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Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 24-26

Rare presentation of hepatocellular carcinoma

Department of Medical Gastroenterology, Government Stanley Medical College, Chennai, Tamil Nadu, India

Date of Submission02-Apr-2021
Date of Decision09-Jul-2021
Date of Acceptance12-Aug-2021
Date of Web Publication01-Jan-2022

Correspondence Address:
Revathy Shanmugam Marimuthu
Department of Medical Gastroenterology, Government Stanley Medical College, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ghep.ghep_13_21

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Hepatocellular carcinoma (HCC) is the most common primary liver tumor with high mortality worldwide. Tumor thrombus (TT) is common in advanced HCC. Portal vein is most commonly involved followed by hepatic vein involvement. Formation of tumor thrombosis is considered a poor prognostic factor. Here, we report a rare case of HCC in a young male with TT extending from the inferior vena cava reaching up to the right atrium without affecting the hemodynamic status.

Keywords: Hepatitis B, hepatocellular carcinoma, right atrium, tumor thrombus

How to cite this article:
Marimuthu RS, Bavanandam S, Manimaran M, Shanmugam C, Sathya G, Yasid M. Rare presentation of hepatocellular carcinoma. Gastroenterol Hepatol Endosc Pract 2022;2:24-6

How to cite this URL:
Marimuthu RS, Bavanandam S, Manimaran M, Shanmugam C, Sathya G, Yasid M. Rare presentation of hepatocellular carcinoma. Gastroenterol Hepatol Endosc Pract [serial online] 2022 [cited 2022 Sep 30];2:24-6. Available from: http://www.ghepjournal.com/text.asp?2022/2/1/24/334693

  Introduction Top

Primary malignant tumors of the liver include hepatocellular carcinoma (HCC), cholangiocarcinoma, hemangiosarcoma, angiosarcomas, and hepatoblastoma. HCC accounts for more than three-fourth of primary malignant tumors of the liver[1] and is often associated with intravascular tumor thrombosis with poor outcome despite availability of multimodal treatment options.[2],[3]

We report a case of HCC associated with extensive intravascular invasion with tumor thrombus up to the right atrium (RA).

  Case Report Top

A 36 year old male presented with insidious onset of abdominal pain of 2 month duration, localized to the right hypochondrium, of varying severity associated with generalized weakness and easy fatigability. He is a known case of chronic hepatitis B diagnosed 10 years ago, on regular treatment, on tablet entecavir 1 mg once daily but lost follow up 12 months prior to presentation. General examination was unremarkable. Systemic examination showed palpable, hard nodular, nontender liver with a span of 18 cm. There was no arterial bruit.

Investigation done a year ago showed HBsAg, HBeAg positivity with hepatitis B virus DNA 1283 IU/L, alanine transaminase 28 IU/L (HBsAg/HBeAg positive chronic infection) and USG abdomen showed liver size of 15.2 cm, regular margins, normal architecture, no evidence of any focal lesion.

On presentation, blood investigations like complete hemogram, renal function test were normal and Liver function test showed AG reversal with normal bilirubin and enzymes.

Triple phase computed tomography (CT) abdomen showed hepatomegaly with a large lobulated heterogeneous lesion of about 14 cm × 8 cm, enhancing in the arterial phase and relative washout in portal venous phase, with extensive tumor thrombus (TT) in the portal vein (PV) and its branches, left, middle hepatic veins, intra and suprahepatic inferior vena cava (IVC) extending up to RA, with underlying cirrhosis and splenomegaly. Positron emission tomography (PET)-CT showed increased tracer concentration in the mass in the left lobe of the liver, IVC, left PV, and RA with pulmonary metastasis [Figure 1].
Figure 1: Fluorodeoxyglucose positron emission tomography–computed tomography showing increased tracer concentration in (A – liver, B – inferior vena cava, C – right atrium. (FDG PET - fluorodeoxyglucose positron emission tomography)

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CT-guided core (needle) liver biopsy from the left lobe showed malignant epithelioid neoplasm with clear cell features and sclerosis, possibly HCC [Figure 2]a and [Figure 2]b. Stain for mucin was negative. Reticulin stains showed loss of reticulin fibers amid the tumor cells. Immunohistochemistry study showed arginase 1: Positive [Figure 3]a and [Figure 3]b.
Figure 2: H- and E-stained sections of liner cores from the liver show (a) sheets of malignant cells arranged in a trabecular pattern in a fibrocollagenous stroma. (b) These cells are polygonal in shape and have round-to-oval hyperchromatic nuclei with pale eosinophilic to clear cytoplasm

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Figure 3: Immunohistochemistry of hepatocellular carcinoma. (a and b) Arginase positivity, (c) hepatocyte paraffin-1 positivity

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Hepatocyte paraffin 1: Positive [Figure 3]c. Glypican 3: Positive and Cytokeratin: CK7, CK19, CK20 negative confirming the diagnosis of HCC.

Since our patient belonged to Barcelona clinic liver cancer Stage C, locoregional therapies such as transarterial chemoembolization (TACE) and surgical resection were not contemplated and hence managed with systemic therapy with sorafenib, however, the patient died on the 34th day due to sustained ventricular tachycardia.

  Discussion Top

HCC has a high risk of tumor thrombosis (44%–62.2%), mostly in the portal venous system. However, involvement of hepatic venous outflow tract by tumor thrombosis is a rare phenomenon. Involvement of IVC and RA was reported in 1.4%–4.9% of cases worldwide.[4]

Clinical presentation of HCC with IVC/RA TT may present with common symptoms of HCC like abdominal pain, pedal edema, palpable mass, with vascular complications like acute or subacute Budd–Chiari syndrome, dyspnea, right heart failure and pulmonary embolism, however, our patient presented with abdominal pain and palpable mass, without any features of right heart failure. Although HCC with TT was diagnosed by Doppler and contrast-enhanced computed tomography abdomen, 18F-fluorodeoxyglucose PET provided valuable information in staging and planning management. Various treatment options for HCC with vascular thrombosis include TACE, transarterial chemoinfusion, transarterial radioembolization, hepatic artery and PV double interventional therapy, and systemic therapy. Yet, the optimal management has not been standardized. As our patient had pulmonary metastasis, he was not a candidate for locoregional therapy or surgical modality and was treated with sorafenib. The overall 5-year survival for HCC is estimated around 20%. The median survival period for HCC with PV thrombosis is 2.7 months only and prognosis is even more worse with IVC and right atrial involvement.

Thus, it is imperative to keep patients under close follow-up and surveillance for HCC, especially in patients with chronic hepatitis B or C, and this case is being presented to highlight the rare presentation of HCC with vascular complication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rawla P, Sunkara T, Muralidharan P, Raj JP. Update in global trends and aetiology of hepatocellular carcinoma. Contemp Oncol (Pozn) 2018;22:141-50.  Back to cited text no. 1
Quencer KB, Friedman T, Sheth R, Oklu R. Tumor thrombus: Incidence, imaging, prognosis and treatment. Cardiovasc Diagn Ther 2017;7:S165-77.  Back to cited text no. 2
Le Treut YP, Hardwigsen J, Ananian P, Saïsse J, Grégoire E, Richa H, et al. Resection of hepatocellular carcinoma with tumor thrombus in the major vasculature. A European case-control series. J Gastrointest Surg 2006;10:855-62.  Back to cited text no. 3
Xia Y, Zhang J, Ni X. Diagnosis, treatment and prognosis of hepatocellular carcinoma with inferior vena cava/right atrium tumor thrombus. Oncol Lett 2020;20:101.  Back to cited text no. 4


  [Figure 1], [Figure 2], [Figure 3]


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