Differentiation of malignant from non-malignant portal vein thrombosis in liver cirrhosis: the challenging dilemma

Abstract

Background PVT is an ultrasonographic finding in up to 8% of patients with liver cirrhosis. Once hepatocellular carcinoma has occurred as the final station in liver cirrhosis, the risk of PVT rises to 40%. Benign and malignant PVT can occur in patients with liver cirrhosis, and it is important to differentiate the nature of PVT as it has a great impact on patient’s management and outcome. Diagnosis Confirming portal vein thrombosis and extension by abdominal ultrasound, contrast-enhanced USG, CT, or MRI. Malignant criteria of PVT are pulsatile pattern in Doppler and heterogeneous contrast enhancement, which are especially seen at the arterial phase, neovascularity within PVT, portal vein thrombus with a diameter of > 23 mm while in benign thrombus, PV diameter does not exceed 20 mm. Visible hypervascular tumor is in close proximity to PVT. Conclusion It is not uncommon to find portal vein thrombosis in patients with liver cirrhosis, despite the fact that malignant variant is the most frequent, but efforts should be gathered to exclude benign PVT which may change the management of the patients dramatically.

Thromboelastometry-Guided Individualized Fibrinolytic Treatment for COVID-19-Associated Severe Coagulopathy Complicated by Portal Vein Thrombosis: A Case Report

“…After substituting the “lacking” tPA, a continuous infusion of rtPA at a dose of 0.05 mg/kg/h used in a previous trial [ 29 ] was administered for systemic fibrinolytic treatment ( Figure 6 ).…”

“…where tPA L is the "lacking" amount of tPA needed to normalize fibrinolysis in a 340 µL of whole blood; ML norm is the normal (100%), and ML actual stands for the measured ML on ClotPro TPA assay; V blood and V plasma are blood and plasma volumes; Htc is hematocrit; rtPA is the dose of alteplase required to restore fibrinolysis. After substituting the "lacking" tPA, a continuous infusion of rtPA at a dose of 0.05 mg/kg/h used in a previous trial [29] was administered for systemic fibrinolytic treatment (Figure 6).…”

“…After PVT was confirmed, we considered a VET-guided individualized systemic fibrinolytic treatment. Initial dose was calculated using the formula by Zátroch et al [ 28 ], while maintenance dose was determined by applying the protocol of a previous study conducted by Hanafy [ 29 ]. Abbreviations: CRP, C-reactive protein; LDH, lactate dehydrogenase; VET, viscoelastic testing; MCF, maximal clot firmness; ML, maximal lysis; LT, lysis time; ARDS, acute respiratory distress syndrome; ALF, acute liver failure; PVT, portal vein thrombosis; rtPA, recombined tissue plasminogen activator.…”

The role of shear wave elastography in differentiation between benign and malignant portal vein thrombosis in hepatocellular carcinoma

“…The malignant criteria of HCC and PVT were assessed using triphasic computed tomography (used in 68 patients) or dynamic magnetic resonance imaging (used only in 10 patients). The malignant PVT was proved if it revealed arterial hyper-enhancement with delayed and venous washout [1,6,7].…”

“…Patients with liver cirrhosis especially those with Child-Pugh grade B or C also have a tendency to develop non-malignant portal vein thrombosis (PVT) in up to 16% of cirrhotic patients, which could be treatable, therefore, the accurate differentiation between tumoral portal vein invasion and non-tumoral PVT is mandatory at the time of HCC diagnosis and staging [5,6].…”