HAIC plus lenvatinib and PD-1 inhibitors for hepatocellular carcinoma with Vp4 portal vein tumor thrombus.

The prognosis of hepatocellular carcinoma (HCC)is poor,and tumor thrombus in the portal vein or in the bile duct is an important influencing factor.Approximately 30%of HCC patients are found to have portal vein tumor thrombus (PVTT)when diagnosed,and their median survival time is about 2.7-4.0 months if they do not receive any treatment.The incidence of HCC complicated with bile duct tumor thrombus (BDTT)is less than 10%,while the prognosis is dismal.Once tumor thrombus extends to the major bile ducts,obstructive jaundice and subsequent hepatic dysfunction are inevitable.The survival time of patients with HCC complicated with BDTT is less than 4 months if they only receive palliative biliary stenting.The management of HCC complicated with PVTT or BDTT is challenging with controversy at present.Different treatment approaches and their benefits for patients with HCC complicated with PVTT or BDTT are introduced in this paper. Key words: Liver neoplasms; Portal vein tumor thrombus; Bile duct tumor thrombus; Treatment

SEE ARTICLE ON PAGE 207 Potential conflict of interest: Nothing to report. The detection of portal vein tumor thrombus (PVTT) in patients with hepatocellular carcinoma (HCC) has important implications for prognosis and treatment. Liver transplantation (LT) is contraindicated due to high rates of recurrence, and the presence of PVTT also informs the choice of locoregional therapy. PVTT and other forms of macrovascular invasion figure into most of the major staging systems for HCC. Diagnosis of PVTT, like the noninvasive diagnosis of HCC, depends on accurate interpretation of cross‐sectional imaging. The frequent occurrence of bland portal vein thrombus in cirrhotic patients, as well as the sometimes subtle imaging findings of tumor thrombus, can make this distinction difficult. Previous studies have identified imaging features associated with PVTT, including portal vein expansion, enhancement, neovascularity, and proximity to tumor. One early study found that the combination of a main portal vein diameter ≥23 mm and/or neovascularity within portal vein thrombus on computed tomography (CT) predicted PVTT with 86% sensitivity and 100% specificity.1 A more recent study has similarly found that enhancement of portal vein thrombus and expansion of the portal vein beyond its normal diameter on CT and magnetic resonance imaging (MRI) were both correlated with the presence of PVTT.2 In this issue of Liver Transplantation, Sherman et al. describe a set of criteria for noninvasive diagnosis of PVTT.3 Their criteria, dubbed the A‐VENA score, consist of 4 imaging features and 1 laboratory marker associated with PVTT. Imaging markers included thrombus enhancement, venous expansion, neovascularity, and proximity to tumor or prior treatment site. Enhancement was defined as Hounsfield units >20. The laboratory marker was measurement of serum alpha‐fetoprotein (AFP), considered diagnostic if >1000 ng/dL. In the study cohort of 467 patients with HCC listed for LT, 59 patients were found to have portal vein thrombus. Of these patients, 12 had been judged to have PVTT on the basis of imaging. Reviewers retrospectively assessed the presence of the 4 imaging criteria, and AFP levels were determined from the medical record. Comparing patients with bland thrombus and tumor thrombus, the presence of 3 or more of the 5 criteria demonstrated impressive diagnostic performance: 100% sensitivity, 93.6% specificity, 80% positive predictive value, and 100% negative predictive value for the presence of tumor thrombus. This study serves as further validation of previously identified imaging features of PVTT. It is important to note, as the authors of the study do, the absence of pathologic confirmation (biopsy of PVTT was performed in only 1 patient). The impression of the radiologist interpreting the images served as the de facto gold standard in this study, as it generally does in clinical practice. Because the imaging features of the A‐VENA score still depend on a radiologist’s interpretation, it would be interesting to examine interreader agreement on the features and the agreement between experienced and novice radiologists. A unique feature of the A‐VENA score is the inclusion of the serum AFP level. This represents a departure from the traditional approach to PVTT diagnosis, which has relied on imaging. An elevated AFP is clinically useful when there is insufficient imaging evidence of tumor thrombus, and adding it as an additional criterion may increase the negative predictive value. In this study, patients with PVTT had significantly higher AFP levels on average than patients without PVTT. However, the absence of elevated AFP should not militate against a diagnosis of PVTT in a patient with suggestive imaging features, particularly in patients with tumors that do not produce AFP. It would be interesting to know how the other 4 markers perform without the inclusion of AFP. It would also be interesting to examine how these criteria perform in an MRI‐based cohort because the vast majority (88%) of the patients in this study were examined by CT. Despite these caveats, this study will be of interest to physicians involved in the diagnosis and management of HCC. Thrombus enhancement, venous expansion, neovascularity, and contiguity with a tumor are the principle features to keep in mind when assessing for PVTT. Although high sensitivity and negative predictive value are important, high specificity and positive predictive value are also critical since a false‐positive diagnosis may preclude a potential recipient from LT. When there is high suspicion but not enough imaging evidence to achieve 100% specificity, biopsy of the portal vein thrombus can be performed.4 AFP levels and trends are therefore important to know when interpreting imaging, particularly after locoregional therapy, and high levels may prompt more careful scrutiny of subtle findings. However, a positive diagnosis of PVTT should rely primarily on imaging appearance, and if necessary, tissue sampling. Future studies should focus on extending the findings of this study to MRI as well as other imaging modalities, such as contrast‐enhanced ultrasound.

