Nghiên cứu đặc điểm lâm sàng, cận lâm sàng, mô bệnh học và hóa mô miễn dịch ung thư biểu mô tế bào gan có huyết khối tĩnh mạch cửa tt tiếng anh

MINISTRY OF EDUCATION

MINSITRY OF NATIONAL

AND TRAINING

DEFENCE

108 INSTITUTE OF CLINICAL MEDICAL AND
PHARMACEUTICAL SCIENCES
------------------------------------------------------

TRINH XUAN HUNG

STUDY OF CLINICAL AND PARACLINICAL,
HISTOPATHOLOGY AND IMMUNOHISTOCHEMICAL
CHARACTERISTICS OF HEPATOCELLULAR
CARCINOMA WITH PORTAL VEIN THROMBOSIS

Speciality: Internal Gastroenterology
Code: 62.72.01.43

SUMMARY OF DOCTORAL THESIS IN MEDICINE

HANOI – 2019


THE DISSERTATION WAS COMPLETED AT
108 INSTITUTE OF CLINICAL MEDICAL AND
PHARMACEUTICAL SCIENCES

Supervisor:
1. Professor Mai Hong Bang MD., PhD.
2. Associate professor Trinh Tuan Dung MD., PhD.

The 1st reviewer:
The 2nd reviewer:
The 3rd reviewer:
The doctoral thesis was protected in front of the thesis review
committee at 108 Institute of Clinical Medical and Pharmaceutical
Sciences.

The thesis can be founded in:
- National library
- Scientific Research Institute of Clinical Medicine and
Pharmacy 108’s library


THE LIST OF PUBLISHCATION RESULTS OF THE THESIS
1. Trịnh Xuân Hùng, Mai Hồng Bàng, Trịnh Tuấn Dũng,
Nguyễn Tiến Thịnh (2019), “Results of portal vein thrombus
biopsy in patients with advanced hepatocellular carcinoma”,
Journal of 108 – Clinical medicine and pharmacy, volume 14 (N
5/2019), 1-7.
2. Trịnh Xuân Hùng, Mai Hồng Bàng, Trịnh Tuấn Dũng,
Nguyễn Tiến Thịnh (2019), “Study on clinical and laboratory
features of advanced hepatocellular carcinoma in patients with
vein thrombosis”, Vietnam medical journal, volume 480, 165-169.


THE LIST OF ACRONYMS

Acronyms

Full writing

AFP

Alpha -Fetoprotein

ALT

Alanine amino transferase

AST

Aspartate amino transferase

BCLC
CT

Barcelona Clinic Liver Cancer
Computered tomography

ECOG

Eastern Cooperative Oncology Group

HbsAg

Hepatitis B surface Antigen

HBV

Hepatitis B virus

HCC

Hepatocellular cancer

HCV

Hepatitis C virus

PVT

Portal vein thrombosis

WHO

World Health Organization


1

INTRODUCTION
Hepatocellular carcinoma (HCC) is a very popular disease in the
world. According to GLOBOCAN data in 2018, HCC is the fifth and the
ninth most commonly diagnosed cancer in men and women, respectively.
There will usually be an estimated 841,000 new diagnosed cases of HCC
and 782,000 died cases. In Vietnam, According to GLOBOCAN data in
2018, the prevalence and mortality of HCC is one of the first commonly

cancer. The mortality of HCC has their equivalence to compare with new
diagnosed cases, this show that HCC were often diagnosed at advance
stages, so the prognose and control of the disease still have difficulties.
The prognose of HCC is often very poor, especially, they are
advance HCC with portal vein thrombosis (PVT). Previous studies show
that HCC with PVT acount for 30-62.2%, the PVT also is signal point out
that primary HCC is a advance HCC with poor prognosis, risk of
oesophagus variceal bleeding, and hepatic failure (e.g. thrombosis in trunk
of portal vein). Mean survival time of pateints with HCC having PVT
without treatment is very short (2.7-4 months), meanwhile that of HCC
having not PVT without treatment is 24.4 months. Detection of PVT,
especailly benign or neoplastic PVT in new diagnosed HCC has key
meaning for prognosis as well as making choice of treatment methods.
There are no any work to study systematicaly characteristics of
histopathology and immunohistochemistry of PVT in patients with HCC in
Vietnam as well as in the world. From the mention above, we carried out
the project with objectives:
1- assessment of clinical characteristics, paraclinical tests, imaging
diagnoses of HCC pateints with PVT


