551-557.  [PubMed]  [DOI]  [Cited in This Article: ]
99.  McCluggage WG, Maxwell P, Patterson A, Sloan JM. Immunohistochemical staining of hepatocellular carcinoma with monoclonal antibody against inhibin. Histopathology. 1997;30:518-522.  [PubMed]  [DOI]  [Cited in This Article: ]
100.  Minervini MI, Demetris AJ, Lee RG, Carr BI, Madariaga J, Nalesnik MA. Utilization of hepatocyte-specific antibody in the immunocytochemical evaluation of liver tumors. Mod Pathol. 1997;10:686-692.  [PubMed]  [DOI]  [Cited in This Article: ]
101.  Porcell AI, De Young BR, Proca DM, Frankel WL. Immunohistochemical analysis of hepatocellular and adenocarcinoma in the liver: MOC31 compares favorably with other putative markers. Mod Pathol. 2000;13:773-778.  [PubMed]  [DOI]  [Cited in This Article: ]
102.  Sato K, Tanaka M, Kusaba T, Fukuda H, Tanikawa K. Immunohistochemical demonstration of alpha-fetoprotein in small hepatocellular carcinoma. Oncol Rep. 1998;5:355-358.  [PubMed]  [DOI]  [Cited in This Article: ]
103.  Tsuji M, Kashihara T, Terada N, Mori H. An immunohistochemical study of hepatic atypical adenomatous hyperplasia, hepatocellular carcinoma, and cholangiocarcinoma with alpha-fetoprotein, carcinoembryonic antigen, CA19-9, epithelial membrane antigen, and cytokeratins 18 and 19. Pathol Int. 1999;49:310-317.  [PubMed]  [DOI]  [Cited in This Article: ]
104.  Murakata LA, Ishak KG, Nzeako UC. Clear cell carcinoma of the liver: a comparative immunohistochemical study with renal clear cell carcinoma. Mod Pathol. 2000;13:874-881.  [PubMed]  [DOI]  [Cited in This Article: ]
105.  Nakatsura T, Kageshita T, Ito S, Wakamatsu K, Monji M, Ikuta Y, Senju S, Ono T, Nishimura Y. Identification of glypican-3 as a novel tumor marker for melanoma. Clin Cancer Res. 2004;10:6612-6621.  [PubMed]  [DOI]  [Cited in This Article: ]
106.  Zynger DL, Dimov ND, Luan C, Teh BT, Yang XJ. Glypican 3: a novel marker in testicular germ cell tumors. Am J Surg Pathol. 2006;30:1570-1575.  [PubMed]  [DOI]  [Cited in This Article: ]
107.  Toretsky JA, Zitomersky NL, Eskenazi AE, Voigt RW, Strauch ED, Sun CC, Huber R, Meltzer SJ, Schlessinger D. Glypican-3 expression in Wilms tumor and hepatoblastoma. J Pediatr Hematol Oncol. 2001;23:496-499.  [PubMed]  [DOI]  [Cited in This Article: ]
108.  Nakatsura T, Nishimura Y. Usefulness of the novel oncofetal antigen glypican-3 for diagnosis of hepatocellular carcinoma and melanoma. BioDrugs. 2005;19:71-77.  [PubMed]  [DOI]  [Cited in This Article: ]
109.  Wang XY, Degos F, Dubois S, Tessiore S, Allegretta M, Guttmann RD, Jothy S, Belghiti J, Bedossa P, Paradis V. Glypican-3 expression in hepatocellular tumors: diagnostic value for preneoplastic lesions and hepatocellular carcinomas. Hum Pathol. 2006;37:1435-1441.  [PubMed]  [DOI]  [Cited in This Article: ]
110.  Yamauchi N, Watanabe A, Hishinuma M, Ohashi K, Midorikawa Y, Morishita Y, Niki T, Shibahara J, Mori M, Makuuchi M. The glypican 3 oncofetal protein is a promising diagnostic marker for hepatocellular carcinoma. Mod Pathol. 2005;18:1591-1598.  [PubMed]  [DOI]  [Cited in This Article: ]
111.  Anatelli F, Chuang ST, Yang XJ, Wang HL. Value of glypican 3 immunostaining in the diagnosis of hepatocellular carcinoma on needle biopsy. Am J Clin Pathol. 2008;130:219-223.  [PubMed]  [DOI]  [Cited in This Article: ]
