Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, CA.
Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA.
Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA.
Differentiating tumor versus bland portal vein thrombosis (PVT) is essential in determining liver transplant (LT) candidacy for patients with hepatocellular carcinoma (HCC). We aimed to evaluate radiographic and clinical features that could noninvasively distinguish tumor PVT from bland PVT in HCC patients. Of 467 patients with HCC listed for LT from 2004-2011, 59 (12.6%) had PVT and 12 of 59 (20.3%) were deemed malignant. When comparing tumor versus bland PVT, thrombus enhancement was seen in 100% versus 8.5%, venous expansion in 91.7% versus 10.6%, neovascularity in 58.3% versus 2.1% and being adjacent to HCC or prior treatment site in 100% versus 21.2% (all p<0.001). Combining these four imaging characteristics with alpha-fetoprotein (AFP) >1000 ng/dL, the presence of ≥3 criteria best characterized tumor PVT with 100% sensitivity, 93.6% specificity, 80% positive predictive value and 100% negative predictive value. No LT recipients with presumed bland PVT had macro-vascular invasion on explant. There were no differences in post-LT survival or HCC recurrence with bland PVT versus no PVT. In conclusion, we proposed noninvasive criteria (A-VENA) based on the presence of ≥3 of the following - AFP >1000, Venous expansion, thrombus Enhancement, Neovascularity, and Adjacent to HCC that could accurately differentiate tumor PVT from bland PVT. Use of A-VENA criteria can assist in standardizing the evaluation of PVT in patients with HCC being considered for LT.