Hepatocellular Carcinoma with Tumor Thrombus Extending from the Portal Vein to the Right Atrium

Abstract

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors. Tumor thrombus formation in advanced HCC stages is common and usually involves the hepatic or portal veins. The formation of tumor thrombus is considered a poor prognostic factor. Herein, we report a rare case wherein the thrombus extended to the inferior vena cava (IVC) reaching the right atrium without affecting the hemodynamic status. This is a 59-year-old male who presented with melena. He was found to have grade 3 esophageal varices with findings suggestive of recent bleeding associated with a large amount of blood in the gastric body that required banding. Computed tomography (CT) of the abdomen and pelvis showed multiple liver masses with an intraluminal IVC mass extending from the hepatic vein into the right atrium. A CT scan of the chest confirmed the presence of a tumor thrombus in the IVC extending to the right atrium. The patient declines surgical intervention and he was discharged. Unfortunately, he passed after a short period of time. In conclusion, tumor thrombus formation is common in HCC. However, expansion of the thrombus to IVC and right atrium is rare and indicates poor prognosis.

Long-Term Survival under Arterial Chemoembolization and Sorafenib of a Patient with Hepatocellular Carcinoma and Tumor Atrial Thrombus: A Case Report and Literature Review

“…According to its anatomic location, there are 3 types of TT: the inferior hepatic type, where the TT is in the IVC and below the diaphragm (type I), the superior hepatic type, where the TT is above the diaphragm but does not invade the RA (type II), and the intracardiac type with the extension of TT in the RA (type III) [2, 3, 5]. Our patient had type III TT.…”

“…HCC with TT in the IVC or RA is a rare entity and may be related with a number of complications (heart failure, pulmonary embolism, lung metastases and death predominantly due to pulmonary embolism and occlusion of the tricuspid valve) and consequently with poor prognosis [2][3][4][5]. Budd-Chiari syndrome and symptoms of acute right heart failure and pulmonary embolism are some of the clinical manifestations of HCC with TT in the RA [2]. Our patient had dyspnea, but no findings compatible with pulmonary embolism or lung metastases were found.…”

“…Based on the BCLC staging system, patients with type III TT are classified as BCLC stage C due to the extrahepatic spread of the HCC. Officially these patients are eligible only for systemic therapy, such as sorafenib [2, 9], but in the literature (Table 1), hepatectomy and thrombectomy under cardiopulmonary bypass have been suggested as treatment modality linked with better prognosis (survival range: 3–30.8 months), compared to nonsurgical therapy [2, 3] (Table 1). However, the procedure is challenging, demands a multidisciplinary team and a high operative risk also exists [3, 4].…”

“…On a global basis, it accounts for approximately 800,000 deaths annually [1]. The formation of tumor thrombus (TT) in advanced HCC is common, and its presence usually involves the portal vein [2]. However, the presence of TT in the inferior vena cava (IVC) and its extension to the right atrium (RA) are rare, approximately 3.8 and 2%, respectively, and associated with a poor prognosis, with a median survival time of 2–5 months for untreated patients [3].…”

“…Overview of case studies on the treatment and survival of patients with hepatocellular carcinoma and tumor atrial thrombus[2,4,7,10, …”