112.  Libbrecht L, Severi T, Cassiman D, Vander Borght S, Pirenne J, Nevens F, Verslype C, van Pelt J, Roskams T. Glypican-3 expression distinguishes small hepatocellular carcinomas from cirrhosis, dysplastic nodules, and focal nodular hyperplasia-like nodules. Am J Surg Pathol. 2006;30:1405-1411.  [PubMed]  [DOI]  [Cited in This Article: ]
113.  Nassar A, Cohen C, Siddiqui MT. Utility of glypican-3 and survivin in differentiating hepatocellular carcinoma from benign and preneoplastic hepatic lesions and metastatic carcinomas in liver fine-needle aspiration biopsies. Diagn Cytopathol. 2009;37:629-635.  [PubMed]  [DOI]  [Cited in This Article: ]
114.  Capurro M, Wanless IR, Sherman M, Deboer G, Shi W, Miyoshi E, Filmus J. Glypican-3: a novel serum and histochemical marker for hepatocellular carcinoma. Gastroenterology. 2003;125:89-97.  [PubMed]  [DOI]  [Cited in This Article: ]
115.  Coston WM, Loera S, Lau SK, Ishizawa S, Jiang Z, Wu CL, Yen Y, Weiss LM, Chu PG. Distinction of hepatocellular carcinoma from benign hepatic mimickers using Glypican-3 and CD34 immunohistochemistry. Am J Surg Pathol. 2008;32:433-444.  [PubMed]  [DOI]  [Cited in This Article: ]
116.  Dhillon AP, Colombari R, Savage K, Scheuer PJ. An immunohistochemical study of the blood vessels within primary hepatocellular tumours. Liver. 1992;12:311-318.  [PubMed]  [DOI]  [Cited in This Article: ]
117.  de Boer WB, Segal A, Frost FA, Sterrett GF. Can CD34 discriminate between benign and malignant hepatocytic lesions in fine-needle aspirates and thin core biopsies? Cancer. 2000;90:273-278.  [PubMed]  [DOI]  [Cited in This Article: ]
118.  Bonetti F, Chilosi M, Pisa R, Novelli P, Zamboni G, Menestrina F. Epithelial membrane antigen expression in cholangiocarcinoma. An useful immunohistochemical tool for differential diagnosis with hepatocarcinoma. Virchows Arch A Pathol Anat Histopathol. 1983;401:307-313.  [PubMed]  [DOI]  [Cited in This Article: ]
119.  Borscheri N, Roessner A, Rocken C. Canalicular immunostaining of neprilysin (CD10) as a diagnostic marker for hepatocellular carcinomas. Am J Surg Pathol. 2001;25:1297-1303.  [PubMed]  [DOI]  [Cited in This Article: ]
120.  D’Errico A, Baccarini P, Fiorentino M, Ceccarelli C, Bonazzi C, Ponzetto A, Scoazec JY, Mancini AM, Grigioni WF. Histogenesis of primary liver carcinomas: strengths and weaknesses of cytokeratin profile and albumin mRNA detection. Hum Pathol. 1996;27:599-604.  [PubMed]  [DOI]  [Cited in This Article: ]
121.  Duclos-Vallee JC, Emile JF, Rifai K, Roque-Afonso AM, Feray C, Petit C, Samuel D. Intense isolated expression with preS1 (large protein) antibodies in the liver graft associated with severe acute hepatitis B virus reactivation. J Hepatol. 2001;34:962.  [PubMed]  [DOI]  [Cited in This Article: ]
122.  Lau SK, Prakash S, Geller SA, Alsabeh R. Comparative immunohistochemical profile of hepatocellular carcinoma, cholangiocarcinoma, and metastatic adenocarcinoma. Hum Pathol. 2002;33:1175-1181.  [PubMed]  [DOI]  [Cited in This Article: ]
