Abdominal imaging
Case TypeClinical Case
Authors
Nikoletta Pyrrou 1, Angeliki Papachristodoulou 1, Vasileios Rafailidis 1, Adonis Protopapas 2, Panos Prassopoulos 1
60 years, male
A 60-year-old male patient with history of chronic HCV hepatitis and alcohol uptake presented with raised alpha-fetoprotein (AFP) (460ng/ml).
US examination demonstrated an enlarged portal vein (PV) with echogenic material filling the lumen; in addition, a 4.4 x 4.2 cm juxta-positioned ill-defined, slightly echogenic hepatic lesion in segment VIII was noted (Figure 1). Contrast-enhanced ultrasound (CEUS) examination was performed for further characterisation. The PV echogenic lesion showed arterial phase hyperenhancement and washout (Figure 2). A similar appearance was simultaneously noted in the juxta-positioned lesion. After bursting the microbubbles with a high Mechanical Index (MI) pulse and using temporal maximum intensity projection, the internal vascular architecture of the material was disclosed; a dense network of irregular and branching neoplastic vessels was delineated inside the lesion (Figure 2). A second injection of contrast agent was done in order to further evaluate the focal liver lesion on arterial phase imaging. The patient underwent MRI with hepatobiliary contrast agent (Primovist), also showing the PV filling defect, along with the hepatic focal lesion. The latter exhibited hepatobiliary phase hypointensity and restriction on diffusion-weighted MRI (DW-MRI) (Figure 3). A CT-guided biopsy of the liver lesion was performed, and histological examination revealed a hepatocellular carcinoma (HCC). The patient was treated with immunotherapy.
In the Liver Imaging Reporting And Data System (LI-RADS), tumour-in-vein (TIV) indicates the presence of an unequivocal enhancing soft tissue in the vein, regardless of visualisation of parenchymal mass and is an important complication of hepatocellular carcinoma (HCC) [1–7]. Diagnosing an observation as LIRADS-TIV is clinically significant as it affects prognosis and may limit treatment options. Transplantation is, in general, contraindicated, and surgery resection is performed on rare occasions [8,9].
AFP is a biomarker used for the surveillance, diagnosis and treatment response of HCC. The combination of CEUS and AFP can improve the diagnostic performance of the characterisation of portal vein thrombosis.
Conventional B-mode ultrasound (US) may depict the echogenic thrombus within an enlarged portal vein [10]. Colour-Doppler US (CDUS) can confirm the lack of flow in the thrombosed portal vein, while it might detect arterial flow inside the thrombus, suggesting its malignant nature; however, the sensitivity of CDUS for differentiating benign and malignant thrombosis may be limited, as in our case [11–14]. Contrast-enhanced Computed Tomography (CECT) has high sensitivity and specificity in detecting portal vein thrombosis, and may help in differentiating malignant from benign thrombosis [15–16]. DW-MRI may be occasionally helpful in characterising LI-RADS TIV; however, small PV thrombi might be missed on MRI [17].
On contrast-enhanced cross-sectional imaging, LI-RADS TIV exhibits arterial-phase hyperenhancement – earlier and higher than the liver parenchyma – and washout in the venous and delayed phases, similarly to the tumour of origin, in terms of intensity and timing. Conversely, benign portal vein thrombosis is non-enhancing in the different post-contrast phases [18–22]. Many studies confirmed high sensitivity and specificity (of CEUS in differentiating malignant from benign PVT [11,23–27]. Based on these promising results, “differential diagnosis between malignant and benign portal vein thrombosis” has been included in official guidelines and recommendations for CEUS published by EFSUMB (Recommendation 20, LoE 2, strong recommendation) [28]. Thanks to its real-time nature, CEUS continuously visualises the thrombus with arterial phase hyperenhancement and subsequent washout with good contrast, spatial and temporal resolution and hence is highly accurate in the diagnosis of malignant portal vein thrombosis [29,30]. This real-time scanning nature allows for the depiction of early enhancement, potentially missed on a poorly-timed CT and MRI acquiring static images [31].
