Malignant Portal Vein Thrombosis Research Articles

Percutaneous electrochemotherapy of malignant main portal veins thrombosis: A prospective case series

Introduction and aim: Cirrhotic patients with malignant main portal vein thrombosis (MMPVT) from Hepatocellular Carcinoma (HCC) are excluded from any known curative treatment. Electrochemotherapy (ECT) is a non-thermal ablation of tumors. We treated prospectively, with ECT a series of patients with MMPVT.

Portal Vein Thrombosis in Patients with Hepatocellular Carcinoma: Diagnostic Accuracy of Gadoxetic Acid-enhanced MR Imaging.

Purpose To assess the diagnostic performance of gadoxetic acid-enhanced magnetic resonance (MR) imaging in the evaluation of portal vein thrombosis (PVT) in patients with hepatocellular carcinoma (HCC). Materials and Methods This retrospective study was approved by the institutional review board. The requirement to obtain informed consent was waived. A total of 366 patients with HCC who underwent gadoxetic acid-enhanced MR imaging between January 2007 and May 2013, including 134 with malignant PVT, 49 with benign PVT, and 183 without PVT matched for age and sex, comprised our study population. PVTs were complete in 125 patients and partial in 58 and were located in a major portal vein (n = 159) or segmental portal vein (n = 24). Two radiologists independently reviewed the MR images and assessed the sensitivity, specificity, and accuracy in the detection and characterization of PVT according to location (major vs segmental) and type (complete vs partial). The Fisher exact or χ(2) test was used to evaluate sensitivity difference between the subsets. Results Gadoxetic acid-enhanced MR imaging showed good sensitivity (reviewer 1, 84% [154 of 183 patients]; reviewer 2, 70% [129 of 183 patients]) and high specificity (reviewer 1, 89% [163 of 183 patients]; reviewer 2, 96% [176 of 183 patients]) in the detection of PVT. Diagnostic accuracy for differentiating malignant PVT from benign PVT was high (reviewer 1, 92% [141 of 154 patients]; reviewer 2, 95% [122 of 129 patients]). However, there was slightly lower sensitivity for detecting segmental PVT compared with that of major PVT in the malignant PVT group (reviewer 1, 95% [104 of 110 patients] vs 88% [21 of 24 patients]; reviewer 2, 82% [90 of 110 patients] vs 79% [19 of 24 patients]; P = .203 and .775 for reviewers 1 and 2, respectively). Conclusion Gadoxetic acid-enhanced MR imaging provided good diagnostic performance in the detection of PVT and the differentiation of malignant from benign PVT in patients with HCC. However, caution is needed when evaluating potential candidates for curative treatment because of the low sensitivity for segmental PVT in the malignant PVT group. (©) RSNA, 2016 Online supplemental material is available for this article.

Color Doppler US and tri-phasic CT in differentiating benign from malignant portal vein thrombosis (PVT)

Objective: To evaluate the efficacy of color Doppler US and tri-phasic CT in discriminating benign from malignant PVT. Patients and methods: This study included 30 patients presented ultrasonically with PVT and referred for color Doppler US and Tri-phasic CT examination for discriminating the benign from malignant PVT. The color Doppler US and tri-phasic CT results were compared and correlated with available histopathological results in the patients who had FNAC. Results: Those 30 patients were classified according to US, Tri-phasic CT, lab., findings into two groups: G.(A) included 16 patients with malignant PVT and G.(B) included 14 patients with benign PVT. Intrathrombus pulsatile flow was depicted in 12 patients with malignant PVT (12/16) (75%), while non-depicted in 14 patients with benign PVT with 100% specificity. On tri-phasic CT, neovascularity and an early arterial enhancement of PVT were depicted in 14 cases with malignant PVT with 87.5% sensitivity and non-depicted in 14 benign cases with PVT with 100% specificity. Conclusion: Distinguishing benign from malignant PVT in patients with HCC is required to determine the management plan. The color Doppler study of PVT should be an essential step in evaluation of patients with HCC. The combination of Color Doppler US and tri-phasic CT is common and essential for more accurate evaluation and differentiation of benign from malignant PVT.

