Search Results (43)

Background/Objectives: Portal vein tumor thrombus (PVTT) is a severe complication of hepatocellular carcinoma (HCC) and is associated with poor outcomes. This study aimed to describe the imaging and clinical characteristics observed among HCC patients with PVTT who survived longer than one year following combined systemic therapy and radiotherapy. Methods: This retrospective, single-center study included 26 consecutive HCC patients with PVTT who survived more than one year after combined treatment. Baseline characteristics included PVTT extent classified according to the Liver Cancer Study Group of Japan—VP1 (segmental portal vein invasion), VP2 (second-order portal vein invasion), VP3 (first-order portal vein invasion), and VP4 (main portal trunk or contralateral PV invasion) and liver function assessed by Child–Pugh class and ALBI grade. Contrast-enhanced CT or MRI was evaluated at baseline and 6 months after treatment using RECIST 1.1 criteria. Results: The cohort was predominantly male (69%), and most patients had extensive PVTT (VP3–VP4, n = 19). Preserved liver function was common at baseline (Child–Pugh class A, n = 24; ALBI grade I, n = 14). Tumor response was observed in 23 patients (88%) during follow-up. Frequently observed post-treatment imaging findings included portal vein recanalization (n = 12), collateral circulation (present in 7 patients at baseline and 6 at follow-up), and compensatory liver hypertrophy (n = 6). Conclusions: Among HCC patients with PVTT who survived longer than one year after combined therapy, portal vein recanalization, collateral circulation, and compensatory liver hypertrophy were commonly observed imaging features. Given the retrospective design and survivor-selection nature of the study, these findings should be interpreted as descriptive observations rather than evidence of treatment efficacy or prognostic determinants. Full article

Background/Aim: Adequate portal inflow is essential for liver graft regeneration following transplantation. Intraoperative portal venography (IOPV) provides real-time assessment of portal vein patency, stenosis, thrombus formation, and portosystemic collaterals. In addition to imaging, portal vein pressure gradient (portal vein pressure minus inferior vena cava pressure) was also measured. This study assessed the impact of IOPV on surgical decision-making and post-transplant outcomes to establish criteria for patient selection. Methods: From November 2016 to November 2024, 34 liver transplant patients with portal inflow insufficiency (flow velocity < 10 cm/s), large shunts (>1 cm), or portal vein thrombosis underwent IOPV. Of the patients, one received deceased donor liver transplantation (DDLT), and the others received living donor liver transplantation (LDLT). Preoperative computed tomography (CT) and ultrasound (US) assessed portal vein patency, thrombus, and shunts. Postoperative US and CT monitored portal flow and graft regeneration. Results: IOPV influenced surgical planning in all cases, leading to shunt ligation or stenting, and improved portal vein flow velocity from 6.3 (IQR, 0–9.0) to 30.8 (IQR, 22.2–36.7) cm/s (p < 0.001). Adequate inflow was achieved in 32 patients, 2 had persistent low flow or occluded flow owing to severe adhesion after transplant and failure to close large collateral veins. Graft regeneration ranged from 104% to 255% within a year. Conclusions: IOPV is a valuable tool in liver transplantation vascular surgery, optimizing surgical strategies and portal inflow. Early integration into routine practice may improve graft outcomes. Further prospective, longitudinal research is needed to refine patient selection and assess long-term benefits. Full article

Because hepatocellular carcinoma (HCC) is a radiosensitive cancer, radiation therapy has been used for the treatment of HCC; however, external beam therapies are currently not described in most of the guidelines for the treatment of HCC. External beam therapies include photon beam therapies and particle beam therapies, which are composed of X-rays or gamma rays and beams of carbon ions or protons, respectively. The focus of this narrative review is carbon-ion radiotherapy (C-ion RT). C-ion RT is well tolerated by elderly patients with HCC and/or sarcopenic patients. In general, a single HCC greater than 30 mm is a good indication for C-ion RT in patients with Child Grade A/B or ALBI Grade 1/2. The local control rates and overall survival rates at 5 years after C-ion RT for HCCs larger than 30 mm are excellent, with fewer adverse events, such as radiation-induced liver damage. Advanced HCC with portal vein tumor thrombus is also an indication for C-ion RT in certain selected patients. C-ion RT is a promising therapeutic option for patients with HCC. Full article