Written informed patient consent for publication has been obtained.
[1] Cohen J, Edelman RR, Chopra S (1992) Portal vein thrombosis: a review. Am J Med 92(2):173-82. doi: 10.1016/0002-9343(92)90109-o. (PMID: 1543202)
[2] Shukla A, Giri S (2022) Portal Vein Thrombosis in Cirrhosis. J Clin Exp Hepatol 12(3):965-979. doi: 10.1016/j.jceh.2021.11.003. (PMID: 35677518)
[3] Valla DC, Condat B (2000) Portal vein thrombosis in adults: pathophysiology, pathogenesis and management. J Hepatol 32(5):865-71. doi: 10.1016/s0168-8278(00)80259-7. (PMID: 10845677)
[4] Rajani R, Björnsson E, Bergquist A, Danielsson A, Gustavsson A, Grip O, Melin T, Sangfelt P, Wallerstedt S, Almer S (2010) The epidemiology and clinical features of portal vein thrombosis: a multicentre study. Aliment Pharmacol Ther 32(9):1154-62. doi: 10.1111/j.1365-2036.2010.04454.x. (PMID: 21039677)
[5] Amitrano L, Guardascione MA, Brancaccio V, Margaglione M, Manguso F, Iannaccone L, Grandone E, Balzano A (2004) Risk factors and clinical presentation of portal vein thrombosis in patients with liver cirrhosis. J Hepatol 40(5):736-41. doi: 10.1016/j.jhep.2004.01.001. (PMID: 15094219)
[6] Intagliata NM, Caldwell SH, Tripodi A (2019) Diagnosis, Development, and Treatment of Portal Vein Thrombosis in Patients With and Without Cirrhosis. Gastroenterology 156(6):1582-99.e1. doi: 10.1053/j.gastro.2019.01.265. (PMID: 30771355)
[7] Tarantino L, Ambrosino P, Di Minno MN (2015) Contrast-enhanced ultrasound in differentiating malignant from benign portal vein thrombosis in hepatocellular carcinoma. World J Gastroenterol 21(32):9457-60. doi: 10.3748/wjg.v21.i32.9457. (PMID: 26327753)
[8] Quirk M, Kim YH, Saab S, Lee EW (2015) Management of hepatocellular carcinoma with portal vein thrombosis. World J Gastroenterol 21(12):3462-71. doi: 10.3748/wjg.v21.i12.3462. (PMID: 25834310)
[9] Silva JP, Berger NG, Tsai S, Christians KK, Clarke CN, Mogal H, White S, Rilling W, Gamblin TC (2017) Transarterial chemoembolization in hepatocellular carcinoma with portal vein tumor thrombosis: a systematic review and meta-analysis. HPB (Oxford) 19(8):659-66. doi: 10.1016/j.hpb.2017.04.016. (PMID: 28552299)
[10] Van Gansbeke D, Avni EF, Delcour C, Engelholm L, Struyven J (1985) Sonographic features of portal vein thrombosis. AJR Am J Roentgenol 144(4):749-52. doi: 10.2214/ajr.144.4.749. (PMID: 3883708)
[11] Tarantino L, Francica G, Sordelli I, Esposito F, Giorgio A, Sorrentino P, de Stefano G, Di Sarno A, Ferraioli G, Sperlongano P (2006) Diagnosis of benign and malignant portal vein thrombosis in cirrhotic patients with hepatocellular carcinoma: color Doppler US, contrast-enhanced US, and fine-needle biopsy. Abdom Imaging 31(5):537-44. doi: 10.1007/s00261-005-0150-x. (PMID: 16865315)
[12] Tanaka K, Numata K, Okazaki H, Nakamura S, Inoue S, Takamura Y (1993) Diagnosis of portal vein thrombosis in patients with hepatocellular carcinoma: efficacy of color Doppler sonography compared with angiography. AJR Am J Roentgenol 160(6):1279-83. doi: 10.2214/ajr.160.6.8388620. (PMID: 8388620)
