Hepatocellular Carcinoma Migrating to the Right Atrium through the Inferior Vena Cava

An 82-year-old man presented to the emergency department of the King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia, in 2013 with jaundice, bilateral lower limb oedema and dyspnoea. His laboratory test results were normal, except for elevated α-fetoprotein levels (258.3 ug/L). An ultrasound showed a right hepatic lobe hepatocellular carcinoma (HCC) in segments 6 and 7 of the liver, with tumour extension into the inferior vena cava (IVC) and a right atrial mass lesion. An urgent computed tomography (CT) scan of the abdomen indicated that the HCC was located in the liver segments 6 and 7 and invading the right hepatic vein; in addition, the confluence of the IVC extended into the right atrium where a tumour thrombus was present [Figure 1]. An ultrasound-guided fine needle aspiration cytology biopsy also revealed the presence of an HCC. An echocardiogram showed sinus rhythm and a large mass in the right atrium occupying most of the cavity and extending into the IVC, causing interesting medical image Sultan Qaboos University Med J, February 2018, Vol. 18, Iss. 1, pp. e118–119, Epub. 4 Apr 18 Submitted 7 Nov 17 Revision Req. 10 Jan 18; Revision Recd. 14 Jan 18 Accepted 25 Jan 18

A n 82-year-old man presented to the emergency department of the King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia, in 2013 with jaundice, bilateral lower limb oedema and dyspnoea.His laboratory test results were normal, except for elevated α-fetoprotein levels (258.3 ug/L).An ultrasound showed a right hepatic lobe hepatocellular carcinoma (HCC) in segments 6 and 7 of the liver, with tumour extension into the inferior vena cava (IVC) and a right atrial mass lesion.
An urgent computed tomography (CT) scan of the abdomen indicated that the HCC was located in the liver segments 6 and 7 and invading the right hepatic vein; in addition, the confluence of the IVC extended into the right atrium where a tumour thrombus was present [Figure 1].An ultrasound-guided fine needle aspiration cytology biopsy also revealed the presence of an HCC.An echocardiogram showed sinus rhythm and a large mass in the right atrium occupying most of the cavity and extending into the IVC, causing   flow obstruction.A CT scan and magnetic resonance imaging of the abdomen and chest showed the HCC migrating through the hepatic veins and the IVC to the right atrium, with a tumour thrombus in the right atrium [Figure 2].After the diagnosis was made, the patient did not respond to treatment and died due to cardiopulmonary failure during the admission period.

Comment
The heart is affected in up to 20% of metastatic HCC cases. 1 Although HCC has a tendency to spread into the venous system, intracardiac involvement is extremely rare and has a very poor prognosis. 2Metastasis to the heart can occur via the blood stream, the lymphatic system or direct invasion through the IVC to the right atrium, with the latter occurring in 6.5-44% of HCC patients. 3,4Such patients often exhibit symptoms of heart failure due to flow obstruction or a thromboembolism. 4,5Survival usually does not exceed four months, regardless of the type of treatment offered. 4c k n o w l e d g e m e n t s The authors wish to acknowledge the involvement of Dr Mohamed Neimatallah, Department of Radiology, King Faisal Specialist Hospital & Research Center, in the care of the reported patient.

Figure 1 :
Figure 1: A: Computed tomography (CT) scan of the abdomen and chest of an 82-year-old man in the coronal view showing a hepatocellular carcinoma migrating through the inferior vena cava to the right atrium (arrows).B: Chest CT scan showing a tumour thrombus in the right atrium (arrowhead).

Figure 2 :
Figure 2: A: Computed tomography scan of the abdomen and chest of an 82-year-old man in the sagittal view showing a hepatocellular carcinoma (HCC) migrating through the hepatic veins and inferior vena cava to the right atrium (arrow), with a tumour thrombus located in the right atrium (arrowhead).B: Magnetic resonance imaging of the chest and abdomen in the coronal view showing the HCC migrating to the right atrium (arrow) and the tumour thrombus in the right atrium (arrowhead).