Advanced Hepatocellular Carcinoma with Subtotal Occlusion of the Inferior Vena Cava and a Right Atrial Mass

Hepatocellular carcinoma usually metastasizes to regional lymph nodes, lung, and bones but can rarely invade the inferior vena cava with intravascular extension to the right atrium. We present the case of a 75-year-old man who was admitted for generalized oedema and was found to have advanced HCC with invasion of the inferior vena cava and endovascular extension to the right atrium. In contrast to the great majority of hepatocellular carcinoma, which usually develops on the basis of liver cirrhosis due to identifiable risk factors, none of those factors were present in our patient. 1. Introduction Primary hepatocellular carcinoma (HCC) is a quite uncommon tumor in North America and Western Europe but is the fifth most common cancer worldwide and the third leading cause of cancer-related death [1, 2]. Most cases of HCC occur in patients with chronic liver disease or preexisting liver cirrhosis. Common causes for liver cirrhosis are chronic alcoholic liver disease or chronic viral hepatitis due to hepatitis B virus or hepatitis C virus infection [2]. Other risk factors for the development of HCC are metabolic diseases like hemochromatosis or alpha1-antitrypsin deficiency, autoimmune liver diseases (autoimmune hepatitis, primary biliary cirrhosis), and aflatoxin exposition [1, 3–5]. The incidence of HCC shows striking variations between different geographic regions and among different racial and ethnic background within the same country, suggesting a crucial role of genetic and environmental factors in the pathogenesis of HCC [6, 7]. HCC is an aggressive tumor and can show extensive metastazation. It usually metastasizes to regional lymph nodes, lung, or bone but sometimes shows invasion of major blood vessels with endovascular extension [8, 9]. In this report, we present the rare case of an advanced hepatocellular carcinoma with invasion of the inferior vena cava and intravascular extension to the right atrium in a patient without any preexisting liver disease. 2. Case Report A 75-year-old Caucasian man presented to the emergency room of our hospital for dyspnea and new onset generalized oedema rapidly progressing over one week. The patient was known for stable coronary artery disease, paroxysmal atrial fibrillation with oral anticoagulation, chronic obstructive bronchitis, hypertension, and dyslipidemia. He had stopped smoking 3 years before, had no history of alcoholism, and had never taken illegal drugs. Vital signs at presentation were stable. The patient was afebrile and not in respiratory distress. Physical examination revealed generalized oedema