2

2- analysis of imaging, histopathology and immunohistochemistry
characteristics of PVT, and safe biopsic technic, supplemental survival time
and involving factors in pateins with PVT.
* Thesis layout:
The thesis has 123 pages, including: Introduction (2 pages), Chapter 1:
Overview (36 pages), Chapter 2: Subjects and methods (20 pages), Chapter
3: Results (28 pages), Chapter 4: Discussion (34 pages), Conclusion (2

pages), Recommendations (1 page). The thesis has 34 tables, 26 images.
The thesis has 141 references: 21 Vietnamese references and 127
English references.
* The new main contributions of the thesis
In Vietnam, this is the first study that biospy of PVT was carried out in
HCC

pateints,

assessment

of

deffirentiation

of

PVT,

staining

immunohistochemistry to assess angiogenesis level in PTV involving with
supplemental survival time. The benign or malignant PVT are also
standards for indication and contraindication of some HCC treating
methods. Therefore, the thesis has very reliable and scientific meanings in
clinical practise. The results of project shown that, the biospy of PVT in
HCC patients is pretty safe technic with less complications (it is a problem
that professionals are previously hesitant to mention).
CHAPTER I: OVERVIEW
1.1. Epidemiology of hepatocellular carcinoma in the world and Vietnam

HCC is the very common malignant disease, it is commonly detected
in late stage, very poor prognosis, and high mortality in short time. The
estimated 500.000-1.000.000 new cases of HCC, and estimated 600.000
died cases worldwide.


3

Frome GLOBOCAN data in 2018, HCC is leading cancer in Vietnam,
new HCC incidence as well as mortality are higher than lung cancer and
stomach cancer, approcimately 25.335 new diagnosed cases and the
mortality of HCC, acount for 15.4% and 21.5% (19.568 cases) of total of
cancer, respectively. Therefore, nowadays, the trend of HCC have been
increasing according to the time and this is indeed a hude challenge for
medicine in my country.
1.2. Diagnosis of hepatocellular carcinoma
1.2.1.Clinical symptoms
The clinical symptoms of HCC are often present in late stage of
the disease because of good functional balance of liver.
1.2.2. Marker of hepatocellular carcinoma
Alpha-Fetoprotein is a tumer marker for HCC that is used most
in diagnose of HCC.
1.2.3. Imaging diagnose of HCC
1.2.3.1. Ultrasound : This is the leading technic for screening
localized lesions in the liver, including: B-mode ultrasound, doppler
ultrasound, Contrast - enhanced Ultrasound.
1.2.3.2. Computed tomography scan: Nowadays, this is the most
widely used technique to diagnose HCC. Multi-sequential 3-dimensional
CT scan (artery stage, portal vein and late stage) is considered a standard
technique for HCC diagnosis.

1.2.3.3.

Magnetic

resonance

imaging:

providing

very

good

characteristics of typical angiogenesis of HCC with sensitivity and
specificity up to 90-95%.
In addition, there are also somme technique such as: Digital
Subtraction Angiography and positron emission tomography/computer


4

tomography (PET/CT).
1.2.4. Anapathology
The differentiation level of HCC cells: according to Edmondson
and Steiner, Armed Forces Institute of Pathology as well as the World
Health Organization, differentiation level of HCC cells was often divided
into 4 different levels: high and medium , low and non-differentiated levels
basing on ratio of nucleus/cytoplasm.
1.2.5. Diagnostic criteria of hepatocellular carcinoma

- The diagnotic and follow-up process is more simplified in American
Liver Foundation's guidelines in 2011.
- According to the guidelines of Vietnam Ministry of public Health
in 2012:
• There are Anapathologic criteria of HCC
• Diagnosing images of abdominal CT scans with contrast agent or
abdominal MRI with contrast agent + AFP concentration is higher than
normal, but less than 400 ng/mL + B or C hepatitis
1.3. Portal vein thrombosis
Portal vein thrombosis can occur in many different diseases, but
the most common is cirrhosis with HCC. Other diseases, including: other
cancer diseases, bone marrow disorders, bacterial infection, post-surgery,
estrogen treatment, and portal hypertension without cirrhosis.
1.3.1. Frequency of portal vein thrombosis
The PVT frequency of 10-25 % for solitary cirrhosis, a result of study
with a large sample size of 701 solitary cirrhotic patients showed that the
prevalence of PVT in solitary cirrhotic patient of 11%.
The frequency of PVT in HCC is much higher than others, with the
detected rate of PVT of advance HCC of 40 to 90.2%. A result of


