|Year : 2016 | Volume
| Issue : 1 | Page : 50-52
A rare case of hepatocellular carcinoma with right atrial invasion
Sandeep Murgi Babukumar, Vishwanth Kumbar, Gouri Kaveriappa, Ram Shenoy Basti, HB Suresh
Department of Radio-diagnosis, Father Muller Medical College, Mangalore, Karnataka, India
|Date of Web Publication||21-Jan-2016|
H B Suresh
Department of Radio-diagnosis, Father Muller Medical College, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
An elderly male came with h/o loss of appetite and weight loss since 3 months. On evaluation, prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) values were high. Hepatitis B surface antigen (HbSAg) screening was reactive and serum alfa-fetoprotein (AFP) was raised. Ultrasound examination revealed a hepatic mass with inferior vena caval extension and direct invasion of the right atrium. Computed tomography (CT) scan of the lower thorax and abdomen was performed, which confirmed the ultrasound diagnosis. The patient had a brief stay in the hospital and got discharged against medical advice; he was not available for follow-up. Hepatocellular carcinomas (HCCs) commonly metastasizes to the lung, bone, brain, and adrenal glands. About 70% of the patients with HCCs have hepatic and portal vein invasions but encroachment into the right atrium is very rare. The most common symptoms of cardiac metastasis include asymptomatic cases, bilateral lower leg edema, and exertional dyspnea in that order. Typical complications of intravascular tumor extension lead to secondary Budd-Chiari syndrome, right heart insufficiency, or massive pulmonary embolism. The prognosis of HCC with atrial invasion is poor, with median survival ranging from 1 month to 4 months. HCC in these cases may be more aggressive, with a shorter doubling time. The risk for cardiopulmonary collapse is higher, with heart failure or sudden death. Surgical interventions as well as nonsurgical approaches have been used in the treatment of patients with symptomatic inferior vena cava (IVC)/right atrial tumor thrombi. There are few reports of en bloc hepatectomy and resection of the right atrial thrombus under cardiopulmonary bypass. Routine screening in patients with HCC, such as including chest imaging as part of surveillance computed tomographic scans, may facilitate earlier detection and treatment.
Keywords: Computed tomography (CT), hepatocellular carcinoma, right atrial thrombus, ultrasound
|How to cite this article:|
Babukumar SM, Kumbar V, Kaveriappa G, Basti RS, Suresh H B. A rare case of hepatocellular carcinoma with right atrial invasion. Muller J Med Sci Res 2016;7:50-2
|How to cite this URL:|
Babukumar SM, Kumbar V, Kaveriappa G, Basti RS, Suresh H B. A rare case of hepatocellular carcinoma with right atrial invasion. Muller J Med Sci Res [serial online] 2016 [cited 2018 Feb 24];7:50-2. Available from: http://www.mjmsr.net/text.asp?2016/7/1/50/174640
A 67-year-old man came with history of (h/o) loss of appetite and weight loss since 3 months. On evaluation, prothrombin time PT (57.6 s), activated partial thromboplastin time (aPTT) (42.4 s), and international normalized ratio (INR) (4.15) values were high. Hepatitis B surface antigen (HbSAg) screening was reactive and serum alfa-fetoprotein (AFP) was raised (1.5 ng/mL).
On ultrasound imaging [Figure 1], the liver was enlarged with heteroechoic rounded mass lesion in segment VII and VIII with necrotic areas within. Echogenic intraluminal lesion was noted in the upper third of the hepatic segment of inferior vena cava (IVC) with extension to the right atrium where a lobulated mass of 6.5 × 4.5 cm was noted. Minimal ascites were also present.
|Figure 1: Ultrasound image showing heteroechoic mass in the liver with extension to the right atrium|
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Contrast enhanced computed tomography [Figure 2] and [Figure 3] of the abdomen and lower thorax was performed, which revealed a heterogeneously enhancing mass lesion in the liver with central areas of necrosis. The lesion showed splaying of the hepatic veins with extension into the IVC near the hepatic vein confluence and the right atrium. Hepatic veins were compressed by the mass and showed no e/o infiltration. The portal vein was dilated (16 mm) but patent. A few enlarged periportal lymph nodes were seen.
