Hepatocellular Carcinoma With Cardiac Metastasis Presenting as Presyncope

Hepatocellular carcinoma (HCC) is a common primary tumor of the liver that is highly invasive and can even invade the portal and hepatic veins in later stages. In this report, we present one such rare case of HCC invading the right atrium. A 69-year-old male patient recently diagnosed with HCC secondary to hepatitis C presented to the hospital after experiencing an episode of near syncope. On examination, he had a distended abdomen consistent with ascites with positive fluid shift, elevated jugular vein distention (JVD), and bilateral pitting lower extremity edema. He had an elevated alkaline phosphatase of 298 U/L (34-104) with a total bilirubin of 2.7mg/dL (0.3-1) and a D-dimer of 1.67ugFEU/mL (<0.5). On admission, CT scan of the chest and abdomen showed extensive invasion of the liver by neoplasm and a large 7 cm mass extending from the intrahepatic inferior vena cava to the right atrium. A transthoracic echocardiogram confirmed this, which also better visualized the cardiac anatomy. Due to the extent of the disease, the patient ultimately opted for palliative care. The prognosis for patients with HCC who have an invasion of the right atrium remains dismal, with a median survival of only five months. Surgical extraction of the thrombus with resection of the tumor, liver transplantation, and systemic chemotherapy are some of the treatment modalities employed in such patients; however, historically, the median survival has remained only a few months. With the advent of new techniques and a better understanding of the disease, this seems to be changing and a curative approach can now be considered.