Hepatocellular carcinoma tumor thrombus entering the inferior vena cava treated with percutaneous RF ablation: a case report

  • Pietro Gatti
  • Antonio Giorgio
  • Emanuela Ciracì
  • Italia Roberto
  • Alessandro Anglani
  • Spano Sergio
  • Fernando Rizzello
  • Valentina Giorgio
  • Stefano SemeraroEmail author
Case Report



Hepatocellular carcinoma (HCC) is the most common form of liver cancer. In advanced cancer stages (metastatic disease and/or vascular invasion), the generally accepted standard of care is systemic therapy using sorafenib as first-line treatment and, recently, regorafenib and nivolumab as second-line treatment, but the quality of life and the prognosis of patients remain very poor. Our paper reports a case of US-guided radiofrequency ablation (RFA) of both intraparenchymal HCC and inferior vena cava tumor thrombus.


We treated a patient with HCC associated with tumor thrombus extending into vena cava after failure of sorafenib therapy using US-guided radiofrequency ablation (RFA).


A good radiological and clinical response was observed in association with excellent tolerability. The patient has been followed up for 15 months from the ablation, is alive, and is in a good clinical condition without evidence of tumor recurrence.


This is the first case in which this minimally invasive percutaneous procedure has been successfully used to treat an HCC thrombus entering the vena cava.


Hepatocellular carcinoma Sorafenib Locoregional therapy Tumor thrombus US-guided radiofrequency ablation 



Hepatocellular carcinoma


Barcelona clinic liver cancer


Overall survival


Transarterial chemoembolization


Hepatic arterial infusion chemotherapy


High-intensity focused ultrasound




Microwave ablation


Radiofrequency ablation


Child–Pugh score


Performance status




Selective internal radiation therapy


Locoregional therapy


Tumor thrombus


Contrast-enhanced computerized tomography


Inferior vena cava




Percutaneous ethanol injection


Drug-eluting bead


Contrast-enhanced ultrasound


International normalised ratio




Food and Drug Administration


European Medicines Agency


Quality of life



This study was not funded by anyone.

Compliance with ethical standards

Conflict of interest

All the authors (Pietro Gatti, Antonio Giorgio, Emanuela Ciracì, Italia Roberto, Alessandro Anglani, Sergio Spano, Fernando Rizzello, Valentina Giorgio, Stefano Semeraro) declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from the participant included in the study.


