Right Atrial Metastasis Nine Years after Initial Hepatocellular Carcinoma: A Case Report

Background: Hepatocellular carcinoma HCC has an incidence of 10/100000 in the European population, and the fifth most common cancer in men worldwide. Nevertheless intra-cardiac metastasis of HCC is rare, with an incidence of less than 6% at autopsy of HCC-diagnosed patients. Diagnosis can be very challenging, especially in the absence of specific cardiac symptoms. We report an unusual case of HCC with a large infiltration into the right atrium (without inferior vena cava involvement) 9 years after the initial diagnosis of HCC.

Case Report: In January 2017, a 66- year old male known to have a previous HCC, presented with shortness of breath and angina pectoris. He was diagnosed with coronary artery disease and was referred for coronary artery bypass grafting (CABG). Preoperative transthoracic echocardiography showed a mobile solid tumor at the coronary sinus, and hence, the suspected diagnosis of myxoma. In 2008 this patient underwent curative partial hepatectomy for HCC. Annual follow-ups showed no recurrence, nor metastasis of the primary carcinoma. During CABG, the tumor was resected and was sent for histopathological examination. Histopathology reported a right atrial metastatic tumor of HCC. Oncological staging, including liver ultrasound, and cardiac and cerebral Magnetic resonance imaging (MRI) showed another suspected metastatic mass in the ventricular septum.

Conclusion: There is no known published literature reporting infiltration of the intra-atrial and ventricular septum nine years after initial diagnosis of HCC. Patients with a known history of HCC with no recurrence, nor metastasis of the primary carcinoma even many years after the initial therapy, should always be suspected for intra-cardiac metastasis when presenting with specific cardiac symptoms. Complete oncological staging is advised to facilitate multidisciplinary management.