İnfiltratif HCC ve tümör trombüsü

Özet

İnfiltratif HCC, net sınırlı tek bir kitle oluşturmadan karaciğer parankimine yayılan ve portal ven dallarına tümör uzanımı gösterebilen HCC biçimidir. Çok fazlı BT’de belirsiz sınırlı heterojen parankim, genişlemiş portal ven ve damar içinde kontrastlanan yumuşak doku aranır. Tümör trombüsü ile bland trombüsün ayrımı, damar içeriğinin kontrastlanması ve tümörle ilişkisinin gösterilmesine dayanır; yalnız ven oklüzyonu tümör invazyonunu kanıtlamaz. Bu patern küçük kitleyi görünmez kılabilir ve makrovasküler yayılımın atlanması hastalığın evresini eksik gösterir.

Faz ve pencere

Kontrastsız

İnfiltratif parankim normal karaciğerden hafif farklı veya belirsiz atenüasyonlu görünebilir; damar içindeki trombüs çoğunlukla yumuşak doku yoğunluğundadır. Kontrastsız seri damar içi dokunun canlı kontrastlanmasını gösteremez.

Arteriyel tanısal

İnfiltratif tümör parankimde yamalı hiper-kontrastlanma gösterebilir. Portal ven içindeki tümör dokusunda arteriyel kontrastlanma, damar lümenindeki yumuşak dokunun canlı tümör olmasını destekler.

Portal tanısal

Tümör içeren portal ven dalı genişleyebilir ve kontrastlanan yumuşak doku lümeni doldurabilir; tümör dokusu arteriyel faza kıyasla göreli washout gösterebilir. Komşu portal dalların açıklığı ve intrahepatik perfüzyon farkları bu seride daha iyi karşılaştırılır.

Gecikmiş

Damar içi dokunun çevre parankime göre kontrast davranışı ve infiltratif alanın sınırları yeniden incelenir. Tek başına gecikmiş faz bulgusu bland trombüsten ayrım için yeterli değildir.

Önerilen pencereler: Batın (G 400 / M 50), Karaciğer (G 150 / M 30).

BT bulguları

• Tek bir yuvarlak kitle yerine segmentler arasında belirsiz sınırlı, yamalı parankim atenüasyon veya kontrastlanma farkı
• İnfiltratif parankim alanından portal ven dalına uzanan kontrastlanan yumuşak doku
• İnfiltratif HCC’ye portal ven tümör trombozu sıkça eşlik eder.
• Arteriyel fazda damar içi dokunun kontrastlanması; portal veya gecikmiş seride göreli washout
• Tümör dokusu ile portal ven içeriği arasında doğrudan devamlılık veya aynı kontrastlanma karakteri
• Trombüsün portal ana dala, sağ-sol dallara veya mezenterik ven yönüne uzanımının haritalanması
• Portal ven tıkanmasına eşlik eden bölgesel perfüzyon farklılığı, kollateral damarlar veya portal hipertansiyon bulguları
• İnfiltratif alandan ayrı uydu odaklar, lenf düğümleri ve ekstrahepatik yayılım bulguları

Ölçütler ve sınıflamalar

LI-RADS LR-TIV

LI-RADS CT/MRI v2018’de LR-TIV, damarda kesin kontrastlanan yumuşak doku bulunduğunda kullanılır; eşlik eden parankimal kitlenin gösterilmesi şart değildir. Damar oklüzyonu, genişlemesi veya komşu kitlenin varlığı tek başına LR-TIV ölçütünü karşılamaz. İnfiltratif görünüm tek başına LR-M anlamına gelmez; LR-M, HCC’ye özgü olmayan malign gözlemler için kullanılır. LR-TIV malign damariçi tümörü belirtir; histolojik tümör tipini tek başına belirlemez.

Normalde

Normal portal ven ana gövdesi ve intrahepatik dalları homojen kontrastla dolu, konturu düzgün ve lümeni açıktır; damar içinde kitle biçimli yumuşak doku bulunmaz. Normal karaciğer portal fazda homojen boyanır; şüpheli alanda parankim-damar devamlılığını ve trombüsün aynı fazdaki kontrastlanmasını komşu açık portal dallarla karşılaştır.

