Pawlik TM et al. (2007) Preoperative assessment of hepatocellular carcinoma tumor grade using needle biopsy: implications for transplant eligibility. Ann Surg 245: 435–442

The introduction of stringent eligibility criteria for hepatic transplantation for hepatocellular carcinoma (HCC) has resulted in marked improvement in outcomes. There is the possibility, however, that a subset of patients might exist who would benefit from liver transplantation despite not meeting these criteria. Recently, some centers have begun to incorporate assessments of tumor grade—as determined by needle core biopsy (NCB)—into selection protocols for hepatic transplantation for HCC. As a result of a study of 211 patients treated for HCC, Pawlik et al. have concluded that tumor grade assessed by NCB might be misleading and should not be used to decide which patients receive transplants.

The authors compared preoperative NCB-assessed tumor grade with final surgical pathologic tumor grade. A higher proportion of HCC cases were classified as poorly differentiated on assessment of the final surgical specimen than on preoperative NCB (27.9% vs 15.1%; P <0.05); poor differentiation has previously been associated with worse post-transplantation outcomes. Preoperative NCB and postoperative surgical pathology had poor agreement as to tumor grade (κ = 0.18; P <0.0001), with a 3-tier grading scheme showing consensus in only 45.2% of cases. Unlike final pathologic tumor grade, preoperative NCB-assessed tumor grade was not associated with presence of microscopic vascular invasion—a strong predictor of post-transplantation prognosis. Additionally, final pathologic grade was an independent predictor of outcome in a multivariate model that included established clinicomorphologic prognostic variables such as tumor size and number—tumor grade determined by NCB was not.