5

retrospective cohort study with 336 HCC patients in Thailand showed PVT
rate of 50%. The rate of 31% of another study with 194 patients was
carried out in the United States.
1.3.2. Pathogenesis of portal vein thrombosis
PVT is due to reducing flow rate of the portal vein system, vascular
endothelial damage and coagulopathy in cirrhosis. In addition to cirrhosis,
HCC also directly invades the portal vein system, or metastasis of cancer

cells into the portal system is considered a most essential factor for a
formation of malignant PVT. The development of cancer tissue with
platelet aggregation inside the vein facilitate thrombosis to develop and
spread. In addition, the compression of the tumor in the portal vein system
enhances to obstruct the flow rate, which is also a factor to motivate
formation of thrombosis.
1.3.3. Diagnosis of portal vein thrombosis
In order to detect and diagnose PVT, imaging diagnosis plays a
extreme key role, however, the result of cell aspiration with small needle
or biospy of thrombosis are considered a gold standard of the diagnose.
1.3.3.1. Imaging diagnosis
In order to diagnose malignant PVT basing on 3 signs, including:
appearance of a clear invasive image of tumor into the lumen, a
stretch of the portal vein of 23 mm or more and angiogenesis in PVT.
1.3.3.2. Histopathology and immunohistochemistry tests
Histopathology test of PVT is a gold standard of diagnosis of benign
PVT or malignant PVT. Differentiation level of PVT as well as tumor in liver
were devided into 4 separated levels, including: high, medium, and low, and
nondifferentiation. However, in some suspicious cases, especially poor or
non-differentiated PVT immunohistochemistry can be used to determine


6

whether PVT derived from HCC. Immunohistochemistry is also significant
for assessment of vessels as well as level of angiogenesis in PVT.
Basic methods for selecting PVT specimens:
* Cell aspiration using small needle according to the ultrasound guide.
* Biopsy: selecting PVT specimens by using a biopsy gun (FAST gun).
* Surgery: dissection of the liver and selecting PVT specimens

1.3.4. Treatment of HCC with PVT
The standard drug for treatment in the stage with preserved liver
function is Sorafenib. Some recent clinical trials have shown that HCC
with PVT can also consider for surgery, injection with 100% alcohol in
thrombosis, Transarterial radioembolization (TARE) with yttrium-90microspheres, stereotactic body radiation therapy using CyberKnife.
CHAPTER II:
Subjects and methods
2.1. Subjects: 101 patients with PVT were diagnosed at 108 Central
Military Hospital from 8/2012 to 12/2017.
2.1.1. Subject Selection
-The patients were positively diagnosed HCC according to one of three
criteria of the Vietnam Ministry of Health in 12/2012 below:
+ HCC with PVT
+ Coagulation function: prothrombin ≥ 60%; number of phlatelet ≥
60.000/mm3.
+ General status of patient (ECOG): from 0 to 2 scores (WHO).
- Age: from 18 to 90 years old.
- No gender inequality
- The patients agree to take part in the study in writing for assurance.


7

2.1.2. Exclusive criteria
- Severe liver disease: Child - Pugh C, hepatic encephalopathy, ascites.
- Bleeding esophageal varicose.
- Tumors of HCC and PVT are in a position where biopsy cannot be
performed.
- Some internal diseases that increase the risk of bleeding, renal failure,
liver failure, venous occlusion in the liver, Rendu - Osler disease.

- Pregnant women and nursing mothers
- Uncooperative patients, do not obey the process of study
2.2. Methods
2.2.1. Research design
Cross-sectional and longitudinal study.
2.2.2. Sample size
Convenience sample, n=101.
2.2.3. Equipment
Modern testing machines, imaging and anapathology diagnostic
facilities are routinely used in the hospital, biopsy guns (FAST gun),
biopsy needles.
2.2.4. Steps of research process
2.2.4.1. Subject Selection: Clinical and paraclinical examinations
* Paraclinical examinations:
- Routine blood tests (Hematology tests, Common blood chemistry
tests, immunological tests).
- imaging diagnosis: Ultrasound, Multi-sequential 3-dimensional CT scan
* The patient is explained about the study and making guarantee.
2.2.4.2. Technical procedure
PVT Specimens was collected by biopsy though the skin according to