This review delves into the complexities of managing portal vein thrombosis (PVT) in the context of liver transplantation (LT). PVT, which is a common finding in cirrhotic livers, can significantly jeopardize LT outcomes. Here, we explore the incidence, underlying mechanisms, and comprehensive management strategies for PVT throughout the pre-, intra-, and postoperative phases of LT in cirrhotic patients. Before transplantation, key interventions include anticoagulation therapies, transjugular intrahepatic portosystemic shunts (TIPS), and various endovascular techniques aimed at recanalizing the portal vein. During LT, surgical approaches range from straightforward eversion thrombectomy to more intricate procedures, such as jump grafts from the superior mesenteric vein (SMV), renoportal anastomosis (RPA), and portocaval hemitransposition, tailored to the extent of the thrombosis. In cases of extensive PVT, multivisceral transplantation (MVT) emerges as a viable option. Post-transplant management centers on thromboprophylaxis and anticoagulation, balancing the prevention of thrombotic events with the risk of bleeding complications. This review underscores the critical importance of early identification and proactive management of PVT to enhance outcomes for LT candidates. Full article

Background: The treatment landscape for advanced hepatocellular carcinoma (HCC) has evolved significantly recently; however, access to novel agents remains limited because of high costs. This study aimed to evaluate the systemic treatment patterns and survival outcomes for advanced HCC across different systemic treatment sequences under real-world resource constraints. Methods: This retrospective study was conducted at a tertiary center in Southern Thailand. The medical records of patients (n = 330) with advanced HCC treated with systemic therapy between 2010 and 2024 were reviewed. Outcomes included overall survival (OS), progression-free survival (PFS), and objective response rate (ORR). Prognostic factors for OS were investigated. Results: First-line therapies included tyrosine kinase inhibitor (TKI; 69.7%), chemotherapy (23.3%), immunotherapy (IO)/targeted therapy (3.6%), dual IO (1.8%), and IO monotherapy (1.5%). The median OS, PFS, and ORR for each cohort were 7.2, 5.2, 10.9, 8.5, and 8.6 months; 3.94, 3.22, 3.48, 6.19, and 2.69 months; and 9.6%, 10.4%, 16.7%, 0%, and 20.0%, respectively. OS improved with increasing lines of therapy (4.5, 12.2, 19.4, and 40.7 months for one to four lines, respectively). Portal vein tumor thrombus, ascites, elevated bilirubin level, high alpha-fetoprotein level, and poor Eastern Cooperative Oncology Group performance status were associated with poor prognosis; multiple treatment lines and overweight status were associated with improved OS. Conclusions: In this large real-world cohort, TKIs remained the mainstay effective treatment option because of limited access to IO-based regimens. Sequential systemic therapy significantly improved survival, emphasizing the importance of preserving treatment eligibility and multidisciplinary team involvement. Chemotherapy could be considered a viable option in resource-limited settings. Full article

Background: Pancreatic Ductal Adenocarcinoma (PDAC) is one of the most common malignancies associated with thrombotic events. While there is research present on various techniques of portal vein reconstruction, there is limited published data on the techniques and/or considerations of reconstruction in the setting of complete portal vein occlusion. We therefore sought to analyze and present our experience of this clinical scenario. Methods: This was a retrospective analysis of a prospectively collected database. All patients who underwent portal vein resection and/or reconstruction during a pancreatic resection were included. Post-operatively, all patients underwent a contrast-enhanced CT scan on post-operative day 1 to assess for any portal vein thrombus. Results: Pancreatic resection with portal vein reconstruction was performed in 183 patients. Complete PV occlusion was seen in 12 patients at the time of surgery. In those patients with an occluded PV, reconstruction options included primary repair with end-end anastomosis (n = 2) or use of an interposition graft (n = 9). Interposition graft conduits included the left renal vein (n = 6), tubularized bovine pericardium (n = 3), and femoral vein (n = 1). Post-operative portal vein thrombus was seen in 4/12 patients. The majority of patients (n = 7) were discharged on therapeutic anticoagulation, 4 were discharged on an antiplatelet, and 1 patient received neither. Conclusions: Based on our series, we would recommend attempting PV reconstruction in these patients with an interposition graft (with autologous left renal vein or bovine pericardium). We believe that with this technique, the post-operative thrombosis risk is similar to PV reconstructions in non-occluded patients. Full article

