Asymptomatic Right Atrium Extension of a Hepatocellular Carcinoma Detected by Echocardiography

Abstract

This report describes a case of involvement of inferior vena cava and the right atrium (RA) by a hepatocellular carcinoma (HCC), incidentally discovered during a transthoracic echocardiography in a patient with segmental left ventricular dysfunction, 18 years after a myocardial infarction and with a moderate calcified aortic valvular stenosis.

Case report

A 55-year-old smoker with a past medical history of diabetes type II, hypertension, hypercholesterolaemia, who had a myocardial infarction at the age of 40, underwent a cardiological control examination to evaluate the progression of a moderately severe calcified valvular aortic stenosis and the global and segmental left ventricular function. He described a general fatigue and a slightly reduced exercise tolerance.

On physical examination, the general state was slightly diminished. A subicterus was visible on the sclera and the skin. The epigastrium and the right hypochondrium palpation were slightly sore.

A transthoracic echocardiography (TTE) revealed a mild segmental left ventricular dysfunction, there was infero-basal akinesia and the ejection fraction was at the lower limit of normal (50%). The calcified valvular aortic stenosis was quite severe with a maximal gradient of 58 mm Hg, a mean gradient of 38 mm Hg and an opening area of 1.1 cm² (0.5 cm²/m²).

The examination unexpectedly revealed a mobile mass in the right atrium (RA) seeming to grow out of the inferior vena cava (IVC) (Figure 1A–C) and a large hepatic mass (Figure 1D).

Erythropoietin (EPO) was elevated to 41 U/l (normal value 5–25 U/l), Interleukin-6 (IL-6) to 48.9 pg/mL (normal value <0.3 pg/mL), and alpha-foetoprotein (AFP) was elevated to more than 12,000 kU/l (normal value <0.5 kU/l). The blood counts showed a polycythaemia with elevation of haemoglobin to 200 g/l and a haematocrit to 59%. White blood cells were normal and platelets were slightly diminished to 120 G/l. The patient was not known to have a pre-existing renal or hepatic disease.

A thoraco-abdominal computed tomography (CT) scan showed the presence of a huge right hepatic mass with extension into the IVC and the RA (Figure 2 and Figure 3).

The clinical and radiological presentation, associated with a high level of AFP and EPO clarified the diagnosis of hepatocellular carcinoma (HCC) and no biopsy was performed. Indeed, the extension of the tumour precluded any surgical treatment and was considered as chemoresistant by the oncology consultant. A symptomatic palliative treatment was performed and the patient died three weeks after the diagnostic examination. An autopsy has not been performed due to the absence of family consent.

Discussion

Diagnosis of an IVC and RA mass by routine TTE, along with the biological results, initially pointed to a renal cell carcinoma. A CT scan showing a huge hepatic mass, also objectivated at abdominal ultrasound examination, before the diagnosis of HCC was established.

The most frequent tumour involving IVC and RA is the renal cell tumour (about 4–10% cases) [1] followed by carcinoma of the thyroid, testicular tumours and then HCC [2].

HCC is the fifth most common tumour worldwide. Its annual incidence ranges between 3% and 9%. The highest annual incidence rates are found in countries which are endemic for viral hepatitis. In contrast, in western countries alcoholic cirrhosis is predominant [3,4].

Most cases of HCC are discovered at an advanced stage and the tumour most frequently spreads to the lungs, peritoneum, adrenal glands and bones. Extrahepatic extension or metastasis of HCC is an unusual form of secondary cardiac malignancy [2].

HCC extension to IVC and the RA have a poor prognosis [5,6]. In fact, this patient died 3 weeks after the diagnostic examination. In addition, this case highlights the importance of a comprehensive echocardiographic examination even in straight forward follow-up conditions, such as controls of a known valvulopathy.