FDG-avid portal vein tumor thrombosis from hepatocellular carcinoma in contrast-enhanced FDG PET/CT

Document Type : Original Article


1 Unit of PET/CT and Cyclotron, Choray Hospital, Vietnam

2 Department of Liver Tumor, Choray Hospital, Vietnam

3 Dipartimento Di Scienze Biomediche Avanzate, Facoltá Di Medicina E Chirurgia, Università Degli Studi Di Napoli Federico II, Italia


Objective(s): In this study, we aimed to describe the characteristics of portal vein tumor thrombosis (PVTT), complicating hepatocellular carcinoma (HCC) in contrast-enhanced FDG PET/CT scan.
Methods: In this retrospective study, 9 HCC patients with FDG-avid PVTT were diagnosed by contrast-enhanced fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT), which is a combination of dynamic liver CT scan, multiphase imaging, and whole-body PET scan. PET and CT DICOM images of patients were imported into the PET/CT imaging system for the re-analysis of contrast enhancement and FDG uptake in thrombus, the diameter of the involved portal vein, and characteristics of
liver tumors and metastasis.
Results: Two patients with previously untreated HCC and 7 cases with previously treated HCC had FDG-avid PVTT in contrast-enhanced FDG PET/CT scan. During the arterial phase of CT scan, portal vein thrombus showed contrast enhancement in 8 out of 9 patients (88.9%). PET scan showed an increased linear FDG uptake along the thrombosed portal vein in all patients. The mean greatest diameter of thrombosed portal veins was 1.8 ± 0.2 cm, which was significantly greater than that observed in normal portal veins (P<0.001). FDG uptake level in portal vein thrombus was significantly higher than that of blood pool in the reference normal portal vein (P=0.001). PVTT was caused by the direct extension of liver tumors.
All patients had visible FDG-avid liver tumors in contrast-enhanced images. Five out of 9 patients (55.6%) had no extrahepatic metastasis, 3 cases (33.3%) had metastasis of regional lymph nodes, and 1 case (11.1%) presented with distant metastasis. The median estimated survival time of patients was 5 months.
Conclusion: The intraluminal filling defect consistent with thrombous within the portal vein, expansion of the involved portal vein, contrast enhancement, and linear increased FDG uptake of the thrombus extended from liver tumor are findings of FDG-avid PVTT from HCC in contrast-enhanced FDG PET/CT.