Objective To investigate the clinical efficacy and prognostic factors of hepatectomy for hepatocellular carcinoma (HCC). Methods The retrospective case-control study was conducted. The clinico-pathological data of 789 HCC patients who were admitted to the Sichuan Cancer Hospital Affiliated to School of Medicine of University of Electronic Science and Technology of China from January 2009 to January 2016 were collected. There were 669 males and 120 females, aged from 42 to 60 years, with a median age of 52 years. Surgical procedures were determined according to the preoperative and intraoperative comprehensive evaluations of patients. Observation indicators: (1) situations of surgical treatment; (2) postoperative pathological examinations of patients; (3) follow-up and survival situations; (4) prognostic factors analysis. Follow-up using outpatient examination and telephone interview was performed to detect patients′ survival up to May 2017. Normality of measurement data was done using the K-S test. Measurement data with skewed distribution were represented as M (range). Count data were described as absolute number or percentage. The survival rate and survival curve were respectively calculated and drawn by the Kaplan-Meier method. The univariate analysis and multivariate analysis were done using the Log-rank test and COX regression model, respectively. Results (1) Situations of surgical treatment: all the 789 patients underwent successful hepatectomy, liver volume dissected accounting for 32.5% (range, 17.0%-52.0%) of the total liver volume. Of the 789 patients, 413 underwent anatomical hepatectomy including 116 of hepatic segmentectomy, 136 of right hemihepatectomy, 77 of left hemihepatectomy, 57 of left lateral lobe hepatectomy, 27 of central hepatectomy, 376 underwent nonanatomical hepatectomy including 344 of partial hepatectomy, 17 of extended right hemihepatectomy, 15 of extended left hemihepatectomy. Volume of intraoperative blood loss was 400 mL (range, 200-500 mL) in the 789 patients and 173 had intraoperative blood transfusion. Of the 789 patients, 240 had postoperative complications(68 with postoperative severe complications), including 65 of liver insufficiency, 37 of ascites and pleural effusion, 37 of pulmonary complications, 19 of infectious complications, 17 of cardiovascular complications, 17 of abdominal hemorrhage, 11 of gastrointestinal complications, 9 of neruologic complications, 8 of postoperative bile leakage, 10 of other complications, 11 of death; the same patient can merge multiple complications. The 229 survival patients with complications were cured by symptomatic supportive treatment. Duration of postoperative hospital stay was 9 days (range, 7-11 days). (2) Postoperative pathological examinations. Results of postoperative pathological examinations showed 17 patients with bile duct tumor thrombus, 92 with naked eye tumor thrombus at portal vein branches and 167 with microvascular invasion. Of the 789 patients, High-, moderate-, low-differentiated carcinoma were detected in 19, 678, 92 patients, respectively. (3) Follow-up and survival situations: 690 of the 789 patients were followed up for 1-96 months, with a median time of 21 months. The 1, 3, 5-year overall survival rates were 82.1%, 66.1%, 59.2% in the 789 patients. (4) Prognostic factors analysis: results of univariate analysis showed that level of preoperative alphafetoprotein (AFP), Child grade of preoperative liver function, Barcelona clinic liver cancer staging, tumor diameter, surgical procedure of hepatectomy, volume of intraoperative blood loss, intraoperative blood transfusion, postoperative complications, postoperative severe complications, bile duct tumor thrombus, portal vein tumor thrombus, vascular invasion were related factors affecting prognosis of HCC patients after hepatectomy (χ2=8.603, 8.864, 39.970, 28.978, 6.376, 26.144, 8.955, 6.596, 9.910, 7.288, 37.566, 19.183, P<0.05). Results of multivariate analysis showed that tumor diameter, volume of intraoperative blood loss, portal vein tumor thrombus were independent factors affecting prognosis of HCC patients after hepatectomy (hazard ratio=1.085, 1.000, 2.259, 95% confidence interval: 1.053-1.118, 1.000-1.001, 1.621-3.146, P<0.05). Conclusion Hepatectomy for HCC has a good safety, with satisfactory clinical efficacy. Tumor diameter, volume of intraoperative blood loss, portal vein tumor thrombus are independent factors affecting prognosis of HCC patients after hepatectomy. Key words: Liver neoplasms; Liver cancer; Hepatectomy; Prognosis; Vascular tumor thrombus; Portal vein tumor thrombus

