Extrahepatic portal venous obstruction of different pathogenesis in pancreatic diseases: reports of 4 autopsy cases with chronic pancreatitis and pancreatic carcinoma

Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion

A broad range of abdominal and pelvic tumors can manifest with or develop intraluminal venous invasion. Imaging features at cross-sectional modalities and contrast-enhanced US that allow differentiation of tumor extension within veins from bland thrombus include the expansile nature of tumor thrombus and attenuation and enhancement similar to those of the primary tumor. Venous invasion is a distinctive feature of hepatocellular carcinoma and renal cell carcinoma with known prognostic and treatment implications; however, this finding remains an underrecognized characteristic of multiple other malignancies-including cholangiocarcinoma, adrenocortical carcinoma, pancreatic neuroendocrine tumor, and primary venous leiomyosarcoma-and can be a feature of benign tumors such as renal angiomyolipoma and uterine leiomyomatosis. Recognition of tumor venous invasion at imaging has clinical significance and management implications for a range of abdominal and pelvic tumors. For example, portal vein invasion is a strong negative prognostic indicator in patients with hepatocellular carcinoma. In patients with rectal cancer, diagnosis of extramural venous invasion helps predict local and distant recurrence and is associated with worse survival. The authors present venous invasion by vascular distribution and organ of primary tumor origin with review of typical imaging features. Common pitfalls and mimics of neoplastic thrombus, including artifacts and anatomic variants, are described to help differentiate these findings from tumor in vein. By accurately diagnosing tumor venous invasion, especially in tumors where its presence may not be a typical feature, radiologists can help referring clinicians develop the best treatment strategies for their patients. ^©RSNA, 2020.

Pancreatic carcinoma associated with portal vein tumor thrombus: three case reports

Pancreatic carcinoma associated with portal vein tumor thrombus (PVTT) is rare. Here, we report three cases of resected pancreatic carcinoma associated with PVTT. In all three cases, preoperative images obtained using computed tomography and endoscopic ultrasonography revealed a tumor thrombus in the portal vein, which was connected to an irregular mass in the pancreas. All cases underwent surgical resection of the primary lesion and the PVTT. The pathological diagnoses of the tumors were two cases of tubular adenocarcinoma and one case of nonfunctioning endocrine carcinoma. We also retrospectively examined other patients who underwent surgical excision with portal vein resection.

A case of acinar cell carcinoma of the pancreas that formed extensive tumor thrombus of the portal vein

A 58-year-old man was admitted to our hospital because of anorexia and back pain. He had been previously diagnosed with chronic pancreatitis with blood thrombus of the splenic vein at another hospital. Abdominal ultrasonography and computed tomography revealed a large mass in the body and tail of the pancreas, which directly invaded the stomach and the spleen. Small nodular metastases in both lungs were also detected. Furthermore, tumor thrombus continuously involved the splenic and proximal superior mesenteric vein, main portal vein, and its right intrahepatic branch. A metastatic mass was disclosed in the adjacent liver. The specimens obtained from portal tumor thrombus were histologically compatible with acinar cell carcinoma. Portal tumor thrombus is a rare condition in pancreatic tumors; however, it seems to be important to differentiate tumor thrombus from blood thrombus of the portal vein in order to know the true clinical stage and provide a suitable treatment.

Limitations of percutaneous techniques in the treatment of portal vein thrombosis

New therapeutic alternatives to portal vein thrombosis (PVT) include the percutaneous, transhepatic infusion of fibrinolytic agents, balloon dilatation, and stenting. These maneuvers have proven to be effective in some cases with acute, recent PVT. We have treated two patients with acute PVT via transhepatic or transjugular approaches and by using pharmacologic and mechanical thrombolysis and thrombectomy. Although both patients clinically improved, morphologic results were only fair and partial rethrombosis was observed. The limitations of percutaneous procedures in the recanalization of acute PVT in noncirrhotic patients are discussed.