  1. 1.
    Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A (2015) Global cancer statistics, 2012. CA Cancer J Clin 65:87–108CrossRefGoogle Scholar
  2. 2.
    Adhoute X, Penaranda G, Raoul JL, Le Treut P, Bollon E, Hardwigsen J et al (2016) Usefulness of staging systems and prognostic scores for hepatocellular carcinoma treatments. World J Hepatol 8:703–715. CrossRefGoogle Scholar
  3. 3.
    European Association for the Study of the Liver (2018) EASL clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol 69:182–236
  4. 4.
    Heimbach JK, Kulik LM, Finn RS, Sirlin CB, Abecassis MM, Roberts LR et al (2018) AASLD guidelines for the treatment of hepatocellular carcinoma. Hepatology 67:358–380. CrossRefGoogle Scholar
  5. 5.
    Kudo M, Matsui O, Izumi N, Iijima H, Kadoya M, Imai Y et al; Liver Cancer Study Group of Japan (2014) JSH consensus-based clinical practice guideline for the management of hepatocellular carcinoma: 2014 update by the Liver Cancer Study Group of Japan. Liver Cancer 3:458–468.
  6. 6.
    Omata M, Cheng AL, Kokudo N, Kudo M, Lee JM, Jia J et al (2017) Asia–Pacific clinical practice guidelines on the management of hepatocellular carcinoma: a 2017 update. Hepatol Int 11:317–370. CrossRefGoogle Scholar
  7. 7.
    Le Grazie M, Biagini MR, Tarocchi M, Polvani S, Galli A (2017) Chemotherapy for hepatocellular carcinoma: the present and the future. World J Hepatol 9:907–920. (review) CrossRefGoogle Scholar
  8. 8.
    Gbolahan OB, Schacht MA, Beckley EW, LaRoche TP, O'Neil BH, Pyko M (2017) Locoregional and systemic therapy for hepatocellular carcinoma. J Gastrointest Oncol 8:215–228. CrossRefGoogle Scholar
  9. 9.
    Giorgio A, Di Sarno A, de Stefano G, Farella N, Scognamiglio U, de Stefano M et al (2009) Hepatocellular carcinoma with cirrhosis: are patients with neoplastic main portal vein invasion eligible for percutaneous radiofrequency ablation of both the nodule and the portal venous tumor thrombus? Am J Roentgenol 193(4):948–954. CrossRefGoogle Scholar
  10. 10.
    Giorgio A, Calisti G, Montesarchio L, Scognamiglio U, Matteucci P, Coppola C et al (2014) Hepatocellular carcinoma invading portal venous system in cirrhosis: long-term results of percutaneous radiofrequency ablation of both the nodule and portal vein tumor thrombus. A case control study. Anticancer Res 34:6785–6790Google Scholar
  11. 11.
    Florman S, Weaver M, Primeaux P, Killackey M, Sierra R, Gomez S et al (2009) Aggressive resection of hepatocellular carcinoma with right atrial involvement. Am Surg 75:1104–1108Google Scholar
  12. 12.
    Luo X, Zhang B, Dong S, Zhang B, Chen X (2015) Hepatocellular carcinoma with tumor thrombus occupying the right atrium and portal vein: a case report and literature review. Medicine (Baltimore) 94:e1049CrossRefGoogle Scholar
  13. 13.
    Le Treut YP, Hardwigsen J, Ananian P, Saïsse J, Grégoire E, Richa H et al (2006) Resection of hepatocellular carcinoma with tumor thrombus in the major vasculature. A European case–control series. J Gastrointest Surg 10:855–862Google Scholar
  14. 14.
    Lin HH, Hsieh CB, Chu HC, Chang WK, Chao YC, Hsieh TY (2007) Acute pulmonary embolism as the first manifestation of hepatocellular carcinoma complicated with tumor thrombi in the inferior vena cava: surgery or not? Dig Dis Sci 52:1554–1557CrossRefGoogle Scholar
  15. 15.
    Papp E, Keszthelyi Z, Kalmar NK, Papp L, Weninger C, Tornoczky T et al (2005) Pulmonary embolization as primary manifestation of hepatocellular carcinoma with intracardiac penetration: a case report. World J Gastroenterol 11:2357–2359CrossRefGoogle Scholar
  16. 16.
    Saynak M, Ozen A, Kocak Z, Cosar-Alas R, Uzal C (2007) Sudden death: a case report of hepatocellular carcinoma with tumor thrombus extending into the right atrium. J BUON 12:556Google Scholar
  17. 17.
    Llovet JM, Ricci S, Mazzaferro V, Hilgard P, Gane E, Blanc J-F et al (2008) Sorafenib in advanced hepatocellular carcinoma. N Engl J Med 359:378–390CrossRefGoogle Scholar
  18. 18.
    Cheng A-L, Kang Y-K, Chen Z, Tsao C-J, Qin S, Kim JS et al (2009) Efficacy and safety of sorafenib in patients in the Asia–Pacific region with advanced hepatocellular carcinoma: a phase III randomised, double-blind, placebo-controlled trial. Lancet Oncol 10:25–34. CrossRefGoogle Scholar
  19. 19.
    Cheng A-L, Guan Z, Chen Z, Tsao C-J, Qin S, Kim JS et al (2012) Efficacy and safety of sorafenib in patients with advanced hepatocellular carcinoma according to baseline status: Subset analyses of the phase III Sorafenib Asia–Pacific trial. Eur J Cancer 48:1452–1465. CrossRefGoogle Scholar
