Echocardiographic detection of a metastatic right atrial mass in a patient with previously un-diagnosed hepatocellular carcinoma who presents with dyspnea

doi:10.4236/health.2011.32015

Paper Menu >>

Journal Menu >>

Vol.3, No.2, 82-85 (2011) Health

doi:10.4236/health.2011.32015

Echocardiographic detection of a metastatic right atrial

mass in a patient with previously un-diagnosed

hepatocellular carcinoma who presents with dyspnea

Ber-Ren Fang1,4*, Chin-Yew Lin2,4, I-Ping Yen3,4

1Division of Cardiology, Cardinal Tien Hospital Yung Ho Branch, Yung Ho City, Taipei County, Taiwan, China;

*Corresponding Author: kaec15@MS27.hinet.net;

2Department of Pathology, Cardinal Tien Hospital, Yuan-Ho City, Taipei County, Taiwan, China;

3Division of Cardiology, Cardinal Tien Hospital, Xian Dian City, Taipei County, Taiwan, China;

4 Fu-Jen Catholic University, College of Medicine, Xin Zhung City,Taipei County, Taiwan, China.

Received 3 January 2011; revised 19 January 2011; accepted 29 January 2011

ABSTRACT

A 69-year-old woman had experienced resistant

edema of lower extremities and progressive

dyspnea on exertion for two months. The pa-

tient visited our emergency room owing to ex-

acerbation of her dyspnea symptom. Echocar-

diography demonstrated a mobile mass in the

right atrium. Transesophageal echocardiogra-

phy revealed a right atrial mass arising from the

inferior vena cava which was partially mobile.

The patient underwent urgent open heart sur-

gery with resection of the right atrial mass and

curettage of the tumor thrombus in the inferior

vena cava. Histologic examination of the re-

sected right atrial mass revealed the features of

metastatic hepatocellular carcinoma. Subse-

quent work-up revealed that alpha-fetoprotein

level was 3780 ng/ml. Abdominal echocardi-

ography showed a tumor mass in the right lobe

of the liver. The post-operative course was

complicated by pneumonia, sepsis, and multi-

organ failure. The patient died 48 days after

surgery.

Keywords: Hepatocellular Carcinoma;

Right Atrial Metastasis; Echocardiography

1. INTRODUCTION

Intracardiac metastasis of hepatocellular carcinoma

(HCC) is rare. Before the era of echocardiography, an-

temortem diagnosis of this condition was difficult and

the condition was usually an incidental finding during

autopsy. However, since the widespread application of

two-dimensional and transesophageal echocardiography

in general practice, diagnosis of this condition has in-

creased [1-3]. This study presents a case of previously

un-diagnosed HCC presenting with dyspnea and resis-

tant leg edema. Echocardiography detected a right atrial

mass that was removed surgically and was proven his-

tologically to be a metastatic HCC.

2. CASE REPORT

A 69-year-old woman had experienced resistant ede-

ma of the lower extremities and progressive dyspnea on

exertion for two months. The patient felt exacerbation of

her dyspnea symptom lasting a few days, and was re-

ferred to our emergency-department by a local doctor. In

the emergency room, physical examination revealed

blood pressure 122/63 mmHg, and pulse rate 84 beats

per minute. The sclera was not icteric, conjunctiva was

slightly pale, and the jugular veins were engorged. A

grade 2/6 systolic murmur was heard at the left lower

sternal border, and significant edema of the lower ex-

tremities was noted. Chest x-ray film revealed slight

cardiomegaly. Moreover, electrocardiography demon-

strated normal sinus rhythm. White blood cell count was

7700/mm3; hemoglobin was 10.1 gm/dl; blood urea ni-

trogen was 24 mg/dl, and creatinine was 1.8 mg/dl.

Echocardiography was arranged to investigate the possi-

ble cardiac cause of dyspnea and the nature of the car-

diac murmur. Transthoracic echocardiography demon-

strated a mass in the right atrium. The mass was partially

mobile, and may prolapse into the right ventricle during

the diastolic phase and moreover may return to the right

atrium during the systolic phase. The mass appeared to

arise from the junction of the right atrium and the infe-

rior vena cava (Figure 1). Doppler echo demonstrated

evidence of mild tricuspid stenosis and regurgitation.

Since the presence of the right atr ial mass was considered

B.-R. Fang et al. / Health 3 (2011) 82-85

8383

Figure 1. Apical four chamber view of two-dimensional echo-

cardiography demonstrating a mobile mass in the right atrium.

The mass may prolapse into the right ventricle during the dia-

stolic phase (upper panel) and may return to the right atrium

during systolic phase (lower panel). Abbreviations: LA, left

atrium; LV, left ventricle; M, mass; RA, right atrium; RV, right

ventricle.

a surgical emergency, the patient underwent urgent open

heart surgery. Immediately prior to surgery, transe-

sophageal echocardiography revealed a right atrial mass

arising from the inferior vena cava which was partially

mobile (Figure 2). On surgery, a mass measuring

8X5X3 cm and arising from the inferior vena cava was

noted and excised. Curettage of the tumor thrombus in

the inferior vena cava was performed as low as possible.