8

ultrasound guidance or surgery of liver tumor and removing whole PVT.
* Techniques of PVT biospy
- Indication: Suspicion of benign or malignant PVT.
- Contraindication:

coagulation disorders; ascites; the patient has

combined severe diseases
- Utilize of ultrasound examination before performence of the PVT
biospy, after that choosing the position of the PVT biopsy through skin,
put the patients on a favorable position.
- Preparation of insertion of the needle into the biopsy gun (FAST gun).
- Determination of puncturable point on the skin, and then disinfection
and making local anesthetization with 2% lidocaine.
- Puncturing the needle biopsy through the skin, the needle should be
passed the healthy parenchyma of liver and then stopping before reaching
for the edge of the thrombus.
- Turn on the trigger of FAST gun so that the tip of needle
automatically go into the thrombus.
- Pulling out the needle and bandaging
- The specimens were put into 10% formol, carrying them to department
of anapathology for histopathology and immunohistochemistry tests.
- After biospy, the patients were motionlessly lied for 3-4 hours, they
were monitored pulse, blood pressure, and abdominal state.
* Procedure of histopathology and immunohistochemistry tests
- Specimens were processed by routine methods using synchronous
system of Microm (Germany). Dyeing of specimens with automatic dyeing
machine HMS-70 to assess the damage of liver cells, morphology and
structure of liver tumors.
- Immunohistochemistry test: The dyeing was performed by Ventana's


9

BenchMark Ultra automatic dyeing machine (United States). Depending
on specific cases, it could be dyed by markers, including: Hepar-1,

Hepatocyte, AFP, CK7, CK 20, CDx2, Vimentin, Chromogranin, NSE,
Synaptophysin and so on; assessment of angiogenesis in thrombosis using
2 additional markers such as CD31 and CD34.
* Post-biopsy monitoring: Some common side effects were liver pain
and fever. Monitoring of severe complications (bleeding, perforation, ..)
mornitoring of extra-survival time, the patient could be whether or
not interventionally treated according to the hospital cancer council.
2.2.5. Research criteria
2.2.5.1. Clinical and paraclinical examinations
* Clinical criteria:
- Age: The patients were devided into 3 groups, including: under ages
40; ages 41to 60, and ages 60 and older.
- Gender: men, women.
- Risk factors, other diseases.
- Clinical symptoms:
- Using The ECOG Performance Status as one such measurement to
assess how a patient's disease was progressing, including: level 0, 1, and 2.
* Paraclinical criteria:
- Hematology tests, biochemical tests, immunology tests.
- AFP was divided 4 levels: AFP ≤ 25IU / ml, AFP> 25 - 200 IU / ml,
AFP> 200-400 IU / ml, AFP> 400 IU / ml (1IU / ml = 0.92ng / ml) .
- Gastroscopy: The classification of esophageal varices (normal
esophageal varices, grade I, II, III).
2.2.5.2. Criteria of imaging diagnosis
* Characteristics of liver tumors: location, number, size, u properties


10

* PVT characteristics: location, size, properties.

- Classification of PVT according to Japan Cancer Research
Association (2015), including:
+ GradeVp0: no thrombosis in lumen of portal vein.
+ Grade Vp1: thrombosis appeared in distant branch of portal.
+ Grade Vp2: thrombosis appeared in the 2nd branch of portal vein
+ Grade Vp3: thrombosis appeared in the first branch of portal vein
+ Grade Vp4: thrombosis appeared in the major trunk of portal vein.
2.2.5.3. Criteria of cirrhosis stages
- Cirrhosis stages according to Child- Pugh.
- HCC stages according to Okuda.
- HCC stages according to Barcelona system
2.2.5.4.Criteria of PVT histopathology and immunohistochemistry
Specimens were collected by biopsy through the skin and surgery.
* Benign or malignant thrombosis.
* Cell differentiation of thrombosis: There were 4 grades of
differentiation (high, medium, low and nondifferentiation)
* The level of angiogenesis in thrombosis according to the research
convention:
- Low level of angiogenesis: Total area of angiogenesis increases less
than 10% area of tumor sample.
- Medium level of angiogenesis: Total area of angiogenesis accounts
for 10% - 20% area of the tumor sample.
- High level of angiogenesis: Total area of angiogenesis increases
much more than 20% area of the tumor sample.
* Characteristics of immunohistochemistry test of suspected cases.
* Relationship between PVT and liver tumor characteristics, cirrhosis,