Background/Objectives: In chronic liver disease, a rebalanced coagulation state often results in an increased risk of thrombosis, particularly in the splanchnic region. While systemic coagulation abnormalities are well documented, alterations in regional (portal) hemostasis remain underexplored. This study aimed to compare systemic and portal hemostasis during liver transplantation and to determine whether systemic parameters can accurately predict regional coagulation status. Methods: Thirty-five liver transplant recipients were included in this study. Systemic blood samples (S1–S5) were collected from the external jugular vein at five surgical time points, while portal blood samples (R3) were obtained immediately before reperfusion simultaneously with S3. All samples were analyzed using ClotPro^® viscoelastic assays, conventional coagulation tests, and blood gas analysis. Results: The EX-test comparison between S3 and R3 samples revealed a discrepancy between systemic and regional hemostasis in 45.7% of patients. Among these, eight regional samples exhibited hypocoagulation characterized by coagulation factor consumption and hyperfibrinolysis. Another eight samples demonstrated hypercoagulation with fibrinolytic shutdown, which was confirmed by a fibrin-rich thrombus identified via scanning electron microscopy. Systemic samples failed to predict these regional variations. Conclusions: Regional (portal) hemostasis significantly differs from systemic coagulation and cannot be accurately predicted using systemic assays alone. These findings suggest that fibrinolytic shutdown in the portal vein may contribute to intraoperative and long-term graft damage, highlighting a potential need for regional coagulation assessment during liver transplantation. Full article

Background: Examinations of procalcitonin (PCT) and Ki-67 expression levels in hepatocellular carcinoma (HCC) patients who have undergone liver transplantation (LT) through immunohistochemical analyses of tumor tissue may reveal the biological characteristics of the tumor, thus informing the selection of HCC patients for LT. Methods: Hepatectomy specimens from 86 HCC patients who underwent LT were obtained and analyzed immunohistochemically for the expression of PCT and Ki-67. The percentage and intensity of PCT staining, as well as the percentage of Ki-67 expression, were assessed for each patient. The impacts of PCT and Ki-67 expression on disease-free survival, overall survival, and the recurrence rate were studied, as well as their correlations with other clinicopathological features. Results: The recurrent HCC group showed a higher Ki-67 level (p < 0.001), larger maximum dominant tumor diameter (p < 0.001), and higher rate of vascular invasion (p = 0.001). The pre-transplant AFP (p = 0.001), maximum dominant tumor diameter (p < 0.001), number of tumor nodules (p < 0.001), rate of vascular invasion (p = 0.001), and Ki-67 level (p = 0.044) were higher in patients beyond the Milan criteria. Similarly, the pre-transplant AFP (p < 0.001); maximum dominant tumor diameter (p < 0.001); number of tumor nodules (p < 0.001); rates of portal vein tumor thrombus (p = 0.002), poor differentiation (p = 0.021), and vascular invasion (p < 0.001); and Ki-67 level (p = 0.010) were higher in patients beyond the expanded Malatya criteria. The maximum dominant tumor diameter (p = 0.006); Ki-67 level (p = 0.003); rates of vascular invasion (p < 0.001), cases beyond the Milan criteria (p = 0.042) and the expanded Malatya criteria (p = 0.027), and portal vein tumor thrombus (p = 0.020); and presence of recurrence (p < 0.001) were higher in HCC patients with mortality. The Kaplan–Meier estimates indicated that Ki-67 levels exceeding 5% significantly affected DFS and OS. Although the Kaplan–Meier estimates indicated that a PCT staining percentage of ≥25% did not have a statistically significant effect on DFS or OS, the outcomes may be considered clinically significant. Conclusions: This study demonstrated that the Ki-67 proliferation index can be used as a predictive biomarker of the biological behavior of HCC. Furthermore, we claim that PCT expression over a particular threshold might impact recurrence and survival, and we believe that further multicenter prospective studies focused on standardized PCT antibody staining are crucial in order to determine its potential as a biomarker for HCC. Full article

