Thorough assessment of portal venous thrombosis in patients with HCC allows adequate selection of candidates for liver transplantation

Background. Portal venous thrombosis (PVT) is often considered an absolute contraindication to liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) in order to avoid the risk of listing patients with neoplastic vascular infiltration. However, also benign PVT may occur in HCC-patients. Objectives. To prospectively assess whether defined diagnostic criteria allow evaluation of the nature of PVT in HCC-patients and allow safe selection of candidates to LT. Methods. We analysed 34 HCC-patients, in whom PVT was detected or already known at the time of assessment for LT or developed during follow-up while on the waiting list. The benign nature of the thrombus was established using the combination of the following criteria: lack of vascularization of the thrombus at contrast enhanced ultrasound and ceCT or ceMRI, steadiness/regression of thrombosis during follow-up, absence of mass-forming aspects of PVT, absence of features of disruption of the vessel walls, distance from the HCC and negative biopsy of the thrombus in case of uncertainty. Patients who did not fulfill the criteria for benignity of PVT were excluded from the waiting list. Results. The outcome of 34 patients analysed so far is as follows: 13 were listed and transplanted, with no sign of malignant PVT at explant pathological examination; 9 were admitted in the list and are still actively waiting. Two patients died forHCCunrelated causes while actively listed. Of the remaining 10 patients, 7 were not included or excluded from the list for a high suspicion or confirmation of malignant PVT, whereas 3 were included and subsequently excluded for progression in size of HCC without evidence of malignant PVT. Conclusion. An accurate assessment of the nature of PVT is feasible and allows safe selection of HCC candidates to OLT.