Highly metabolic thrombus of the portal vein： ^18F fluorodeoxyglucose positron emission tomography/computer tomography demonstration and clinical significance in hepatocellular carcinoma

AIM： To assess the ability of ^18F-fluorodeoxyglucose positron emission tomography/computer tomography （^18F-FDG PET/CT） to differentiate between benign and malignant portal vein thrombosis in hepatocellular carcinoma （HCC） patients.
METHODS： 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 ^18F-FDG PET/CT. The presence or absence of a highly metabolic thrombus on ^18F-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. ^18SF-FDG PET/CT, and US, CT or MRI results were compared.
RESULTS： 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. ^18F-FDG PET/CT showed a highly metabolic thrombus in 4 of the 5 patients. ^18F-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 ^18F-FDG PET/CT.
CONCLUSION： ^18F-FDG PET/CT may be helpful in discriminating between benign and malignant portal vein thrombi. Patients may benefit from ^18F-FDG PET/CT when portal vein thrombi can not be diagnosed exactly by US, CT or MRI.     

Portal vein thrombosis complicating hepatocellular carcinoma. Value of ultrasound-guided fine-needle biopsy of the thrombus in the therapeutic management

Abstract: During a 4-year period portal vein thrombosis was diagnosed in 20 Child class A patients with cirrhosis by means of ultrasound and ultrasound-Doppler study. Seventeen of them showed single or multiple focal liver lesions diagnosed as hepatocellular carcinoma by ultrasound-guided fine-needle biopsy and the remaining three a coarse liver echo-pattern without focal lesions. One patient was found to have developed portal vein thrombosis after the fifth ethanol injection of a single hepatocellular carcinoma lesion 17 mm in diameter. Ultrasound-guided fine-needle biopsy of the thrombus was performed on all the patients: portal vein thrombosis was neoplastic in 13 cases and non-neoplastic in seven cases (five patients with a single lesion; one with two lesions; one with coarse liver echo-pattern). Among the five patients with a single lesion, one had already been treated by percutaneous ethanol injection therapy. There were no complications related to the biopsy procedures. The diagnosis of non-neoplastic thrombosis allowed five new patients to be recruited for percutaneous ethanol injection treatment and allowed it to continue in the patient with portal vein thrombosis occurring after the fifth ethanol injection. The routine use of ultrasound-guided fine-needle biopsy of portal vein thrombosis yields an accurate diagnosis of the nature of the thrombus and can improve the selection for percutaneous ethanol injection treatment of patients with cirrhosis with hepatocellular carcinoma lesions.     

Validation of an extension of the international non-invasive criteria for the diagnosis of hepatocellular carcinoma to the characterization of macroscopic portal vein thrombosis

Background and Aim: We aimed to validate the non‐invasive criteria for the characterization of portal vein thrombosis (PVT) in patients with cirrhosis and hepatocellular carcinoma (HCC). In a prospective study, we examined the impact of arterial hypervascularity, as established by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases recommendations for the non‐invasive diagnosis of HCC, as a criterion for characterizing macroscopic PVT (EASL/AASLD extension criteria). Methods: A total of 96 cases of PVT detected using ultrasonography in patients with cirrhosis and HCC were included in the study. When coincidental arterial hypervascularity was detected by contrast perfusional ultrasonography and helical computed tomography, the thrombus was considered malignant according to our EASL/AASLD extension criteria. In all cases, an ultrasound‐guided biopsy examination of the thrombus was performed. Results: Coincidental hypervascularity was found in 54 of 96 nodules (56.2%), and all were malignant upon biopsy (100% positive predictive value). Twenty‐four (25%) had negative results with both techniques (non‐vascular thrombus). Biopsies showed HCC in five non‐vascular thrombi (5.3% of all thrombi) and in 13 of 18 thrombi with a hypervascularity result from only one technique. Conclusions: The EASL/AASLD extension criteria for non‐invasive diagnosis of malignant thrombosis were satisfied in 75.2% of malignant thrombi; thus, a biopsy is frequently required in this setting. However, in the presence of coincidental hypervascularity of a thrombus with both techniques, a biopsy is not required (absolute positive predictive value for malignancy). Relying on imaging techniques in thrombi could miss the diagnosis of malignant portal invasion in up to 24.9% of cases.     

