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1: Cancer. 1995 Apr 15;75(8):2057-62.
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Percutaneous fine-needle aspiration of portal vein thrombi as a staging technique for hepatocellular carcinoma. Cytologic findings of 46 patients.

Dusenbery D, Dodd GD 3rd, Carr BI.

Department of Pathology, University of Pittsburgh Medical Center, PA 15213-2582, USA.

BACKGROUND. Detection of portal vein tumor invasion in patients with hepatocellular carcinoma (HCC) is important in determining therapy and prognosis. Fine-needle aspiration (FNA) of a portal vein thrombus under ultrasound guidance facilitates the distinction of malignant from benign thrombus without resorting to laparotomy. In this study, the FNA findings of 46 patients who underwent this procedure are described. METHODS. Cytologic findings of 48 aspirations from 46 patients who underwent percutaneous ultrasound-guided portal vein FNA were reviewed. RESULTS. Twenty-nine of the 46 patients had a prior or concurrent biopsy-confirmed diagnosis of HCC at the time of portal vein FNA. On cytologic review, 39 of the aspirates were positive for malignancy, 6 were negative, and 3 were suspicious. Histologic follow-up of three of the six patients with negative aspirates confirmed bland thrombi in their portal veins. No complications resulted from the FNA procedure. Of the 39 aspirates positive for HCC, 22 were well differentiated, 5 were well to moderately differentiated, 9 were moderately differentiated, and 3 were poorly differentiated. In all except the poorly differentiated tumors, a trabecular cellular arrangement was detected in either smears or cell blocks. The cytologic findings in these aspirates, in general, mirror those found in aspirates of HCC in the liver proper. CONCLUSIONS. Portal vein FNA is an effective, well tolerated method for disease staging of patients with HCC. When used as the initial diagnostic procedure, in selected patients, it can provide the diagnosis and staging information simultaneously.

PMID: 7697594 [PubMed - indexed for MEDLINE]
2: AJR Am J Roentgenol. 1993 Aug;161(2):229-33.
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Percutaneous biopsy of portal vein thrombus: a new staging technique for hepatocellular carcinoma.

Dodd GD 3rd, Carr BI.

Department of Radiology, University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh 15213.

OBJECTIVE. Accurate staging of hepatocellular carcinoma is necessary to determine appropriate treatment. In particular, neoplastic invasion of the portal vein is a contraindication for hepatic resection or transplantation. Unfortunately, imaging cannot always differentiate benign from malignant portal vein thrombi. We therefore undertook a study to determine the efficacy and safety of sonographically guided percutaneous biopsy of portal vein thrombi as a staging technique for patients with hepatocellular carcinoma. SUBJECTS AND METHODS. We performed percutaneous biopsy of portal vein thrombi in 12 men and two women (43-76 years old) who were being considered for hepatic resection or transplantation. All of the patients had hepatic cirrhosis and 13 had histologically proved intrahepatic hepatocellular carcinoma. Biopsies were performed under continuous color Doppler sonographic guidance by using 20-gauge aspiration needles with occlusive stylets. Each needle was positioned with its tip embedded in the thrombus before the stylet was removed. During aspiration, the needle was carefully controlled to keep its tip within the lumen of the portal vein. To evaluate for possible false-positive results, an additional identical needle was passed in and out of only the hepatic parenchyma in five patients. RESULTS. Adequate specimens were obtained in all 14 patients. Twelve specimens contained malignant hepatocytes, and two contained benign thrombi. One of the benign thrombi in a patient who had a 3-cm hepatocellular carcinoma of the parenchyma was confirmed by examining the resected liver after transplantation. The other patient who had a benign thrombus had no clinical or imaging evidence of hepatocellular carcinoma. No complications associated with biopsy occurred. None of the control needles contained hepatocytes. The patients' discomfort during biopsy was approximately the same as the discomfort experienced during previous liver biopsies. The average length of the procedure was 20 min. CONCLUSION. Sonographically guided percutaneous biopsy of portal vein thrombi is a safe, accurate, useful, and well-tolerated diagnostic procedure for the staging of hepatocellular carcinoma.

PMID: 8392785 [PubMed - indexed for MEDLINE]
3: Abdom Imaging. 2006 Sep-Oct;31(5):537-44.
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Diagnosis of benign and malignant portal vein thrombosis in cirrhotic patients with hepatocellular carcinoma: color Doppler US, contrast-enhanced US, and fine-needle biopsy.

Tarantino L, Francica G, Sordelli I, Esposito F, Giorgio A, Sorrentino P, de Stefano G, Di Sarno A, Ferraioli G, Sperlongano P.