11

and other related factors.
2.2.5.5. Post-biopsy complication
Symptoms: pain, fever, fatigue, nausea, vomiting.
- Pain levels: mild, moderate, severe
- Complications: bleeding, pleural effusion and gas, perforation of
hollow organs ...
2.2.5.6. Chỉ tiêu về thời gian sống và hệ số tương quan
- Total survival time
- Pearson correlation coefficient (r)
- Relationship analysis
2.2.6. Statistical analysis: Data were analyzed using SPSS 22.0
software. Statistical significance was defined as p value <0.05.
CHAPTER III. RESULTS
3.1. Clinical characteristics, paraclinical tests, imaging diagnosis of
liver tumors in hepatocellular carcinoma patients with portal vein
thrombosis.
3.1.1. General characteristic
- The mean age of 54.8 ± 11.9. The most common is over ages 40,
group of ages 41-60 accounts for 64.4% and over ages 60 accounts for
27.7%.
- Domination of male (93.1%), male / female ratio ̴ 13.4/1.
- Risk factors: hepatitis B (86.1%), hepatitis C (2.0%), hepatitis B +
alcoholism (38.6%), hepatitis B + hepatitis C (2.0%), alcoholism (49.5%).
- Pre-treatment clinical symptoms: 95% patients had major clinical
symptoms such as right upper quadrant pain, 28% fatigue, 80.2% anorexia,


12

20.8% digestive disorders, 65.3% weight loss, 44.6% liver enlargement,

13.9% spleen enlargement.
- Most patients (86.1%) had ECOG of 0 points; 12.9% of 1 point; only
1.0% ECOG of 2 points
3.1.2. Paraclinical tests
- Patients have normal number of erythrocytes and hemoglobin. Mean
prothrombin ratio of 85.4 ± 13.3%.
- Transaminase: AST of 101.4 ± 74.8 U/l; ALT of 56.2 ± 30.7U/l;
GGT of 273.7 ± 243.5 U/l; bilirubin of 21,6 ± 17,9 µmol/l.
- 15.8% of AFP was in normal; 21.8% of AFP increased from 26 to
200 IU/ml; AFP of 23.8% increased from 201 to 400 IU/ml, and 38.6% of
AFP increased over 400 U/l.
- 71.3% of patients without esophagus vein varicose, 5% of this with
grade I; 16.8% of this with grade II, 6.9% of this with grade III.
3.1.3. Morphological characteristics of liver tumors in HCC patients
with PVT
- Ultrasound: most tumor (68.3%) located in right lobe, 22.8% of tumor
located in both lobes, 8.9% of tumor located in left lobe; 52.5% of only one
tumor, 27.7% of over 3 tumors; high-level angiogenesis in tumor was 37.6%,
medium-level angiogenesis was 23.8%, low-level angiogenesis was 29.7%,
no angiogenesis was 8.9%;
Hyperechogenicity is 55.4%, hypoechogenicity is 18.8%, mixed
echogenicity of 25.7%; mean size of tumor was 9.61 ± 3.37 cm.
- Computed tomography scan: Tumor in right lobe was 59,4%, tumor
in both 2 lobes was 31,7%, tumor in left lobe was 8,9%; only one tumor
was 53,5%, 28,7% of over 3 tumors; high-level angiogenesis was 47,5%;


13

mean size of tumor was 10,99 ± 3,7 cm, mean size of tumor over 10 cm was

59,4%.
- The relationship between liver tumor size and AFP concentration is
statistical significance (p<0.05).
3.1.4. Classification of stage of disease and liver function
- Liver function: Child-Pugh A is 96%, Child-Pugh B is 4.0%.
- Okuda classification: stage 1, 2, 3 was 54,4%, 44,6%, 1,0%,
respectively.
- Barcelona Clinic Liver Cancer classification: 98% of advance stage,
2.0% of late stage.
3.2. Imaging characteristics, histopathology, immunohistochemistry
of portal vein thrombosis, safety of biopsy technique, extra-survival time
and some related factors
3.2.1. Imaging diagnosis
- Ultrasound: 97% of patients with PVT, including: 56.1% of major
trunk, 66.3% of right branch; 6,1% of left branch, 27.6% of both 2 branch;
12.2% of angiogenesis; mean thrombosis size was 1.58 ± 0.39 cm, in which
5.1% of <1cm, 82.7% of 1- 2 cm, and 12.2% 2 cm
- Computed tomography scan: Recognized PVT was 81,2% (in which,
3 cases were not diagnosed by ultrasound), including: 49.1% of major
trunk, 68.3% of right branch, 8.5% left branch, 23.2% of both 2 branch;
12.2% of PVT with angiogenesis
Mean PVT size was 1.56 ± 0.37 cm, in which, 6.1% of <1cm, 84.1%
of 1-2 cm, and 9.8% of >2 cm
- The relationship between location of PVT and liver tumor was
statistical significance (p<0.05).