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.     

Differential diagnosis of focal liver lesions in signal-enhanced ultrasound using BR 1, a second-generation ultrasound signal enhancer

AIM: The aim was to evaluate the diagnostic value of contrast-enhanced ultrasound in the differential diagnosis of focal liver lesions, in a blinded experiment. In clinical routine the examiner can generally be influenced by the patient's history. METHOD: 62 patients with focal liver lesions, which could not be clearly differentiated and diagnosed by conventional ultrasound, were examined with contrast-enhanced (BR1, SonoVue, Bracco) ultrasound and included in a blinded prospective and randomized study. The examinations performed on a Sequoia 512 (Acuson) in a coherent contrast imaging method were recorded by an S-VHS recorder and afterwards analyzed by an examiner who did not know the patient's history. The basis of the diagnosis was the dynamic appearance and enhancement of the ultrasound contrast enhancer in different phases of liver perfusion. The conformation of the diagnoses was made by corresponding reference methods, as computer tomography, magnetic resonance imaging, biopsy and clinical follow-up. RESULTS: The following diagnoses were confirmed by reference methods: 18 patients with metastases, 4 hepatocellular carcinomas, 19 haemangiomas, 6 focal nodular hyperplasias, 13 patients with focal fatty infiltration and 2 patients with focal fatty sparing. 59 out of 62 patients with one or more liver lesions were correctly diagnosed by contrast-enhanced ultrasound. CONCLUSION: Second-generation ultrasound contrast enhancers improve the differential diagnosis of benign and malignant liver lesions considerably, especially in a blinded study.     

Transjugular intrahepatic portosystemic shunt with covered stents for hepatocellular carcinoma with portal vein tumor thrombosis

AIM: To evaluate transjugular intrahepatic portosystemic shunt(TIPS) with covered stents for hepatocellular carcinoma(HCC) with main portal vein tumor thrombus(PVTT). METHODS: Eleven advanced HCC patients(all male, aged 37-78 years, mean: 54.3 ± 12.7 years) presented with acute massive upper gastrointestinal bleeding(n = 9) or refractory ascites(n = 2) due to tumor thrombus in the main portal vein. The diagnosis of PVTT was based on contrast-enhanced computed tomography and color Doppler sonography. The patients underwent TIPS with covered stents. Clinical characteristics and average survival time of 11 patients were analyzed. Portal vein pressure was assessed before and after TIPS. The follow-up period was 2-18 mo. RESULTS: TIPS with covered stents was successfully completed in all 11 patients. The mean portal vein pressure was reduced from 32.0 to 11.8 mmHg(t = 10.756, P = 0.000). Gastrointestinal bleeding was stopped in nine patients. Refractory ascites completely disappeared in one patient and was alleviated in another. Hepatic encephalopathy was observed in six patients and was resolved with drug therapy. During the follow-up, ultrasound indicated the patency of the shunt and there was no recurrence of symptoms. Death occurred 2-14 mo(mean: 5.67 mo) after TIPS in nine cases, which were all due to multiple organ failure. In the remaining two cases, the patients were still alive at the 16- and 18-mo follow-up, respectively. CONCLUSION: TIPS with covered stents for HCC patients with tumor thrombus in the main portal vein is technically feasible, and short-term efficacy is favorable.     

