Radiological Management of Hepatocellular Carcinoma Associated With Hepatic Venous Outflow Tract Obstruction

Abstract

Background and Aim: Hepatocellular carcinoma (HCC) associated with hepatic venous outflow tract obstruction (HVOTO) is an unusual entity which has recently gained recognition. Treatment of both entities is essential in prolonging survival. Interventional radiologic techniques are the established therapeutic options for HVOTO and HCC and thus treatment becomes challenging. We illustrate two representative cases treated successfully treated at our centre. Methods: Patients with clinical diagnosis of HVOTO were evaluated by ultrasound Doppler, multiphase CT liver (MPCT)/dynamic MRI. HVOTO was confirmed by the presence of intrahepatic venous obstruction on Doppler and the treatment was based on the site/type of venous obstruction and included inferior vena cava(IVC) angioplasty or hepatic vein angioplasty (both with or without stenting) and trans-jugular intrahepatic port-systemic shunt (TIPS)/direct intrahepatic port-systemic shunt. On MPCT, HCC diagnosis was based on the modified EASL criteria. Staging and treatment options were according to the Barcelona clinic liver cancer (BCLC) staging. Results: Case one was diagnosed with absent all three hepatic veins with BCLC B stage HCC on MPCT and Doppler. TIPS was performed for HVOTO and subsequently TACE was undertaken for HCC. Follow up Doppler confirmed normal flow through the shunt and HCC depicted complete response. Case two was diagnosed with stenosis of all hepatic veins and IVC stenosis at cavo-atrial junction with intrahepatic collaterals. He also had BCLC B stage HCC on MPCT. IVC angioplasty was performed following which there was persistent stenosis on Doppler assessment, IVC stenting was subsequently performed which restored the normal calibre and flow in IVC. TACE was done for HCC and the residual tumor was completed treated by acetic acid ablation. Conclusion: Radiological techniques play a key role in the diagnosis and management of HVOTO-HCC. Both the entities need to be treated and this makes the treatment very challenging.