CASE 18468 Published on 05.03.2024

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Teaching Case

Section

Abdominal imaging

Case Type

Clinical Case

Authors

Nikoletta Pyrrou¹, Angeliki Papachristodoulou¹, Vasileios Rafailidis¹, Adonis Protopapas², Panos Prassopoulos¹

¹ Department of Radiology, AHEPA University Hospital of Thessaloniki, Aristotle University of Thessaloniki, Greece

² First Propedeutic Department of Internal Medicine, AHEPA University Hospital of Thessaloniki, Aristotle University of Thessaloniki, Greece

Patient

60 years, male

Categories

Area of Interest Abdomen, Liver ; Imaging Technique Ultrasound ;

No Procedure ; Special Focus Neoplasia ;

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Clinical History

A 60-year-old male patient with history of chronic HCV hepatitis and alcohol uptake presented with raised alpha-fetoprotein (AFP) (460ng/ml).

Differential Diagnosis List

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LI-RADS tumour-in-vein due to HCC

Benign portal vein thrombus in liver cirrhosis

Common bile duct cholangiocarcinoma with liver metastasis

Chronically thrombosed portal vein with recanalisation

Imaging Findings

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.

Discussion

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.

References

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