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Another portal vein thrombosis?

13 Jan, 17 | by abhichauhan

 

Figure 1

Figure 2

A 62 year old male was undergoing antiviral therapy for HCV cirrhosis. He was asymptomatic with normal liver function tests and a normal alpha fetoprotein level. Routine liver ultrasound suggested a new portal vein thrombosis. CT imaging (figure1) and subsequent pathology specimen (figure 2) demonstrate a unique lesion. What’s in the portal vein?

Submitted by

J.Doherty, C.Braniff, S.Oon, J. O’ Neill, P A. Mc Cormick.

Liver transplant Unit, St Vincent’s University Hospital, Dublin.

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  • Azazello

    Not sure!
    Liver doesn’t look that shrunken and spleen isn’t that big; no ascites either. No other liver masses / extrahepatic masses except something in right portal vein and some perfusion defect. Really difficult to look at the histology because of compression artefact but clot within vein evident — hard to tell if there is something within clot. Vein wall looks intact, and there doesn’t seem to be tumour and AFP is normal so HCC and external invasion less likely. Well-defined something in the lower left of the right-hand histology image — could this be an infectious agent? Or other odd foreign body? Interested to know the answer…

  • Aine Sinead

    Very interesting case.
    Looks like portal vein thrombosis on imaging but histology not matching …maybe HCC

  • C carey

    Interesting case. Hep C would increase the chance of portal vein thrombosis in any case but then the antiviral therapy should reduce that. Does he have other risk factors? A simple thrombus still seems to be the most likely possibility but I look forward to finding out the answer

  • E Fallon

    Very interesting case.

  • Deepti Ranganathan

    Very interesting case! Is it some sort of thrombus?

  • E Doody

    Is a HCC not unlikely if the alphafetoprotein is normal?

  • Тимосије Јованоски

    Is it cavernous transformation ?

  • Jayne Doherty

    Answer:
    Thanks to everyone for reading and commenting on this case of the month and I hope you found it interesting.

    Our patient is a 62 year old male with known HCV cirrhosis who had a suspected portal vein thrombosis (PVT) on a routine liver ultrasound. He proceeded to have a 4 phase CT of the liver which suggested a 1.6cm Hepatocellular Carcinoma (HCC) and a malignant portal vein thrombus. After a multidisciplinary team discussion, he underwent a right hepatectomy.
    Histological examination of the surgical specimen confirmed a HCC which surprisingly was growing exclusively within the branches of the portal vein. Our patient is now 9 months’ post-surgery. He is asymptomatic with no evidence of HCC recurrence radiologically or biochemically.
    This case describes the extremely rare finding of an isolated malignant PVT or intravascular HCC. PVT is present in 10%-40% of cases at the time of HCC diagnosis, and is an adverse prognostic factor. Although rare clinicians should think of HCC when they see a PVT in a cirrhotic patient.

    If there are any further questions regarding the case please comment and I will reply.

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