Diffuse hepatocellular carcinoma with malignant portal vein thrombus

Case contributed by Mohamed Salah Ayyad
Diagnosis almost certain


Decompensated liver function

Patient Data

Age: 70 years
Gender: Male

Cirrhotic liver with ill-defined lesion near totally infiltrating the right lobe showing enhancement in the arterial phase and washout in portal and delayed phases. Thrombosed both the right anterior and the right posterior branches of the portal vein and the main portal vein trunk. The thrombus is seen extending to the splenic vein showing a similar pattern of enhancement to the previously described lesion suggesting a tumoral thrombus. No intra- or extra-hepatic or biliary radicle dilatation.

Contracted gall bladder with hyperdense stone seen inside.

Enlarged spleen with dilated abdominal collaterals suggesting portal hypertension.

Malrotated right kidney with normal parenchymal thickness, size, density, and mild hydroureteronephrosis. Normal size, density, and parenchymal thickness of the left kidney. No backpressure changes.

Mild peri-hepatic free fluid.

Case Discussion

Hepatocellular carcinoma is becoming one of the most prevalent cancers worldwide. The survival rate averages between 6 and 20 months. Patients with hepatitis B and C are the most susceptible. The main blood supply of the tumor tissue is through the hepatic artery. For this reason, the tumor exhibits a classic pattern of enhancement in the arterial phase of triphasic CT study and washout in portal and delayed phases.

Portal vein thrombosis is present in 40% of hepatocellular carcinoma cases at the time of diagnosis. Thrombus enhancement is highly suggestive of malignant thrombus. Triphasic CT shows high specificity for the diagnosis of malignant portal vein invasion.

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