Criteria for diagnosing benign portal vein thrombosis in the assessment of patients with cirrhosis and hepatocellular carcinoma for liver transplantation.

Malignant portal vein thrombosis is a contraindication for liver transplantation. Patients with cirrhosis and early hepatocellular carcinoma (HCC) may have either malignant or benign (fibrin clot) portal vein thrombosis. The aim of this study was to assess prospectively whether well-defined diagnostic criteria would enable the nature of portal vein thrombosis to be established in patients with HCC under consideration for liver transplantation. Benign portal vein thrombosis was diagnosed by the application of the following criteria: lack of vascularization of the thrombus on contrast-enhanced ultrasound and on computed tomography or magnetic resonance imaging, absence of mass-forming features of the thrombus, absence of disruption of the walls of veins, and, if uncertainty persisted, biopsy of the thrombus for histological examination. Patients who did not fulfill the criteria for benign thrombosis were not placed on the transplantation list. In this study, all patients evaluated at our center during 2001-2007 with a diagnosis of HCC in whom portal vein thrombosis was concurrently or subsequently diagnosed were discussed by a multidisciplinary group to determine their suitability for liver transplantation. The outcomes for 33 patients who met the entry criteria of the study were as follows: in 14 patients who were placed on the transplantation list and underwent liver transplantation, no malignant thrombosis was detected when liver explants were examined histologically; 5 patients who were placed on the transplantation list either remained on the list or died from causes unrelated to HCC; in 9 patients, liver transplantation was contraindicated on account of a strong suspicion, or confirmation, of the presence of malignant portal vein thrombosis; and 5 patients who were initially placed on the transplantation list were subsequently removed from it on account of progression of HCC in the absence of evidence of neoplastic involvement of thrombosis. In conclusion, for a patient with HCC and portal vein thrombosis, appropriate investigations can establish whether the thrombosis is benign; patients with HCC and benign portal vein thrombosis are candidates for liver transplantation.

Cost analysis of recall strategies for non-invasive diagnosis of small hepatocellular carcinoma.

BACKGROUND: Which is the least expensive recall policy for nodules in the cirrhotic liver remains unclear. AIM: Aim of the study was to analyze the costs of different recall diagnostic strategies of hepatocellular carcinoma (HCC) on cirrhosis on a real series of patients. METHODS: 75 consecutive small liver nodules (10-30 mm) detected at conventional ultrasonography in 60 patients with cirrhosis were submitted to contrast-enhanced ultrasound, computed tomography and gadolinium-magnetic resonance imaging with a final diagnosis established according to the latest guidelines which include different strategies for nodules 10-19 mm or > or =20mm. The actual costs required to fully characterise any nodule and staging HCC in every patient, if one or the other imaging modality had been used as the first diagnostic step, were calculated. The theoretical hypothesis that each nodule was present in each patient was also investigated from an economical point of view. RESULTS: The recall strategy starting with contrast-enhanced ultrasound plus computed tomography is the least expensive strategy for patients with at least one nodule 10-19 mm in size, in nearly all combinations (single or double nodules). In patients with single 20-30 mm nodules the least expensive strategy is to start with computed tomography and to use contrast-enhanced ultrasound as a second step technique. CONCLUSIONS: wider use of contrast-enhanced ultrasound has the potential to save healthcare costs after first ultrasound detection of a single small nodule in cirrhosis.