Detection of Tumor Thrombus in Hepatocellular Carcinoma

HomeRadiologyVol. 302, No. 1 PreviousNext Reviews and CommentaryFree AccessEditorialDetection of Tumor Thrombus in Hepatocellular CarcinomaGlen R. Morrell Glen R. Morrell Author AffiliationsFrom the Department of Radiology and Imaging Sciences, University of Utah, 30 North, 1900 East #1A071, Salt Lake City, UT 84132.Address correspondence to the author (e-mail: [email protected]).Glen R. Morrell Published Online:Sep 28 2021https://doi.org/10.1148/radiol.2021211984MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Bae et al in this issue.Glen Morrell, MD, PhD, is associate professor in the Abdominal Imaging Section in the Department of Radiology and Imaging Sciences at the University of Utah and affiliated Huntsman Cancer Center and adjunct faculty in the Department of Electrical and Computer Engineering. His clinical practice includes CT, MRI, and US of the abdomen and pelvis, including a large volume of cancer imaging. His research interests include novel MRI technologies for cancer imaging.Download as PowerPointOpen in Image Viewer Imaging plays a central role in the treatment of patients with hepatocellular carcinoma (HCC). The diagnosis of HCC is typically made on the basis of findings at contrast-enhanced CT (CECT) or MRI in combination with clinical data, such as serum α-fetoprotein levels. Image findings also strongly influence the selection of therapies for patients with HCC. The presence of enhancing soft tissue in a portal or hepatic vein is indicative of tumor thrombus and is a critical finding in the radiologic evaluation of HCC. Tumor thrombus is associated with dramatically decreased survival (1). Although there is some controversy about the role of surgery in the presence of tumor thrombus (2), the widely used Barcelona system considers tumor thrombus an absolute contraindication to resection (3). Patients with tumor thrombus are not considered eligible for liver transplant according to the Milan criteria (3) and Organ Procurement and Transplantation Network guidelines (4). The ability of the radiologist to accurately diagnose tumor thrombus is a matter of life and death for patients with HCC.In this issue of Radiology, Bae et al (5) investigate the accuracy of CECT and hepatobiliary contrast agent–enhanced (HBA) MRI for the detection of enhancing portal or hepatic vein thrombus. In a retrospective review of data over a 10-year period, they identified 1322 patients with cirrhosis or hepatitis who underwent both CECT and HBA MRI and subsequently a hepatic resection or transplant. Among these, 101 had macroscopic portal or hepatic vein thrombus at pathologic examination of the resected or explanted liver. CECT and HBA MRI were found to have similar sensitivity for the detection of macroscopic tumor in vein (TIV) (64% and 62%), and both were essentially 100% specific. Interobserver agreement between the three radiologists was substantial or better.This study expands on a previously published study by the same group reporting the accuracy of CECT and MRI for the detection of main portal vein thrombus in 310 patients (6). The current study is more robust, with a larger and more clinically representative population, and with pathologic examination as the reference standard for all patients.Bae et al have couched their results in the language of the American College of Radiology Liver Imaging Reporting and Data System (LI-RADS), including the LI-RADS category of LR-TIV and additional image findings mentioned in LI-RADS, which they refer to as “features suggestive of TIV (FSTIV).” However, in LI-RADS, the only finding that results in classification as TIV is “unequivocal enhancing soft tissue in vein” (7). Other findings, including those referred to as FSTIV, are not directly relevant to the LI-RADS classification. Thus, the current study evaluated the accuracy of CT and MRI in the detection of enhancing soft tissue in the vein and did not provide information about the accuracy or appropriateness of LI-RADS itself. The findings referred to as FSTIV are described in LI-RADS as additional features sometimes associated with TIV, which when seen should prompt careful examination for tumor thrombus. These features do not directly contribute to the LI-RADS score and are offered in LI-RADS as reminders to the radiologist, who ideally should be diligently looking for enhancing tissue in the vein in every scan anyway.The study sample described by Bae et al is both a strength and a limitation of the study. The ideal study sample might be the typical gamut of patients undergoing imaging studies for suspicion of HCC. However, in this ideal population, establishing a ground truth for presence or absence of TIV may be impossible, at least in the United States, because presence of tumor