Infiltrative hepatocellular carcinoma - portal vein tumor thrombus

Case contributed by Dr Mostafa El-Feky


Chronic HCV patient presented with right hypochondrial pain. No regular follow up documented.

Patient Data

Age: 65 years
Gender: Male

The liver shows cirrhotic changes seen as coarsened texture and irregular borders as well as volume dysmorphism.

An exophytic hepatic lesion is seen projecting from segment III posteriorly, measuring 6.8 x 6.5 cm. It has a necrotic core with undefined borders between it and the left lobe hepatic parenchyma. It is indenting the antrum of the stomach and body of the pancreas. It shows arterial hyperenhancement as well as portal venous and delayed washout contrast dynamics.  The lesion is invading the left hepatic lobe, left hepatic and left portal veins.

The liver is studded by otherwise multiple hepatic lesions with the same dynamic contrast enhancement pattern with ill-defined boundaries, largest is noted at segment VI (right lobe) measuring 4.6 x 4.5 cm, invading the right portal vein with tumor thrombus formation extending to the main portal vein thill the level of porta-hepatis.  

Mild splenomegaly (15.7 cm).  

Few bilateral renal calyceal gravels.

Case Discussion

Chronic HCV patient with established cirrhotic liver, currently complicated by multifocal and infiltrative hepatocellular carcinoma (HCC) with portal vein invasion forming tumor thrombus.  

Portal vein thrombus is considered a tumor thrombus, as it shows enhancement on arterial phase, vessel expansion and the indistinction between the thrombus and the tumor itself. Macrovascular invasion is characteristic of HCC with the involvement of the portal vein more common than the hepatic veins. Differentiating bland from tumor thrombus is necessary as they have different management and prognosis.  

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