• Cardiopulmonary bypass
• Heart-first approach
• Hepatocellular carcinoma
• Right atrium
• Thrombectomy

• Male
• Humans
• Aged
• Carcinoma, Hepatocellular/surgery
• Carcinoma, Hepatocellular/pathology
• Liver Neoplasms/surgery
• Liver Neoplasms/pathology
• Cardiopulmonary Bypass/adverse effects
• Chemoembolization, Therapeutic/adverse effects
• Heart Atria/surgery
• Thrombosis/etiology
• Thrombosis/surgery
• Vena Cava, Inferior/surgery
• Vena Cava, Inferior/pathology

Hepatocellular carcinoma (HCC) presenting with tumor thrombus (TT) and inferior vena cava (IVC)/right atrium (RA) infringement point to an advanced-stage disease that is deemed inoperable. Stereotactic body radiotherapy is an emerging treatment option for this group of patients with promising outcomes in recent studies that are comparable to conventional treatment methods, namely, transarterial chemoembolization and transarterial radioembolization. Here, we report a case of HCC with RA extension through the IVC. The patient was referred to our clinic for treatment options, and he was found suitable for magnetic resonance imaging-guided radiotherapy (MRgRT). We treated the patient with MRgRT in five fractions to a total dose of 40 Gray. The tumor was tracked during the treatment sessions, and adaptive treatment planning was performed before each fraction. The patient tolerated the treatment well with no acute grade 3-4 toxicities. The last follow-up showed that the patient had a complete biochemical response and is now a candidate for an orthotopic liver transplant. To our knowledge, this report is the first to document the MRgRT treatment of an HCC with TT and RA extension. MRgRT is safe and feasible for this patient group and can be an effective bridging therapy for liver transplants.

Hepatocellular carcinoma (HCC) is the most important primary malignant liver disease. A large proportion of patients with advanced HCC have macrovascular invasion. HCC tends to infiltrate vascular structures, particularly the portal vein and its branches, and more rarely, the hepatic veins. The intravascular tumor thrombus can affect the inferior vena cava (IVC) or even the right atrium (RA), the latter having a poor prognosis.

HCC is one of the most aggressive malignant tumors. Tumor thrombus (TT) formation in advanced HCC stages is common and usually involves the hepatic or portal veins. Herein, we report a 69-year-old woman who presented with dyspnea to the emergency department. A ventilation/perfusion lung scan was performed, ruling out pulmonary embolism. Hepatopulmonary syndrome and portopulmonary hypertension were discarded with contrasted echocardiography, but a mass in the RA was detected and confirmed by cardiac magnetic resonance imaging. Abdominal computed tomography showed a liver mass with a dynamic enhancement pattern compatible with HCC and an intraluminal IVC mass extending from the hepatic vein into the RA. HCC with TT expansion to IVC and RA is rare and indicates poor prognosis.

HCC with TT expansion to IVC and RA is rare and indicates poor prognosis. There is no consensus about anticoagulation or other interventions in these patients.

• Hepatocellular carcinoma
• Alpha-fetoprotein
• Tumor thrombus
• Right atrium
• Sorafenib
• Case report

• Hepatocellular carcinoma
• Right atrium tumor thrombus
• Sorafenib
• Transarterial chemoembolization

Hepatocellular carcinoma (HCC) is a leading cause of cancer and cancer-related deaths in the world. Some of the risk factors for the development of HCC include Hepatitis B virus (HBV), Hepatitis C virus (HCV), chronic alcoholism, autoimmune hepatitis, among others. One manifestation of HCC includes tumor thrombus (TT) to the right atrium (RA), which occurs in 0.67-4.1% of patients with HCC. Our case focuses on a unique presentation of HCC with RA TT with initial symptoms of nausea and vomiting without signs of cardiac decompensation or hemodynamic instability. Although there is no definitive treatment for TT to the RA, there are a variety of proven avenues of management of HCC TT to the RA, especially pertaining to patients with adequate liver function.

A 63-year old female with a past medical history of untreated HCV and alcohol abuse with no previously known liver disease or history of liver decompensation, presented with nausea, vomiting, and diarrhea. Initial labs revealed hypovolemic hyponatremia and transaminitis with negative ethanol levels. The model for end-stage liver disease (MELD-Na) score was calculated at 27, and she had a Child-Pugh class C score. Follow up labs were significant for elevated alpha-fetoprotein (AFP). Triple-phase CT of the liver revealed a large liver mass with extension into the RA with TT and necrosis of the liver. An echocardiogram revealed a RA mass versus thrombus. Throughout her hospitalization, she never admitted to cardiac symptoms, including shortness of breath, palpitations, or chest pain. No tachycardia was noted, and her blood pressure remained stable. She was not a candidate for surgery or chemotherapy. The patient declined any heroic measures, and palliative care was consulted for further management. She was transferred to hospice, where she died one week later. 

There are numerous etiologies and clinical presentations of HCC with TT to the RA. Its disease course is insidious and may not present as symptomatic until there is a sizable tumor burden. Therefore, treatment options for HCC with TT to the RA are reliant on HCC screening for at-risk populations, early diagnosis, and each individual patient’s baseline liver function.

• alcohol
• cirrhosis
• heart
• hepatitis b
• hepatitis c
• hepatocellular carcinoma
• inferior vena cava
• right atrium
• screening
• tumor thrombus