Characterization of liver lesions by real-time contrast-enhanced ultrasonography

OBJECTIVE: The aim of this study was to identify the most common patterns of various common liver lesions at real-time contrast-enhanced ultrasonography with second-generation contrast agents and their role in the differentiation of malignant from benign lesions. PATIENTS AND METHODS: The enhancement pattern in the arterial phase and its modifications in subsequent portal and sinusoidal phases were separately evaluated in (i) 171 liver lesions detected at conventional ultrasonography in 125 noncirrhotic patients (87 metastases, six cholangiocellular carcinoma, 38 focal nodular hyperplasia, 30 hemangiomas, seven focal fatty sparing/changes, two hepatocellular adenomas and one hepatocellular carcinoma) and (ii) 75 lesions detected in 67 cirrhotic patients (66 hepatocellular carcinoma and nine dysplastic nodules). The final diagnosis was made by contrast-enhanced helical computed tomography and/or magnetic resonance imaging or by ultrasonography-guided biopsy when the diagnosis was equivocal at conventional imaging techniques (45 lesions). RESULTS: In noncirrhotic patients, the hypoechoic pattern in portal and sinusoidal phase (rapid washout) or the markedly hypoechoic or anechoic pattern in sinusoidal phase (marked late washout) showed a sensitivity, specificity and accuracy of 96.8, 100 and 98.2% for the diagnosis of malignancy. In cirrhotic patients, early arterial enhancement showed a sensitivity of 93.9% for the diagnosis of malignancy, with a specificity as low as 55.5% given the presence of arterial enhancement in 5/9 nodules resulted dysplastic at histological analysis. CONCLUSION: Real-time contrast-enhanced ultrasonography provides sensitive and specific criteria for the differential diagnosis between benign and malignant liver lesions, and in most cases it may replace more expensive and invasive imaging techniques.     

Evaluation of quantitative contrast harmonic imaging to assess malignancy of liver tumors： A prospective controlled two-center study

AIM： To establish the extent to which contrast enhancement with SonoVue in combination with quantitative evaluation of contrast-medium dynamics facilitates the detection of hepatic tumors.
METHODS： One hundred patients with histologically confirmed malignant or benign hepatic tumor （maximum size 5 cm） were analyzed. Contrast-enhanced ultrasound （bolus injection 2.5 mL SonoVue） was carried out with intermittent breath-holding technique using a multifrequency transducer （2.5-4 MHz）. Native vascularization was analyzed with power Doppler. The contrast-enhanced dynamic ultrasound investigation was carried out with contrast harmonic imaging in true detection mode during the arterial, portal venous and late phases. Mechanical index was set at 0.15. Perfusion analysis was performed by post-processing of the raw data [time intensity curve （TIC） analysis]. The cutoff of the gray value differences between tumor and normal liver tissue was established using Receiver Operating Characteristic （ROC） analysis 64-line multislice computed tomography served as reference method in all cases. Magnetic resonance tomography was used additionally in 19 cases.
RESULTS： One hundred patients with 59 malignant （43 colon, 5 breast, 2 endocrine metastases, 7 hepatocellular carcinomas and 2 kidney cancers） and 41 benign （15 hemangiomas, 7 focal nodular hyperplasias, 5 complicated cysts, 2 abscesses and 12 circumscribed fatty changes） tumors were included. The late venous phase proved to be the most sensitive for classification of the tumor type. Fifty-eight of the 59 malignant tumors were classified as true positive, and one as false negative. This resulted in a sensitivity of 98.3%. Of the 41 benign tumors, 37 were classified as true negative and 4 as false negative, which corresponds to a specificity of 90.2%. Altogether, 95.0% of the diagnoses were classified as correct on the basis of the histological classification. No investigator-dependency （P = 0.23）was noted.
CONCLUSION： The results show the     

Positron emission tomography/computed tomography with (18)F-fluorodeoxyglucose identifies tumor growth or thrombosis in the portal vein with hepatocellular carcinoma

Patients suffering from hepatocellular carcinoma (HCC) with tumor thrombus in the portal vein generally have a poor prognosis. Portal vein tumor thrombus must be distinguished from portal vein blood thrombus, and this identification plays a very important role in management of HCC. Conventional imaging modalities have limitations in discrimination of portal vein tumor thrombus. The application of positron emission tomography (PET) with 18F-fluorodeoxyglucose (18F-FDG) for discrimination between tumor extension and blood thrombus has been reported in few cases of HCC, while portal tumor thrombosis and portal vein clot identified by 18F-FDG PET/CT in HCC patients has not been reported so far. We present two HCC cases, one with portal vein tumor thrombus and one thrombosis who were identified with 18F-FDG PET/CT. This report illustrates the complimentary value of combining the morphological and functional imaging in achieving a correct diagnosis in such clinical situations.     

