Immunocytochemical panel as a diagnostic aid in fine needle aspiration cytology of malignant liver lesions

Fine needle aspiration cytology (FNAC) of the liver is used mainly for the diagnosis of focal lesions, and usually performed percutaneously under the guidance of computed tomography (CT), magnetic resonance imaging (MRI), or ultrasonography (USG) using a disposable needle of 22-23gauge, and 10cc syringe, the length of the needle is 80-150 mm. Malignant liver tumors are classified cytomorphologically into tow diagnostic categories:- 1- Primary tumors 2- Metastatic tumors. The vast majority of malignancies in the liver are metastatic adenocarcinomas. In majority of these cases the patients have a known history of a primary tumor elsewhere; however some of those patients do not demonstrate a known primary tumor, cells or tissues obtained by FNA from liver metastasis can give hints to the site of the primary tumor. Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver, the differential diagnosis of HCC versus metastatic carcinoma is clinically important because prognosis and treatment approaches are different. FNA of tumors can type and classify primary and metastatic liver tumors both cytomorphologically used H and E stain assested by advanced immunocytochemical tumor marker panel to confirm diagnosis first and to know the primary origion of the tumor using (CA15.3, AFP, CA19.9, CEA, CA125, PSA). Aim of study 1. The role of FNAC in diagnosis of the malignant liver lesions.
2. Assisted immunocytochemical tumor marker panel for differentiation between malignant Primary and metastatic liver lesion first. 3. To reach the actual primary organ origion of metastatic lesion secondly.
UMaterials and methods A prospective study involving 47 cases which are collected by FNAC of liver under ultrasonic guidance. The period of the study was from first of December 2010 to first of June 2011, the cases were selected from the cytopathological laboratory of Al- Kadhimiya Teaching Hospital, and from one private laboratory of Dr. Yarub Adress Abd Al-Qadir in Baghdad. Clinicopathological parameters such as (age, sex of the patients, primary site of the tumor, size of the tumor, gross ultrasonic appearance, lobe involvement, presence of liver disease and clinical symptoms) were obtained. Ethical approval for use of all specimens was obtained and the cytopathologic diagnosis was confirmed by review of freshly prepared hematoxylin and eosin stained slides by the supervisor Four cytological smears were taken, one slide was stained by H and E for cytopathological revision, and other slides were stained
immunocytochemically for panel. Results • CA15.3 expressed in 15 (31. 9%) of cases Clinicopathological assessment revealed that the age of patients range from 6-82 years, with a (mean+standard error of mean) of (51.87+2.37) years with the majority of cases 29 (61.7%) were equal or above fifty years, while 18 (38.3%) were below fifty years. The majority of cases 26 (55.3%) were female, and 21 (44.7%) of cases were males with male to female ratio (M: F) of 1:1.23. Regarding the primary site of the tumor; the majority of the studied cases 15 (31.9%) were from the breast, while the remaining were from colon, lymphoma, prostate, ovary, lung, kidney, pancreas, liver, neuroblastoma, gastrointestinal stromal tumors, and thyroid. The most common gross ultrasonic appearance was multiple masses 45 (95.7%), while 2 (4.3%) of cases were solitary. The majority of cases 25 (53.1%) were medium in size, 13 (27.7%) of cases were small, milliary size, 7 (14.8%) of cases were large, few and scattered, 2 (4.3%) of cases were huge and solitary. Only 2 (4.3%) of cases had liver disease (cirrhosis), while 45 (95.7%) of cases had no cirrhosis. The majority of cases 45 (95.7%) involved both lobes of liver, while 2 (4.3%) of cases involved single lobe. The majority of cases 35 (74.5%) presented with incidental symptoms, while 5 (10.6%) of cases presented with lymphadenopathy, 5 (10.6%) presented with a mass, 2 (4.3%) presented with signs and symptoms of chronic liver disease ( jaundice, ascites, hepatomegaly, easy bruising and bleeding, weight loss, loss of appetite, enlarged spleen, drowsiness and confusion). Regarding the immunocytochemical markers expression: • 9 (19.1%) of cases expressed CEA
• 3 (6.4%) of cases expressed EMA • 3 (6.4%) of cases expressed PSA • 3 (6.4%) of cases expressed CA 125 • 2 (4.3%) of cases expressed CA 19.9 • 2 (4.3%) of cases expressed AFP • 2 (4.3%) of cases expressed CD45 • 1 (2.1%) of cases expressed C-Kit • 1 (2.1%) of cases expressed CD15 • 1 (2.1%) of cases expressed Calcitonin • 1 (2.1%) 0f cases expressed NSE Conclusions Fine needle aspiration of the liver is an accepted, simple, relatively safe, easy procedure with relatively neglicable complications with sensitivity and diagnostic accuracy of 100% for diagnosis of malignant liver lesions in correlation with final clinical and histopathological diagnosis. Using the immunocytochemical techniques increasing the sensitivity of FNA for diagnosis of malignant liver lesions of unknown primary origin. The sensitivity of immunocytochemistry is 93.61% for diagnosis of malignant liver lesions of unknown primary origin in correlation with final clinical and histopathological diagnosis. The most common age group seen in this study was above the age of 50years with female predominance. The majority of cases are metastatic carcinoma, and the majority of these are from the breast and colon.