Histologic examination of the excised right atrial mass

revealed features of metastatic HCC (Figure 3). Work-

up for HCC was subsequently performed. ALT was 11

u/L (normal <36 u/L), AST was 33 u/L (normal <34 u/L),

albumin was 2.7 gm/dl, HBS Ag was positive, anti-HC

antibody was negative, and alpha-fetoprotein was 3789

Figure 2. Transesophageal echocardiography displaying a

mass in the right atrium. The mass arises from the junction of

the right atrium and the inferior vena cava. Abbreviations: M,

mass; RA, right atrium; RV, right ventricle.

ng/ml (normal <20 ng/ml). Abdominal ech ocardiography

identified a tumor mass measuring 8.0X7.8 cm in the

right lobe of the liver. Liver cirrhosis and ascites were

also noted. The post-operative course was complicated

by pneumonia, sepsis, respiratory failure and renal fail-

ure. T he pat ie n t died 48 day s aft er s urgery.

3. DISCUSSION

The reported incidence of right atrial metastasis in

hepatocellular carcinoma ranges from 0.67% to 4.1%

[4,5]. According to autopsy findings, hepatocellular car-

cinoma tend to extend from the hepatic vein to the infe-

rior vena cava and then into the right atrium. Kato et al.

[4] described the autopsy findings in five patients with

HCC who had tumor metastasis to the right atrium. In

four of five patients in that series the tumor thrombus

completely occluded the right hepatic vein and inferior

vena cava and extended into the right atrium. Moreover,

in another patient the hepatic vein was unaffected but the

tumor thrombus was partially occluding the inferior vena

cava and extending into the right atrium. In another au-

topsy series of 18 patients with HCC who had right atrial

metastasis reported by Kojiro et al. [5], tumor thrombus

involving the hep atic v ein and the inferior v ena cav a was

found in 15 (83.3%) of the 18 cases. The presence of

tumor thrombus in the inferior vena cava and right

atrium may hinder venous return to the right heart, thus

reducing cardiac output, and can also cause “secondary

Budd-Chiari syndrome” which is characterized by diu-

retic resistant leg edema, ascites and dilatation of ab-

dominal wall veins [6]. In the present case, the patient

experienced progressive dyspnea on exertion and diu-

retic resistant leg edema. These symptoms and signs are

B.-R. Fang et al. / Health 3 (2011) 82-85

Figure 3. Histopathologic features of resected right atrial mass.

Upper panel: This photograph demonstrating diffusely infil-

trating neoplastic cells which appear in trabecular or sheet

patterns of growth with occasional pseudoglandular formation

(arrow-head). The malignant cells have distinct cellular borders

and pleomorphic nuclei with prominent nucleoli (Hematoxy-

lin-eosin stain, original magnification X 200). Lower panel:

The immunohistochemical staining for anti-HepPar 1 showing

strongly and diffusely positive in the tumor cells, confirming

the diagnosis of metastatic hepatocellular carcinoma. (Im-

munoperoxidase staining with HepPar-1, original magnifica-

tion X 200).

caused by reduced cardiac output and secondary Budd-

Chiari syndrome. Echocardiography plays an important

role in the detection of intracardiac mass. The character-

istics and site of attachment of the mass may offer im-

portant information regarding the nature of the right atri-

al mass. Cardiac myxoma, which are rarely located in

the right atrium, are generally highly mobile, and are

mostly attached to the interatrial septum. Thrombus

generally is fixed to the atrial wall, but also can be mo-

bile. Meanwhile, metastatic tumor mass is generally

fixed, but also can be mobile and is largely adherant to

the junction of the right atrium and the inferior vena ca-

va. Since tumor thrombus in the inferior vena cava is

common in patients with HCC and right atrial metastasis,

whenever an right atrial mass is detected by echocardi-

ography, the inferior vena cava should be carefully

scanned to exclude the possibility of cardiac involve-

ment in malignancy [7]. However, transesophageal

echocardiography gives more information about precise

site of attachment to the atrial wall or interatrial septum

and clearly illustrates the relationship with the inferior

and superior vena cava [8]. When the right atrial mass is

mobile as in the present case, the mass may move back

and forth through the tricuspid orifice, causing systolic

and/or diastolic murmur. The presence of thrombi (either

attached or free-floating) in the right cardiac chambers

carries the risk of pulmonary embolism and sudden

death [9]. In most of these cases, pulmonary embolism

has been observed to occur within a few days after

echocardiographic diagnosis [9]. Ehrich et al. [10] re-

ported a patient with HCC and right atrial metastasis

who suffered a sudden drop in blood pressure. Surgical

excision of the metastatic right atrial mass caused

symptomatic relief, and the patient was still alive one

year after surgery. Masaki et al. [11] described two pa-

tients with HCC and right atrial metastasis. Surgical re-

moval of the tumor thrombus improved the dyspnea

symptoms in each case. The subsequent course revealed

one patient that survived for eight months and was able

to return to work, while the other patient h ad unsatisfac-

tory recovery and died suddenly one month after surgery.