Background/Objectives: Contrast-enhanced ultrasound (CEUS) is a non-invasive imaging technique with similar accuracy to CT and MRI for the diagnosis of hepatocellular carcinoma (HCC). CEUS offers several advantages in patient populations who have contraindications for CT or MRI. There are limited prospective studies in the United States evaluating the diagnostic equivalence of CEUS following transcatheter arterial chemoembolization (TACE) with same-day CT/MRI. This prospective pilot study compared CEUS and CT/MRI in patients with HCC following TACE in a United States population using Lumason^® contrast agent and the Liver Reporting and Data System (LI-RADS). Methods: Following institutional review board protocols, adult patients with a diagnosis of HCC were included. Follow-up CT/MRI was directed by referring clinicians, and CEUS was performed on the same day. CEUS was used to evaluate for treated lesion(s), new lesion(s), and portal vein thrombus before and after Lumason^®. Any subsequent follow-up imaging was reviewed. Results: In 26 enrolled patients, 33 target lesions were identified (size range 0.9–16.8 cm), and 26 were LI-RADS-5 or -M. CEUS identified 19 cases of residual tumor, 12 with no viable disease; CT/MRI identified 17 cases of residual tumor, 16 with no viable disease (p = 0.617). Both CEUS and CT/MRI identified five portal vein thrombi. Two lesions were missed or miscategorized on CEUS, while six were missed or miscategorized on CT/MRI (p = 0.289). Six new lesions were identified on both CEUS and CT/MRI. Of these new lesions, four were identified only by CT/MRI and three only by CEUS. Conclusions: CEUS is comparable to CT/MRI performed at identical follow-up intervals in evaluating for residual versus treated HCC following first-time TACE. Full article

Vascular liver diseases (VLDs) include different pathological conditions that affect the liver vasculature at the level of the portal venous system, hepatic artery, or venous outflow system. Although serological investigations and sometimes histology might be required to clarify the underlying diagnosis, imaging has a crucial role in highlighting liver inflow or outflow obstructions and their potential causes. Cross-sectional imaging provides a panoramic view of liver vascular anatomy and parenchymal patterns of enhancement, making it extremely useful for the diagnosis and follow-up of VLDs. Nevertheless, multiparametric ultrasound analysis provides information useful for differentiating acute from chronic portal vein thrombosis, distinguishing neoplastic invasion of the portal vein from bland thrombus, and clarifying the causes of venous outflow obstruction. Color Doppler analysis measures blood flow velocity and direction, which are very important in the assessment of VLDs. Finally, liver and spleen elastography complete the assessment by providing intrahepatic and intrasplenic stiffness measurements, offering further diagnostic information. Full article

Purpose: In the present study, we aimed to assess the effectiveness and safety of immune-targeted therapy (IT) with or without transarterial chemoembolization (TACE) for advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT). Patients and methods: This was a multicenter retrospective study that included 265 HCC patients with PVTT (IT + TACE: 82, IT: 183). Overall survival (OS) and progression-free survival (PFS), as well as tumor responses and adverse events, were evaluated. Results: Patients in the IT + TACE group experienced significantly longer overall survival (OS) and progression-free survival (PFS) periods, compared with those in the IT group (OS 19.0 vs. 13.0 months, p < 0.001; PFS 12.0 vs. 7.3 months, p < 0.001). Multivariable analysis confirmed IT + TACE as an independent predictor for improved OS and PFS. Subgroup analysis demonstrated the benefits of IT + TACE in patients with rich PVTT blood supply. Preoperative imaging and DSA offered predictive value. Conclusions: TACE combined with IT provides a safe and effective treatment option for advanced-HCC patients with PVTT, particularly those with abundant PVTT blood supply. Full article

Portal vein thrombosis (PVT) is a challenging and controversial complication of cirrhosis. Experimental models that reproduce cirrhotic PVT and effective pharmacological therapies are limited. We aimed to investigate the nature course and mechanisms of PVT in cirrhosis. A novel PVT model was developed via two-step total portal vein ligation in healthy and thioacetamide (TAA)-cirrhotic rats. Circulating and liver-infiltrating neutrophils were isolated from individuals with cirrhosis to examine neutrophil extracellular traps (NETs) and explore their unique characteristics and implications in PVT-associated fibrosis in cirrhosis. We further validated macrophage–myofibroblast transition (MMT) via multiplex immunofluorescence and single-cell sequencing. In the experimental model, cirrhosis promoted PVT development and portal vein intimal thickening. Interestingly, cirrhosis promoted spontaneous resolution of PVT due to instability of thrombus structure, along with pulmonary and intrahepatic clots. NETs-MMT mediate cirrhotic PVT and PVT-associated fibrosis, including fibrotic thrombus remodeling and increased hepatic collagen deposition. Mechanistically, caspase-4-dependent activation of neutrophils and GSDMD mediated the formation of NETs. The extracellular DNA of NETs promoted TGF-β1/Smad3-driven MMT. Inhibiting GSDMD with disulfiram suppressed cirrhotic PVT and prevented associated fibrosis. The cirrhotic PVT model reflected the following three main characteristics of cirrhotic PVT: spontaneous resolution, immunothrombosis, and intimal fibrosis. Targeting NETs with GSDMD inhibitors may serve as a new therapeutic concept to treat cirrhotic PVT. Full article

