Case Presentation:
A 78 year old man with atrial fibrillation and hemochromatosis complicated by locally advanced hepatocellular carcinoma (HCC) was admitted from a skilled nursing facility with new onset bilateral lower extremity edema. He was undergoing physical rehabilitation after having his fourth transarterial chemoembolization (TACE) procedure, which was complicated by post-embolization syndrome requiring a prolonged hospitalization.
He reported discomfort in his legs related to edema, but also endorsed fatigue and progressive dyspnea on exertion. On exam he had normal vital signs and no supplemental oxygen requirement. Cardiac exam revealed moderate jugular venous distension, an irregular rhythm, and no murmurs. His lungs were clear to auscultation, and his extremities had 4+ pitting edema to the sacrum. Labs were notable for a BNP of 236 pg/mL, Na of 133 mmol/L, and Cr of 0.87 mg/dL. Chest x-ray was significant for small bilateral pleural effusions. Transthoracic echocardiography (TTE) revealed a 6.4 x 4.3 cm mass occupying nearly the entire right atrium, and extending to the inferior vena cava (IVC).
A heparin infusion was initiated to treat a presumed intracardiac thrombus or neoplasm. Venography revealed subtotal occlusion of the IVC by a mass extending from the hepatic veins into the right atrium. Biopsy of the cardiac mass confirmed poorly differentiated HCC. Cardiology, thoracic surgery, oncology, and radiation oncology determined that the patient was not a candidate for surgical resection or chemotherapy due to his comorbidities. Palliative radiation was considered, but the patient’s symptoms acutely worsened before it could be initiated. Given his rapid decompensation, the patient elected to pursue hospice care. He was transitioned to a local hospice facility and died twelve days later.
Discussion:
Congestive heart failure is frequently encountered by hospitalists. While ischemic heart disease and systemic hypertension are the most common causes of heart failure, this case illustrates the importance of considering a broad range of etiologies. HCC is a common malignancy, and has been noted to have cardiac involvement in up to 6.3% of cases. For this patient, direct extension of the primary HCC lesion progressed to consume nearly the entire right atrium leading to severely impaired right ventricular filling and symptomatic heart failure. Patients with intracardiac involvement from direct extension or metastatic spread of malignancy require a multidisciplinary approach to deliver optimal care.
Conclusions:
The IVC and right atrium are under-recognized sites of metastatic spread of several common cancers, including HCC. As atrial involvement portends a poor prognosis, early identification can significantly alter patient management and potential treatment options. Echocardiography should be considered in patients with malignancy and unexplained heart failure symptoms.