In the present case the patient died 48 days after surgery

owing to sepsis and multi-organ failure. The rationale for

surgical treatment in these patients is as follows: first,

prevention of sudden death possibly due to massive

pulmonary embolism [1,9,12], second, improvement of

life quality by ameliorating the symptoms of reduced

cardiac output (dyspnea) and secondary Budd-Chiari

syndrome [10-12].

In conclusion, diagnosing right atrial metastasis in

HCC is difficult because the symptoms and signs are

nonspecific. However, right atrial metastasis should be

considered when patients with HCC present with dysp-

nea, abnormal cardiac sounds and Budd-Chiari syn-

drome. Echocardiography is the most useful diagnostic

tool for detecting metastatic right atrial mass.

REFERENCES

[1] Chua, S.O., Chiang, C.W., Lee, YS, Liaw, Y.F., Chang,

C.H. and Hung, J.S., (1989) Echocardiographic findings

of mobile atrial hepatocellular carcinoma report of five

cases. Journal of Ultrasound in Medicine, 8, 347-352.

[2] Camp, G.V., Abdulsater, J., Cosyns, B., Liebens, I. and

Vamdenbossche, J.L., (1994) Transesophageal echocar-

diography of right atrial metastasis of a hepatocellular

carcinoma. Chest, 105, 945-947.

doi:10.1378/chest.105.3.945

[3] Vlasseros, I., Tapanlis, E., Katsaros, A., Katsaros, A.,

Kountouras, D. and Gialafos, I. (2003) Metastatic hepa-

B.-R. Fang et al. / Health 3 (2011) 82-85

8585

tocellular carcinoma into the right atrium and ventricle:

echocardiographic diagnosis and follow-up. Echocardi-

ography, 20, 387-388.

doi:10.1046/j.1540-8175.2003.03047.x

[4] Kato, Y., Tanaka, N., Kobayashi, K., Ikeda, T., Hattori, N.

and Nonomura, A. （1983）Growth of hepatocellular

carcinoma into the right atrium: report of five cases.

Annals of Internal Medicine, 99, 472-474.

[5] Kojiro, M., Nakahara, H., Sugihara, S., Murakami, T.,

Nakashima, T. and Kawasaki, H. (1984) Hepatocellular

carcinoma with intra-atrial tumor growth. Archives of

Pathology & Laboratory Medicine 108, 989-992.

[6] Takeuchi, J., Takada, A., Hasumura, Y., Matsuda, Y. and

Ikegami, F. (1971) Budd-Chiari syndrome associated

with obstruction of the inferior vena cava: a report of

seven cases. American Journal of Medicine. 51, 11-20.

doi:10.1016/0002-9343(71)90319-6

[7] Oh, J.K., Seward, J.B. and Tajik, A.J. (1999) The Echo

Manual, 2th Edition, Lippincott Williams & Wilkins,

Philadelphia.

[8] Mugge, A., Daniel, W.G., Haverich, A. and Lichtlen, P.R.,

(1991) Diagnosis of noninfective mass lesions by

two-dimensional echocardiography: comparison of the

trasthoracic and transesophageal approaches. Circulation,

83, 70-78.

[9] Farfel, Z., Shecht er, M., Vered, Z., Ra th, S., Goor, D. and

Gafni, J. (1987) Review of echocardiographically diag-

nosed right heart entrapment of pulmonary emboli-in-

transit with emphasis on management. American Heart

Journal, 113, 171-178.

doi:10.1016/0002-8703(87)90026-3

[10] Ehrich, D.A., Widmann, J.J., Berger, R.L. and Abelmann,

W.H. (1975) Intracavitary cardiac extension of Hepatoma.

The Annals of Thoracic Sur g ery, 19, 206-211.

doi:10.1016/S0003-4975(10)64004-0

[11] Masaki, N., Hayashi, S., Maruyama, T., Okabe, H., Ma-

tsukawa, M., Unno, J., et al. , (1994) Marked clinical im-

provement in patients with hepatocellular carcinoma by

surgical removal of extended tumor mass in right atrium

and pulmonary arteries. Cancer Chemotherapy and

Pharmacology, 33, suppl 1, 7-11.

doi:10.1007/BF00686660

[12] Fujisaki, M., Kurihara, E., Kikuchi, K., Nishikawa, K.

and Uematsu, Y. (1991) Hepatocellular carcinoma with

tumor thrombus extending into the right atrium: report of

a successful resection with the use of cardiopulmonary

bypass. Surgery, 109, 214-219.