14

- Classification of PVT according to Japan Cancer Research

Association: 7.0% of Vp2, 36.6% of Vp3, 56,4% of Vp4. The relationship
between classification of PVT and size of liver tumor was statistical
significance (p<0.05).

3.2.2.

PVT

characteristics

based

on

histopathology

and

immunohistochemistry
- Methods of collection of PVT specimen: There are 7 patients using
surgery, 94 patients using biopsy though the skin under ultrasound
guidance, in which patients with only once, the second, and the third time
of biopsy were 92.5%, 6.4%, and 1.1 %, respectively. The total number of
biopsies were 102 times.
- All PVTs of patients with HCC were malignant thromboses.
Medium-grade differentiation of tumor cells in the thromboses accounted
for the highest rate of 58.4%, low-grade differentiation of 32.7%, highgrade differentiation accounted for only 8.9%.
- Low-grade angiogenesis in PVTs of 5%, medium-grade of 46.5% and
high- grade of 48.5%.
- The relationship between angiogenesis and tumor cell differentiation

in thrombosis had statistical significance (p<0.001).
- There was no correlation between assessed angiogenesis basing on
immunohistochemistry and ultrasound and CT scan with Kappa index <0.2.
3.2.3. Safety of PVT biopsy technique
- There was no any serious complication such as: bleeding, hollow
visceral perforation and diaphragm, pleural air, pleural effusion.
- Pain in various levels: mild pain mainly accounted for 66.7%,
medium and severe pain was 20.6%, 5.8%, respectively. There were 7
patients using surgery without serious complications.


15

3.2.4. extra-survival time of HCC patients with PVT
- The mean overall survival time (OS) was 8.6 ± 7.8 months, and
minimum of this was 1 month, the maximum of this is 51 months, in which
<3 months accounted for 30.7%, 3-6 months accounted for 20.8%, 6-12
months accounted for 20.8%, 13-24 months accounted for 23.8% and 24
months accounted for 4.0%.
- The relationship between cell differentiation, classification of PVT,
and stage of disease according to Okuda classification, intervened treatment
and extra-survival time had statistical significance (p<0.05)
CHAPTER 4. DISCUSSIONS
4.1. Clinical characteristics, some paraclinical tests, imaging
diagnosis of liver tumors of hepatocellular carcinoma patients with
portal vein thrombosis.
4.1.1. General charateristic
Age and gender characteristics: Research results showed that the ages
40 and older accounts for significantly (92.1%), in which the ages 41-60 is
the highest (64.4%). HCC could be diagnosed in all ages, including: the

lowest in those ages 18, the highest in those ages 90, the mean age is 54.8 ±
11.9. Our results were similar to domestic and foreign authors. The HCC
incidence of men dominated women (93.1% vs 6.9%), male/ female is
13.4/1. Nguyen Tien Thinh's research showed that male/female of 11/1,
research of Floridi C et al had male/female ratio ~ 6/1.
Risk factors: results of other authors shown that 70-90% of HCC cases
were related to hepatitis B virus. Research results showed that the rate of
HCC patients with HBV was 86.1%, HCC patients with alcohol was 49.5%.


16

The study of Nguyen Thi Thu Huyen showed a similar results of hepatitis B
of 76.8%.
Clinical symptoms: In our study, main symptoms were right upper
quadrant pain (95%), anorexia (80.2%), fatigue (87.1%), weight loss
(65.3%) and patients with enlarged liver (44.6%). Nguyen Thi Thu Huyen
(2017) showed that of patients had clinical manifestations (73.2%), being
tired (73.2%),

having right upper quadrant pain (28%), weight loss

(18.2%), enlarged liver (15.8%). This difference was probably due to the
patients in the stage with PVT and larger tumor size, more tumors so that
the disease in late stage and symptoms were more obvious.
4.1.2. Paraclinical characteristics
Hematology test: The indicators of complete blood count test,
coagulation test was normal. The average platelet count of the study was
207 ± 97.7 G / L, the average prothrombin rate was 85.4%, ensuring safety
for the procedure of PVT biopsy.

Serum AFP: The results showed that 15.8% of normal AFP (≤ 25IU /
ml), 84.2% of over 25 IU/ml, in which 62.4% of AFP above 200 IU / ml.
The study of Nguyen Tien Thinh (2011) showed that 39.7% of AFP was
normal and only 52.9% of AFP was over 100ng/ml, a study of Thai Doan
Ky (2015) showed that 43.8% of AFP was under 25 IU/ml and only 33.3%
of AFP is over 200 IU/ml. There was such a difference because our subjects
were patients with advanced liver cancer.
Esophageal varicose on the endoscopy: The study showed that only
28.7% of cases with esophageal vein varicose and only 6.9% of Esophageal
varicose vein grade III. My results were similar to results of Nguyen Thi
Anh Dao (2012), only 36.2% of patients with esophageal varicose and only
7.9% of esophageal varicose grade III.


