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DOI: 10.1055/s-0042-100199
Endoscopic ultrasound-guided fine needle aspiration of splenic vein thrombosis: a novel approach to the portal venous system
Publikationsverlauf
Publikationsdatum:
01. Februar 2016 (online)
A diagnosis of portal system thrombosis can be easily obtained with conventional digital imaging [1]; however, the etiology of the thrombosis can be difficult to assess in the absence of the characteristic hallmarks of a malignant or benign thrombus. When a definitive diagnosis is required, transabdominal ultrasound-guided fine needle aspiration (FNA) of the portal vein thrombus can be performed [2], but this technique is not widely used because of the risk of post-biopsy bleeding complications.
We report the case of a 29-year-old man with a history of hepatocellular carcinoma (HCC), for which he had undergone a major hepatic resection when still a child. After a 20-year recurrence-free interval, a left lobe hepatectomy was performed because of HCC recurrence. The right lobe was treated 9 months later with multiple transarterial chemoembolizations because of multifocal recurrence. When, 6 months later, a major radiological and alpha-fetoprotein tumor response was observed, the patient underwent liver transplantation.
One year after the transplant, a splenic vein thrombosis was detected on a computed tomography (CT) scan ([Fig. 1]). An endoscopic ultrasound (EUS)-guided approach was considered the most appropriate to obtain a diagnosis as to the nature of the thrombus. An EUS-guided FNA was performed using a transgastric approach ([Fig. 2]), with a 25-gauge needle (Wilson-Cook Medical, Winston-Salem, North Carolina, USA), without any immediate or delayed complications ([Video 1]).
Qualität:
Cytopathologic examination of the specimen revealed malignant cells consistent with HCC ([Fig. 3]). Given the advanced stage of the disease, the patient was referred for systemic treatment. He died 9 months later.
EUS provides a unique opportunity to image the region in close proximity to the portal vein system. To our knowledge, only three cases of EUS-FNA of the portal vein have been reported [3] [4]. This is the first reported case of EUS-FNA of the splenic vein.
When liver transplantation or major surgery is planned, a firm diagnosis of possible neoplastic invasion of the portal system is critical as macrovascular invasion is a major determinant of prognosis [5]. Conversely, EUS-FNA of a thrombus in the portal system may help to indicate interventional vs. systemic anti-thrombotic approaches in benign thrombosis. Future studies should establish the efficacy and safety profile of this technique, especially when vessel occlusion is partial or the thrombus is floating.
Endoscopy_UCTN_Code_TTT_1AS_2AC
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References
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- 2 Dodd 3rd GD, Carr BI. Percutaneous biopsy of portal vein thrombus: a new staging technique for hepatocellular carcinoma. AJR Am J Roentgenol 1993; 161: 229-233
- 3 Lai R, Stephens V, Bardales R. Diagnosis and staging of hepatocellular carcinoma by EUS-FNA of a portal vein thrombus. Gastrointest Endosc 2004; 59: 574-577
- 4 Storch I, Gomez C, Contreras F et al. Hepatocellular carcinoma (HCC) with portal vein invasion, masquerading as pancreatic mass, diagnosed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Dig Dis Sci 2007; 52: 789-791
- 5 Minagawa M, Makuuchi M, Takayama T et al. Selection criteria for hepatectomy in patients with hepatocellular carcinoma and portal vein tumor thrombus. Ann Surg 2001; 233: 379-384