CASE 6248 Published on 24.02.2008

A case of recurrent gastric carcinoma in the portal vein: imaging findings

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Roka Namoto Matsubayashi¹⁾²⁾, Kiyohisa Hiraka¹⁾, Kotaro Yasumori¹⁾, Toru Muranaka²⁾, and Seiya Momosaki3⁾ 1) Department of Radiology, National Hospital Organization Kyushu Medical Center 2) Clinical Reseach Institute, National Hospital Organization Kyushu Medical Center 3) Department of Pathology, National Hospital Organization Kyushu Medical Center

Patient

58 years, male

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Clinical History

A 58-year-old man complained jaundice. He had undergone a gastrectomy for gastric carcinoma. Contrast-enhanced CT showed portal thrombosis with early periportal enhancement in the liver. The periportal region showed prolonged enhancement. The biopsy specimen of the portal tract revealed diffuse infiltration of signet ring cell carcinoma with fibrosis and vessels.

Imaging Findings

A 58-year-old man was admitted to our hospital due to general fatigue, appetite loss and jaundice for one month. He had undergone a total gastrectomy for advanced gastric carcinoma five years previously. No remarkable findings were pointed out on non-contrast enhanced CT five months previously. Laboratory data on admission were ((): normal range): serum total bilirubin (T-bil) 17.1mg/dl (0.3-1.2), (ALP) 1585 IU/l (115-359), CA 19-9 199 IU/ml (0-36). The previously operated gastric carcinoma was poorly differentiated adenocarcinoma with signet ring cells. Severe lymphatic and vascular invasion were noted. Abdominal ultrasonography (US ) showed portal thrombus in the bilateral lobes of the liver. Color Doppler imaging revealed vascular flow surrounding the portal thrombus. No hepatic metastases were detected (Fig. 1). Dynamic contrast-enhanced CT showed early linear enhancement surrounding the portal thrombus. The portal thrombus showed weak enhancement on early images. In the portal and delayed phases, the portal thrombus showed slow enhancement. The surrounding area of portal vein exhibited prolonged strong enhancement (Fig. 2). On MR imaging (MRI), the portal tract showed low signal intensity on a T2-weighted image. On a T1-weighted image, the structure showed low signal intensity. Dynamic study revealed early enhancement surrounding the portal thrombus and prolonged enhancement of the portal tract (Fig. 3). The specimen of needle biopsy from portal tract of the liver showed invasive proliferation of numerous signet-ring cells with edematous fibrous stroma (Fig 4a). Many capillaries were noted (Fig. 4b, blue arrows).

Discussion

To our knowledge, there are 24 reported cases of gastric carcinoma with tumor thrombosis in the portal venous system that have sufficient information for analysis (including our present case) (Table 1) (1-12). Moderately differentiated adenocarcinoma is the most prevalent histologic pattern in cases of portal thrombosis. 10 cases in these cases had no metastasis in the liver (41.7%). 13 cases showed high serum levels of AFP (54.2%). In previous reports, 13 cases showed high AFP levels, and their carcinomas showed aggressive growth and poor prognosis. These gastric carcinomas tended to show hepatoid adenocarcinoma, which is characterized by medullary nest or trabecular arrangement of the cancer cells. The hypotheses for the mechanism of portal thrombosis with gastric carcinoma are: 1. Direct invasion from the gastric carcinoma to the portal vein. 2. Invasion from liver metastases (4). 3. Translymphatic spread along the portal tract (13). 4. Hematogenous metastasis via the lymphaticoportal venous anastomosis(Nakata et al. 1998) (10). Venous invasion by cancer cells may be the common necessary condition for gastric carcinoma to metastasize to the liver and to form tumor thrombi in the portal system. However, it remains unclear why gastric carcinoma associated with portal thrombosis is quite rare. Terayama et al. (13) showed histologic growth patterns of liver metastases (Table 2). Gastric carcinoma, gall bladder or bile duct and pancreas carcinomas tend to show portal tract type. Since our case showed severe venous extension and lymphatic permeation, we consider that both translymphatic and venous extensions may have caused the formation of the portal thrombus. On US and CT, hyper vascular flow or early strong enhancement in the periportal region were observed. These findings reflected abundant newly formed vessels in foci of the gastric carcinoma. Delayed prolonged enhancement in the periportal region on CT and MRI reflected severe fibrotic changes.

Differential Diagnosis List

Those findings were compatible with recurrence of gastric carcinoma.

Final Diagnosis

Those findings were compatible with recurrence of gastric carcinoma.