Emergency anticoagulation treatment for cirrhosis patients with portal vein thrombosis and acute variceal bleeding

Abstract

Objective. To determine the safety and efficacy of anticoagulation treatment for portal vein thrombosis in cirrhosis patients with acute variceal bleeding, with patient eligibility determined by contrast ultrasonography findings. Materials and methods. This prospective study included 23 consecutive cirrhosis patients (63.8 ± 11.8 years old, 12 males and 11 females) with emergency admission for acute variceal bleeding with or without portal vein thrombus. Eligibility for anticoagulation treatment was determined by positive intra-thrombus enhancement on contrast ultrasonography (perflubutane microbubble agent, 0.0075 mL/kg) performed before endoscopy. Low-molecular-weight heparin was administered after hemostasis was achieved by band ligation. Repeated band ligation or injection sclerotherapy combined with argon plasma coagulation was performed for variceal disappearance. Results. Hemostasis was achieved in all 10 patients with active bleeding. Five of these patients had portal vein thrombus, and all showed positive intra-thrombus enhancement on contrast ultrasonography. Anticoagulation treatment of these five patients resulted in complete recanalization of the portal vein within 2–11 days. There were no significant differences in the number of endoscopic treatment sessions or the length of hospital stay between the groups with and without thrombosis, and no complications including rebleeding were reported. Long term, none of the patients who continued oral anticoagulation treatment had recurrence of thrombosis (4/5). Variceal recurrence occurred only in the non-thrombosis group (2/18) during the follow-up period (median: 351 days). Conclusions. Early anticoagulation treatment in cirrhosis patients with portal vein thrombosis and acute variceal bleeding may be safe, tolerated, and effective in cases with positive intra-thrombus enhancement on contrast ultrasonography.     

Sonographic characterisation of hepatocellular carcinoma at time of diagnosis

BACKGROUND: Hepatocellular carcinoma (HCC) is a malignant liver tumour with a high prevalence world-wide. For screening procedures conventional transabdominal B-mode ultrasound and AFP determination are commonly used. We investigated 100 consecutive patients with histologically proven hepatocellular carcinoma in order to evaluate sonographic characteristics in unselected patients and to compare native and contrast-enhanced ultrasonographic techniques. PATIENTS AND METHODS: We investigated 100 consecutive patients with hepatocellular carcinoma at time of diagnosis with respect to echogenicity, patterns of vascularity, and portal/hepatic vein thrombosis. In addition to B-mode and native power Doppler sonography, contrast-enhanced power Doppler sonography with SHU 508A was used in 65 patients. RESULTS: The ultrasound appearance with conventional B-mode of hepatocellular carcinoma was hypoechoic in 48 % of the cases, isoechoic in 9 %, hyperechoic in 19 %, and in 25 % a mixture between hyper- and hypoechoic appearance was found compared to the surrounding liver tissue. Contrast-enhanced power Doppler sonography with SHU 508A changed the pattern of tumour vascularity in 27 % of patients into hypervascular, mainly in small lesions. DISCUSSION: At the time of diagnosis, the most commonly observed finding in hepatocellular carcinoma is that they appear hypervascular, independent of their size. The use of ultrasound contrast media should be considered to achieve characterisation of liver nodules in cirrhotic livers because they can improve the evaluation of tumour vascularity. Hypovascular HCC are found in about 10 % even after the administration of a contrast agent.     

Ultrasound-guided fine needle aspiration biopsy of portal vein thrombosis in liver cirrhosis: Results in 15 patients