Spontaneous Regression of HCC: A Case Report

The spontaneous regression of HCC is extremely rare. This event could be explained by a strong and persistent activation of the immune system directed against the neoplastic cells or a sudden change in vascular inflow resulting in autoinfarction. We report herein a case of 51-year-old man who presented with a diagnosis of HCV induced cirrhosis. The initial liver ultrasound revealed an ill defined right lobe lesion approximately 7 x 8 cm in diameter, involving segments VII and VIII with malignant portal vein thrombosis. Baseline laboratory tests included: FBS 72 mg/dl, 2-hour postprandial sugar was 166 mg/dl, Hb 12.1 g/dl, WBC 3 000/cmm, neutrophils 1500/cmm, platelet count 70 000/cmm, ALT 85 U/L, AST 100 U/L, total serum bilirubin 1.8 mg/dl, serum albumin 3.3 g/dl, prothrombin time 13.1 seconds (70%) with calculated Child A compensated cirrhosis according to Child Pugh scoring. The initial AFP was 19,309 ng/ml. The triphasic CT (Figure 1) revealed a large invasive right lobe mass in segment IV,V,VI,VIII with an arterial blush and rapid washout pattern diagnostic for HCC, with associated with thrombosis of the right branch of portal vein with a porta hepatis lymphe node consistent with metastatic HCC. The patient had an ECOG performance status of 0, and according to the BCLC staging for HCC, Stage C (advanced stage) disease. Sorafenib was not available and the patient did not receive any other treatment. A triphasic CT, performed 4 months later, demonstrated (Figure 2) a marked decrease in the size of the lesion, with 4 x 3.8 cm in maximum dimensions. The thrombosed right portal vein branch showed cavernous transformation and no malignant neovascularization. The AFP was 1,923 ng/ml, laboratory tests: FBS 206 mg/dl, urea 22 mg/dl, creatinine 0.7 mg/dl, ALT 63 U/L, AST 77 U/L, total serum Bilirubin was 1.7 mg/dl, serum albumin 3.3g/dl. The patient was at a good general condition and remained at an ECOG performance status of 0. In conclusion, we report here a rare event in a patient with HCC, wherein the HCC underwent a spontaneous event that resulted in a marked decrease in the tumor size and area of neovascularization. This rare spontaneous event, which can change a patient's prognosis substantially, needs to be recognized by clinicians who monitor patients with HCC, both on and off treatment as well as in clinical trials.Figure 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Contrast-enhanced ultrasound in differentiating malignant from benign portal vein thrombosis in hepatocellular carcinoma

Portal vein thrombosis (PVT) may occur in liver cirrhosis patients. Malignant PVT is a common complication in cirrhotic patients with concomitant hepatocellular carcinoma (HCC) and, in some cases, it may be even the initial sign of an undetected HCC. Detection of malignant PVT in a patient with liver cirrhosis heavily affects the therapeutic strategy. Gray-scale ultrasound (US) is widely unreliable for differentiating benign and malignant thrombi. Although effective for this differential diagnosis, fine-needle biopsy remains an invasive technique. Sensitivity of color-doppler US in detection of malignant thrombi is highly dependent on the size of the thrombus. Contrast-enhanced computed tomography (CT) and contrast-enhanced magnetic resonance (MRI) can be useful to assess the nature of portal thrombus, while limited data are currently available about the role of positron emission tomography (PET) and PET-CT. In contrast with CT, MRI, PET, and PET-CT, contrast-enhanced ultrasound (CEUS) is a fast, effective, well tolerated and cheap technique, that can be performed even in the same session in which the thrombus has been detected. CEUS can be performed bedside and can be available also in transplanted patients. Moreover, CT and MRI only yield a snapshot analysis during contrast diffusion, while CEUS allows for a continuous real-time imaging of the microcirculation that lasts several minutes, so that the whole arterial phase and the late parenchymal phase of the contrast diffusion can be analyzed continuously by real-time US scanning. Continuous real-time monitoring of contrast diffusion entails an easy detection of thrombus maximum enhancement. Moreover, continuous quantitative analyses of enhancement (wash in - wash out studies) by CEUS during contrast diffusion is nowadays available in most CEUS machines, thus giving a more sophisticated and accurate evaluation of the contrast distribution and an increased confidence in diagnosis in difficult cases. In conclusion, CEUS is a very reliable technique with a high intrinsic sensitivity for portal vein patency assessment. More expensive and sophisticated techniques (i.e., CT, MRI, PET, and PET-CT) should only be indicated in undetermined cases at CEUS.