To study the methods of surgery for hepatocellular carcinoma (HCC) with tumor thrombi in portal vein (TTPV). To Analyze and summarize the clinical information from 138 HCC patients with tumor thrombi in portal vein collected during January 1990 and January 2003. Thirty-seven patients receiving palliative therapy died from 1 to 8 months, and average survival time is 3.9 months. 101 patients had operation treatment, 23 of them underwent hepatoma resection, and average survival time was 10.9 months; 78 patients underwent hepatoma resection and removal of tumor thrombi, and average survival time was 26.8 months. 52 of whom underwent hepatic artery and portal vein chemoembolization, the 1-, 3-, 5-year survival rates was 96.2%, 51.9%, 11.5%, the 1-, 3-, 5-year survival rates of the 26 patients who didn't undergo chemoembolization were 76.9%, 23.1%, 0%. Operation treatment can comparatively extend the survival time of hepatocellular carcinoma with tumor thrombi in portal vein patients, and the best choice is hepatoma resection and removal of tumor thrombi, hepatic artery and portal vein chemoembolization after operation can enhance the effect.

e15646 Background: Patients with hepatocellular carcinoma (HCC) accompanied with portal vein tumor thrombus (PVTT) have a poor prognosis. Although transarterial chemoembolization (TACE) plus sorafenib (TACE-S) could lead to an improved survival than TACE alone in HCC patients with first- or second-branch PVTT (branch PVTT), the survival was very limited. We compared the safety and efficacy of TACE plus Iodine125 brachytherapy (TACE-I) with TACE-S in patients with unresectable HCC and branch PVTT. Methods: The medical records of consecutive patients with HCC and branch PVTT who underwent TACE-I (TACE-I group) or TACE-S (TACE-S group) from January 2015 to December 2017 were retrospectively evaluated. Iodine125 seeds were implanted into the PVTT under CT guidance 3-5 days after the initial TACE. The matched peripheral dose of Iodine125 brachytherapy was set to be 120-140 Gy. Sorafenib was administered 400 mg twice daily. Outcomes of patients who underwent TACE-I, including adverse events, treatment responses, time to progression (TTP), and overall survival (OS), were compared with those of patients who underwent TACE-S. Results: One hundred and twenty patients were included in the analysis; 62 patients underwent TACE-I and 58 underwent TACE-S. The overall incidence of adverse events was significantly lower in TACE-I group than in TACE-S group (58.1% vs. 93.1%, P &lt; .001), and incidence of grade 3 or higher adverse events also was significantly lower in TACE-I group than in TACE-S group (3.2% vs. 27.6%, P &lt; .001). PVTT OR rates at 12 weeks (58.1% vs. 13.8%, P &lt; .001) and at 24 weeks after the treatment (68.9 % vs. 10.9%, P &lt; .001) in TACE-I group were higher than those in TACE-S group. TACE-I led to significantly longer TTP (median, 11.2 months vs. 6.2 months, P &lt; .001) and OS (median, 20.9 months vs. 14.0 months, P &lt; .001) than TACE-S. In uni- and multivariable analyses, TACE-I treatment, PVTT extent, tumor size ≥10 cm, PVTT OR at 12 weeks, and intrahepatic tumor OR at 12 weeks were independent prognostic factors for OS. Conclusions: TACE-I had less side effects and may improve OS than TACE-S for HCC patients with branch PVTT.

