Background
An uncommon finding in otherwise common hepatocellular carcinoma (HCC) is metastasis to the endocardium. Frequent sites of metastasis include invasion into vascular system, lungs, bone, lymphatics and brain. However, endocardial involvement rarely develops in patients with HCC and carries a poor prognosis. Cardiac metastasis may result from hematogenous spread, direct invasion, or tumor spread via inferior vena cava to the right atrium. We report a case of a 73 year old female patient with unexpected finding of isolated endocardial metastasis from HCC to the right atrium due to HCC. Written informed consent was obtained from the patient’s family.
Materials and Methods
A 73 year old female with PMH of atrial fibrillation, CKD hospitalized for light headedness found to have AKI on CKD, UTI and right atrial masses. Physical exam revealed patient hemodynamically stable with no murmurs, jaundice, or tenderness to palpation.
Laboratory results significant for WBC 4.8, Hb 10.2, Plt 68, Cl 115, Cr 2.0, BUN 32. Coagulation shows PT 23.7, INR 2.1 (4.63 on admission), PTT 35.2. LFTs; Total bilirubin 2.2, AST 43, ALT 32, Alb 2.4. Other studies showed reactive HCV, HCV RNA quantitative 415315, gamma globulins 1.8, and normal AFP at 5.56.
Echocardiogram revealed 2-3 mobile atrial masses with greatest diameters of 3.06 and 3.45 cm. These appeared attached to the interatrial septum. Mild-moderate tricuspid valve regurgitation. LVEF normal at 65-70% with No regional wall motion abnormalities. Left and right coronary angiogram were performed and showed no significant coronary artery disease
U/S abdomen showed an ill-defined hypoechogenic liver lesion. CT chest/abdomen revealed nodular contour of the liver (highly suggestive of cirrhosis with moderate ascites). Median sternotomy with cardiopulmonary bypass and right atrial masses excision was performed and samples sent to pathology.
Results
Histopathologic examination showed a tumor arranged in trabecular pattern. The individual tumor cells showed large vesicular nuclei with prominent nucleoli and abundant amount of eosinophilic cytoplasm. Findings were consistent with poorly differentiated neoplasm on frozen section with final pathology results revealing metastatic Hepatocellular Carcinoma. The tumor cells were positive for Heppar-1 and were negative for CK7, Alpha feto protein, vimentin, actin, desmin, cytokeratin immunohistochemical stains, confirming the diagnosis.
Conclusions
Only 5% of all cardiac metastasis involve the endocardium. Usually these are larger tumors in the liver. The intracavitary lesion can lead to tricuspid obstruction or tumor emboli.. Typically culprits are renal carcinoma and hepatocellular carcinoma. Up to 40 percent of small HCCs can have normal AFP in serum.
Our case is unique in that isolated endocardial metastasis with a small primary HCC unilobar seen only on ultrasound and not CT. Our patient is recovering post operatively currently with the support of plasma and platelet transfusions. Overall prognosis is poor because of underlying cirrhosis and vascular metastasis. Targeted systemic antiangiogenic therapy and local therapy will be tried once patient recovers from surgery in addition to hepatitis C treatment may be contemplated. In conclusion, we report a rare finding of isolated metastasis of HCC to the endocardium.