Hepatocellular Carcinoma With Tumor Thrombus to the Hepatic Veins and the Right Atrium: A Case Report and Review Exploring Various Presentations and Treatment Options

Abstract

Hepatocellular carcinoma (HCC) is a leading cause of cancer and cancer-related deaths in the world. Some of the risk factors for the development of HCC include Hepatitis B virus (HBV), Hepatitis C virus (HCV), chronic alcoholism, autoimmune hepatitis, among others. One manifestation of HCC includes tumor thrombus (TT) to the right atrium (RA), which occurs in 0.67-4.1% of patients with HCC. Our case focuses on a unique presentation of HCC with RA TT with initial symptoms of nausea and vomiting without signs of cardiac decompensation or hemodynamic instability. Although there is no definitive treatment for TT to the RA, there are a variety of proven avenues of management of HCC TT to the RA, especially pertaining to patients with adequate liver function.A 63-year old female with a past medical history of untreated HCV and alcohol abuse with no previously known liver disease or history of liver decompensation, presented with nausea, vomiting, and diarrhea. Initial labs revealed hypovolemic hyponatremia and transaminitis with negative ethanol levels. The model for end-stage liver disease (MELD-Na) score was calculated at 27, and she had a Child-Pugh class C score. Follow up labs were significant for elevated alpha-fetoprotein (AFP). Triple-phase CT of the liver revealed a large liver mass with extension into the RA with TT and necrosis of the liver. An echocardiogram revealed a RA mass versus thrombus. Throughout her hospitalization, she never admitted to cardiac symptoms, including shortness of breath, palpitations, or chest pain. No tachycardia was noted, and her blood pressure remained stable. She was not a candidate for surgery or chemotherapy. The patient declined any heroic measures, and palliative care was consulted for further management. She was transferred to hospice, where she died one week later.There are numerous etiologies and clinical presentations of HCC with TT to the RA. Its disease course is insidious and may not present as symptomatic until there is a sizable tumor burden. Therefore, treatment options for HCC with TT to the RA are reliant on HCC screening for at-risk populations, early diagnosis, and each individual patient's baseline liver function.

Surgical Treatment of Hepatocellular Carcinoma with a Tumor Thrombus Invading the Right Atrium: A Case Report

“…HCC with TT extension through the hepatic veins and IVC into the RA is reported in up to 3% of all cases [3, 4]. Besides, studies have reported even a higher rate (4.1%) upon autopsy for patients without previously known diagnosis of HCC and TT reaching RA [6, 7].…”

Tumor Lysis Syndrome Following Thoracotomy Under Cardiopulmonary Bypass in a Case of Hepatocellular Carcinoma With Right Atrial and Inferior Vena Cava Tumor Thrombus

“…Contrary to general expectations, the disease process is often insidious and without primary cardiac symptoms. Instead, patients usually present with more non-specific symptoms such as cachexia, edema, abdominal distention or pain, and dyspnea secondary to pulmonary embolism or Budd-Chiari syndrome [ 11 ]. As a result, clinical diagnosis may sometimes be delayed until the IVC and RA masses are relatively large making intervention more difficult and the treatment course more complicated.…”

Differential diagnosis of cardiac tumors: General consideration and echocardiographic approach

“…Tumor thrombus is a consequence of tumor invasion into the venous system, with activation of the coagulation and the simultaneous growth of both tumor and thrombus; it is rather frequent in the portal system in patients with hepatocarcinoma, but it can be observed also in the inferior vena cava invaded by a liver, gynecological or other abdominal cancers and requires a therapeutic approach not limited to anticoagulation (as is the case of simple thrombosis). 37 , 38 , 39 , 40 , 41 , 42 Tumor thrombi have been reported also in the pulmonary veins. 43 The histology‐based likelihood and the age of the patient at the time of presentation .…”

“…A right atrial mass without any relationship with the inferior vena cava and with the same echogenicity of intrapleural metastasis of sarcoma is probably a metastasis (Figure 1). Tumor thrombus is a consequence of tumor invasion into the venous system, with activation of the coagulation and the simultaneous growth of both tumor and thrombus; it is rather frequent in the portal system in patients with hepatocarcinoma, but it can be observed also in the inferior vena cava invaded by a liver, gynecological or other abdominal cancers and requires a therapeutic approach not limited to anticoagulation (as is the case of simple thrombosis) 37–42 . Tumor thrombi have been reported also in the pulmonary veins 43 …”