Ultrasound Guided Fine-Needle Aspiration Cytology (FNAC) of Portal Vein Thrombus: A Novel Diagnostic and Staging Technique for Occult Hepatocellular Carcinoma

Abstract

Sukumar Ramaswami, Ashwin Rammohan, Jeswanth Sathyanesan, Ravichandran Palaniappan

Introduction: The diagnosis of Hepatocellular Carcinoma (HCC) is usually established using noninvasive radiological imaging and tumor markers. The stage at diagnosis is a critical factor in the treatment, course and prognosis of HCC. Patients with Tumor Portal vein thrombus (PVT) are considered to have an advanced disease and are only offered palliative therapy. Therefore, every possible attempt should be made to accurately stage HCC. Fine-needle aspiration cytology (FNAC) of PVT is an effective procedure for diagnosing and staging HCC. We present a case where we used Ultrasound (USG) guided FNAC of a PVT to successfully diagnose and stage HCC in the absence of a well-defined liver mass on imaging. Case report: A 43-year-old Hepatitis B surface antigen positive male presented with a 3-month history of fatigue, jaundice and fever. On examination he had hepatomegaly. His liver function tests were elevated, but his alpha-fetoprotein was normal. USG and Computed Tomography (CT) showed a thrombus in the portal vein but failed to show a well-defined liver lesion. FNAC was taken from the PVT, which was positive for malignancy. He was offered palliative chemotherapy and a steroid for his pyrexia. He is on follow-up. Conclusion: FNAC is a safe, quick, easy and economical technique to diagnose and stage HCC in the presence of portal vein thrombus, especially in patients where the tumor is occult on imaging. It also affords an accurate method to differentiate between malignant and nonmalignant PVT, thereby aiding appropriate therapeutic decision making