123.  Morrison C, Marsh W Jr, Frankel WL. A comparison of CD10 to pCEA, MOC-31, and hepatocyte for the distinction of malignant tumors in the liver. Mod Pathol. 2002;15:1279-1287.  [PubMed]  [DOI]  [Cited in This Article: ]
124.  Oliveira AM, Erickson LA, Burgart LJ, Lloyd RV. Differentiation of primary and metastatic clear cell tumors in the liver by in situ hybridization for albumin messenger RNA. Am J Surg Pathol. 2000;24:177-182.  [PubMed]  [DOI]  [Cited in This Article: ]
125.  Rocken C, Licht J, Roessner A, Carl-McGrath S. Canalicular immunostaining of aminopeptidase N (CD13) as a diagnostic marker for hepatocellular carcinoma. J Clin Pathol. 2005;58:1069-1075.  [PubMed]  [DOI]  [Cited in This Article: ]
126.  Saad RS, Luckasevic TM, Noga CM, Johnson DR, Silverman JF, Liu YL. Diagnostic value of HepPar1, pCEA, CD10, and CD34 expression in separating hepatocellular carcinoma from metastatic carcinoma in fine-needle aspiration cytology. Diagn Cytopathol. 2004;30:1-6.  [PubMed]  [DOI]  [Cited in This Article: ]
127.  Tseng SC, Jarvinen MJ, Nelson WG, Huang JW, Woodcock-Mitchell J, Sun TT. Correlation of specific keratins with different types of epithelial differentiation: monoclonal antibody studies. Cell. 1982;30:361-372.  [PubMed]  [DOI]  [Cited in This Article: ]
128.  Xiao SY, Wang HL, Hart J, Fleming D, Beard MR. cDNA arrays and immunohistochemistry identification of CD10/CALLA expression in hepatocellular carcinoma. Am J Pathol. 2001;159:1415-1421.  [PubMed]  [DOI]  [Cited in This Article: ]
129.  Grigioni WF, D’Errico A, Bacci F, Gaudio M, Mazziotti A, Gozzetti G, Mancini AM. Primary liver neoplasms: evaluation of proliferative index using MoAb Ki67. J Pathol. 1989;158:23-29.  [PubMed]  [DOI]  [Cited in This Article: ]
130.  Chu PG, Ishizawa S, Wu E, Weiss LM. Hepatocyte antigen as a marker of hepatocellular carcinoma: an immunohistochemical comparison to carcinoembryonic antigen, CD10, and alpha-fetoprotein. Am J Surg Pathol. 2002;26:978-988.  [PubMed]  [DOI]  [Cited in This Article: ]
131.  Lee HS, Kim WH, Kang GH. Hepatocyte expressions in hepatocellular carcinomas, gastrointestinal neoplasms, and non-neoplastic gastrointestinal mucosa: its role as a diagnostic marker. J Korean Med Sci. 2003;18:842-848.  [PubMed]  [DOI]  [Cited in This Article: ]
132.  Lugli A, Tornillo L, Mirlacher M, Bundi M, Sauter G, Terracciano LM. Hepatocyte paraffin 1 expression in human normal and neoplastic tissues: tissue microarray analysis on 3,940 tissue samples. Am J Clin Pathol. 2004;122:721-727.  [PubMed]  [DOI]  [Cited in This Article: ]
133.  Onofre AS, Pomjanski N, Buckstegge B, Bocking A. Immunocytochemical diagnosis of hepatocellular carcinoma and identification of carcinomas of unknown primary metastatic to the liver on fine-needle aspiration cytologies. Cancer. 2007;111:259-268.  [PubMed]  [DOI]  [Cited in This Article: ]
134.  Siddiqui MT, Saboorian MH, Gokaslan ST, Ashfaq R. Diagnostic utility of the HepPar1 antibody to differentiate hepatocellular carcinoma from metastatic carcinoma in fine-needle aspiration samples. Cancer. 2002;96:49-52.  [PubMed]  [DOI]  [Cited in This Article: ]
135.  Wang L, Vuolo M, Suhrland MJ, Schlesinger K. HepPar1, MOC-31, pCEA, mCEA and CD10 for distinguishing hepatocellular carcinoma vs. metastatic adenocarcinoma in liver fine needle aspirates. Acta Cytol. 2006;50:257-262.  [PubMed]  [DOI]  [Cited in This Article: ]
