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Vessels
Tumor
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Tumor Infiltration
Tumor Infiltration
Tumor infiltration into the portovenous system is not infrequent, and in primary hepatic malignancies it is observed quite often at the porta hepatis. Ultrasonography can differentiate between tumor infiltration and thrombosis of the portal vein, but may be difficult to perform for some segments. If color-flow Doppler imaging demonstrates tumor vessels within the “thrombotic material,” this will confirm the diagnosis of tumorous thrombosis (Fig.1.105).
In CEUS, tumor infiltration shows a contrast enhancement (Fig.1.106).
At the confluence and along the splenic vein, tumor infiltration may be one complication of pancreatic cancer, with extensive infiltration of the tumor into the vessel usually being a sign of inoperability. Under good conditions in such cases, ultrasonography may be able to demonstrate direct infiltration of the portal vessels by continuity.18
Fig. 1.105 Patient with hepatocellular carcinoma (TU). TH = thrombosis.
a Demonstration of the tumor and the echogenic portal vein immediately adjacent to it.
Fig. 1.106 Patient with liver cirrhosis and hepatocellular carcinoma.
a Echogenic portal vein (arrows; thrombosis TH) and multiple masses (M).
b Color-flow duplex scanning confirmed the diagnosis of portal vein thrombosis. The discrete flow signals within the thrombotic material raise the suspicion of a tumorous thrombus.
b Contrast-enhanced ultrasound (CEUS) depicts an enhancing within the echogenic portal vein (TH, arrows) as a sign for tumor thrombosis.
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Tips, tricks, and pitfalls
The dilation of the lumen of the portal vein is not a reliable parameter to diagnose portal hypertension. A better correlation exists between the extent of portal hypertension and the maximal flow rate measured in the portal vein (< 12 cm/s). There can be an overlap between the normal and pathological range of flow rates. This can lead to a false evaluation, if the flow rate is the only value that is considered.
A false normal flow rate can primarily occur due to intrahepatic shunts and an efflux via the paraumbilical veins to the paraumbilical varicose veins (“caput medusae”), which are distinctly
visible in color duplex sonography. Further, a caudal directed efflux via the iliac vein as in a spontaneous portocaval shunt can cause a false normal flow rate. In these cases the flow rate can be elevated up to 40 cm/s. A so-called “Cruvei- lier–Baumgarten syndrome” is present if the umbilical vein is persistently open without the existence of liver cirrhosis.
A transjugular intrahepatic portosystemic shunt (TIPS) is an iatrogenic portosystemic shunt (cf. Chapter 2, Fig. 2.110, p. 116).
A particular situation is “segmental portal hypertension”. It is based on lack of compression of a
feeder vein. This is mainly caused by tumor compression/ infiltration of the superior mesenteric and splenic vein (infiltration by a pancreatic tumor, lymph node compression in metastasis/ lymphoma). The diagnosis arises from the knowledge of the underlying condition and the particular sonographic findings (Fig. 1.107).
If a conspicuous widening is detected in a feeder vein, especially, if it is the superior mesenteric vein, mesenteric lymph node metastasis should be looked for.
Fig. 1.107
a Extensive enlargement of the superior mesenteric vein up to 17.4 mm caused by intra-abdominal lymphomas (final-stage chronic lymphocytic leukemia (CLL), severe splenomegaly with dilatation of all portal branches).
b Solitary enlargement of the superior mesenteric vein (VMS) in a local metastatic spread of a pancreatic carcinoma.
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Intraluminal Mass
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