[13] Furuse J, Matsutani S, Yoshikawa M, Ebara M, Saisho H, Tsuchiya Y, Ohto M (1992) Diagnosis of portal vein tumor thrombus by pulsed Doppler ultrasonography. J Clin Ultrasound 20(7):439-46. doi: 10.1002/jcu.1870200705. (PMID: 1324947)
[14] Rossi S, Rosa L, Ravetta V, Cascina A, Quaretti P, Azzaretti A, Scagnelli P, Tinelli C, Dionigi P, Calliada F (2006) Contrast-enhanced versus conventional and color Doppler sonography for the detection of thrombosis of the portal and hepatic venous systems. AJR Am J Roentgenol 186(3):763-73. doi: 10.2214/AJR.04.1218. (PMID: 16498104)
[15] Tublin ME, Dodd GD 3rd, Baron RL (1997) Benign and malignant portal vein thrombosis: differentiation by CT characteristics. AJR Am J Roentgenol 168(3):719-23. doi: 10.2214/ajr.168.3.9057522. (PMID: 9057522)
[16] Qian LJ, Zhu J, Zhuang ZG, Xia Q, Cheng YF, Li JY, Xu JR (2012) Differentiation of neoplastic from bland macroscopic portal vein thrombi using dual-energy spectral CT imaging: a pilot study. Eur Radiol 22(10):2178-85. doi: 10.1007/s00330-012-2477-3. (PMID: 22622347)
[17] Catalano OA, Choy G, Zhu A, Hahn PF, Sahani DV (2010) Differentiation of malignant thrombus from bland thrombus of the portal vein in patients with hepatocellular carcinoma: application of diffusion-weighted MR imaging. Radiology 254(1):154-62. doi: 10.1148/radiol.09090304. (PMID: 20032150)
[18] Rafailidis V, Fang C, Yusuf GT, Huang DY, Sidhu PS (2018) Contrast-enhanced ultrasound (CEUS) of the abdominal vasculature. Abdom Radiol (NY) 43(4):934-47. doi: 10.1007/s00261-017-1329-7. (PMID: 28983674)
[19] Salman S (2012) Portal vein thrombosis with contrast-enhanced ultrasound in a patient with hepatocellular carcinoma: a case study. Australas J Ultrasound Med 15(2):67-70. doi: 10.1002/j.2205-0140.2012.tb00229.x. (PMID: 28191145)
[20] Piscaglia F, Gianstefani A, Ravaioli M, Golfieri R, Cappelli A, Giampalma E, Sagrini E, Imbriaco G, Pinna AD, Bolondi L; Bologna Liver Transplant Group (2010) Criteria for diagnosing benign portal vein thrombosis in the assessment of patients with cirrhosis and hepatocellular carcinoma for liver transplantation. Liver Transpl 16(5):658-67. doi: 10.1002/lt.22044. (PMID: 20440775)
[21] Kwon JH, Yoo SH, Nam SW, Lee YJ, Shin YR (2020) Diagnostic Role of Contrast-enhanced Ultrasound in the Discrimination of Malignant Portal Vein Thrombosis in Patients With Hepatocellular Carcinoma. Anticancer Res 40(8):4351-63. doi: 10.21873/anticanres.14438. (PMID: 32727763)
[22] Chen J, Zhu J, Zhang C, Song Y, Huang P (2020) Contrast-enhanced ultrasound for the characterization of portal vein thrombosis vs tumor-in-vein in HCC patients: a systematic review and meta-analysis. Eur Radiol 30(5):2871-80. doi: 10.1007/s00330-019-06649-z. (PMID: 32020403)
