Macrovascular Malignant Portal Vein Thrombosis in Cirrhotic Patients with HCC

Abstract

1.1. Background: The presence of macrovascular malignant portal vein thrombosis (MMPVT) in patients with HCC is one of the most significant prognostic factors. Without treatment, the survival is less than 3 months [1]. Standard treatment regimens have not been established in these patients. 1.2. Aims: Our aim was to explore the prevalence and degrees of MMPVT in cirrhotic patients with HCC. Also, we aimed at determination of a correlation between the degree of MMPVT and both the tumour burden and the degree of liver function impairement. 1.3. Methods: The diagnosis of HCC in cirrhotic patients was based on the EASL guidelines. On contrast-enhanced CT scans, MMPVT was identified by the presence of a low-attenuation intra-luminal filling defect. Intrathrombus vascularity, observed in the arterial phase of imaging studies after the administration of contrast, has been reported to be a sign that is specific for MMPVT on CT [3]. MMPVT was graded into 4 grades according to Nonami grading [3]. Child-Turcotte-Puph (CTP) score was calculated for every patient and AFP was measured. Neutrophil- lymphocyte ratio (NLR) was calculated by dividing the neutrophil count by the lymphocyte count, provided that there was no ongoing infection. 1.4. Results: In 247 consecutive cirrhotic HCC patients (88.9% males, 11.1% females), the mean age was 58.87±7.42 years. MMPVT was detected in 63 patients (57 male, 6 females) representing 26% of all HCC cases. G1 MMPVT was present in 4 patients (6.3%), G2 in 19 patients (30.1%), G3 in 4 patients (6.3%) and G4 in 36 patients (57.1%). In HCC cases with MMPVT the tumor was multifocal or diffuse in 53 patients (82.5%) and unifocal in 11 patients (17.5%).The serum AFP level, CTP score and NLR were significantly higher in presence of MMPVT (P =.022,.005 and<.0005 respectively).The tumor size was significantly larger in presence of MMPVT(P<.0005).There was a significant positive correlation between the grade of MMPVT and CTP score (r = 0.205- p<0. 001), serum AFP level (r = o.423 –p< 0. 0001) and tumor size (r =o.275 - p< 0. 0001).The cut-off serum AFP value above which HCC patients had high risk of having MMPVT was 373.5 ngm/ml with sensitivity of 74.1% and specificity of 77.9% and area under the curve(AUC) of 77.6%.The cut-off tumor size above which HCC patients had high risk of having MMPVT is 5.9 cm with sensitivity of 64.5% and specificity of 72.1% and AUC of 70.5%. 1.5. Conclusion: MMPVT of different degrees was present in 26% of cirrhotic HCC cases. It is associated with tumor burden, aggressiveness and degree of liver function impairment.