Hepatology and Interventional Ultrasound Unit, S. Giovanni di Dio Hospital, ASL NA3, Frattaminore, Naples, Italy. [email protected]

BACKGROUND: We assessed the role of contrast-enhanced ultrasound (CEUS) in the differential diagnosis between benign and malignant portal vein thrombosis in patients who had cirrhosis with hepatocellular carcinoma (HCC). METHODS: Fifty-four consecutive patients who had cirrhosis, biopsy-proved HCC, and thrombosis of the main portal vein and/or left/right portal vein on US were prospectively studied with color Doppler US (CDUS) and CEUS. CEUS was performed at low mechanical index after intravenous administration of a second-generation contrast agent (SonoVue, Bracco, Milan, Italy). Presence or absence of CDUS signals or thrombus enhancement on CEUS were considered diagnostic for malignant or benign portal vein thrombosis. Twenty-eight patients also underwent percutaneous portal vein fine-needle biopsy (FNB) under US guidance. All patients were followed-up bimonthly by CDUS. Shrinkage of the thrombus and/or recanalization of the vessels on CDUS during follow-up were considered definitive evidence of the benign nature of the thrombosis, whereas enlargement of the thrombus, disruption of the vessel wall, and parenchymal infiltration over follow-up were considered consistent with malignancy. CDUS, CEUS, and FNB results were compared with those at follow-up. RESULTS: Follow-up (4 to 21 months) showed signs of malignant thrombosis in 34 of 54 patients. FNB produced a true-positive result for malignancy in 19 of 25 patients, a false-negative result in six of 25 patients, and a true-negative result in three of three patients. CDUS was positive in seven of 54 patients. CEUS showed enhancement of the thrombus in 30 of 54 patients. No false-positive result was observed at CDUS, CEUS, and FNB. Sensitivities of CDUS, CEUS, and FNB in detecting malignant thrombi were 20%, 88%, and 76% respectively. Three patients showed negative CDUS and CEUS and positive FNB results; follow-up confirmed malignant thrombosis in these patients. One patient showed negative CDUS, CEUS, and FNB findings. However, follow-up of the thrombus showed US signs of malignancy. Another FNB confirmed HCC infiltration of the portal vein. CONCLUSION: CEUS seems to be the most sensitive and specific test for diagnosing malignant portal vein thrombosis in patients with cirrhosis.

PMID: 16865315 [PubMed - indexed for MEDLINE]
4: Hepatobiliary Pancreat Dis Int. 2005 May;4(2):234-8.
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Ultrasound-guided fine needle aspiration biopsy in differential diagnosis of portal vein tumor thrombosis.

Yang L, Lin LW, Lin XY, Gao SD, He YM, Yang FD, Xue ES, Lin XD.

Department of Ultrasound, Union Hospital, Fujian Medical University, Fuzhou 350001, China. [email protected]

BACKGROUND: Portal vein tumor thrombosis (PVTT) is a serious complication and a major metastatic way of hepatocellular carcinoma(HCC). But portal vein benign thrombosis(PVBT) always appears in patients with hepatocirrhosis, and PVTT should be differentiated from PVBT. The aim of this study was to probe the value of ultrasound-guided fine needle aspiration biopsy in differential diagnosis of PVTT. METHODS: Twenty-two HCC patients with portal vein thrombosis and 8 hepatocirrhosis patients with portal vein thrombosis were studied by ultrasound-guided fine needle aspiration biopsy. Twelve portal vein thrombosis filling portal vein embranchment of the 30 portal vein thrombosis patients were examined by 18G automatic biopsy. The positive rates of aspiration biopsy cytology and histology were calculated and compared with those of automatic biopsy. RESULTS: The positive rates of fine needle aspiration biopsy cytology and histology were 93.3% (28/30) and 90.0% (27/30), respectively. They were not different markedly from that of automatic biopsy 91.7% (11/12). In aspiration biopsy of 22 HCC patients with PVTT, HCC cellular was found in 19 portal vein thrombosis patients (86.4%) by cytology examination and in 18 portal vein thrombosis patients (81.8%) by histology examination. In total, 20 tumor thrombi were detected. The other two were diagnosed as benign thrombosis. No HCC cell and/or tissue was observed in 8 patients with hepatocirrhosis associated with portal vein thrombosis. CONCLUSIONS: Ultrasound-guided fine needle biopsy in detecting PVTT shows a high positive rate and is of diagnostic value. The positive rate is not apparently different from that of automatic biopsy. Hence the case that fails to be diagnosed by color Doppler flow imaging(CDFI) and pulsed Doppler can be detected early by ultrasound-guided fine needle aspiration biopsy.

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PMID: 15908321 [PubMed - indexed for MEDLINE]
5: AJR Am J Roentgenol. 1993 Jun;160(6):1285-7.
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Fine-needle aspiration biopsy of portal vein thrombus: value in detecting malignant thrombosis.

Vilana R, Bru C, Bruix J, Castells A, Sole M, Rodes J.

Department of Radiology, Hospital Clínic i Provincial, University of Barcelona, Spain.