References

[1] Aruga A, Watanabe T, Hiyama Y, et al. A case of tumor thrombosis of the extrahepatic portal vein (cavernous transformation) secondary to gastric cancer. Nippon Shokakibyo Gakkai Zasshi 1986;83:2243-2247 (In Japanese). (PMID: 3820746)

[2] Yamada K, Takeuti K, Miyata H, et al. A case of AFP-producing gastric carcinoma with diffuse portal invasion both inside and outside the liver. J. Nihon Univ. Med. Ass. 1988;47:661-666 (In Japanese).

[3] Ishikawa K, Kodama M, Niwa M, et al. Shuyou sokusen ni yori kangai monmyaku heisoku wo kitashita igan no ichi setsujo rei. Geka Shinryo 1988;11:1569-1572 (In Japanese).

[4] Ozeki Y, Onitsuka A, Matsumoto K, et al. A case of gastric cancer forming a tumor embolus in the portal vein. Nippon Shokakibyo Gakkai Zasshi 1988;85:2255-2260 (In Japanese). (PMID: 3062212)

[5] Takayasu K, Tajiri H, Noguchi M, et al. Imaging diagnosis of portal tumor thrombus secondary to gastric cancer. Gastrointestinal Radiology 1989;14:161-163. (PMID: 2651198)

[6] Araki T, Suda K, Sekikawa T, et al. Portal venous tumor thrombosis associated with gastric adenocarcinoma. Radiology 1990;174:811-814. (PMID: 1689502)

[7] Hoshino M, Arai K, Tamura K, et al. A case of advanced gastric cancer associated with pylemphraxis for tumor. Nippon Rinsho Gekagakkai Zasshi 1990;51:322-326 (In Japanese).

[8] Yamashina T, Kawanishi J, Akiyama S, et al. A case of gastric cancer forming a tumor embolus in the portal vein with marked response to CDDP/UFT therapy. The Clinical Report 1991;25:300-302 (In Japanese).

[9] Sugawara Y, Konishi T, Hiraishi M, et al. Portal tumor thrombi due to gastric cancer. Hepato-Gastroenterology 1996;43:1000-1005. (PMID: 8884328)

[10] Nakata Y, Watanabe Y, Nakata T, et al. Early gastric cancer associated with synchronous liver metastasis and portal tumorous embolism: report of a case. Surg Today Jpn J Surg 1998;28:753-757. (PMID: 9697271)

[11] Yamaguchi Masahiko Midorikawa T, Saito M, et al. Tumor thrombus in the splenic vein originated from gastric carcinoma that produced ?-fetoprotein. Hepato-gastroenterology 2003;50:1693-1696. (PMID: 14571819)

[12] Hoshimoto S, Hagiuda J, Igarashi N, et al. A case of gastric cancer with tumor embolus in the portal vein successfully treated with TS-1 and CDDP. Jpn J Cancer Chemother 2004;31:1079-1081 (In Japanese). (PMID: 15272589)

[13] Terayama N, Terada T, Nakanuma Y. Histologic growth patterns of metastatic carcinomas of the liver. Jpn J Clin Oncol 1996;26:24-29. (PMID: 8551663)

Case information

URL:	https://www.eurorad.org/case/6248
DOI:	10.1594/EURORAD/CASE.6248
ISSN:	1563-4086

Figure 1

Fig.1

Abdominal ultrasonography (US) shows portal thrombus in the bilateral lobes of the liver.

Color Doppler imaging reveals abundant vascular flow in the periportal region. No apparent hepatic metastases are detected.

Figure 2

Fig. 2

Dynamic contrast-enhanced abdominal CT. An early image shows strong linear enhancement surrounding the portal thrombus. The portal thrombus shows relatively weak enhancement.

In the portal (b) and delayed (c and d) phases, the portal thrombus is slowly enhanced. The area surrounding the portal vein exhibits prolonged strong enhancement, and the enhanced area is widened than that on an early image.

Figure 3

Fig. 3

MRI. A T2-weighted image shows relatively low signal intensity structure along the portal tract.

On a T1-weighted image, the structure shows low signal intensity.

Dynamic study shows early linear strong enhancement surrounding the portal thrombus (c) and prolonged strong enhancement of the portal tract (d).

Figure 4

Fig. 4

Microscopic examination (Hematoxyline-eosin stain, x200). The specimen of needle biopsy from periportal to portal tract of lateral segment (S3) of the liver reveals invasive proliferation of numerous signet-ring cells with edematous fibrous stroma.