British Journal of Radiology (2005) 78, 841-844
© 2005 British Institute of Radiology
doi: 10.1259/bjr/37052159
Hepatocellular carcinoma tumour thrombus in a re-canalised para-umbilical vein: detection by 18-fluoro-2-deoxyglucose positron emission tomography imaging
C J Beadsmoore, MRCP, FRCR
1
H K Cheow, MRCP, FRCR
1
E Sala, PhD, FRCR
2
D J Lomas, FRCP, FRCR
2
P Gibbs, FRCS
3
V Save, MBChB, MRCPath
4
M E D Alison, MRCP
5 and
K K Balan, MD, FRCP
1
Departments of 1 Nuclear Medicine, 2 Radiology, 3 Surgery, 4 Pathology and 5 Hepatology, Addenbrooke's Hospital, Cambridge CB2 2QQ, UK
Correspondence: Dr K K Balan, Department of Nuclear Medicine, Box 170, Addenbrooke's Hospital, Cambridge CB2 2QQ, UK
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Abstract
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This case report describes an unusual site of tumour thrombus in a re-canalised para-umbilical vein, in a patient with hepatocellular carcinoma (HCC) and cirrhosis. The tumour thrombus was suspected on conventional radiography and confirmed using PET imaging, illustrating the complimentary value of structural and functional imaging in achieving the correct diagnosis.
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Case report
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A 62-year-old man with a history of presumed hepatocellular carcinoma (HCC) in the setting of cirrhosis due to chronic hepatitis B infection was referred for 18-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) imaging to assess his suitability for liver transplantation. The patient had previously undergone embolisation of a presumed HCC in segment 4 of the liver and now presented with a suspected recurrence involving segments 7 and 8. An upper abdominal ultrasound (Toshiba Aplio 80) (Figure 1
) showed the right lobe lesion and a serpiginous structure arising from segment 4 and passing over the surface of the left lobe running towards the diaphragm. This structure contained echogenic material and returned Doppler signal around its periphery. The appearances were those of a thrombus in a re-canalised para-umbilical vein, the possibility of tumour thrombus was raised due to the pattern of blood flow.
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Figure 1. Transabdominal ultrasound of the upper abdomen demonstrating a serpiginous structure within the anterior peritoneal cavity containing echogenic material with peripheral Doppler signal (arrow). The appearances are consistent with a re-canalised para-umbilical vein containing thrombus.
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CT examination (Siemens Somatom Sensation 16; Siemens, Erlangen, Germany) with imaging in arterial and portal phases after the administration of 100 ml Iopamidol 300 mg ml–1 (Niopam 300; Bracco, UK) was performed to look for additional areas of enhancement indicating multi-focal HCC and also to determine the nature of the thrombus in the re-canalised para-umbilical vein. The images (Figure 2) confirmed the presence of an area of abnormal enhancement in the lesion in segments 7 and 8. The re-canalised umbilical vein was demonstrated but did not significantly enhance, so tumour thrombus could not be confirmed.
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Figure 2. Arterial phase contrast-enhanced CT showing a small liver with an irregular margin containing an area of abnormal enhancement in the right lobe, consistent with an hepatocellular carcinoma on a background of cirrhosis (arrowhead). The serpiginous structure seen on ultrasound is demonstrated (arrow), with a little peripheral enhancement.
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For PET scanning, a whole-body PET scanner (GE PET Advance; GE, Milwaukee, WI) was used. Attenuation-corrected whole-body emission images were acquired 60 min after the intravenous injection of 370 MBq (10 mCi) 18F-FDG. The orthogonal images showed irregularly increased uptake in the right lobe of the liver consistent with HCC (Figure 3). A further area of intense uptake was seen in the anterior abdomen at the site of the re-canalised para-umbilical vein.
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Figure 3. Whole-body orthogonal 18F-FDG PET images show irregularly increased FDG uptake in the right lobe of the liver (long arrow) indicating active tumour. There is also abnormal metabolic activity (arrowhead) anterior to the liver in the abdomen corresponding to the para-umbilical vein indicating viable tumour. Note extravasation of FDG into left elbow.
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Open biopsy under general anaesthetic of the material in the falciform ligament (re-canalised para-umbilical vein) was performed, which confirmed the presence of tumour thrombus (Figure 4).
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Figure 4. (a) Hepatocellular carcinoma (HCC) in para-umbilical vein. Tumour filling large calibre vein with adjacent smaller thrombosed vein. (b) HCC medium power. Medium power image of tumour.
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Discussion
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HCC is the fourth most common cancer world wide [1] with an incidence ranging from 4 per 100 000 in North America [2] to 80 per 100 000 in China [3]. The long-term prognosis for these patients is poor and surgery offers the only option for a cure. Therefore, accurate staging of the tumour and exclusion of patients with extrahepatic disease are important prior to surgery.
HCCs have a tendency to invade large veins, with tumour growth found in the portal veins in up to 64% of patients, with a further 23.3% demonstrated as having tumour thrombus in their hepatic veins at post mortum [4]. The more advanced the tumour the more extensive and distant the tumour thrombus becomes. In patients with tumours measuring over 9 cm in diameter 2.1% are found to have tumour thrombus in their para-umbilical veins [5].
The established structural imaging modalities such as ultrasound (US), CT and MRI all demonstrate moderate sensitivity in the detection of HCC in cirrhotic livers (40%, 50–79%, 70%, respectively) [8, 9]. FDG-PET has not been shown to be more sensitive than the structural imaging modalities in the detection of HCC in the cirrhotic liver with sensitivities of 55% and 64% being reported in relatively small studies [10, 11], with higher grade (poorly differentiated tumours) showing FDG-PET positivity [12]. The differential FDG accumulation within HCCs of different grades suggests that FDG-PET positivity could have prognostic implications making it a useful adjunct to CT. FDG-PET does have the advantage over the other modalities in that it images the whole body, allowing the detection of extrahepatic disease [8, 9]. There have been studies involving small numbers of patients which suggest a further beneficial role of 18F-FDG PET in the monitoring of patients with HCC, as metabolic changes occur after treatment earlier than structural changes [8, 9, 13].
Whilst there are anecdotal reports of FDG accumulation related to venous thrombosis [14, 15], the only study to look specifically at this found that FDG accumulation is seen in infected thrombus but none was detected in non infected venous thrombosis. [16]. In our case, the FDG uptake was confirmed by histopathology as tumour thrombus rather than simple or infected thrombus.
Received for publication November 18, 2004.
Revision received February 2, 2005.
Accepted for publication February 24, 2005.
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References
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Abstract
Case report
