Introduction: Tumor thrombus is a tumor that extends into the vessel wall. Hepatocellular Cancer is associated with portal vein thrombus (35% of the HCC cases) and hepatic vein thrombus (2% of the HCC cases). In very rare cases, HCC can lead to tumor thrombus extending beyond the portal/hepatic veins. We present a case of a patient with cardiac extension of the tumor thrombus.
Case Description/Methods: A 63-year-old man with a history of alcohol abuse presented with jaundice, altered mental status and coffee ground emesis. His initial vital signs were stable. He was drowsy but alert to name and place. Physical examination revealed icteric sclera, distended abdomen with shifting dullness and 2+ lower extremity pitting edema. Rectal exam revealed melena. Laboratory studies were remarkable for hemoglobin of 6.7 mg/dl, alanine transaminase(ALT) of 52 IU/ml, Aspartate transaminase (AST) of 145 IU/ml, total bilirubin of 10.6 mg/dl and a positive hepatitis C virus antibody with a viral load of 186 IU/ml. Due to concern for cardiac dysfunction in the setting of fluid overload, an echocardiogram was done which revealed a hypoechoic mass measuring 2.8 x 4.9 cm with irregular borders attached to the posterior right atrial wall. CT scan non contrast of the abdomen revealed cirrhosis with intrahepatic biliary dilatation(right >left). Further characterization by CT Liver tri-phase revealed a 20 cm infiltrative mass within right and left lobe of the liver with tumor thrombus occluding right and left portal vein extending into the hepatic vein, IVC and right atrium. Alpha fetoprotein level was 8200 ng/ml. Multidisciplinary team evaluation (surgery, oncology, hepatology) concluded that there were no viable treatment options given the extent of tumor burden and the degree of hepatic decompensation. Patient was transitioned to comfort care and discharged home with hospice services
Discussion: Tumor thrombus formation is a common complication of HCC, however the extension of tumor thrombus into the right atrium is rare and a sign of poor prognosis .There are limited treatment options available in patients with extensive thrombus invasion with decompensated liver disease presenting additional challenges. Patients with tumor thrombus should not be anticoagulated. Physicians should be aware that in patients with decompensated cirrhosis, a cardiac mass can be a sign of underlying HCC.
Figure: Fig 1a and Fg 1b - Mass noted on the Echocardiogram Fig 1C and 1d- Tumor thrombus noted in the heart on CT Chest
Aalam Sohal indicated no relevant financial relationships.
Dhuha Alhankawi indicated no relevant financial relationships.
Arpine Petrosyan indicated no relevant financial relationships.
Timothy Wang indicated no relevant financial relationships.
Marina Roytman indicated no relevant financial relationships.
Aalam Sohal, MD, Dhuha Alhankawi, MD, Arpine Petrosyan, MD, Timothy Wang, MD, Marina Roytman, MD. P1854 - Hepatocellular Cancer Presenting as a Cardiac Mass on Echocardiogram, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.