Prognostic factors in patients with hepatocellular carcinoma (HCC) with tumor thrombosis are not well established, especially for those given external-beam radiation therapy (EBRT). Patients (n = 136) with HCC who had portal vein (PV) or inferior vena cava (IVC) tumor thrombus received EBRT between January 1998 and October 2007. Demographic variables, laboratory values, tumor characteristics, and treatment modalities were determined at diagnosis and before EBRT. The total radiation dose ranged from 30 to 60 Gy (median, 50 Gy) and was focused on the tumor thrombi. Predictors of survival were identified using the univariate and multivariate analysis. Of the 136 patients, the tumor thrombus completely disappeared in 41 patients (30.1%), 36 patients (26.5%) had a partial response, 49 patients (36%) had stable disease, and 10 patients (7.4%) had progressive disease. On multivariate analysis, pretreatment unfavorable predictors were associated with lower albumin, higher gamma-glutamyltransferase and alpha-fetoprotein levels, poorer Child-Pugh classification, intrahepatic multifocality, lymph node metastases, poorer response to EBRT, and 2-dimension EBRT technique. Survival rates at 1, 2, and 3 years were 31.8%, 17.5%, and 8.8% for patients with PV tumor thrombi; 66.3%, 21.1%, and 15.8% for IVC tumor thrombi; and 25%, 8.3%, and 0% for PV plus IVC tumor thrombi, respectively. Overall median survival was 9.7 months. This study provides detailed information about the survival outcomes and prognostic factors of HCC with tumor thrombi in a relatively large cohort of patients treated with radiation, and the results will help in understanding the potential factors that influence survival for patients with HCC after EBRT.

IntroductionPrevious trials demonstrated that anti-angiogenesis or anti-programmed death protein 1 (PD-1) monotherapy showed unsatisfied effect in advanced hepatocellular carcinoma (HCC). No study existed that focus on the effects of camrelizumab and apatinib (“C+A”) combination therapy for HCC patients with the location and extent of portal vein tumor thrombus (PVTT) as the main variable being assessed. This study was to compare the efficacy and tolerability of “C+A” for HCC patients with PVTT.MethodsWe retrospectively analyzed patients with advanced HCC and PVTT who underwent “C+A” therapy in a multicenter retrospective cohort from Jan 2019 to July 2020. Outcomes of patients who underwent “C+A” were analyzed by using the Kaplan–Meier method according to types of PVTT: PVTT in the main portal vein (type A), PVTT in the first-order portal vein branch (type B), and PVTT in second- or lower-order portal vein branches (type C).ResultsSixty-three patients were finally included and the mean duration of follow-up was 12.6 ± 4.5 months. The objective response rate (ORR) and disease control rate (DCR) for the whole cohort were 44.0% and 75.0%, respectively. The median overall survival (OS), progression-free survival (PFS) and time to progression (TTP) were 14.8 months, 11.8 months and not yet reached (NR), respectively. Patients with type B (OS, 15.9 months; PFS, 14.0 months; TTP, NR) or type C (OS, 16.0 months; PFS, 14.9 months; NR) PVTT appear to have better survival benefits compared with type A (OS, 5.8 months; PFS, 5.0 months; TTP, 7.0 months). Along with AFP, the absence of main PVTT was an independent predictive factor for survival at uni- and multivariate analysis.ConclusionCamrelizumab and apatinib yielded a promising outcome in patients with advanced HCC who developed a tumor thrombus in the first lower-order portal vein branches and was generally safe and had manageable side effects.