Ayırıcı tanı

Bland portal ven trombozu

lümen dolum defekti kontrastlanmaz; damar içi yumuşak doku canlı tümör gibi arteriyel boyanma göstermez.

Pyleflebit

enfekte trombüs çevresinde portal ven duvarı kontrastlanması ve inflamasyon odağı görülebilir; damar içi solid kontrastlanan tümör dokusu beklenen ayırt edici bulgu değildir.

Kavernöz transformasyonda kronik portal ven trombozuna çok sayıda periportal kollateral damar eşlik edebilir.

Portal ven basısı ayırıcı tanıda değerlendirilirken, portal ven içinde tümör trombozu olup olmadığı ayrıca incelenmelidir.

Safra yolu tümörünün damar komşuluğu

kitle portal hilusta damarları sarabilir; tümörün damar lümenine girdiğini göstermek için doğrudan intraluminal kontrastlanan doku aranır.

Tuzaklar

• Damar genişlemesi tümör trombüsünü tek başına kanıtlamaz; LR-TIV için lümen içindeki dokuda kesin kontrastlanma göster. Oklüzyon, damar genişlemesi veya komşu kitle yalnızca ipucudur; infiltratif parankim görünümü tek başına LR-TIV değildir.
• İnfiltratif HCC’de belirgin kitle sınırı olmayabilir; yalnızca yuvarlak kitle aramak yaygın parankim tümörünü ve ona eşlik eden portal ven yayılımını kaçırabilir.
• Çok erken arteriyel zamanlamada damar içi kontrast farkı belirsiz kalabilir; portal ve gecikmiş fazlarla birlikte değerlendir, uygun teknikli inceleme gereksinimini belirt.
• Portal ven akımına bağlı yalancı dolum defekti veya karışma, kesitler boyunca kalıcı yumuşak doku ve gerçek kontrastlanma göstermeyebilir.

Kendini dene

1. Yüksek riskli karaciğerde portal ven lümeninde kesin kontrastlanan yumuşak doku görülüyor. Damar bulgusu hangi LI-RADS kategorisidir?

   • LR-TIV
   • LR-M
   • LR-4
   • LR-NC
   Cevabı göster

   LR-TIV. LI-RADS CT/MRI v2018’de damarda kesin kontrastlanan yumuşak doku, parankimal kitle görünmese bile LR-TIV’dir. Kategori malign tümörün damar içinde olduğunu belirtir, histolojik kaynağı tek başına belirlemez; infiltratif görünüm tek başına LR-TIV değildir.

2. Portal ven içinde dolum defekti var ancak arteriyel seride kontrastlanmıyor ve damar çapı artmamış. Hangi tanı daha olasıdır?

   • Bland trombüs
   • LR-TIV
   • İnfiltratif HCC
   • Hipervasküler metastaz
   Cevabı göster

   Bland trombüs. Kontrastlanmayan ve damarı genişletmeyen dolum defekti bland trombüs lehinedir; tek başına dolum defekti tümör invazyonu anlamına gelmez. LR-TIV için damarda kesin tümör bulgusu, özellikle intraluminal kontrastlanan yumuşak doku aranır.

İlgili konular

• Hepatoselüler karsinom ve LI-RADS
• β-katenin aktive hepatoselüler adenom
• Fibrolameller HCC

Kaynaklar

Bu sayfadaki 51 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla otomatik olarak karşılaştırıldı; 4 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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Eğitim amaçlıdır; hasta başında tanı ve tedavi kararının yerine geçmez, tıbbi tavsiye değildir. Metinler yapay zekâ desteğiyle yazıldı ve otomatik bir adımda kaynak alıntılarıyla karşılaştırıldı; bu bir tıbbi doğrulama değildir ve içerik uzman radyolog incelemesinden geçmedi. Klinik kararlarda güncel kılavuzları, kurum protokollerini ve radyoloji raporunu esas alın.