thrombus is deemed a contraindication to resection or transplant; no pathologic specimens would be available to confirm the presence of macroscopic TIV. The authors’ institution follows a different guideline, called the Hong Kong Liver Cancer staging system (8), in which tumor thrombus is not an absolute contraindication to resection or transplant. Bae et al were able to define a study sample in which the CT and MRI findings could be evaluated against the ground truth of pathologic examination. This is a strength of the study. However, because the study sample is defined with reference to the Hong Kong Liver Cancer staging system, the application of these results to patient populations in other parts of the world where systems such as the Barcelona and Milan criteria are used is somewhat uncertain.Regardless of the question of generalizability of the study sample, Bae et al reach a few interesting and useful conclusions. The results suggest that either CECT or HBA MRI may be used with equal accuracy for detection of enhancing soft tissue in the vein. Both were demonstrated to be extremely specific for this diagnosis but only moderately sensitive. This lack of sensitivity could prompt the future inclusion in LI-RADS of additional imaging criteria for TIV in addition to the current unequivocal enhancing soft tissue in vein, such as apparent diffusion coefficient at MRI. Improved accuracy of diagnosis of TIV will allow more appropriate and effective treatment decisions for patients with HCC and may help to clarify the future role of resection or transplant in patients with TIV.Disclosures of Conflicts of Interest: G.R.M. disclosed no relevant relationships.References1. Mähringer-Kunz A, Steinle V, Düber C, et al. Extent of portal vein tumour thrombosis in patients with hepatocellular carcinoma: the more, the worse? Liver Int 2019;39(2):324–331. Crossref, Medline, Google Scholar2. Chan SL, Chong CC, Chan AW, Poon DM, Chok KS. Management of hepatocellular carcinoma with portal vein tumor thrombosis: review and update at 2016. World J Gastroenterol 2016;22(32):7289–7300. Crossref, Medline, Google Scholar3. Mazzaferro V, Bhoori S, Sposito C, et al. Milan criteria in liver transplantation for hepatocellular carcinoma: an evidence-based analysis of 15 years of experience. Liver Transpl 2011;17(Suppl 2):S44–S57. Crossref, Medline, Google Scholar4. OPTN Policies Effective as of. July 27, 2021 [Repeal 1.4.F].https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf. Accessed August 20, 2021. Google Scholar5. Bae JS, Lee JM, Jeon SK, et al. LI-RADS tumor in vein at CT and hepatobiliary MRI. Radiology 2021.https://doi.org/10.1148/radiol.2021210215. Published online September 28, 2021. Link, Google Scholar6. Bae JS, Lee JM, Yoon JH, et al. How to best detect portal vein tumor thrombosis in patients with hepatocellular carcinoma meeting the Milan criteria: gadoxetic acid–enhanced MRI versus contrast-enhanced CT. Liver Cancer 2020;9(3):293–307. Crossref, Medline, Google Scholar7. Chernyak V, Fowler KJ, Kamaya A, et al. Liver Imaging Reporting and Data System (LI-RADS) version 2018: imaging of hepatocellular carcinoma in at-risk patients. Radiology 2018;289(3):816–830. Link, Google Scholar8. Cheung TT, Kwok PC, Chan S, et al. Hong Kong consensus statements for the management of unresectable hepatocellular carcinoma. Liver Cancer 2018;7(1):40–54. Crossref, Medline, Google ScholarArticle HistoryReceived: Aug 4 2021Revision requested: Aug 20 2021Revision received: Aug 22 2021Accepted: Aug 26 2021Published online: Sept 28 2021Published in print: Jan 2022 FiguresReferencesRelatedDetailsAccompanying This ArticleLI-RADS Tumor in Vein at CT and Hepatobiliary MRISep 28 2021RadiologyRecommended Articles LI-RADS Tumor in Vein at CT and Hepatobiliary MRIRadiology2021Volume: 302Issue: 1pp. 107-115Venous Thrombosis and Hypercoagulability in the Abdomen and Pelvis: Causes and Imaging FindingsRadioGraphics2020Volume: 40Issue: 3Multimodality Imaging of Abdominopelvic Tumors with Venous InvasionRadioGraphics2020Volume: 40Issue: 7pp. 2098-2116Role of US LI-RADS in the LI-RADS AlgorithmRadioGraphics2019Volume: 39Issue: 3pp. 690-708Transsplenic Portal System Catheterization: Review of Current Indications and TechniquesRadioGraphics2022Volume: 42Issue: 5pp. 1562-1576See More RSNA Education Exhibits Multimodality Imaging of Tumor Thrombus in Hepatocellular CarcinomaDigital Posters2022Portal Vein Potpourri: From Thrombosis to TherapyDigital Posters2019Multimodality Imaging of Portal Vein Thrombosis: Diagnosis and Influence on Clinical ManagementDigital Posters2022 RSNA Case Collection Portal vein thrombosisRSNA Case Collection2020Left vertebral vein tumor thrombusRSNA Case Collection2020Arterioportal fistulaRSNA Case Collection2021 Vol. 302, No. 1 Metrics Altmetric Score PDF download