Percutaneous fine-needle aspiration of portal vein thrombi as a staging technique for hepatocellular carcinoma. Cytologic findings of 46 patients

Abstract

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.

Tumoural portal vein thrombosis

“…Thrombosis can also be the first sign of an unsuspected HCC (6,15). Although both types of thrombi are associated with a bad prognosis, patients with HCC and tumoural PVT have a very short life expectancy.…”

“…The diagnosis of tumour thrombi is straight forward by the demonstration of tumour cells inside the thrombus. However, if the fine-needle aspiration is performed improperly, hepatic cells can be obtained from the adjacent liver rather than from the thrombus (6). Therefore, the mere presence of cells in the aspirate is not sufficient evidence for a positive diagnosis (15).…”

“…In this situation it is important for the selection of therapy and prognosis to determine the degree and nature of the venous thrombus (12). Furthermore, in cirrhotic patients, PVT can be the initial sign of an undetected HCC (6,15). Patients with cirrhosis also may develop non-tumoural PVT.…”

“…Helical CT can suggest the maligpant condition of the thrombus by visualizing either tumour neovascularity or diffuse thrombus enhancement (3). Also, portal vein fine-needle aspiration of the thrombus under ultrasound guidance has been used as an effective and well-tolerated method for disease staging of patients with HCC (2,4,6,15).…”

Hepatocellular cancer in liver transplantation

“…6,10,23 When necessary, invasive maneuvers such as percutaneous fine-needle aspirates or biopsies (2%-3% incidence of needle-tract seeding) should be undertaken. 1,20,24,25 Despite this, close to 30% of tumors in cirrhotics were understaged, despite extensive preoperative workups. 26 In addition, circulating tumor cells were demonstrated to be present in patients with advanced HCC.…”