|Figure 2: Axial image of the contrast enhanced CT scan of abdomen in arterial phase, showing hepatic mass lesion with right atrial invasion|
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|Figure 3: Coronal reformatted image shows heterogeneously enhancing hepatic mass (solid white arrow), displacing the hepatic vein (open white arrow), extending to the inferior venacava and right atrium (solid black arrow)|
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Ultrasound-guided fine-needle aspiration from the liver mass revealed features of hepatocellular carcinoma.
| Discussion|| |
Hepatocellular carcinomas (HCCs) commonly metastasizes to the lung, bone, brain, and adrenal glands.  About 70% of the patients with HCCs have hepatic and portal vein invasions but encroachment into the right atrium is very rare; however, autopsy studies suggest that the incidence of HCC with cardiac involvement may be underestimated. 
The formation of the right atrial embolus has a growth process. First, the tumor perforates the wall of the hepatic veins and/or IVC, then the tumor extends into the lumen of the vein and grows within. The tumor in the lumen can grow upward and/or downward, and if it grows upward it may get into the right atrium (RA) and continues slow growth there.  Isolated cardiac metastases that are discontinuous with an intrahepatic HCC are extremely rare. Cardiac metastases are notably located in the right ventricle (RV), RA, and left ventricle (LV).  Virtually all reported cases of HCC with intracaval invasion have preexisting liver cirrhosis and/or at least one classical risk factor for HCC as in our case.
The symptoms may be insignificant, with lower leg edema resistant to diuretics therapy being the most commonly reported symptom. Many patients are asymptomatic before diagnosis and they could be diagnosed incidentally during surveillance abdominal imaging with chest extension. Apart from this, right atrial involvement may be the first manifestation of HCC. In a recent study, the most common symptoms of cardiac metastasis included asymptomatic in 39%, bilateral lower leg edema in 37.5%, and exertional dyspnea in 31.3% of the patients.  Typical complications of intravascular tumor extension lead to secondary Budd-Chiari syndrome More Details, right heart insufficiency, or massive pulmonary embolism secondary to detached tumor tissue or superimposed thrombotic material. 
The diagnosis of HCC is typically made by radiological liver imaging without need for biopsy, especially in patients with cirrhosis or chronic hepatitis B infection. The revised American Association for the Study of Liver Diseases (AASLD) guidelines for diagnosing HCC do not require elevation of AFP >200 ng/mL, as it is observed that there are significant false-positives (in cirrhotic patients) and false-negatives.  Our patient had underlying hepatitis B infection and all the typical radiological features of HCC, and normal AFP values.
Routine screening in patients with HCC, such as including chest imaging as part of surveillance computed tomographic scans, may facilitate earlier detection and treatment. A screening examination using transesophageal echocardiography in HCC patients has showed that the prevalence of subclinical cardiac metastasis in HCC patients to be as high as 11%.  Indium-111-oxine labeled platelet scintigraphy can also demonstrate embolic showers from a right atrial metastasis of HCC into the lung. 
Vascular invasion in patients with HCC is a major predictor of mortality as well as tumor recurrence following surgical intervention. In a study, the tumor size and serum AFP level, alone or in combination, were found useful in predicting the presence or absence of vascular invasion. One series showed that the incidence of vascular invasion increases as the tumor size increases and patients with tumor size >5 cm and serum AFP levels >1,000 ng/mL had an 82% incidence of vascular invasion. 
Not surprisingly, the prognosis of HCC with atrial invasion is poor, with median survival ranging from 1 month to 4 months. HCC in these cases may be more aggressive, with a shorter doubling time. The risk for cardiopulmonary collapse is higher, with heart failure or sudden death. 
Surgical interventions such as en bloc hepatectomy and resection of the right atrial thrombus under cardiopulmonary bypass as well as nonsurgical approaches, such as transcatheter arterial chemoembolization and radiotherapy, have been used in the treatment of patients with symptomatic IVC/right atrial tumor thrombi. 
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Conflicts of Interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]