136.  Wieczorek TJ, Pinkus JL, Glickman JN, Pinkus GS. Comparison of thyroid transcription factor-1 and hepatocyte antigen immunohistochemical analysis in the differential diagnosis of hepatocellular carcinoma, metastatic adenocarcinoma, renal cell carcinoma, and adrenal cortical carcinoma. Am J Clin Pathol. 2002;118:911-921.  [PubMed]  [DOI]  [Cited in This Article: ]
137.  Chu P, Wu E, Weiss LM. Cytokeratin 7 and cytokeratin 20 expression in epithelial neoplasms: a survey of 435 cases. Mod Pathol. 2000;13:962-972.  [PubMed]  [DOI]  [Cited in This Article: ]
138.  Hammar SP. Metastatic adenocarcinoma of unknown primary origin. Hum Pathol. 1998;29:1393-1402.  [PubMed]  [DOI]  [Cited in This Article: ]
139.  Maeda T, Kajiyama K, Adachi E, Takenaka K, Sugimachi K, Tsuneyoshi M. The expression of cytokeratins 7, 19, and 20 in primary and metastatic carcinomas of the liver. Mod Pathol. 1996;9:901-909.  [PubMed]  [DOI]  [Cited in This Article: ]
140.  Stroescu C, Herlea V, Dragnea A, Popescu I. The diagnostic value of cytokeratins and carcinoembryonic antigen immunostaining in differentiating hepatocellular carcinomas from intrahepatic cholangiocarcinomas. J Gastrointestin Liver Dis. 2006;15:9-14.  [PubMed]  [DOI]  [Cited in This Article: ]
141.  Yoon SK. Recent advances in tumor markers of human hepatocellular carcinoma. Intervirology. 2008;51 Suppl 1:34-41.  [PubMed]  [DOI]  [Cited in This Article: ]
142.  Canick JA, MacRae AR. Second trimester serum markers. Semin Perinatol. 2005;29:203-208.  [PubMed]  [DOI]  [Cited in This Article: ]
143.  Chen J, Rocken C, Treiber G, Jentsch-Ulrich K, Malfertheiner P, Ebert MP. Clinical implications of alpha-fetoprotein expression in gastric adenocarcinoma. Dig Dis. 2003;21:357-362.  [PubMed]  [DOI]  [Cited in This Article: ]
144.  Ding X, Yang LY, Huang GW, Yang JQ, Liu HL, Wang W, Peng JX, Yang JQ, Tao YM, Chang ZG. Role of AFP mRNA expression in peripheral blood as a predictor for postsurgical recurrence of hepatocellular carcinoma: a systematic review and meta-analysis. World J Gastroenterol. 2005;11:2656-2661.  [PubMed]  [DOI]  [Cited in This Article: ]
145.  Grizzi F, Franceschini B, Hamrick C, Frezza EE, Cobos E, Chiriva-Internati M. Usefulness of cancer-testis antigens as biomarkers for the diagnosis and treatment of hepatocellular carcinoma. J Transl Med. 2007;5:3.  [PubMed]  [DOI]  [Cited in This Article: ]
146.  Gupta S, Bent S, Kohlwes J. Test characteristics of alpha-fetoprotein for detecting hepatocellular carcinoma in patients with hepatitis C. A systematic review and critical analysis. Ann Intern Med. 2003;139:46-50.  [PubMed]  [DOI]  [Cited in This Article: ]
147.  Hiroshima K, Iyoda A, Toyozaki T, Haga Y, Baba M, Fujisawa T, Ishikura H, Ohwada H. Alpha-fetoprotein-producing lung carcinoma: report of three cases. Pathol Int. 2002;52:46-53.  [PubMed]  [DOI]  [Cited in This Article: ]
148.  Sakata J, Shirai Y, Wakai T, Kaneko K, Nagahashi M, Hatakeyama K. Preoperative predictors of vascular invasion in hepatocellular carcinoma. Eur J Surg Oncol. 2008;34:900-905.  [PubMed]  [DOI]  [Cited in This Article: ]
