Vol.3, No.2, 82-85 (2011) Health
doi:10.4236/health.2011.32015
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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
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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
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84
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
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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. 1983Growth 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.