Quadrant pain

HISTORY: A 56-year-old male with known hepatitis B.  Weight loss and

right upper quadrant pain.

 

 FINDINGS: Images 1 and 2 are transverse and longitudinal images of the

right lobe of the liver demonstrating a complex solid mass (arrows,

Image 1).  Image 3 is a scan of the portal vein demonstrating

enlargement of the portal vein by a diffuse hypoechoic mass (arrows,

Image 3).  Note on Image 4, which is a longitudinal scan of the left

portal vein, there is a thrombus extending to the proximal portion of

the anterior division of the left portal vein.

 

Image 5 is a B- color image of the right lower lobe of the liver

demonstrating branching hypoechoic tumor thrombus within the anterior

posterior divisions of the right portal vein.  Image 6 is a color

Doppler scan of the portal vein demonstrating intrinsic color Doppler

flow within the tumor thrombus.  Image 7 is a spectral Doppler tracing

documenting arterial flow within the portal vein.  Image 8 is a

transverse scan of the portahepatis demonstrating numerous periportal

venous collaterals from the portal vein tumor thrombus.  Image 9 is a

color Doppler scan of the right lobe of the liver demonstrating the

large mass which is predominantly avascular.

DIAGNOSIS: Hepatocellular carcinoma with portal vein invasion.

 

DISCUSSION: The sonographic findings in this case clearly demonstrate

evidence of tumor thrombus within the portal vein from the patient's

hepatocellular carcinoma.  The color Doppler demonstration of intrinsic

arterial flow within the thrombus enables a precise diagnosis of active

tumor invasion rather than bland thrombus.  Although the tumor mass

within the right lobe is relatively avascular, this is somewhat unusual

for primary hepatocellular carcinoma.  In 75% of patients, significant

increased intra-lesional flow will be identified with color Doppler

sonography.  In only 25% of cases the lesions will appear hypo- or

avascular.  Portal venous invasion, although typical for hepatocellular

carcinoma, may also occur in cholangiocarcinoma or metastases.

Percutaneous biopsy of the portal vein thrombus may also be helpful to

distinguish bland thrombus from neoplastic invasion.