Hepatocellular Carcinoma With Tumor Thrombus Extending to the Right Atrium

Abstract

Introduction: 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 were the thrombus extended to the of Inferior Vena Cava (IVC) reaching the right atrium without affecting the hemodynamics of the patient. Case presentation: A 59—year—old male with a history of untreated Hepatitis C and 50 pack—year smoking, presented with melena, cramping abdominal pain and palpitations for 5 days. Physical examination was remarkable for tachycardia and epigastric tenderness. He was started on Octreotide and Pantoprazole infusions with prophylactic Ceftriaxone. He had an Esophagogastroduodenoscopy which showed grade 3 esophageal varices with findings of suggestive of recent bleeding that required banding (figure 1). A 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 (figure 2). A Magnetic Resonance Imaging (MRI) of the abdomen confirmed the diagnosis of HCC. His Alpha—fetoprotein level was 53,320 ng/ml. A CT scan of the chest confirmed the presence of a tumor thrombus in the IVC extending to the right atrium. Oncology team determined that the patient was not a candidate for surgical or ablative therapies. Since his symptoms improved during his stay, patient preferred to avoid any intervention for his thrombus. Therefore, he was discharged with a plan to receive palliative treatment with sorafenib as outpatient. Conclusion: Tumor thrombus formation is common in HCC. However, expansion of the thrombus to the IVC and right atrium is rare and indicate poor prognosis.3016_A.tif Figure 1: An EGD where part “A” is showing grade III esophageal varices with sign of recent bleeding, and part “B” is showing the banding that was done3016_B.tif Figure 2: A CT scan of the abdomen showing a tumor thrombus extending through the IVC.