Editorial: TIPSS in patients with cirrhosis and hepatocellular carcinoma – authors' reply

With great interest, we read the editorial by Rowe and Tripathi and thank the authors for their comments concerning our paper published in the current issue of AP&T.1, 2 Patients with end-stage liver disease are often affected by portal hypertension and hepatocellular carcinoma (HCC). Symptomatic portal hypertension (SPH) is associated with impaired survival in HCC patients. In our retrospective observation study investigating TIPSS implantation in HCC patients, we were able to show a good clinical control of SPH in HCC patients, especially in those with small HCC.2 As the authors state correctly, our patients were highly selected and the decision to perform TIPSS implantation was made on an individual basis. Due to the retrospective design of our study, it was not entirely possible to evaluate the absolute contraindications in patients with HCC and SPH who were not allocated to TIPSS implantation. However, main contraindications included uncontrolled tumour growth and poor performance status of a given patient, but absolute and relative contraindications need to be clearly defined in further studies. Indeed, another important issue to be investigated will be the role of TIPSS implantation in patients with malignant portal vein thrombosis in HCC patients. Furthermore, Rowe and Tripathi point out that it will be important to stratify these patients according to the BCLC classification to determine overall survival. We fully agree with this comment and indeed further studies are needed that include a control group of HCC patients with SPH, who are therefore treated with medical or endoscopic treatment. In our opinion, it will be important to focus on patients with BCLC A suffering from SPH and are therefore not allocated to curative surgical resection. TIPSS may resolve SPH and thus, these patients may be allocated to surgery. Further prospective studies including a control group should focus on this important issue. In summary, our retrospective observation study highlights several important points and clinical relevant aspects, which can be evaluated in further well-designed prospective studies. The authors' declarations of personal and financial interests are unchanged from those in the original article.2

OCCULT HEPATITIS B VIRUS INFECTION IN PATIENTS WITH CHRONIC HEPATITIS C VIRUS INFECTION AND HEPATOCELLULAR CARCINOMA

Hepatocellular carcinoma is one of the most common cancers worldwide. Primary known risk factors for HCC are Hepatitis C virus (HCV), Hepatitis B virus (HBV) and alcoholic liver disease. There is little information about occult HBV and its relation to HCC in chronic . We aimed to evaluate the prevalence and the possible clinical impact of occult HBV infection in chronic HCV patients with hepatocellular carcinoma. Patient and methods: A total number of 140 patients with hepatocellular carcinoma were examined, 118 patients were included in this study. They had positive HCV-RNA, negative HBsAg and radiological evidence of Hepatocellular carcinoma, previous antiviral therapy or serological evidence of autoimmune hepatitis and were divided into two groups according to their HBc-Ab status: Group (I) 93 patients positive for HBc-Ab (Occult HBV/HCV dual infection), Group (II) 25 patients negative for HBc-Ab (HCV mono infection). The rest of HCC patients were coinfected with HCV and HBV, 8 patients had HBV infection (+ve HBV sAg and –ve HCV Ab) and 4 patients had negative tests for both HCV and HBV were excluded. Results: A statistically significant increase in serum levels of AST, ALT, bilirubin, Alpha-fetoprotein with more cirrhosis, ascites, liver decompensation (according to Child-Turcott-Pugh score) and more hepatic focal lesions and malignant portal vein thrombosis (through radiological diagnosis) in Group (I) as compared to Group (II), while there was no statistically significant difference among Group (I) and Group (II) as regarding PT% or spleen size. Conclusion: Occult HBV infection is extensively common among HCC chronic hepatitis C infected patients and presence of occult HBV infection is associated with more deterioration of liver status. Key words: Occult HBV, chronic HCV, HCC.