Hepatic infarction with portal thrombosis

A case of hepatic infarction with portal thrombosis is reported. A 63-year-old woman with liver cirrhosis and esophageal varices was admitted for treatment of the esophageal varices. Endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS) were performed. Two months later, she experienced right hypochondralgia and right flank pain. Serum transaminase levels were suddenly elevated, and computed tomography scans of the liver showed multiple small nodular lesions. Her condition worsened, and she died of hepatic failure. Autopsy revealed splenic and portal vein thrombosis, multiple hepatic infarction, and evidence of chronic pancreatitis. We believe that liver cirrhosis and chronic pancreatitis were the main risk factors for the portal thrombosis, and the treatment for esophageal varices appeared to have triggered the thrombosis. The hepatic infarction was caused by the portal thrombosis.

Noncirrhotic portal vein thrombosis causing sudden unexpected death. A rare cause of fatally ruptured esophageal varices

Noncirrhotic portal vein thrombosis (PVT) is a rare disease that usually presents with small nonfatal "herald bleeding" with low mortality. Classic findings of noncirrhotic PVT include esophageal varices, splenomegaly, a normal liver, and an organized thrombus of the portal vein. We present a case of previously unreported sudden unexpected death from noncirrhotic PVT in an asymptomatic elderly woman, review the literature of this entity, and examine the pathophysiology of the formation of fatally ruptured varices. The portal vein must be carefully examined in all cases where there is no coexisting cirrhosis.

Resected acinar cell carcinoma of the pancreas with tumor thrombus extending into the main portal vein: report of a case

The incidence of acinar cell carcinoma has been reported to be about 1% of all pancreatic neoplasms, and pancreatic cancer combined with tumor growth extending into the portal vein is a rare condition. We herein report a case of acinar cell carcinoma of the pancreas with a tumor thrombus extending into the main portal trunk. Preoperative imaging of the portal vein, consisting of computed tomography (CT), magnetic resonance imaging (MRI), and angiography, revealed an oval shadow defect in the main portal trunk along with an irregular mass in the pancreatic head. At operation, we confirmed a tumor thrombus extending from a tumor in the pancreatic head into the main portal trunk via the pancreatoduodenal veins. A pancreatoduodenectomy combined with partial resection of the portal vein was thus performed under a temporary portal vein shunt from the ileocecal vein to the umbilical vein. Immunohistochemical examination for alpha 1-antichimotrypsin and electron microscopic examination confirmed the diagnosis of acinar cell carcinoma of the pancreas with a tumor thrombus in the portal vein. Surgical excision combined with portal vein resection may therefore improve the prognosis of selected patients with portal tumor thrombus.

Extrahepatic portal vein obstruction in adults detected by ultrasound with frequent lack of portal hypertension signs

Extrahepatic portal vein obstruction (EHPO) was seen in 54 adult patients at the Chiba University Hospital and affiliated hospitals from 1978 to 1991. They were classified according to the background disease (Group A, unknown aetiology; Group B, benign disease; Group C, malignant disease). Among the initial symptoms and signs, abdominal pain was the most frequent in Group A (37%), and symptoms attributable to the primary disease in Groups B (44%) and C (75%). Definite or probable diagnosis was made in 45 of the 54 patients (81.8%) by ultrasound (US) examination carried out because of these symptoms and signs. Signs of portal hypertension were observed in 67% of patients; oesophageal varices were seen in 60%. Extrahepatic portal vein obstruction without portal hypertension signs was characterized by thick extensive hepatopetal collaterals or patency of some intrahepatic portal veins. Extrahepatic portal vein obstruction patients without portal hypertension remained free of its signs for more than 3 years of follow up and, in fact, EHPO without portal hypertension signs was a common occurrence. Emphasis is made on the diagnostic value of US examination which was useful in identifying the relation of clinical manifestation of EHPO to pathophysiology, and on the frequent lack of portal hypertension signs in this disease.

Portal vein thrombosis: a review

Portal vein thrombosis (PVT) is a rare condition that affects both children and adults. This article reviews the existing literature on PVT, with an emphasis on recent developments. A comprehensive description of etiologic factors and clinical aspects is presented. Treatment issues that remain unresolved are addressed and a framework for the diagnostic work-up and management of patients with PVT is provided.