2240 Hepatocellular Carcinoma With Vascular Invasion and Cardiac Metastasis: A Case of Veno-Occlusive Disease Causing Progressive Liver and Renal Failure

Abstract

INTRODUCTION: Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver. The most frequent sites of metastasis are the lungs, the bones, the lymphatics, and the brain. We present a case of a 61-year-old female found to have advanced stage HCC with isolated metastasis to the right atrium and IVC, which is extremely rare with incidence of 2.7-4.1%. Prognosis is very poor. CASE DESCRIPTION/METHODS: A 61-year-old female presented with two weeks of generalized weakness and diarrhea. Physical exam revealed bilateral lower extremity edema. Laboratory data revealed a cholestatic injury pattern with an R factor of 1.1. CT of the abdomen and pelvis showed abdominal lymphadenopathy and a 3-cm mass in the right hepatic lobe. Diagnostic paracentesis showed a serum-ascites albumin gradient (SAAG) of 1.9 and a fluid protein of 2.7 g/dL. Treatment with lactulose, fluids, and albumin improved her mental status, but the patient’s renal function and diffuse edema continued worsening. Following a therapeutic paracentesis of 4 liters of peritoneal fluid, she had a primary hepatocellular injury pattern with R factor 14. With an alpha-fetoprotein (AFP) level of 1700, the diagnosis of HCC was confirmed. An echocardiogram showed a bilobed mass in the inferior portion of the right atrium. Magnetic resonance venography revealed occlusion of the right intrahepatic portal vein. Fine needle aspiration biopsy confirmed hepatocellular carcinoma. Due to having end-stage HCC, Child-Pugh Class C with expected survival less than 3 months, only palliative treatment was offered. DISCUSSION: HCC with isolated metastasis to the right atrium presents with right heart failure, manifesting as lower extremity edema, jugular venous distention, and ascites as seen in our patient. Only 1.2-4.1% of all HCC have metastasis to the heart, with around 17 reported cases in the literature of isolated metastasis to the heart. Our patient had an extremely rare case of an isolated right atrium metastasis of HCC. Sorafenib is the first line treatment option for advanced HCC but the delay in diagnosis, as well as our patient’s complex presentation, limited treatment. We recommend that echocardiography should be routinely performed for all patients with advanced HCC to prevent unexpected and fatal cardiovascular complications. This case illustrates the subtle presentation of HCC and that early diagnosis is key for treatment. Further studies need to investigate the current and novel treatment options for both HCC and cardiac metastasis.