[23] Rossi S, Ghittoni G, Ravetta V, Torello Viera F, Rosa L, Serassi M, Scabini M, Vercelli A, Tinelli C, Dal Bello B, Burns PN, Calliada F (2008) Contrast-enhanced ultrasonography and spiral computed tomography in the detection and characterization of portal vein thrombosis complicating hepatocellular carcinoma. Eur Radiol 18(8):1749-56. doi: 10.1007/s00330-008-0931-z. (PMID: 18369630)
[24] Dănilă M, Sporea I, Popescu A, Sirli R, Sendroiu M (2011) The value of contrast enhanced ultrasound in the evaluation of the nature of portal vein thrombosis. Med Ultrason 13(2):102-7. (PMID: 21655535)
[25] Song ZZ, Huang M, Jiang TA, Zhao QY, Yao L, Mou Y, Zhao JK, Ao JY, Chen F, Chen Y (2010) Diagnosis of portal vein thrombosis discontinued with liver tumors in patients with liver cirrhosis and tumors by contrast-enhanced US: a pilot study. Eur J Radiol 75(2):185-8. doi: 10.1016/j.ejrad.2009.04.021. (PMID: 19464131)
[26] Danila M, Sporea I, Popescu A, Șirli R (2016) Portal vein thrombosis in liver cirrhosis - the added value of contrast enhanced ultrasonography. Med Ultrason 18(2):218-33. doi: 10.11152/mu.2013.2066.182.pvt. (PMID: 27239658)
[27] Chammas MC, Oliveira AC, D Ávilla MJ, Moraes PH, Takahashi MS (2019) Characterization of Malignant Portal Vein Thrombosis with Contrast-Enhanced Ultrasonography. Ultrasound Med Biol 45(1):50-55. doi: 10.1016/j.ultrasmedbio.2018.09.009. (PMID: 30366607)
[28] Dietrich CF, Nolsøe CP, Barr RG, Berzigotti A, Burns PN, Cantisani V, Chammas MC, Chaubal N, Choi BI, Clevert DA, Cui X, Dong Y, D'Onofrio M, Fowlkes JB, Gilja OH, Huang P, Ignee A, Jenssen C, Kono Y, Kudo M, Lassau N, Lee WJ, Lee JY, Liang P, Lim A, Lyshchik A, Meloni MF, Correas JM, Minami Y, Moriyasu F, Nicolau C, Piscaglia F, Saftoiu A, Sidhu PS, Sporea I, Torzilli G, Xie X, Zheng R (2020) Guidelines and Good Clinical Practice Recommendations for Contrast-Enhanced Ultrasound (CEUS) in the Liver-Update 2020 WFUMB in Cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS. Ultrasound Med Biol 46(10):2579-2604. doi: 10.1016/j.ultrasmedbio.2020.04.030. (PMID: 32713788)
[29] Zhang XY, Luo Y, Wen TF, Jiang L, Li C, Zhong XF, Zhang JY, Ling WW, Yan LN, Zeng Y, Wu H (2014) Contrast-enhanced ultrasound: Improving the preoperative staging of hepatocellular carcinoma and guiding individual treatment. World J Gastroenterol 20(35):12628-36. doi: 10.3748/wjg.v20.i35.12628. (PMID: 25253968)
[30] Soresi M, Giannitrapani L, Cervello M, Licata A, Montalto G (2014) Non invasive tools for the diagnosis of liver cirrhosis. World J Gastroenterol 20(48):18131-50. doi: 10.3748/wjg.v20.i48.18131. (PMID: 25561782)
[31] Kim TK, Jang HJ (2014) Contrast-enhanced ultrasound in the diagnosis of nodules in liver cirrhosis. World J Gastroenterol 20(13):3590-6. doi: 10.3748/wjg.v20.i13.3590. (PMID: 24707142)
| URL: | https://eurorad.org/case/18468 |
| DOI: | 10.35100/eurorad/case.18468 |
| ISSN: | 1563-4086 |
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Conventional US findings
CEUS findings
MRI findings