Sa1004 Measurement of Liver and Spleen Stiffness by ARFI Elastography: Intra-and Inter-Observer Variability and Predictors of Variability

Staging hepatocellular carcinoma (HCC) is an esential step in the decision regarding treatment options. Malignant portal vein thrombosis is a contraindication for all curative treatment, thus establishing the nature (benign or malignant) of PVT is mandatory for staging the disease. The AIM of this paper was to assess the role of contrast enhanced ultrasound (CEUS) for the staging of HCC in patients with liver cirrhosis. METHODS: We evaluated 86 consecutive patients with liver cirrhosis and known HCC, who were discovered with PVT located in different parts of the portal system. Before CEUS we performed a standard ultrasound and a Doppler examination. We used 2.4 ml of second generation contrast agent (SonoVue) for every examination. During the CEUS examination we followed the arterial, portal and late phases as defined in the EFSUMB Guidelines (1) and also the enhancement pattern as described by Rossi et al. (Type 1: thrombus enhancement is absent in all three phasesbenign thrombus; and for malign thrombus-Type 2: diffuse thrombus enhancement that is visible only during the early arterial phase; Type 3: linear or punctate enhancement; Type 4: multilinear or multipunctate enhancement)(2). RESULTS: PVT was located in the proximity of HCC in 63 of the 86 cases (73.2 %). 11 cases (12.7%) were Type 1 Rossi (benign thrombus), 44 cases (51.1%) were Type 2, 14 cases (16.2%) were Type 3 and 17 cases (19.7%) were Type 4 Rossi. Using CEUS we could characterise and obtain a conclusive diagnosis in 85 of the 86 patients (98.8%). CONCLUSIONS CEUS is a method with a good sensibility for the characterisation of PVT in patients with HCC, that allows the staging of the disease for a good therapeutic decision. BIBLIOGRAPHY: 1. M. Claudon, C. F. Dietrich, B. I. Choi, D. O. Cosgrove, M. Kudo, C. P. Nolsoe, F. Piscaglia, S. R. Wilson, R. G. Barr, M. C. Chammas, N. G. Chaubal, M.-H. Chen, D. A. Clevert, J. M. Correas, H. Ding, F. Forsberg, J. B. Fowlkes, R. N. Gibson, B. B. Goldberg, N. Lassau, E. L. S. Leen, R. F. Mattrey, F. Moriyasu, L. Solbiati, H.-P. Weskott, H.-X. Xu. Guidelines and Good Clinical Practice Recommendations for Contrast Enhanced Ultrasound (CEUS) in the Liver-Update 2012. Published online: 2012 Ultraschall in Med. 2. Rossi S. et al. Contrast-Enhanced Versus Conventional and Color Doppler Sonography for the Detection of Thrombosis of the Portal and Hepatic Venous Systems. AJR 2006; 186:763-773.

Sa1003 Diagnosis of Benign and Malignant Portal Vein Thrombosis in Cirrhotic Patients With Hepatocellular Carcinoma Using Contrast-Enhanced Ultrasound (CEUS)

Staging hepatocellular carcinoma (HCC) is an esential step in the decision regarding treatment options. Malignant portal vein thrombosis is a contraindication for all curative treatment, thus establishing the nature (benign or malignant) of PVT is mandatory for staging the disease. The AIM of this paper was to assess the role of contrast enhanced ultrasound (CEUS) for the staging of HCC in patients with liver cirrhosis. METHODS: We evaluated 86 consecutive patients with liver cirrhosis and known HCC, who were discovered with PVT located in different parts of the portal system. Before CEUS we performed a standard ultrasound and a Doppler examination. We used 2.4 ml of second generation contrast agent (SonoVue) for every examination. During the CEUS examination we followed the arterial, portal and late phases as defined in the EFSUMB Guidelines (1) and also the enhancement pattern as described by Rossi et al. (Type 1: thrombus enhancement is absent in all three phasesbenign thrombus; and for malign thrombus-Type 2: diffuse thrombus enhancement that is visible only during the early arterial phase; Type 3: linear or punctate enhancement; Type 4: multilinear or multipunctate enhancement)(2). RESULTS: PVT was located in the proximity of HCC in 63 of the 86 cases (73.2 %). 11 cases (12.7%) were Type 1 Rossi (benign thrombus), 44 cases (51.1%) were Type 2, 14 cases (16.2%) were Type 3 and 17 cases (19.7%) were Type 4 Rossi. Using CEUS we could characterise and obtain a conclusive diagnosis in 85 of the 86 patients (98.8%). CONCLUSIONS CEUS is a method with a good sensibility for the characterisation of PVT in patients with HCC, that allows the staging of the disease for a good therapeutic decision. BIBLIOGRAPHY: 1. M. Claudon, C. F. Dietrich, B. I. Choi, D. O. Cosgrove, M. Kudo, C. P. Nolsoe, F. Piscaglia, S. R. Wilson, R. G. Barr, M. C. Chammas, N. G. Chaubal, M.-H. Chen, D. A. Clevert, J. M. Correas, H. Ding, F. Forsberg, J. B. Fowlkes, R. N. Gibson, B. B. Goldberg, N. Lassau, E. L. S. Leen, R. F. Mattrey, F. Moriyasu, L. Solbiati, H.-P. Weskott, H.-X. Xu. Guidelines and Good Clinical Practice Recommendations for Contrast Enhanced Ultrasound (CEUS) in the Liver-Update 2012. Published online: 2012 Ultraschall in Med. 2. Rossi S. et al. Contrast-Enhanced Versus Conventional and Color Doppler Sonography for the Detection of Thrombosis of the Portal and Hepatic Venous Systems. AJR 2006; 186:763-773.