Main Subjects

1. Anh PT, Duc NB. The situation with cancer control in Vietnam. Jpn J Clin Oncol. 2002; 32 Suppl:S92-7.
2. Connolly GC, Chen R, Hyrien O, Mantry P, Bozorgzadeh A, Abt P, et al. Incidence, risk factors and consequences of portal vein and systemic thromboses in hepatocellular carcinoma. Thromb Res. 2008; 122(3):299-306.
3. Llovet JM, Bustamante J, Castells A, Vilana R, Ayuso Mdel C, Sala M, et al. Natural history of untreated nonsurgical hepatocellular carcinoma: rationale for the design and evaluation of therapeutic trials. Hepatology. 1999; 29(1):62-7.
4. Jia L, Kiryu S, Watadani T, Akai H, Yamashita H, Akahane M, et al. Prognosis of hepatocellular carcinoma with portal vein tumor thrombus:assessment based on clinical and computer tomography characteristics. Acta Med Okayama. 2012; 66(2):131-41.
5. Takizawa D, Kakizaki S, Sohara N, Sato K, Takagi H, Arai H, et al. Hepatocellular carcinoma with portal vein tumor thrombosis: clinical characteristics, prognosis, and patient survival analysis. Dig Dis Sci. 2007; 52(11):3290-5.
6. Englesbe MJ, Kubus J, Muhammad W, Sonnenday CJ, Welling T, Punch JD, et al. Portal vein thrombosis and survival in patients with cirrhosis. Liver Transpl. 2010; 16(1):83-90.
7. Lertpipopmetha K, Auewarakul CU. High incidence of hepatitis B infection-associated cirrhosis and hepatocellular carcinoma in the Southeast Asian patients with portal vein thrombosis. BMC Gastroenterol. 2011; 11(1):66.
8. Tarantino L, Francica G, Sordelli I, Esposito F, Giorgio A, Sorrentino P, et al. Diagnosis of benign and malignant portal vein thrombosis in cirrhotic patients with hepatocellular carcinoma: color Doppler US, contrast-enhanced US, and fine-needle biopsy. Abdom Imaging. 2006; 31(5):537-44.
9. Sorrentino P, D'Angelo S, Tarantino L, Ferbo U, Bracigliano A, Vecchione R. Contrast-enhanced sonography versus biopsy for the differential diagnosis of thrombosis in hepatocellular carcinoma patients. World J Gastroenterol. 2009; 15(18):2245-51.
10. Danila M, Sporea I, Popescu A, Sirli R, Sendroiu M. The value of contrast enhanced ultrasound in the evaluation of the nature of portal vein thrombosis. Med Ultrason. 2011; 13(2):102-7.
11. Rossi S, Ghittoni G, Ravetta V, Torello Viera F, Rosa L, Serassi M, et al. Contrast-enhanced ultrasonography and spiral computed tomography in the detection and characterization of portal vein thrombosis complicating hepatocellular carcinoma. Eur Radiol. 2008; 18(8):1749-56.
12. Tublin ME, Dodd GD, 3rd, Baron RL. Benign and malignant portal vein thrombosis: differentiation by CT characteristics. AJR Am J Roentgenol. 1997; 168(3):719-23.
13. Shah ZK, McKernan MG, Hahn PF, Sahani DV. Enhancing and expansile portal vein thrombosis: value in the diagnosis of hepatocellular carcinoma in patients with multiple hepatic lesions. Am J Roentgenol. 2007; 188(5):1320-3.
14. Nishie A, Yoshimitsu K, Asayama Y, Irie H, Tajima T, Hirakawa M, et al. Radiologic detectability of minute portal venous invasion in hepatocellular carcinoma. Am J Roentgenol. 2008;190(1):81-7.
15. Sandrasegaran K, Tahir B, Nutakki K, Akisik FM, Bodanapally U, Tann M, et al. Usefulness of conventional MRI sequences and diffusion-weighted imaging in differentiating malignant from benign portal vein thrombus in cirrhotic patients. Am J Roentgenol. 2013; 201(6):1211-9.
16. Ho CL, Yu SC, Yeung DW. 11C-acetate PET imaging in hepatocellular carcinoma and other liver masses. J Nucl Med. 2003; 44(2):213-21.
17. Talbot JN, Fartoux L, Balogova S, Nataf V, Kerrou K, Gutman F, et al. Detection of hepatocellular carcinoma with PET/CT: a prospective comparison of 18F-fluorocholine and 18F-FDG in patients with cirrhosis or chronic liver disease. J Nucl Med. 2010; 51(11):1699-706.
18. Chen YK, Hsieh DS, Liao CS, Bai CH, Su CT, Shen YY, et al. Utility of FDG-PET for investigating unexplained serum AFP elevation in patients with suspected hepatocellular carcinoma recurrence. Anticancer Res. 2005; 25(6C):4719-25.
19. Han AR, Gwak GY, Choi MS, Lee JH, Koh KC, Paik SW, et al. The clinical value of 18F-FDG PET/CT for investigating unexplained serum AFP elevation following interventional therapy for hepatocellular carcinom. Hepatogastroenterology. 2009; 56(93):1111-6.
20. Agrawal A, Purandare N, Shah S, Puranik A, Rangarajan V. Extensive tumor thrombus of hepatocellular carcinoma in the entire portal venous system detected on fluorodeoxyglucose positron emission tomography computed tomography. Indian J Nucl Med. 2013; 28(1):54-6.
21. Sun L, Guan YS, Pan WM, Chen GB, Luo ZM, Wei JH, et al. Highly metabolic thrombus of the portal vein: 18F
fluorodeoxyglucose positron emission tomography/ computer tomography demonstration and clinical significance in hepatocellular carcinoma. World J Gastroenterol. 2008; 14(8):1212-7.
22. Sun L, Wu H, Pan WM, Guan YS. Positron emission tomography/computed tomography with (18) F-fluorodeoxyglucose identifies tumor growth or thrombosis in the portal vein with hepatocellular carcinoma. World J Gastroenterol. 2007; 13(33): 4529-32.
23. Sharma P, Kumar R, Jeph S, Karunanithi S, Naswa N, Gupta A, et al. 18F-FDG PET-CT in the diagnosis of tumor thrombus: can it be differentiated from benign thrombus? Nucl Med Commun. 2011; 32(9):782-8.
24. Hu S, Zhang J, Cheng C, Liu Q, Sun G, Zuo C. The role of F-FDG PET/CT in differentiating malignant from benign portal vein thrombosis. Abdom Imaging. 2014; 39(6):1221-7.
25. Ter Voert EE, van Laarhoven HW, Kok PJ, Oyen WJ, Visser EP, de Geus-Oei LF. Comparison of liver SUV using unenhanced CT versus contrast-enhanced CT for attenuation correction in 18F-FDG PET/CT. Nucl Med Commun. 2014; 35(5):472-7.