Cholangiopathy has been described in survivors of severe COVID-19, presenting significant clinical parallels to the pre-pandemic condition of secondary sclerosing cholangitis in critically ill patients (SSC-CIP). We aimed to examine the liver histopathology of individuals with persistent cholestasis after severe COVID-19. Methods: We subjected post-COVID-19 cholestasis liver samples to routine staining techniques and cytokeratin 7 immunostaining and semi-quantitatively analyzed the portal and parenchymal changes. Results: All ten patients, five men, had a median age of 56, an interquartile range (IQR) of 51–60, and required intensive care unit and mechanical ventilation. The median and IQR liver enzyme concentrations proximal to biopsy were in IU/L: ALP 645 (390–1256); GGT 925 (664–2169); ALT 100 (86–113); AST 87 (68–106); and bilirubin 4 (1–9) mg/dL. Imaging revealed intrahepatic bile duct anomalies and biliary casts. We performed biopsies at a median of 203 (150–249) days after molecular confirmation of infection. We found portal and periportal fibrosis, moderate-to-severe ductular proliferation, and bile duct dystrophy in all patients, while we observed hepatocyte biliary metaplasia in all tested cases. We observed mild-to-severe parenchymal cholestasis and bile plugs in nine and six cases. We also observed mild swelling of the arteriolar endothelial cells in five patients. We observed a thrombus in a small portal vein branch and mild periductal fibrosis in one case each. One patient developed multiple small biliary infarctions. We did not observe ductopenia in any patient. Conclusions: The alterations were like those observed in SSC-CIP; however, pronounced swelling of endothelial cells, necrosis of the vessel walls, and thrombosis in small vessels were notable. Full article

Vascular invasion of hepatocellular carcinoma involves tumor plugs in the main trunk of the portal vein, bile ducts, and veins, and it indicates poor prognosis. It is often associated with portal hypertension, which requires evaluation and management. Treatment includes hepatic resection, systemic pharmacotherapy, hepatic arterial infusion chemotherapy, and radiation therapy. Recurrence rates post-hepatic resection are high, and systemic drug therapy often has limited therapeutic potential in patients with a poor hepatic reserve. Single therapies are generally inadequate, necessitating combining multiple therapies with adjuvant and systemic pharmacotherapy before and after hepatectomy. This narrative review will provide an overview of the treatment of hepatocellular carcinoma with vascular invasion. Full article

The “vein definition” for locally advanced pancreatic ductal adenocarcinoma (LA PDAC) assumes portal-to-superior mesenteric vein (PV/SMV) unreconstructability due to tumor involvement or occlusion. Radical pancreatectomies with SMV resection without PV/SMV reconstruction are scarcely discussed in the literature. Retrospective analysis of 19 radical pancreatectomies for “low” LA PDAC with SMV and all its tributaries resection without PV/SMV reconstruction has shown zero mortality; overall morbidity—56%; Dindo–Clavien—3–10.5%; R0—rate—82%; mean operative procedure time—355 ± 154 min; mean blood loss—330 ± 170 mL; delayed gastric emptying—25%; and clinically relevant postoperative pancreatic fistula—8%. In three cases, surgery was associated with superior mesenteric (n2) and common hepatic artery (n1) resection. Surgery was completed without vein reconstruction (n13) and with inferior mesenteric-to-splenic anastomosis (n6). There were no cases of liver, gastric, or intestinal ischemia. A specific complication of the SMV resection without reconstruction was 2–3 days-long intestinal edema (48%). Median overall survival was 25 months, and median progression-free survival was 18 months. All the relapses, except two, were distant. The possibility of successful SMV resection without PV/SMV reconstruction can be predicted before surgery by CT-based reconstructions. The mandatory anatomical conditions for the procedure were as follows: (1) preserved SMV-SV confluence; (2) occluded SMV for any reason (tumor or thrombus); (3) well-developed inferior mesenteric vein collaterals with dilated intestinal veins; (4) no right-sided vein collaterals; and (5) no varices in the upper abdomen. Conclusion: “Low” LA PDACs involving SMV with all its tributaries can be radically and safely resected in highly and specifically selected cases without PV/SMV reconstruction with an acceptable survival rate. Full article