Rapidly Progressive Hepatocellular Carcinoma Mimicking Benign Portal Vein Thrombosis: A Case Report

Portal vein thrombosis (PVT) is commonly associated with liver cirrhosis, irrespective of the presence of hepatocellular carcinoma (HCC). Given that malignant PVT is a poor prognostic factor in patients with HCC, it is important to differentiate malignant PVT from benign PVT. Because malignant PVT has been reported to be contiguous with parenchymal HCC, in most cases, the presence of PVT alone indicates a benign entity. We report the case of a patient with rapid progression of malignant PVT mimicking benign PVT but without definite parenchymal HCC on imaging modalities.

Hepatocellular Carcinoma Presenting as an Incidental Isolated Malignant Portal Vein Thrombosis

Portal vein thrombosis is frequently associated with hepatocellular carcinoma (HCC). Tumor invasion into the portal vein by direct venous extension or metastasis occurs in up to 70% of HCC patients (Cedrone et al., Liver 16:94-8, 1996). However, presentation as an isolated malignant portal vein thrombosis without any evidence of obvious hepatoma-like lesions in the liver by imaging studies is extremely uncommon. We present an unusual case of HCC presenting as a malignant portal vein thrombus, proven on biopsy of the thrombus without any evidence of primary liver lesion. This, to our knowledge, is the first case of HCC presenting as an incidental isolated malignant portal vein thrombosis. The importance of doing delayed enhancement imaging studies to rule out malignant portal vein thrombosis is emphasized. A 60-year-old man presented with acute substernal chest pain. Physical examination revealed icterus. Examination of the abdomen did not reveal any organomegaly. Liver function test revealed a predominantly conjugated bilirubinemia. Abdominal sonogram revealed thrombosis and occlusion of the posterior right portal vein. Liver parenchyma was homogenous with no intrahepatic mass. Computed tomography (CT) of the abdomen and pelvis after administration of oral and intravenous contrast with delayed views revealed arterial enhancement of the right portal vein thrombus with delayed washout. MRI of the abdomen with gadolinium confirmed the right portal vein thrombus without focal hepatic mass. Aspiration of the right portal vein thrombus under CT guidance revealed hepatocellular carcinoma which was confirmed by immunohistochemistry. Serum alpha-fetoprotein level was very high. Patient was started on sorafenib with subsequent decrease in alpha-fetoprotein level. He was doing well till the date of this report. This unusual case of hepatocellular carcinoma presenting as an incidental malignant portal vein thrombosis without any primary liver lesion is extremely rare. Other reported cases of malignant portal vein thrombosis have been in patients with underlying hepatoma, cirrhosis, or with intrabiliary hepatocelluar carcinoma. In the clinical setting of portal vein thrombosis, imaging studies showing enhancement of the thrombus in the arterial phase are important in leading to the diagnosis of malignancy.

