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Surgical Treatment of Hepatocellular Carcinoma with a Tumor Thrombus Invading the Right Atrium: A Case Report
Laura Veinberga1,2, Kristians Meidrops2,3, Roberts Rumba4
1Department of Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia.
Insights
Hepatocellular carcinoma with tumor thrombus in the inferior vena cava and right atrium requires complex surgery. This case demonstrates successful hepatectomy and cavo-atrial thrombectomy, offering favorable outcomes for advanced liver cancer.
Area of Science:
- Hepatobiliary Surgery
- Cardiovascular Surgery
- Oncology
Background:
- Hepatocellular carcinoma (HCC) with tumor thrombus (TT) extending into the inferior vena cava (IVC) and right atrium (RA) presents a rare but severe clinical challenge.
- This advanced stage of liver cancer is linked to a high risk of sudden death from pulmonary embolism or acute heart failure, necessitating aggressive intervention.
Observation:
- A 61-year-old male presented with symptoms indicative of advanced HCC, including a TT invading the IVC and RA.
- A multidisciplinary team convened to plan a complex surgical strategy involving both hepatobiliary and cardiovascular surgeons.
Findings:
- The patient underwent a staged surgical procedure: initial right hemihepatectomy followed by cardiopulmonary bypass for cavo-atrial thrombectomy to remove the TT.
- Postoperative recovery was stable, with discharge on the 8th day. Histopathological analysis confirmed grade 2/3 HCC, clear cell variant with vascular invasion.
Implications:
- This case highlights the necessity of interdisciplinary collaboration for managing extensive HCC with IVC/RA thrombus.
- Despite the technical complexity and high perioperative risks, combined surgical resection can achieve favorable clinical outcomes for this challenging presentation of liver cancer.
Abstract:
Up to 3% of all hepatocellular carcinomas (HCCs) present with a tumor thrombus (TT) in the inferior vena cava (IVC) and right atrium (RA). Extensive growth of HCC into the IVC and the RA is associated with a particularly poor prognosis. This clinical condition is related to a high risk of sudden death due to pulmonary embolism or acute heart failure. Therefore, a technically challenging treatment undergoing hepatectomy and cavo-atrial thrombectomy is necessary. We report a 61-year-old man presenting with right subcostal pain, progressive weakness, and periodic shortness of breath for 3 months. He was diagnosed with advanced HCC with a TT extending from the right hepatic vein into the IVC and RA. A multidisciplinary meeting with cardiovascular and hepatobiliary surgeons, oncologists, cardiologists, anesthesiologists, and radiologists was held to determine the best treatment approach. Initially, the patient underwent right hemihepatectomy. As follows, the cardiovascular stage using cardiopulmonary bypass was successfully performed, removing the TT from the RA and ICV. In the early postoperative period, the patient remained stable and was discharged on the 8th postoperative day. A morphological examination revealed grade 2/3 HCC, a clear cell variant with microvascular and macrovascular invasion. Immunohistochemical staining was positive for HEP-1, CD10, whereas negative for S100. The morphological and immunohistochemical results corresponded to HCC. The treatment of such patients requires the cooperation of various specialties. Although the approach of the surgery is extremely complex including specific technical support, as well as high perioperative risks, the result offers favorable clinical outcomes.
