Rapidly Progressive Hepatocellular Carcinoma Mimicking Benign Portal Vein Thrombosis: A Case Report
A 39-year-old man was admitted for hematemesis. Esophageal varices without active bleeding were detected on following endoscopy. To evaluate the etiology of the esophageal varices, contrast-enhanced abdominal computed tomography (CT) with 64 channel multi-detector row CT scanner was performed. Abdominal CT scan showed liver cirrhosis without parenchymal mass and PVT with mild enhancement in the mild dilated right portal vein (17 mm in diameter; ). He had diagnosed as hepatitis B-induced cirrhosis of Child-Pugh A classification. He had never known about hepatitis B infection before admission. Laboratory tests revealed the following: alpha fetoprotein (1,276 IU/mL; normal, <5.8), gamma-glutamyl transpeptidase (389 IU/L; normal, <75), aspartate amino transferase (25 IU/L; normal, <38), alanine amino transferase (8 IU/L; normal, <43), alkaline phosphatase (107 IU/L; normal, <117), total blilirubin (0.7 mg/dL; normal, <1.3), and direct bilirubin (0.2 mg/dL; normal, <0.4).\nAlthough there was no delineated parenchymal mass on abdominal CT, an occult HCC was suspected because of the markedly elevated alpha fetoprotein. Therefore liver magnetic resonance imaging (MRI) was performed for evaluation of HCC. Liver MRI also revealed only PVT with mild enhancement within mild dilated right portal vein (17 mm in diameter) in cirrhotic liver without evidence of parenchymal mass (). There was no evidence of hepatic tumor, such as a HCC, on CT and MRI. Conservative treatment that focused on control of bleeding and prevention of recurrent variceal hemorrhage was done during the next 1 month. We decided to perform percutaneous ultrasound-guided biopsy of PVT and following liver MRI was performed before ultrasound-guided biopsy.\nFollow-up MRI showed that the extent of enhancing PVT with high T2 signal intensity was more increased in the right portal vein and the PVT diameter was greater (22 mm) than the CT findings on admission. There was also no parenchymal mass on follow-up MRI. Percutaneous ultrasound-guided biopsy of the PVT was performed (). Vascularity was detected within the PVT on color Doppler ultrasound. The PVT was pathologically confirmed to be a HCC (). There was no evidence of extrahepatic involvement on imaging modalities, thus we decided to perform a right hepatectomy for curative treatment. However, the right hepatectomy could not be done, because, 20 days later, the pre-operative CT revealed that the PVT in the right portal vein had extended to the left and the main portal vein had a greater diameter (23 mm; ). At that time, the level of alpha fetoprotein was markedly elevated to 17,500 IU/mL. The interval between first admission and preoperative CT scan was just 50 days. The patient died after 1 year despite chemotherapy with five cycles of etoposide and epirubicine.