Distinguishing Tumor From Bland Portal Vein Thrombus in Liver Transplant Candidates With Hepatocellular Carcinoma: the A‐VENA Criteria

Abstract

Differentiating tumor versus bland portal vein thrombosis (PVT) is essential in determining liver transplantation (LT) candidacy for patients with hepatocellular carcinoma (HCC). We aimed to evaluate radiographic and clinical features that could noninvasively distinguish tumor PVT from bland PVT in HCC patients. Of 467 patients with HCC listed for LT from 2004 to 2011, 59 (12.6%) had PVT and 12 of 59 (20.3%) were deemed malignant. When comparing tumor versus bland PVT, thrombus enhancement was seen in 100% versus 8.5%; venous expansion was seen in 91.7% versus 10.6%; neovascularity was seen in 58.3% versus 2.1%; and being adjacent to HCC or prior treatment site was seen in 100% versus 21.3% (all P < 0.001). Combining these 4 imaging characteristics with alpha‐fetoprotein (AFP) >1000 ng/dL, the presence of ≥3 criteria best characterized tumor PVT with 100% sensitivity, 93.6% specificity, 80% positive predictive value, and 100% negative predictive value. No LT recipients with presumed bland PVT had macrovascular invasion on explant. There were no differences in post‐LT survival or HCC recurrence with bland PVT versus no PVT. In conclusion, we proposed noninvasive criteria that could accurately differentiate tumor PVT from bland PVT called A‐VENA, which is based on the presence of ≥3 of the following: AFP >1000 ng/dL; venous expansion; thrombus enhancement; neovascularity; and adjacent to HCC. Use of the A‐VENA criteria can assist in standardizing the evaluation of PVT in patients with HCC being considered for LT.

Liver transplantation for hepatocellular carcinoma after successful treatment of macrovascular invasion – a multi‐center retrospective cohort study

“…In an effort to improve the quality of the study, a centralized radiological assessment confirmed the presence of a vascular invasion in 30 patients, who were the final studied population. This assessment was based on previously defined characteristics known to be associated with a vascular invasion, including thrombus enhancement, venous expansion, neovascularity, and proximity of the thrombus with a previously treated HCC nodule .…”

“…It could affect either the portal vein or hepatic veins, and was defined as the presence of a contrast‐enhancing endovascular mass located in the area of a known HCC. The lesion could also demonstrate A‐VENA criteria, including a venous expansion, and/or intra‐thrombus neovascularity and/or direct invasion of the portal vein/hepatic vein . In order to improve the homogeneity of the radiological diagnosis, imaging was centrally assessed by an expert liver radiologist to confirm the presence of macrovascular invasion.…”

Management of Portal and Mesenteric Venous Thrombosis

“…65 Making the diagnosis of tumor thrombus generally requires close correlation with a patient's clinical history, serological studies, and cross-sectional imaging characteristics, though diagnostic criteria have recently been proposed in a single-center retrospective study. 65,66 Many patients with cirrhosis who develop a PVT are asymptomatic due to splanchnic decompression through an existing spontaneous portosystemic shunt, and the PVT is discovered incidentally detected on routine US screening for HCC. 1 Some patients may also present with symptoms of abdominal discomfort or in the setting of hepatic decompensation, such as new or worsening ascites or gastrointestinal bleeding.…”

Noninvasive Assessment of Hepatocellular Carcinoma Tumor Thrombus: Is It All in Vein?

“…(2) In this issue of Liver Transplantation, Sherman et al describe a set of criteria for noninvasive diagnosis of PVTT. (3) Their criteria, dubbed the A-VENA score, consist of 4 imaging features and 1 laboratory marker associated with PVTT. Imaging markers included thrombus enhancement, venous expansion, neovascularity, and proximity to tumor or prior treatment site.…”

“…In this issue of Liver Transplantation , Sherman et al describe a set of criteria for noninvasive diagnosis of PVTT . Their criteria, dubbed the A‐VENA score, consist of 4 imaging features and 1 laboratory marker associated with PVTT.…”