Progressive dyspnea and a right atrial mass in an 80-year-old man

Abstract

Hepatocellular carcinoma (HCC) is among the five most frequent causes of cancer death worldwide, according to the WHO. The disease is related to alcohol abuse, viral infections, and other causes of cirrhosis, and unfortunately, in some developed countries, the incidence shows an increasing trend. Although the diagnosis of the HCC often relies upon the context of a chronic hepatopathy, some cases may present a silent course, and the initial symptoms ensue when the disease is in an advanced stage with no chance for any therapeutic attempt. The clinical picture of the HCC is varied, and unexpected forms may surprise the clinician. One of the unusual presentations of the HCC is shock by the blockage of the venous return to the right atrium by the inferior vena cava infiltration. Herein we present a case of an old patient who sought medical care complaining of dyspnea. The clinical workup disclosed a right thorax pleural effusion and imaging exams depicted a mass in the right hepatic lobe, invasion of the inferior vena cava (IVC) and the right atrium (RA). During the attempts of clinical investigation, the patient passed away. The autopsy disclosed an HCC involving the right hepatic lobe, with the invasion of the IVC and the RA. The authors highlight the importance of recognizing the bizarre presentation of not so rare diseases.

Keywords: Carcinoma, Hepatocellular; Embolism, Liver Neoplasms, Budd-Chiari Syndrome.

Figure 1. A – Axial contrast enhanced abdominal CT demonstrates a large heterogeneous mass in the periphery of the right hepatic lobe, with exophytic growth (white arrow), associated with tumoral thrombosis of the right portal vein and ascites; B – Axial contrast enhanced CT image obtained at the inferior third of the thorax demonstrates the solid mass into the right atrium (black arrow); C, D, E and F are autopsy images: C – Cross-section of the liver showing the neoplastic mass (white arrow) occupying the right lobe and disseminating via portal and supra-hepatic veins (black arrows); D – Diaphragmatic surface of the liver showing the inferior vena cava completely occluded by tumoral thrombus (black arrows); E – Postero-inferior aspect of the heart showing complete occlusion of the inferior vena cava, at its atrial entrance, by a tumor thrombus (Tu); LA- left atrium; F – Opened right atrium, showing the tumor thrombus invading the right atrial (RA) cavity.

Figure 2. The panel shows some of the microscopic findings. A – Neoplastic nodule (N) in the liver, showing features of hepatocellular carcinoma; B – Tumoral thrombus inside the inferior vena cava. The groups of neoplastic cells (N) are intermingled with necrotic debris and fibrin; C – Small metastatic nodule in the lung parenchyma; D – Acute pancreatitis. There is extensive steatonecrosis (Sn). (H&E; magnification bars: A – 100µm; B – 200 µm; C –1000 µm; D – 200 µm).