Criteria for diagnosing benign portal vein thrombosis in the assessment of patients with cirrhosis and hepatocellular carcinoma for liver transplantation

Malignant portal vein thrombosis is a contraindication for liver transplantation. Patients with cirrhosis and early hepatocellular carcinoma (HCC) may have either malignant or benign (fibrin clot) portal vein thrombosis. The aim of this study was to assess prospectively whether well-defined diagnostic criteria would enable the nature of portal vein thrombosis to be established in patients with HCC under consideration for liver transplantation. Benign portal vein thrombosis was diagnosed by the application of the following criteria: lack of vascularization of the thrombus on contrast-enhanced ultrasound and on computed tomography or magnetic resonance imaging, absence of mass-forming features of the thrombus, absence of disruption of the walls of veins, and, if uncertainty persisted, biopsy of the thrombus for histological examination. Patients who did not fulfill the criteria for benign thrombosis were not placed on the transplantation list. In this study, all patients evaluated at our center during 2001-2007 with a diagnosis of HCC in whom portal vein thrombosis was concurrently or subsequently diagnosed were discussed by a multidisciplinary group to determine their suitability for liver transplantation. The outcomes for 33 patients who met the entry criteria of the study were as follows: in 14 patients who were placed on the transplantation list and underwent liver transplantation, no malignant thrombosis was detected when liver explants were examined histologically; 5 patients who were placed on the transplantation list either remained on the list or died from causes unrelated to HCC; in 9 patients, liver transplantation was contraindicated on account of a strong suspicion, or confirmation, of the presence of malignant portal vein thrombosis; and 5 patients who were initially placed on the transplantation list were subsequently removed from it on account of progression of HCC in the absence of evidence of neoplastic involvement of thrombosis. In conclusion, for a patient with HCC and portal vein thrombosis, appropriate investigations can establish whether the thrombosis is benign; patients with HCC and benign portal vein thrombosis are candidates for liver transplantation.

Diagnosis of portal vein thrombosis discontinued with liver tumors in patients with liver cirrhosis and tumors by contrast-enhanced US: A pilot study

Aims We assessed the role of contrast-enhanced ultrasound (CEUS) in the differential diagnosis between benign and malignant portal vein thrombosis (PVT) in patients who had liver tumors. Methods Seventeen consecutive patients who had cirrhosis, liver tumors, and PVT were prospectively studied with CEUS. CEUS was performed at low mechanical index after intravenous administration of a second-generation contrast agent (SonoVue, Bracco, Milan, Italy). Presence or absence of thrombus enhancement on CEUS were considered diagnostic for malignant or benign PVT. Five patients also underwent percutaneous portal vein fine-needle biopsy under US guidance. All patients were followed-up. Shrinkage of the thrombus and/or recanalization of the vessels on CDUS during follow-up were considered definitive evidence of the benign nature of the thrombosis, whereas the enlargement of the thrombus, disruption of the vessel wall, and parenchymal infiltration over follow-up were considered consistent with malignancy. Results Follow-up showed signs of malignant thrombosis in 14 of 17 patients. CEUS showed early arterial enhancement of the PVT in 14 patients of 14 malignant PVT, 1 patient of 3 benign PVT and the absence of thrombus enhancement in 2 patients of 3 benign PVT. FNB confirmed the results for malignant PVT in four of five patients, for benign granulomatous inflammation PVT in one of five patients in which CEUS showed early arterial enhancement of the PVT. The sensitivity, specificity and accuracy is 100%, 66.7% and 93.3% at diagnosis of malignant PVT using CEUS. In one patient with intrahepatic bile duct stone, CEUS were positive for malignant PVT, whereas FNB was negative (benign granulomatous inflammation PVT); follow-up examination confirmed benign PVT. Conclusion CEUS seems to be the pretty sensitive and specific test for diagnosing malignant portal vein thrombosis in patients with cirrhosis and tumors.

A case of advanced hepatocellular carcinoma with portal vein tumor invasion controlled by percutaneous ethanol injection therapy

Portal vein invasion is a grave prognostic indicator in the setting of hepatocellular carcinoma (HCC). There is currently no effective method for preventing the invasion of HCC into the main portal vein. We report here a case of advanced HCC with portal vein tumor thrombosis that was effectively treated with percutaneous ethanol injection (PEI), having previously enabled subsequent successive transarterial chemoembolization (TACE). A 60-year-old male patient was diagnosed with a huge HCC, based on computed tomography and angiographic findings. Despite two sessions of TACE, the tumor invaded the right portal vein. PEI was performed on the malignant portal vein thrombosis, and three sessions thereof reduced the extent of tumor thrombi in the portal vein. Successive TACEs were performed to treat the HCC in the hepatic parenchyma. The patient was still living 19 months after the first PEI with no evidence of tumor recurrence, and his liver function remained well preserved.