385 Background: Hepatocellular carcinoma (HCC) with advanced portal vein tumor thrombus (PVTT) in the main portal trunk (MPT) or the first branch of portal vein has poor prognosis. We attempted a multidisciplinary treatment to irradiate the PVTT prior to surgical resection. In this study, we evaluate the therapeutic effect of preoperative radiotherapy (Pre-RT) for HCC with advanced PVTT. Methods: The postoperative prognosis was retrospectively examined in 75 patients with advanced PVTT out of 1,045 patients who underwent hepatectomy for HCC between 1990 and 2015 in our institute. The treatment outcome was compared between the patients who underwent Pre-RT (30Gy/10fr) for PVTT before operation (RT group, n = 34) and patients not underwent Pre-RT (non-RT group, n = 41). Results: Among 75 patients with advanced PVTT, there was no difference in age, sex, extent of PVTT (MPT or first branch of PV), HBV, HCV, T-Bil, PT(%), ICG R15%, Child-Pugh classification, AFP, DCP, intra-operative blood loss, tumor size, tumor number, coexisting hepatic vein or bile duct tumor thrombus, presence of the residual tumor between RT and non-RT group other than adjuvant chemotherapy administration (p = 0.0009). The 5-year overall survival rate of all 75 cases was 18.5%. There was a significant overall survival extension in RT group with 29.4% compared to 16.2% in non-RT group (p = 0.039, log-rank test). Surgery without residual lesions was performed in 64 patients, of which the 5-year recurrence-free survival rate was 10.9%. The 5-year recurrence-free survival rate of RT group (n = 30) (16.1%) was significantly better than non-RT group (n = 34) (5.5%) (p = 0.027, log-rank test). Univariate analysis using Cox proportional hazard model demonstrated that the Pre-RT was the only significant prognostic factor (HR 0.595, 95% CI 0.356 - 0.981, p = 0.042) for overall survival, and the Pre-RT and tumor size over 10cm for recurrence-free survival among these patient’s factors. Conclusions: Multidisciplinary treatment combined preoperative radiotherapy to PVTT and subsequent surgical resection improve the prognosis for the patients of HCC with advanced PVTT extend to MPT or first branch of PV.

Portal vein tumor thrombus (PVTT) in hepatocellular carcinoma (HCC) is a common entity. In colorectal liver metastasis, microscopic tumor invasion into the intrahepatic portal vein is also usually observed, but the incidence of macroscopic tumor thrombus in the first branch and trunk of the portal vein is rare. Most reported cases of PVTT from colorectal cancer had concomitant metastatic nodules in liver parenchyma, and the PVTT was continuous with the liver nodule, like PVTT in HCC. We present a case of PVTT from colorectal cancer with no definite metastatic nodules in liver parenchyma. A 58-year old man underwent laparoscopic high anterior resection for rectosigmoid carcinoma accompanied by bulky tumor thrombus in the branch of the inferior mesenteric vein. Six months later, he received left lobectomy and left caudate resection for liver metastasis. The resected specimen demonstrated there was no metastatic nodule in liver parenchyma and that the left portal system was filled with the tumor thrombus. The patient is alive with no sign of recurrence 66 months after hepatectomy. Even if there is a macroscopic PVTT from colorectal cancer, a better prognosis may be expected when the tumor can be completely resected en-bloc by anatomic hepatectomy including PVTT.

Apatinib Combined With Transarterial Chemoembolization in Patients With Hepatocellular Carcinoma and Portal Vein Tumor Thrombus: A Multicenter Retrospective Study

To evaluate the benefit of typing of tumor thrombi in determining treatment plan and assessing prognosis of hepatocellular carcinoma (HCC) with tumor thrombi in the portal vein. The clinical data of 84 patients of HCC with portal vein tumor thrombi admitted from Jan. 2000 to Jan. 2003 were analyzed retrospectively. The patients, 75 males and 9 females, aged 47 (28 - 70), were divided into 4 groups, groups I - IV, according to imaging examination of the tumor thrombi. The median survival periods and effectiveness of treatment, including surgical resection and non-surgical treatment, were observed. The surgical resection rates were 64.7%, 83.8%, 31.4%, and 0 in the groups I - IV respectively (P = 0.912). The general median survival period of the patients undergoing surgery was 8.0 months, significantly longer than that of the patients receiving non-surgical treatment (4.0 months, P = 0.000 6). In different group of tumor thrombi type, the general median survival period of the patients undergoing surgery was significantly longer than that of the patients receiving non-surgical treatment. The median survival periods were 10.1, 7.2, 5.7 and 3.0 months for groups I (n = 17), II (n = 26), III (n = 35) and groups IV (n = 6) respectively, with significant difference between any 2 groups (all P = 0.000 1). Typing of tumor thrombi helps determine the treatment plan and assess the prognosis of hepatocellular carcinoma patients with tumor thrombi in the portal vein.