Between 1988 and 1992 ultrasound-guided fine needle aspiration biopsies of thromboses in the main branches of the portal vein were carried out in 15 patients with liver cirrhosis. The aims of the study were to evaluate the usefulness, feasibility and diagnostic accuracy of this procedure in cirrhotics with known or suspected hepatocellular carcinoma. The procedure was carried out only in patients with a platelet count ≥40 000/μL and prothrombin activity ≥40%. A single pass, with a 22 gauge spinal needle, was performed in the portal vein lumen. Diagnosis of the aetiology of the portal vein thrombosis was obtained in all 15 cases. In 12 cases, a cytological diagnosis of hepatocellular carcinoma was made. In one case, the neoplastic cells aspirated were compatible with adenocarcinoma, and a subsequent colonoscopy confirmed the presence of colonic cancer. The material aspirated was compatible with chemically-induced thrombosis in one patient who had undergone several percutaneous ethanol injection sessions for treatment of hepatocellular carcinoma, and in the last case only blood was aspirated, thus ruling out the coexistence of hepatic cancer. We conclude that fine needle aspiration biopsy of portal vein thrombosis is a feasible, low risk procedure that facilitates the diagnosis of hepatocellular carcinoma when fine needle biopsy of focal liver lesions fails. Fine needle aspiration biopsy of portal vein thrombosis is also useful in excluding neoplastic aetiology of portal vein thrombosis.     

Angioechographic evaluation of tumor thrombi and the effect of transcatheter arterial embolization in patients with hepatocellular carcinoma

Background: Background: Transcatheter arterial embolization (TAE) is considered to be relatively ineffective in the treatment of portal and/or hepatic vein tumor thrombi associated with hepatocellular carcinoma (HCC). However, we have seen patients with a positively enhanced tumor thrombus on angioechography where necrosis has occurred after TAE. In this study, we compared the angioechographic enhancement of tumor thrombi with the effect of TAE to assess the use of this method in predicting the efficacy of TAE, and in predicting survival. Methods: Angioechography, using a small amount of CO₂ gas injected into the hepatic artery, was performed before TAE in 41 HCC patients with tumor thrombi of the portal vein (PVTT; n= 35) or hepatic vein (HVTT; n= 6). The relationship between the enhancement of the thrombi and the efficacy of TAE was investigated by follow-up ultrasonography. Results: All 13 PVTT that decreased in size had shown positive enhancement (PE) before treatment (P < 0.001), while 6 of the 7 cases (86%) in which the lesions increased in size had shown negative enhancement (NE). The survival of patients with PE was significantly longer than that of patients with NE (P < 0.005). Multivariate analysis identified two clinical variables associated with survival, angioechographic findings of PVTT, and age. There were no correlations between enhancement and HVTT. Conclusions: Determination of enhancement of PVTT on angioechography was useful in predicting the efficacy of TAE treatment of HCC and the survival time. Angioechography may be valuable in treatment decisions for HCC patients with PVTT, especially as a guide to the effectiveness of TAE. Received: March 1, 2001 / Accepted: November 2, 2001     

Contrast-enhanced ultrasound to evaluate the severity of chronic hepatitis C

BACKGROUND: Non-invasive techniques are being developed to assess the severity of liver disease. Haemodynamic changes in the hepatic circulation during the development of liver disease can be evaluated with contrast-enhanced ultrasound. AIM: To evaluate the possible correlation between ultrasound contrast-agent transit times and different stages of chronic hepatitis C. PATIENTS: Sixteen patients with clinically evident hepatitis C virus-related cirrhosis, 22 non-cirrhotic patients with chronic hepatitis C and 14 controls with no clinical evidence of liver disease were studied. METHODS: Contrast-enhanced hepatic ultrasonography was performed with a sulphur hexafluoride-filled microbubble contrast agent, and time curves of hepatic vein signal intensity were analysed to determine the time of enhancement onset (hepatic vein arrival time) and peak enhancement (hepatic vein peak enhancement). RESULTS: Hepatic vein arrival time in cirrhotic patients was significantly shorter (p<0.001) than in non-cirrhotic patients and controls. Within the group with chronic hepatitis C, METAVIR scores of fibrosis and necro-inflammatory changes had no significant effect on hepatic vein arrival times. CONCLUSION: Analysis of the time of onset of ultrasound contrast enhancement of the hepatic vein appears to be a simple, non-invasive method for reliably excluding cirrhosis with signs of portal hypertension, but not for assessing the severity of either chronic hepatitis C or cirrhosis.     

