Subcutaneous seeding of hepatocellular carcinoma after percutaneous needle biopsy.

Background—In patients with a hepatic mass, malignancy can be diagnosed or excluded by a needle biopsy. However, this procedure can cause the formation of subcutaneous metastatic nodules in the needle tract. We present a case of recurrent subcutaneous seeding four years after a biopsy of a small hepatocellular carcinoma (HCC). Case report—A 30 year old woman with hepatitis B liver cirrhosis presented with a raised serum á-fetoprotein (AFP) (271 μg/l; normal: <20 μg/l); ultrasound detected a liver mass. Additional spiral computed tomography showed a 2 cm diameter subcapsular mass in segment V. There were also two satellite lesions, measuring less than 1 cm in the same segment. To confirm the diagnosis of HCC, an ultrasound guided needle biopsy was performed using an 18 gauge Tru-cut needle and Biopty-gun. Two passes were needed to obtain adequate specimens. Subsequent histological examination showed HCC. A right hemihepatectomy was performed, resulting in a radically resected multifocal HCC without vascular ingrowth; the main nodule was located subcapsularly. Follow up consisted of ultrasonography and measurement of serum AFP concentrations twice yearly. After four years, the patient presented with raised serum AFP and a nodule measuring 1 cm diameter in the subcutaneous fat; this was shown by magnetic resonance imaging (fig 1). No hepatic lesions were detected on the liver. An aspiration biopsy showed characteristics of HCC, and the nodule was excised; histological examination revealed a moderately diVerentiated HCC. Discussion—Needle biopsies, especially fine needle biopsies, are considered to be relatively safe and accurate in obtaining a diagnosis of malignancy. However, depending on the retrieval rate, the number of passes needed to obtain suYcient material for histological examination varies. In a porcine model, larger (<20 gauge) needles were more eYcient as fewer passes were needed to obtain enough material for histological examination. Sangalli and colleagues found a 86.6% retrieval rate suitable for histological examination, but d’Aquino and coworkers found only 10 of 27 samples from cirrhotic livers appropriate. The incidence of needle track seeding may rise as a result of the puncture of tumours detected at an early stage in patients with a longer life expectancy. A multicentre questionnaire detected a needle track dissemination risk of Figure 1 Magnetic resonance imaging of the abdomen four years after hemihepatectomy. A subcutaneous nodule 1 cm in diameter is visible in the subcutaneous fat of the abdominal wall. This is the puncture site of the needle biopsy.