Routine review of ascites fluid from patients with cirrhosis or hepatocellular carcinoma is a low-yield procedure: An observational study

Background: Patients with cirrhosis develop ascites for physiologic reasons that are unrelated to malignant progression. However, physicians performing paracentesis in these patients, often send fluid to the cytology laboratory, sometimes specifically looking for hepatocellular carcinoma (HCC). We have investigated the diagnostic yield of these specimens. Materials and Methods: A computerized pathology database search for all ascites fluid cases submitted to the cytology laboratory at a major liver transplant center between November 2004 and April 2008 was performed. Clinical history was obtained for each case. Patients with cirrhosis, with or without HCC, were included in the study. Cytologic diagnoses were compiled and follow-up information was obtained for cases with non-negative findings. Results: A total of 167 specimens from 133 patients ranging from 29 to 85 years of age (mean 56 years) were submitted over the said time period. The causes of cirrhosis included: alcohol - 44; Hepatitis C - 30; Hepatitis B - 6; non-alcoholic steatohepatitis - 7; cryptogenic - 18; other single causes - 6; and multifactorial (alcohol and hepatitis viruses) - 22. Hepatocellular carcinoma (HCC) was present or strongly suspected in 17 patients and had been previously resected in two others. The status of fifteen patients was post liver transplant, with recurrent liver failure. Human immunodeficiency virus was present in seven patients and eight patients had a history of non hepatic malignancies. Among the specimens, 162 were negative, two had atypical lymphocytes worked up for lymphoma, and three had atypical epithelioid cells; none was positive for HCC. Immunohistochemistry demonstrated a mesothelial origin for the atypical epithelioid cells in two cases; in the third case, the patient died shortly after the specimen was collected, with no radiological evidence of HCC. Conclusion: Ascites fluid cytology specimens in patients with cirrhosis, even those known or suspected to have HCC, are almost always negative. Atypical cells seen in such specimens should be treated with skepticism since the likelihood that they represent peritoneal spread of HCC is low.