To compare the therapeutic effect and significances of multimodality treatment for hepatocellular carcinoma (HCC) with tumor thrombi in portal vein (PVTT). HCC patients (n=147) with tumor thrombi in the main portal vein or the first branch of portal vein were divided into four groups by the several therapeutic methods. There were conservative treatment group in 18 out of patients (group A); and hepatic artery ligation(HAL) and/or hepatic artery infusion (HAI) group in 18 patients (group B), in whom postoperative chemoembolization was done periodically; group of removal of HCC with PVTT in 79 (group C) and group of transcatheter hepatic arterial chemoembolization (TACE) or HAI and/or portal vein infusion (PVI) after operation in 32 (group D). The median survival period was 12 months in our series and the 1-,3-, and 5-year survival rates were 44.3%, 24.5% and 15.2%, respectively. The median survival times were 2, 5, 12 and 16 months in group A, B, C and D, respectively. The 1-, 3- and 5-year survival rates were 5.6%, 0% and 0% in group A; 22.2%, 5.6% and 0% in group B; 53.9%, 26.9% and 16.6% in group C; 79.3%, 38.9% and 26.8% in group D, respectively. Significant difference appeared in the survival rates among the groups (P < 0.05). Hepatic resection with removal of tumor thrombi and HCC should increase the curative effects and be encouraged for the prolongation of life span and quality of life for HCC patients with PVTT, whereas the best therapeutic method for HCC with PVTT is with regional hepatic chemotherapy or chemoembolization after hepatic resection with removal of tumor thrombi.

BackgroundSurgical resection is a mainstay to treat hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) in east Asia. However, the postoperative recurrence rate is high. It is necessary to explore neo-adjuvant therapy to increase the surgical resection rate and improve overall survival. Evidence has shown that lenvatinib combined with PD-1 inhibitors is safe and effective in the treatment of advanced unresectable HCC. Radiotherapy is also an effective treatment method for PVTT and has a synergistic effect in combination with PD-1 inhibitors. Surgical resection after Lenvatinib and sintilimab combined with radiotherapy as a neoadjuvant treatment regimen may be a new exploration of HCC with PVTT, but there were not any reported.MethodsThis open-label, single-arm, prospective, multi-center Phase I trial will enroll 20 HCC patients with PVTT who have a resectable primary tumor and no extra-hepatic metastasis. Eligible patients will be given radiotherapy, 3Gy*10 fraction, and will receive lenvatinib 8-12mg once daily and sintilimab 200mg once every three weeks. Surgical resection will be performed 6-8 weeks after radiotherapy. The primary endpoint is safety (number of patients ≥3G TRAE) and the number of patients who complete pre-op treatment and proceed to surgery. The secondary study endpoints include Major Pathological Response (MPR), 1-year tumor recurrence-free rate, Objective Response Rate (ORR), Imaging-Pathology Concordance Rate (IPCR), PVTT regression rate, Median Overall Survival (OS) and Recurrence Free Survival (RFS).DiscussionThis trial may confirm that surgical resection following intensive neoadjuvant therapy can provide a safe and efficient regimen for BCLC stage C patients with PVTT.Clinical trial registrationhttps://clinicaltrials.gov/, identifier (NCT05225116).