  20. 20.
    Bruix J, Qin S, Merle P, Granito A, Huang YH, Bodoky G, Pracht M et al (2017) Regorafenib for patients with hepatocellular carcinoma who progressed on sorafenib treatment (RESORCE): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 389:56–66. CrossRefGoogle Scholar
  21. 21.
    El-Khoueiry AB, Sangro B, Yau T, Crocenzi TS, Kudo M, Hsu C, Kim TY et al (2017) Nivolumab in patients with advanced hepatocellular carcinoma (CheckMate 040): an open-label, non-comparative, phase 1/2 dose escalation and expansion trial. Lancet 389:2492–2502. CrossRefGoogle Scholar
  22. 22.
    Kim G-A, Shim JH, Yoon SM, Jung J, Kim JH, Ryu M-H et al (2015) Comparison of chemoembolization with and without radiation therapy and sorafenib for advanced hepatocellular carcinoma with portal vein tumor thrombosis: a propensity score analysis. J Vasc Interv Radiol 26:320–329. CrossRefGoogle Scholar
  23. 23.
    Song DS, Song MJ, Bae SH, Chung WJ, Jang JY, Kim YS et al (2015) A comparative study between sorafenib and hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma with portalvein tumor thrombosis. J Gastroenterol 50:445–454. CrossRefGoogle Scholar
  24. 24.
    Silva JP, Berger NG, Tsai S, Christians KK, Clarke CN, MoGal H et al (2017) Transarterial chemoembolization in hepatocellular carcinoma with portal vein tumor thrombosis: a systematic review and meta-analysis. HPB (Oxford) 19:659–666. CrossRefGoogle Scholar
  25. 25.
    Vilgrain V, Abdel-Rehim M, Sibert A, Ronot M, Lebtahi R, Castéra Let al; SARAH Trial Group (2014) Radioembolisation with yttrium-90 microspheres versus sorafenib for treatment of advanced hepatocellular carcinoma (SARAH): study protocol for a randomised controlled trial. Trials 15:474.
  26. 26.
    (2017) SARAH: a randomised controlled trial comparing efficacy and safety of selective internal radiation therapy (with yttrium-90 microspheres) and sorafenib in patients with locally advanced hepatocellular carcinoma (GS012). In: The international liver congress 2017Google Scholar
  27. 27.
    Chow PKH, Gandhi M, Tan SB, Khin MW, Khasbazar A, Ong J et al; Asia–Pacific Hepatocellular Carcinoma Trials Group (2018) SIRveNIB: selective internal radiation therapy versus sorafenib in Asia–Pacific patients with hepatocellular carcinoma. J Clin Oncol 36:1913–1921.
  28. 28.
    Poggi G, Gatti C, Teragni C, Delmonte A, Bernardo G (2004) Radiofrequency ablation combined with percutaneous ethanol injection in the treatment of hepatocellular carcinoma and portal vein neoplastic thrombosis. Anticancer Res 24:2419–2421Google Scholar
  29. 29.
    Hirooka M, Koizumi Y, Kisaka Y, Abe M, Murakami H, Matsuura B et al (2010) Mass reduction by radiofrequency ablation before hepatic arterial infusion chemotherapy improved prognosis for patients with huge hepatocellular carcinoma and portal vein thrombus. Am J Roentgenol 194:W221–W226. CrossRefGoogle Scholar
  30. 30.
    Inoue Y, Hayashi M, Katsumata T, Shibayama Y, Tanigawa N (2011) Hepatocellular carcinoma with right atrial tumor thrombus: report of a case. Surg Today 41:1122–1129CrossRefGoogle Scholar
  31. 31.
    Wang Y, Yuan L, Ge RL, Sun Y, Wei G (2013) Survival benefit of surgical treatment for hepatocellular carcinoma with inferior vena cava/right atrium tumor thrombus: results of a retrospective cohort study. Ann Surg Oncol 20(3):914–922. CrossRefGoogle Scholar
  32. 32.
    Li W, Wang Y, Gao W, Zheng J (2017) HCC with tumor thrombus entering the right atrium and inferior vena cava treated by percutaneous ablation. BMC Surg 17:21. CrossRefGoogle Scholar

Copyright information

© Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB) 2019

Authors and Affiliations

  • Pietro Gatti
    • 1
  • Antonio Giorgio
    • 2
  • Emanuela Ciracì
    • 1
  • Italia Roberto
    • 1
  • Alessandro Anglani
    • 3
  • Spano Sergio
    • 4
  • Fernando Rizzello
    • 5
  • Valentina Giorgio
    • 6
  • Stefano Semeraro
    • 1
    Email author
  1. 1.Internal Medicine DivisionOstuni HospitalOstuniItaly
  2. 2.Interventional Ultrasound UnitTortorella Clinical HospitalSalernoItaly
  3. 3.Radiodiagnostic UnitOstuni HospitalOstuniItaly
  4. 4.Interventional Radiology UnitPerrino HospitalBrindisiItaly
  5. 5.Anesthesiology and Reanimation UnitOstuni HospitalOstuniItaly
  6. 6.Pediatric Gastroenterology Unit, Policlinico GemelliSacred Heart UniversityRomeItaly

Personalised recommendations