17

4.1.3. Characteristics of liver tumors
Location of liver tumors: The results show that most of the right lobe
of the liver (68.3% of ultrasound and 59.4% of CT scan), 8.9% in left lobe
of the liver of ultrasound and CT scan. Both imaging methods had a
equivanlence for the ability to diagnose liver tumors and are also consistent
with the researches of many other domestic and foreign authors. According
to Mai Hong Bang et al. (2005), the rate of right liver tumors was 84.6%,
Duong Minh Thang (2009) was 85.7%. In the study of Shi J. et al (2011)
HCC patients with portal vein thrombosis, right liver and left liver tumors
also accounted for 70.1%, 25.2%, respectively.
The number of liver tumors: The study showed that both ultrasound
and CT scan detected most HCC patients with 1 liver tumor (52.5% of
ultrasound and 53.5% of CT scan). This result was also consistent with the
study of Mai Hong Bang et al (2002) that study 220 HCC patients with

59.5% of 1 tumor. Shi J.' et al (2011) showed that up to 90.7% is 1 tumor.
Size of liver tumors: Most liver tumors were over 5 cm, in which over
10 cm size for ultrasound was 10.9%, and 59.4% of this for CT scan, the
size in 5-10 cm range was 61,4% for ultrasound and 36.6% of this for CT
scan. The average tumor size was 9.61 ± 3.37 cm (Ultrasound) and 10.99 ±
3.7 cm (CT scan) was quite large. Research of Nguyen Thi Anh Dao (2012)
showed that 70% of patients with tumor size ≥ 5 cm, average size of 7.96 ±
3.6 cm (ultrasound) and 8.96 ± 4.3 (CT scan) . At the same time, our results
were also consistent with studies, such as the study of Shi J. et al (2011)
showed that 92% of cases having liver tumors with size ≥ 5 cm.

4.1.4. Assessment of stage of the disease accoding to classification system
Liver fuction according to Child-Pugh: Child A account for 96%,
Child B account for 4%. The rates were in line with others studies. Results


18

of Nguyen Thi Thu Huyen’ s study (2017) showed that Child A is 92.7%,
Child B 7.3%; Moreno-Luna L.E (2013) were 87% and 13%, respectively.
4.2. Image characteristics, histopathology, immunohistochemistry
of portal vein thrombosis, safety of biopsy technique, extra-survival
time and some related factors
4.2.1. Characteristics of portal vein thrombosis
In this study, PVT was detected by ultrasound to account for 97%, 3
patients were not detected by ultrasound, but were detected by CT scan and
getting PVT specimens after surgery. Meanwhile, 81.2% of cases were
detected CT scan. This difference because most patients were carried out
biopsy according to the guidance of ultrasound, PVT must be found by
ultrasound before biopsy.

The study of Nguyen Thi Anh Dao (2012) showed that CT scan had
better ability for detection of PVT than ultrasound: detected CT scan
(90.5%) v.s detected ultrasound (76.2 %).
The location of PVT also plays an important role in selection of
appropriate treatment. In this study: PVT in right branch was the most
(66.3%) of ultrasound and 68.3% of this of CT scan, PVT in trunk of portal
vein (56.1%) for ultrasound and 49.4% of that for CT scan, PVT in both 2
lobes (27.6%) for ultrasound and 23.2% of that for CT scan. Basing on
classification of

PVT according to Japanese Liver Cancer Research

Association (2015) PVT in trunk of portal vein (grade Vp4) was 56.4%,
PVT in the first branch or second branch of portal vein (Vp2, Vp3) was
43.6%. The study of Nguyen Thi Anh Dao (2012) was similar with results
of PVT in the trunk or PVT in both branch and trunk (grade Vp4) of 42.8%
for ultrasound and 60.3% for CT scan, PVT in only branch (Vp2 and Vp3)
of 32.3% for ultrasound and 33.3% for CT scan. The study of Tublin et al