OBJECTIVE. The purpose of this study was to assess the usefulness of fine-needle aspiration biopsy of portal vein thrombus to identify or exclude tumor. SUBJECTS AND METHODS. A series of 18 consecutive patients with portal vein thrombosis underwent fine-needle aspiration biopsy of the thrombus. Sixteen had underlying cirrhosis. Fifteen had clinical, biochemical, and imaging evidence of neoplastic invasion of the vein. Two patients had metastatic involvement of the left lobe of the liver, and the others had multinodular (eight cases) or diffuse (five cases) hepatocellular carcinoma. In four cases, the tumor was not clearly identified at sonography. RESULTS. Aspiration biopsy was positive for malignant tumor in 14 cases and negative for malignancy in one. In the three patients with benign portal vein thrombosis, fine-needle aspiration biopsy yielded only hepatocytes, fibrin, and blood cells. No results were false-positive. No complications were detected. CONCLUSION. Fine-needle aspiration biopsy is safe and sensitive for establishing the benign or malignant nature of portal vein thrombosis. This technique may be useful in selecting patients for liver transplantation.

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PMID: 8388621 [PubMed - indexed for MEDLINE]
6: Zhonghua Zhong Liu Za Zhi. 1997 Sep;19(5):362-4.
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[Colored Doppler ultrasound-guided fine-needle aspiration biopsy of portal vein thrombosis: value in diagnosis and assessment of therapeutic efficacy for portal vein thrombosis]

[Article in Chinese]

Chen Y, Chen J, Luo B.

Department of General Surgery, Sun Yat-Sen Memorial Hospital, Guangzhou.

OBJECTIVE: To investigate the value of colored Doppler ultrasound-guided fine-needle aspiration(FNA) biopsy of portal vien thrombosis(PVT) in diagnosis and assessment of therapeutic efficacy for PVT. METHODS: Cytologic findings from 25 portal vien thrombosis patients who underwent FNA were reviewed before and after hepatic arterial chemo-embolization(HAE) and portal vien chemotherapy. RESULTS: 1. Biopsy specimens sufficient for histologic analysis were obtained in all cases (100%). No complications resulted from this procedure. 2. The blood flow within the portal vien with thrombosis could be detected by colored Doppler systems in 25 cases before the patients accepted the treatment. The proliferation and a trabecular cellular arrangement presented in all the cell blocks. Of the 25 cases, 4 (16.0%) demonstrated necrosis of the tumor thrombi and the disappearance of blood flow within portal vein thrombi three weeks after the treatment. Among the 4, 2 were followed-up clinically and underwent second stage resection. 21 (84.0%) cases had no significant change in portal vein thrombosis pathologically and ultrasonically after the treatment. CONCLUSION: Colored Doppler ultrasound-guided FNA biopsy of portal vein thrombi is a safe, accurate, sampling-reliable biopsy technique.

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PMID: 10920917 [PubMed - indexed for MEDLINE]
7: J Gastroenterol Hepatol. 1995 Nov-Dec;10(6):662-5.
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Ultrasound-guided fine needle aspiration biopsy of portal vein thrombosis in liver cirrhosis: results in 15 patients.

De Sio I, Castellano L, Calandra M, Romano M, Persico M, Del Vecchio-Blanco C.

Dipartimento di Internistica Clinica e Sperimentale F. Magrassi-Cattedra di Gastroenterologia, II Ateneo di Napoli Medical School, Italy.

Between 1988 and 1992 ultrasound-guided fine needle aspiration biopsies of thromboses in the main branches of the portal vein were carried out in 15 patients with liver cirrhosis. The aims of the study were to evaluate the usefulness, feasibility and diagnostic accuracy of this procedure in cirrhotics with known or suspected hepatocellular carcinoma. The procedure was carried out only in patients with a platelet count > or = 40,000/microL and prothrombin activity > or = 40%. A single pass, with a 22 gauge spinal needle, was performed in the portal vein lumen. Diagnosis of the aetiology of the portal vein thrombosis was obtained in all 15 cases. In 12 cases, a cytological diagnosis of hepatocellular carcinoma was made. In one case, the neoplastic cells aspirated were compatible with adenocarcinoma, and a subsequent colonoscopy confirmed the presence of colonic cancer. The material aspirated was compatible with chemically-induced thrombosis in one patient who had undergone several percutaneous ethanol injection sessions for treatment of hepatocellular carcinoma, and in the last case only blood was aspirated, thus ruling out the coexistence of hepatic cancer. We conclude that fine needle aspiration biopsy of portal vein thrombosis is a feasible, low risk procedure that facilitates the diagnosis of hepatocellular carcinoma when fine needle biopsy of focal liver lesions fails. Fine needle aspiration biopsy of portal vein thrombosis is also useful in excluding neoplastic aetiology of portal vein thrombosis.

PMID: 8580410 [PubMed - indexed for MEDLINE]
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