Poddar Nishant, Avezbakiyev Boris, He Zili, Jiang Ming, Gohari Arash, Wang Jen Chen
Division of Hematology/Oncology, Brookdale University Hospital Medical Center, Brooklyn, NY 11212, USA.
J Gastrointest Cancer. 2012 Sep;43(3):486-9. doi: 10.1007/s12029-010-9235-z.
Portal vein thrombosis is frequently associated with hepatocellular carcinoma (HCC). Tumor invasion into the portal vein by direct venous extension or metastasis occurs in up to 70% of HCC patients (Cedrone et al., Liver 16:94-8, 1996). However, presentation as an isolated malignant portal vein thrombosis without any evidence of obvious hepatoma-like lesions in the liver by imaging studies is extremely uncommon. We present an unusual case of HCC presenting as a malignant portal vein thrombus, proven on biopsy of the thrombus without any evidence of primary liver lesion. This, to our knowledge, is the first case of HCC presenting as an incidental isolated malignant portal vein thrombosis. The importance of doing delayed enhancement imaging studies to rule out malignant portal vein thrombosis is emphasized.
A 60-year-old man presented with acute substernal chest pain. Physical examination revealed icterus. Examination of the abdomen did not reveal any organomegaly. Liver function test revealed a predominantly conjugated bilirubinemia. Abdominal sonogram revealed thrombosis and occlusion of the posterior right portal vein. Liver parenchyma was homogenous with no intrahepatic mass. Computed tomography (CT) of the abdomen and pelvis after administration of oral and intravenous contrast with delayed views revealed arterial enhancement of the right portal vein thrombus with delayed washout. MRI of the abdomen with gadolinium confirmed the right portal vein thrombus without focal hepatic mass. Aspiration of the right portal vein thrombus under CT guidance revealed hepatocellular carcinoma which was confirmed by immunohistochemistry. Serum alpha-fetoprotein level was very high. Patient was started on sorafenib with subsequent decrease in alpha-fetoprotein level. He was doing well till the date of this report.
This unusual case of hepatocellular carcinoma presenting as an incidental malignant portal vein thrombosis without any primary liver lesion is extremely rare. Other reported cases of malignant portal vein thrombosis have been in patients with underlying hepatoma, cirrhosis, or with intrabiliary hepatocelluar carcinoma. In the clinical setting of portal vein thrombosis, imaging studies showing enhancement of the thrombus in the arterial phase are important in leading to the diagnosis of malignancy.
门静脉血栓形成常与肝细胞癌（HCC）相关。肿瘤通过直接静脉蔓延或转移侵犯门静脉的情况在高达70%的HCC患者中出现（Cedrone等人，《肝脏》16:94 - 8，1996）。然而，影像学检查显示为孤立性恶性门静脉血栓形成且肝脏无明显肝癌样病变证据的情况极为罕见。我们报告一例不寻常的HCC病例，表现为恶性门静脉血栓，经血栓活检证实，而肝脏无原发性病变证据。据我们所知，这是首例HCC表现为偶然发现的孤立性恶性门静脉血栓形成的病例。强调了进行延迟增强影像学检查以排除恶性门静脉血栓形成的重要性。
一名60岁男性因急性胸骨后胸痛就诊。体格检查发现黄疸。腹部检查未发现任何脏器肿大。肝功能检查显示以结合胆红素血症为主。腹部超声检查发现右后门静脉血栓形成及闭塞。肝实质均匀，无肝内肿块。口服和静脉注射造影剂后行腹部和盆腔计算机断层扫描（CT）延迟显像显示右门静脉血栓在动脉期强化并延迟消退。腹部钆增强磁共振成像（MRI）证实右门静脉血栓形成，无肝脏局灶性肿块。在CT引导下对右门静脉血栓进行抽吸，发现肝细胞癌，免疫组化证实。血清甲胎蛋白水平非常高。患者开始使用索拉非尼治疗，随后甲胎蛋白水平下降。截至本报告日期，他情况良好。
这例不寻常的肝细胞癌病例表现为偶然发现的恶性门静脉血栓形成且无原发性肝脏病变极为罕见。其他报道的恶性门静脉血栓形成病例见于有潜在肝癌、肝硬化或肝内胆管肝细胞癌的患者。在门静脉血栓形成的临床情况下，影像学检查显示血栓在动脉期强化对于诊断恶性肿瘤很重要。