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showed that 46 HCC patients with PVT waiting for liver transplantation,
the rate of PVT in right branch accounted for 56.5%, PVT in trunk was
41.3% and in left branch was 23.9% .
Our results also showed an association between position of PVT
and position of liver tumor (p <0.001), many previous studies also showed
that PVT is usually directly related to the location of the tumor. Tublin's
study showed that 32% of tumors directly invaded to portal vein, 62% of
tumors were adjacent to location of the thrombosis and only 3/47 rate of

tumors were far from thrombosis. According to this author, the contiguous
trait of thrombosis and tumors and angiogenesis status were the valuable
traits for suggestion of malignant PVT.
In some previous studies, there was an association between tumor size
and PVT status. In our study, the subjects were the advanced HCC patients
with PVT and the average size of liver tumors is very large (10.99 ± 3.7cm)
and 57.4% of tumor size was over 10cm. Studies of Connolly G.C et al
(2008) and Sithinamsuwan P. et al (2000) showed that liver tumor size was
closely related to PVT status with p <0.05 and p = 0.0005, respectively. A
recent study of Hikmet A et al (2018) showed that the result of PVT in the
trunk is related to the increase of tumor size (only 13.7% of PVT in the
trunk in small size group vs 33.9% of this in moderate size group and
56.4% of big size group of HCC. Our research also showed that the size of
liver tumors was related to the grade of PVT with p = 0.029.
4.2.2. Characteristics of portal venous thrombosis on histopathology
and immunohistochemistry
The technique of PVT biospy with the FAST gun under the guidance
of ultrasound in 94 patients, only 7 patients that underwent surgery to get
PVT. 6/94 patients had the second time biopsy accounting for 6.4%, the


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1/94 had the third biopsy accounted for 1.1%. the results of All cases
showed that PVT tissue was cancer. The study of Osman N.M.M and Samy
L.A.M (2016) showed that all of 33 patients with malignant PVT had HCC
(100%) and tumor invasion into thrombosis was detected in 25/33 patients
(75.7%) with malignant thrombosis. The results of histopathology obtained
from PVT showed that moderate-grade differentiation cells accounted for
58.4%, 32.7% of low-grade differentiation cells, high-grade differentiation

cells accounted for 8.9%. According to some authors, grade of
differentiation cell was related to the stage and size of liver tumors. Earlystage small size of HCC usually has high-grade cell differentiation. When
liver tumors increased in size, the cell differentiation was also more diverse.
The result of angiogenesis in PVT from immunohistochemistry
staining: low-grade angiogenesis was 5%, moderate-grade angiogenesis
was 46.5% and high-grade angiogenesis was 48.5%. This results also
showed that angiogenesis in PVT is also commensurate with the grade of
cell differentiation in thrombosis with statistical significance (p <0.001), it
meaned the more angiogenesis was, the lower the grate of cell
differentiation.
4.2.3. Safety of the PVT biopsy technique
The results showed that serious complications did not occur in 102
biopsies, in which 66.7% of patient only had mild pain, 20.6% of patient
had moderate pain and 5.8% of them suffered a severe pain after biopsy, but
they only needed common painkillers. The results of the other reports also
identify that this procedure was safe. Gerald D. et al (1993) reported results
of PVT biospy though the skin under the guidance of ultrasound of 14
patients with HCC derived from cirrhosis using biospy needle with no
significant complication


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4.2.4. Extra-survival time
The results showed that the mean survival time was 8.6 ± 7.7 months,
in which the interventional untreated group was 5.11 ± 0.89 months, the
treated group was much higher (14.06 ± 1.72 months), this difference is
statistically significant with p <0.01. the extra-survival time was lower than
those of other studies in Vietnam and the world. The study of Nguyen Tien
Thinh (2012) mean survival time after treatment was 19.2 ± 13.9 months,

Dao Duc Tien (2018) studied radioembolization treatment with Yttrium-90.
The result showed that extra-survival time was 27.5 ± 2.9 months.
Such a difference because the study selected patients with later stage of
disease. In the study of Dao Duc Tien, all patients were treated with the
most optimal method (Y90). Research of Garin E. et al (2015), the average
survival time is 18 months. The study of Floridi C. et al (2017), the average
survival time was 27.7 months because this study was only 13.9% of
patients at advanced stage. The study of Le Van Thanh (2012), HCC
patients with PVT had 21.7 ± 4.7 months of extra-survival time after
surgery. The study also showed that the results of cell differentiation, grade
of PVT, stage of disease according to Okuda, interventional treatment was
related to the extra-survival time with p <0.05. This observation is also
consistent with many other research.
CONCLUSIONS
1. Clinical characteristics, some paraclinical tests, imaging
diagnosis of liver tumors in hepatocellular carcinoma patients with
portal vein thrombosis
- The mean age of the patients was 54.8 ± 11.9 with male/female was 13/1.