Clin Endosc.  2021 Sep;54(5):745-753. 10.5946/ce.2020.240.

Role of Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Portal Vein Thrombus in the Diagnosis and Staging of Hepatocellular Carcinoma

• Eskandere D
• Hakim H
• Attwa M
• Elkashef W
• Altonbary AY

• KMID: 2520559
• DOI: http://doi.org/10.5946/ce.2020.240

Abstract

Background/Aims
Malignant portal vein thrombus (PVT) is found in up to 44% of patients with hepatocellular carcinoma (HCC). The nature of the thrombus influences treatment selection. The aim of this study was to assess the safety and efficacy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in determining the nature of PVT in liver cirrhosis and/or HCC.
Methods
A prospective study was conducted in 34 patients with liver cirrhosis and/or HCC with PVT. Under EUS guidance, PVT was punctured using a 22 G FNA needle (Cook Medical, Bloomington, IN, USA) followed by monitoring of the puncture tract using color Doppler. Patients were followed for adverse events 2 hours after recovery.
Results
Throughout the 30-month study period, 34 patients, including 24 males with a mean age of 59±8 years, were enrolled. There were 8 patients with known HCC and 26 with no liver masses detected by computed tomography (CT). EUS-FNA from PVT was positive for malignancy in 3 patients (8.8%), of which only 1 patient was diagnosed with HCC by CT and 2 patients were newly diagnosed with HCC after EUS-FNA. No major complications were reported.
Conclusions
EUS-FNA is a safe and effective technique for determining the nature of PVT that does not fulfill the malignant criteria via imaging studies in patients with liver cirrhosis and/or HCC.

Keyword

Endoscopic ultrasound; Fine needle aspiration; Hepatocellular carcinoma; Portal vein thrombus

Figure

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  Fig. 1. Flowchart of enrolled patients. CT, computed tomography; EUS-FNA, endoscopic ultrasound-guided fine-needle aspiration; HCC, hepatocellular carcinoma; HFL, hepatic focal lesion; PVT, portal vein thrombus.

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  Fig. 2. (A) Endoscopic ultrasound examination showing hyperechoic thrombus totally obstructing the main portal vein. (B) Endoscopic ultrasound-guided fine-needle aspiration using 22 G needle for Portal vein thrombus. (C) Multiple small hepatic focal lesions. (D) Cytopathological examination showing sheets of malignant cells with moderate atypia, prominent nucleoli, and occasional mitotic figures, consistent with poorly differentiated adenocarcinoma.

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  Fig. 3. (A. B) Triphasic computed tomography showing non-enhancing portal vein thrombus with no definite liver masses. (C, D) Endoscopic ultrasound examination showing hyperechoic thrombus partially obstructing the main portal branch with no doppler flow inside and multiple periportal veins (cavernoma). (E, F) Endoscopic ultrasound-guided fine-needle aspiration using 22 G needle for both Portal vein thrombus and hepatic focal lesion.

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  Fig. 4. Cytopathological examination showing sheets of malignant cells with moderate nuclear atypia with granular eosinophilic cytoplasm for PVT (A, B), and hepatic focal lesion (C, D), with positive cytoplasmic reaction for HepPar-1 and Glypican-3, consistent with low-grade hepatocellular carcinoma (E, F).

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