149.  Leerapun A, Suravarapu SV, Bida JP, Clark RJ, Sanders EL, Mettler TA, Stadheim LM, Aderca I, Moser CD, Nagorney DM. The utility of Lens culinaris agglutinin-reactive alpha-fetoprotein in the diagnosis of hepatocellular carcinoma: evaluation in a United States referral population. Clin Gastroenterol Hepatol. 2007;5:394-402; quiz 267.  [PubMed]  [DOI]  [Cited in This Article: ]
150.  Sterling RK, Jeffers L, Gordon F, Sherman M, Venook AP, Reddy KR, Satomura S, Schwartz ME. Clinical utility of AFP-L3% measurement in North American patients with HCV-related cirrhosis. Am J Gastroenterol. 2007;102:2196-2205.  [PubMed]  [DOI]  [Cited in This Article: ]
151.  Liebman HA, Furie BC, Tong MJ, Blanchard RA, Lo KJ, Lee SD, Coleman MS, Furie B. Des-gamma-carboxy (abnormal) prothrombin as a serum marker of primary hepatocellular carcinoma. N Engl J Med. 1984;310:1427-1431.  [PubMed]  [DOI]  [Cited in This Article: ]
152.  Marrero JA, Su GL, Wei W, Emick D, Conjeevaram HS, Fontana RJ, Lok AS. Des-gamma carboxyprothrombin can differentiate hepatocellular carcinoma from nonmalignant chronic liver disease in american patients. Hepatology. 2003;37:1114-1121.  [PubMed]  [DOI]  [Cited in This Article: ]
153.  Nakamura S, Nouso K, Sakaguchi K, Ito YM, Ohashi Y, Kobayashi Y, Toshikuni N, Tanaka H, Miyake Y, Matsumoto E. Sensitivity and specificity of des-gamma-carboxy prothrombin for diagnosis of patients with hepatocellular carcinomas varies according to tumor size. Am J Gastroenterol. 2006;101:2038-2043.  [PubMed]  [DOI]  [Cited in This Article: ]
154.  Volk ML, Hernandez JC, Su GL, Lok AS, Marrero JA. Risk factors for hepatocellular carcinoma may impair the performance of biomarkers: a comparison of AFP, DCP, and AFP-L3. Cancer Biomark. 2007;3:79-87.  [PubMed]  [DOI]  [Cited in This Article: ]
155.  Hippo Y, Watanabe K, Watanabe A, Midorikawa Y, Yamamoto S, Ihara S, Tokita S, Iwanari H, Ito Y, Nakano K. Identification of soluble NH2-terminal fragment of glypican-3 as a serological marker for early-stage hepatocellular carcinoma. Cancer Res. 2004;64:2418-2423.  [PubMed]  [DOI]  [Cited in This Article: ]
156.  Iftikhar R, Kladney RD, Havlioglu N, Schmitt-Graff A, Gusmirovic I, Solomon H, Luxon BA, Bacon BR, Fimmel CJ. Disease- and cell-specific expression of GP73 in human liver disease. Am J Gastroenterol. 2004;99:1087-1095.  [PubMed]  [DOI]  [Cited in This Article: ]
157.  Marrero JA, Fontana RJ, Barrat A, Askari F, Conjeevaram HS, Su GL, Lok AS. Prognosis of hepatocellular carcinoma: comparison of 7 staging systems in an American cohort. Hepatology. 2005;41:707-716.  [PubMed]  [DOI]  [Cited in This Article: ]
158.  Block TM, Marrero J, Gish RG, Sherman M, London WT, Srivastava S, Wagner PD. The degree of readiness of selected biomarkers for the early detection of hepatocellular carcinoma: notes from a recent workshop. Cancer Biomark. 2008;4:19-33.  [PubMed]  [DOI]  [Cited in This Article: ]
159.  Yamagamim H, Moriyama M, Matsumura H, Aoki H, Shimizu T, Saito T, Kaneko M, Shioda A, Tanaka N, Arakawa Y. Serum concentrations of human hepatocyte growth factor is a useful indicator for predicting the occurrence of hepatocellular carcinomas in C-viral chronic liver diseases. Cancer. 2002;95:824-834.  [PubMed]  [DOI]  [Cited in This Article: ]
