Diagnosis of hepatic nodules 20 mm or smaller in cirrhosis: Prospective validation of the noninvasive diagnostic criteria for hepatocellular carcinoma

I read with great interest the study by Forner et al.,1 which validates the American Association for the Study of Liver Disease guidelines. The methods and interpretation of the results, however, raise several concerns. It is well known that the biopsy of small nodular lesions in cirrhosis is not entirely reliable. In fact, needle placement may be difficult and a sampling error may occur. Moreover, it is very difficult to distinguish well-differentiated hepatocellular carcinoma (HCC) from dysplasia nodules on small biopsy specimens, because there is not a clear-cut dividing line between a dysplasia nodule and a well-differentiated tumor.2, 3 In the study by Forner et al.,1 however, a biopsy result was considered the gold standard, and the pathologic results of surgical samples in 60 HCC nodules were not well described. Were the abovementioned factors taken into account in the results of the study by Forner et al.?1 It is well known that cirrhosis is characterized by fibrous septa and many regenerative nodules. These features produce a coarse pattern on ultrasound, which may impair identification of small tumors.3 In the discussion of the study by Forner et al.,1 however, the authors stated that if they recruited patients with multiple nodules, the prevalence of HCC might have been higher. In fact, the patients with multiple nodules had commonly more regenerative nodules than HCC nodules. That is to say, if the authors recruited patients with multiple nodules, the prevalence of HCC might have been lower and the study would have validated the American Association for the Study of Liver Disease guidelines more effectively. Therefore, could the diagnosis of HCC nodules 20 mm or smaller be established without a positive biopsy if both contrast-enhanced ultrasound and magnetic resonance imaging are conclusive in patients with multiple nodules or a sole nodule? Ze-Zhou Song M.S.*, * Department of Ultrasound, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.