Portal vein thrombosis: etiology, diagnostic strategy, therapy and management

Myeloproliferative disorder, liver cirrhosis with portal hypertension, deficiency of natural anticoagulant proteins, gene mutation and hepatocellular carcinoma are the most frequent causes of portal vein thrombosis (PVT). Higher accuracy of the diagnostic methods is the reason why today the cause of PVT can be found more frequently. With imaging methods, PVT with or without cavernous transformation can be diagnosed. Fresh thrombus can be undetected in sonography due to the low echogenity but can be recognized in color Doppler sonography, especially with contrast-enhancing agent. Contrast-enhanced 3D MR angiography allows a comparable accuracy in the detection of PVT as digital subtraction angiography. Therapeutical options of PVT consist of mechanical recanalization of the portal vein, local fibrinolysis with or without placement of transjugular intrahepatic portosystemic stent shunt (TIPS), combination of mechanical recanalization and local fibrinolysis, systemic thrombolytic therapy, anticoagulation alone and surgical thrombectomy. Once PVT is found in sonography, Doppler sonography may be performed in order to distinguish benign from malignant thrombus. If further information is needed, MR angiography or contrast enhanced CT is the next step. If these tests are unsatisfactory, digital subtraction angiography should be performed. Until the early nineties, shunt surgery was recommended in patients with PVT who bled despite endoscopic treatment. Today, in symptomatic noncavernomatous PVT, recanalization with local methods is recommended. Additional implantation of TIPS should be performed when the patient is cirrhotic. In recent PVT in non-cirrhotic patients anticoagulation alone is recommended. It is expected that in old PVT anticoagulation can prevent further extension of the thrombus.     

Portal vein thrombosis relevance on liver cirrhosis: Italian Venous Thrombotic Events Registry

Portal vein thrombosis may occur in cirrhosis; nevertheless, its prevalence, and predictors are still elusive. To investigate this issue, the Italian Society of Internal Medicine undertook the “Portal vein thrombosis Relevance On Liver cirrhosis: Italian Venous thrombotic Events Registry” (PRO-LIVER). This prospective multicenter study includes consecutive cirrhotic patients undergoing Doppler ultrasound examination of the portal area to evaluate the prevalence and incidence of portal vein thrombosis over a 2-year scheduled follow-up. Seven hundred and fifty-three (68 % men; 64 ± 12 years) patients were included in the present analysis. Fifty percent of the cases were cirrhotic outpatients. Viral (44 %) etiology was predominant. Around half of the patients had a mild-severity disease according to the Child–Pugh score; hepatocellular carcinoma was present in 20 %. The prevalence of ultrasound-detected portal vein thrombosis was 17 % (n = 126); it was asymptomatic in 43 % of the cases. Notably, more than half of the portal vein thrombosis patients (n = 81) were not treated with anticoagulant therapy. Logistic step-forward multivariate analysis demonstrated that previous portal vein thrombosis (p < 0.001), Child–Pugh Class B + C (p < 0.001), hepatocellular carcinoma (p = 0.01), previous upper gastrointestinal bleeding (p = 0.030) and older age (p = 0.012) were independently associated with portal vein thrombosis. Portal vein thrombosis is a frequent complication of cirrhosis, particularly in patients with moderate–severe liver failure. The apparent undertreatment of patients with portal vein thrombosis is a matter of concern and debate, which should be addressed by planning interventional trials especially with newer oral anticoagulants. Clinicaltrials.gov identifier NCT01470547.     

Treatment of portal vein tumor thrombus using ¹²5Iodine seed implantation brachytherapy

We reported two cases of liver metastasis with portal vein tumor thrombus that developed after liver transplantation for hepatocellular carcinoma (HCC). Both the patients were women aged 43 and 55 years, who had liver metastasis and portal vein tumor thrombus formation after liver transplantations for HCC. For the treatment of portal vein tumor thrombus, (125)I seeds were implanted into the hepatic tissue under the guidance of preoperative computed tomography (CT) images with a total radiation dose of 130 Gy. Enhanced spiral CT scan was performed for evaluation of the liver at 12 and 16 wk after treatment. Thereafter, upper abdominal CT examination was performed every 2-3 mo. No severe complications associated with the (125)I seeds were seen in these two patients. The upper abdominal CT images (obtained after 3 and 4 mo of treatment) showed that the thrombosis reactions were complete reaction and restoration of the patency of the partially obstructed portal vein with partial obstruction. In the case with complete obstruction of the portal vein, the thrombosis was resolved completely, but blood flow could not be restored. After this treatment, one of the patients is still alive, while the other died within 6 mo after the treatment due to lung metastasis complicated with lung infection, leading to respiratory failure.     