160.  Tsai JF, Jeng JE, Chuang LY, You HL, Ho MS, Lai CS, Wang LY, Hsieh MY, Chen SC, Chuang WL. Serum insulin-like growth factor-II and alpha-fetoprotein as tumor markers of hepatocellular carcinoma. Tumour Biol. 2003;24:291-298.  [PubMed]  [DOI]  [Cited in This Article: ]
161.  Yu H, Rohan T. Role of the insulin-like growth factor family in cancer development and progression. J Natl Cancer Inst. 2000;92:1472-1489.  [PubMed]  [DOI]  [Cited in This Article: ]
162.  Poon RT, Ho JW, Tong CS, Lau C, Ng IO, Fan ST. Prognostic significance of serum vascular endothelial growth factor and endostatin in patients with hepatocellular carcinoma. Br J Surg. 2004;91:1354-1360.  [PubMed]  [DOI]  [Cited in This Article: ]
163.  Annes JP, Munger JS, Rifkin DB. Making sense of latent TGFbeta activation. J Cell Sci. 2003;116:217-224.  [PubMed]  [DOI]  [Cited in This Article: ]
164.  Sacco R, Leuci D, Tortorella C, Fiore G, Marinosci F, Schiraldi O, Antonaci S. Transforming growth factor beta1 and soluble Fas serum levels in hepatocellular carcinoma. Cytokine. 2000;12:811-814.  [PubMed]  [DOI]  [Cited in This Article: ]
165.  Song BC, Chung YH, Kim JA, Choi WB, Suh DD, Pyo SI, Shin JW, Lee HC, Lee YS, Suh DJ. Transforming growth factor-beta1 as a useful serologic marker of small hepatocellular carcinoma. Cancer. 2002;94:175-180.  [PubMed]  [DOI]  [Cited in This Article: ]
166.  Chau GY, Wu CW, Lui WY, Chang TJ, Kao HL, Wu LH, King KL, Loong CC, Hsia CY, Chi CW. Serum interleukin-10 but not interleukin-6 is related to clinical outcome in patients with resectable hepatocellular carcinoma. Ann Surg. 2000;231:552-558.  [PubMed]  [DOI]  [Cited in This Article: ]
167.  Hsia CY, Huo TI, Chiang SY, Lu MF, Sun CL, Wu JC, Lee PC, Chi CW, Lui WY, Lee SD. Evaluation of interleukin-6, interleukin-10 and human hepatocyte growth factor as tumor markers for hepatocellular carcinoma. Eur J Surg Oncol. 2007;33:208-212.  [PubMed]  [DOI]  [Cited in This Article: ]
168.  Cui R, He J, Zhang F, Wang B, Ding H, Shen H, Li Y, Chen X. Diagnostic value of protein induced by vitamin K absence (PIVKAII) and hepatoma-specific band of serum gamma-glutamyl transferase (GGTII) as hepatocellular carcinoma markers complementary to alpha-fetoprotein. Br J Cancer. 2003;88:1878-1882.  [PubMed]  [DOI]  [Cited in This Article: ]
169.  Yoon SK, Lim NK, Ha SA, Park YG, Choi JY, Chung KW, Sun HS, Choi MJ, Chung J, Wands JR. The human cervical cancer oncogene protein is a biomarker for human hepatocellular carcinoma. Cancer Res. 2004;64:5434-5441.  [PubMed]  [DOI]  [Cited in This Article: ]
170.  Hann HW, Lee J, Bussard A, Liu C, Jin YR, Guha K, Clayton MM, Ardlie K, Pellini MJ, Feitelson MA. Preneoplastic markers of hepatitis B virus-associated hepatocellular carcinoma. Cancer Res. 2004;64:7329-7335.  [PubMed]  [DOI]  [Cited in This Article: ]
171.  Masutomi K, Kaneko S, Yasukawa M, Arai K, Murakami S, Kobayashi K. Identification of serum anti-human telomerase reverse transcriptase (hTERT) auto-antibodies during progression to hepatocellular carcinoma. Oncogene. 2002;21:5946-5950.  [PubMed]  [DOI]  [Cited in This Article: ]