To evaluate the characteristic of blood supply of liver portal vein tumor thrombus (PVTT) using perfusion indexes and spectral parameters. Between July 2020 and December 2022, the study enrolled 25 liver cancer patients completed with PVTT (male=20, female=5; age 41-74 years (59.48 ± 9.12)) from the Interventional Department of Jiangsu Cancer Hospital. There were 11 cases of type III PVTT, 12 of type II PVTT, and 2 of type I PVTT (Cheng's classification). All patients underwent spectral perfusion scans through dual-layer spectral detector computed tomography. The PVTTs were divided into proximal and distal groups based on the distance between the tumor thrombus and the main portal vein. The perfusion analysis was performed on the 120-kVp conventional images to generate hepatic perfusion index (HPI). The spectral based images (SBIs) during the artery and venous peak phases were extracted from the perfusion data. The iodine map and 40&100-keV virtual monoenergetic image (VMI) were generated from SBI data. HPI, iodine concentration (IC), CT value at 40 and 100-keV, and spectral slope (40-100keV) of the primary lesion, proximal and distal PVTT, and liver parenchyma were measured and compared. The correlation between the primary lesion and proximal and distal PVTT was analyzed. The IC and spectral slope during the arterial and venous peak phases and HPI of the primary lesion, proximal PVTT, and distal PVTT were highly correlated (P<0.001). The differences between the IC and spectral slope during the arterial and venous peak phases and HPI of the primary lesion, proximal PVTT were statistically significant (P<0.001). The differences between the IC during venous peak phase and HPI of primary lesion, distal PVTT were statistically significant (P<0.001), and there was no statistically significant difference in arterial phase IC, arterial and venous phase spectral slopes. The IC, slope, and HPI of the distal and proximal PVTT were highly correlated with the primary lesion, indicating that PVTT was similar to the primary lesion in the liver that they were both mainly supplied by the hepatic artery. However, there was still significant heterogeneity between the proximal PVTT and the primary lesion, while the difference in the distal PVTT was relatively small.

Objective To detect the mRNA and protein expressions of Bmi-1 in hepatocellular carcinoma (HCC) tissue,pericarcinomatous tissue,portal vein tumor thrombus and normal liver tissue,and to investiage the significance of Bmi-1 in the genesis and progression of HCC.Methods Forty tissues of HCC were collected from the Tongji Hospital of Huazhong University of Science and Technology from January 2005 to December 2009.The mRNA and protein expressions of Bmi-1 in the HCC tissues (40 cases),pericarcinomatous tissues (40 cases),portal vein tumor thrombus ( 11 cases) and normal liver tissues ( 10 cases) were detected by immunohistochemistry,Western blot and real-time polymerase chain reaction.The relationship between the expressions of Bmi-1 and the clinicopathological factors was analyzed.Differences in each group were compared by using the Nemenyi test or Dunnet t test,and the relationship between the clinicopathological factors and the protein expression in the HCC tissues was analyzed by the chi-square test or Fisher exact probability.The survival curve was drawn by the Kaplan-Meier method,and the survival rate was analyzed by the Log-rank test.Results The median relative mRNA expressions of Bmi-1 in the normal liver tissues,pericarcinomatous tissues,HCC tissues and portal vein tumor thrombus were 0.96,2.60,7.51 and 29.95,respectively.The results of immunohistochemistry showed that the high protein expression rates of Bmi-1 in the normal liver tissues,pericarcinomatous tissues,HCC tissues and portal vein tumor thrombus were 10.0％,20.0％,67.5％ and 100.0％,respectively.The high protein expression rates of Bmi-1 in the HCC tissues and portal vein tumor thrombus were significantly higher than those in the normal liver tissues and pericarcinomatous tissues (x2 =17.25,22.77;22.04,23.95,P ＜ 0.05 ). High protein expression of Bmi-1 was also detected in 11 cases of HCC tissues with portal vein tumor thrombus.The results of western blot were consistent with those of the immunohistochemistry.The mRNA and protein expressions of Bmi-1 were correlated with Edmondson grade and portal vein metastasis ( x2 =5.572,P ＜ 0.05 ),whereas they were irrelevant to the tumor size,serum levels of α-fetoprotein and hepatitis B surface antigen ( x2 =0.000,0.019,0.663,P ＞0.05).Patients with high expression of Bmi-1 had poor prognosis.Conclusions Bmi-1 is correlated with the genesis and progression of HCC as well as the formation of portal vein tumor thrombosis.Patients with high Bmi-1 expression have poorer prognosis when compared with those with low Bmi-1 expression. Key words: Liver neoplasms; Bmi-1 gene; Portal vein tumor thrombus