Contrast-enhanced sonography versus biopsy for the differential diagnosis of thrombosis in hepatocellular carcinoma patients

To clarify which method has accuracy: 2nd generation contrast-enhanced ultrasound or biopsy of portal vein thrombus in the differential diagnosis of portal vein thrombosis. One hundred and eighty-six patients with hepatocellular carcinoma and portal vein thrombosis underwent in blinded fashion a 2nd generation contrast-enhanced ultrasound and biopsy of portal vein thrombus; both results were examined on the basis of the follow-up of patients compared to reference-standard. One hundred and eight patients completed the study. Benign thrombosis on 2nd generation contrast-enhanced ultrasound was characterised by progressive hypoenhancing of the thrombus; in malignant portal vein thrombosis there was a precocious homogeneous enhancement of the thrombus. On follow-up there were 50 of 108 patients with benign thrombosis: all were correctly diagnosed by both methods. There were 58 of 108 patients with malignant thrombosis: amongst these, 52 were correctly diagnosed by both methods, the remainder did not present malignant cells on portal vein thrombus biopsy and showed on 2nd generation contrast-enhanced ultrasound an inhomogeneous enhancement pattern. A new biopsy during the follow-up, guided to the area of thrombus that showed up on 2nd generation contrast-enhanced ultrasound, demonstrated an enhancing pattern indicating malignant cells. In patients with hepatocellular carcinoma complicated by portal vein thrombosis, 2nd generation contrast-enhanced ultrasound of portal vein thrombus is very useful in assessing the benign or malignant nature of the thrombus. Puncture biopsy of thrombus is usually accurate but presents some sampling errors, so, when pathological results are required, 2nd generation contrast-enhanced ultrasound could guide the sampling needle to the correct area of the thrombus.

Thrombose portale tumorale et métastase hépatique de cancer colorectal: Une association peu connue

It is rare for portal vein thrombosis to complicate colorectal liver metastases. However malignant portal vein thrombosis must be anticipated when considering hepatic resection. While this finding may influence long-term survival, it does not absolutely contraindicate hepatic resection. We report here a case of colorectal metastasis to the liver with associated macroscopic malignant portal vein thrombosis treated with hepatic resection; the patient is free from recurrence at 5-year follow-up.

Highly metabolic thrombus of the portal vein: 18F fl uorodeoxyglucose positron emission tomography/computer tomography demonstration and clinical signifi cance in hepatocellular carcinoma

To assess the ability of (18)F-fluorodeoxyglucose positron emission tomography/computer tomography ((18)F-FDG PET/CT) to differentiate between benign and malignant portal vein thrombosis in hepatocellular carcinoma (HCC) patients. Five consecutive patients who had HBV cirrhosis, biopsy-proven HCC, and thrombosis of the main portal vein and/or left/right portal vein on ultrasound (US), computer tomography (CT) or magnetic resonance imaging (MRI) were studied with (18)F-FDG PET/CT. The presence or absence of a highly metabolic thrombus on (18)F-FDG PET/CT was considered diagnostic for malignant or benign portal vein thrombosis, respectively. All patients were followed-up monthly with US, CT or MRI. Shrinkage of the thrombus or recanalization of the vessels on US, CT or MRI during follow-up was considered to be definitive evidence of the benign nature of the thrombosis, whereas enlargement of the thrombus, disruption of the vessel wall, and parenchymal infiltration over follow-up were considered to be consistent with malignancy. (18)F-FDG PET/CT, and US, CT or MRI results were compared. Follow-up (1 to 10 mo) showed signs of malignant thrombosis in 4 of the 5 patients. US, CT or MRI produced a true-positive result for malignancy in 4 of the patients, and a false-positive result in 1. (18)F-FDG PET/CT showed a highly metabolic thrombus in 4 of the 5 patients. (18)F-FDG PET/CT achieved a true-positive result in all 4 of these patients, and a true-negative result in the other patient. No false-positive result was observed using (18)F-FDG PET/CT. (18)F-FDG PET/CT may be helpful in discriminating between benign and malignant portal vein thrombi. Patients may benefit from (18)F-FDG PET/CT when portal vein thrombi can not be diagnosed exactly by US, CT or MRI.