超声评估门静脉与HCC患者肝移植预后的关系

目的:探讨超声检查肝细胞癌(hepatocellular carcinoma,HCC)门静脉对肝移植患者预后的诊断价值.方法:收集2000-01/2006-10四川大学华西医院进行肝移植的HCC患者148例,结合患者超声、病理以及临床资料,对患者肝移植后生存情况进行回顾性分析.结果:全组随访时间2.8-69.5(平均16.4)mo.随访期间,肿瘤复发率为43.2%.超声检查无门静脉受累者102例(68.9%),门静脉肝内分支受累者32例(21.6%),门静脉主干受累者14例(9.5%).单因素COX模型分析结果显示:门静脉受累是对累积生存率和无瘤生存率有统计学意义的协变量(RR=2.673,P=0.000).多因素COX逐步回归分析结果显示:门静脉受累是对累积生存率(RR=2.426,P=0.000)和无瘤生存率(RR=2.258,P=0.000)有影响的独立因素.结论:门静脉受累是独立性的预后影响因素,超声检测HCC患者门静脉是否受累有助于患者适应证的选择.     

Value of contrast-enhanced intraoperative ultrasound for cirrhotic patients with hepatocellular carcinoma： A report of 20 cases

AIM： To assess the clinical value of contrast-enhanced intraoperative ultrasound （CE-IOUS） as a novel tool in partial hepatectomy for cirrhotic patients with hepatocellular carcinoma （HCC）.
METHODS： From January 2007 to September 2007, a total of 20 consecutive cirrhotic patients with HCC scheduled to undergo partial hepatectomy were studied. Preoperative contrast enhanced computer tomography （CT） and/or magnetic resonance （MR） scans were performed within 1-2 wk before operation. Intraoperative ultrasound （IOUS） and CE-IOUS were carried out after mobilization of the liver. Lesions on precontrast and postcontrast scans were counted and mapped. CE-IOUS was performed with intravenous injection of ultrasound contrast agents SonoVue （Bracco Imaging, Milan, Italy）. Arterial, portal and late phases of contrast enhancement were recorded and analyzed. Nodules showing arterial phase hyper-enhancing and/or hypo-enhancing in late parenchymal phase were considered malignant and removed surgically. Ultrasound-guided biopsy and ethanol ablation would be an option if the nodule could not be removed surgically. Newly detected nodules on IOUS showing iso-enhancement in both arterial and late phases were considered benign. These nodules were either removed surgically if they were close to the main lesion or followed by examinations of alpha-fetoprotein （AFP） level and ultrasound and/or CT/MR every 3 too.
RESULTS： IOUS found 41 nodules in total, among which 17 （41.46%） were newly detected compared to preoperative imaging. Thirty-three nodules were diagnosed malignant by CE-IOUS, including one missed by IOUS. The sensitivity and specificity of CE-IOUS on detecting HCC nodules are 100% （33/33 and 100% （9/9）, respectively. Nine nodules were considered benign by CE-IOUS, four was confirmed at histology and five by follow-up. CE-IOUS changed the surgical strategy in 35% （7/20） of patients and avoid unnecessary intervention in 30% （6/20） of patients.
CONCLUSION： CE-IOUS is a usef     

Ultrasound and computed tomographic demonstration of portal vein thrombosis in hepatocellular carcinoma

Two cases of multinodular hepatocellular carcinoma (HCC) in which ultrasound and computed tomography (CT) revealed portal vein thrombosis are presented. The diagnostic value of determining the presence of portal vein thrombosis in patients with suspected HCC is discussed.