Hepatobiliary and pancreatic: Inferior vena caval obstruction with hepatocellular cancer

Abstract

A 48-year-old man with chronic hepatitis B infection was admitted with dyspnea, orthopnea, abdominal distension and marked swelling of both legs. Five months previously, he had been treated with a central hepatectomy (Couinaud’s segments 4, 5 and 8) for a trabecular hepatocellular carcinoma that showed moderate differentiation and vascular invasion. Physical examination revealed engorged jugular veins, decreased breath sounds in the right lung base, a mid-systolic murmur, ascites and marked edema involving both legs. He was not clinically jaundiced. Liver function tests were mildly abnormal but the serum level of alpha fetoprotein was within the reference range. A chest X-ray showed a normal cardiac silhouette with a right pleural effusion. Transthoracic echocardiography revealed a mass, 6 × 5 cm, within the right atrium that was protruding from the inferior vena cava. A computed tomography (CT) scan of the upper abdomen (Fig. 1) showed an intrahepatic recurrence and complete thrombosis of the inferior vena cava (arrow). A CT scan of the chest (Fig. 2) showed that the large thrombus had extended contiguously into the right atrium (arrow). He also had a large right pleural effusion. The patient received palliative treatment and subsequently died because of cardiac failure. Hepatocellular carcinoma has a tendency to invade vascular structures. However, spread through the inferior vena cava into the cardiac cavities is rare. Clinical manifestations are variable but include dyspnea, syncope and heart failure. In our patient, the syndrome of inferior vena caval obstruction was characterized by the rapid onset of ascites and edema involving the lower abdomen and legs. Although there are case reports of successful surgical resection, most patients with inferior vena caval obstruction have a poor prognosis. The major causes of death are pulmonary embolism and acute obstruction of the tricuspid valve.