Characterization of Portal Vein Thrombus With the Use of Contrast-Enhanced Sonography

To select an appropriate treatment regimen, it is essential to accurately characterize the nature of a thrombus. This study prospectively assessed the ability of contrast-enhanced sonography to differentiate between benign and malignant portal vein thrombosis in a population of high-risk patients. Fifty-five patients (43 men and 12 women; mean age, 66 years; range, 55-83 years) with thrombi of the portal venous system were examined by power Doppler sonography and contrast-enhanced sonography with the intravenous contrast agent SH U 508A (Levovist; Schering AG, Berlin, Germany). Of the thrombi, 40 were characterized as malignant and 15 as benign. Pulsatile flow in the thrombus on power Doppler sonography and positive enhancement of the thrombus on contrast-enhanced sonography were judged as indications of a malignant thrombus. The sensitivity and specificity of both methods in differentiating the nature of the thrombus were evaluated. The detection of pulsatile flow in a portal vein thrombus as the criterion for diagnosing malignant portal vein thrombus yielded overall sensitivity of 82.5% and specificity of 100%, whereas positive enhancement of the portal vein thrombus itself as a criterion for diagnosing malignancy yielded overall sensitivity and specificity of 100% for each. Contrast-enhanced sonography can be helpful in discriminating between benign and malignant portal vein thrombi.

Diagnosis of benign and malignant portal vein thrombosis in cirrhotic patients with hepatocellular carcinoma: color Doppler US, contrast-enhanced US, and fine-needle biopsy

We assessed the role of contrast-enhanced ultrasound (CEUS) in the differential diagnosis between benign and malignant portal vein thrombosis in patients who had cirrhosis with hepatocellular carcinoma (HCC). Fifty-four consecutive patients who had cirrhosis, biopsy-proved HCC, and thrombosis of the main portal vein and/or left/right portal vein on US were prospectively studied with color Doppler US (CDUS) and CEUS. CEUS was performed at low mechanical index after intravenous administration of a second-generation contrast agent (SonoVue, Bracco, Milan, Italy). Presence or absence of CDUS signals or thrombus enhancement on CEUS were considered diagnostic for malignant or benign portal vein thrombosis. Twenty-eight patients also underwent percutaneous portal vein fine-needle biopsy (FNB) under US guidance. All patients were followed-up bimonthly by CDUS. Shrinkage of the thrombus and/or recanalization of the vessels on CDUS during follow-up were considered definitive evidence of the benign nature of the thrombosis, whereas enlargement of the thrombus, disruption of the vessel wall, and parenchymal infiltration over follow-up were considered consistent with malignancy. CDUS, CEUS, and FNB results were compared with those at follow-up. Follow-up (4 to 21 months) showed signs of malignant thrombosis in 34 of 54 patients. FNB produced a true-positive result for malignancy in 19 of 25 patients, a false-negative result in six of 25 patients, and a true-negative result in three of three patients. CDUS was positive in seven of 54 patients. CEUS showed enhancement of the thrombus in 30 of 54 patients. No false-positive result was observed at CDUS, CEUS, and FNB. Sensitivities of CDUS, CEUS, and FNB in detecting malignant thrombi were 20%, 88%, and 76% respectively. Three patients showed negative CDUS and CEUS and positive FNB results; follow-up confirmed malignant thrombosis in these patients. One patient showed negative CDUS, CEUS, and FNB findings. However, follow-up of the thrombus showed US signs of malignancy. Another FNB confirmed HCC infiltration of the portal vein. CEUS seems to be the most sensitive and specific test for diagnosing malignant portal vein thrombosis in patients with cirrhosis.

265 Diagnosis of benign and malignant portal vein thrombosis by contrast-enhanced us in patients with HCC on cirrhosis

265 Diagnosis of benign and malignant portal vein thrombosis by contrast-enhanced us in patients with HCC on cirrhosis