Yasunobu Dazai MD; Toshikazu Katoh ...

Yasunobu Dazai MD; Toshikazu Katoh MD; Ichijiro Katoh MD; Shouzo Sueda MD; and Ryoichi Yoshida MD

A rare case of hepatocellular carcinoma (HCC) was complicated by the agency of metastatic right atrial tumor thrombus (RATT), which diminished in size onward echocardiograms and showed necrotic change upon computed tomography (CT) scans after chemoembolization therapy.

and nothing else four cases of metastatic RATT complicating HCC and bring to lighted echocardiographically were found in a review of the English literature.[1,2] We report the echocardiographic and CT changes of RATT after chemoembolization therapy using an oily suspension of iodized oil (Lipiodol) and anticancer drugs

CASE REPORT

A 42-year-old man existinged with a family history of liver disease and HCC He had a two-month history of right hypochondralgia and abdominal fullnes Clinical examination revealed mild jaundice and ascites. Anemia, spider nevi and palmar erythema were not seen Auscultation of the heart revealed no abnormalities, and the relations pressure was 142/86 mm Hg The heart rate was 78 beats for minute. Diminished vesicular breathing hardys were heard in the right lower lung field. The superficial veins of the thoracoabdominal region were markedly dilated. The liver was nodular, hard and enlarged to 5 cm below the right costal margin. The [i]hypochondriasis[/i] was enlarged to 5 cm below the left costal margin. Leg edema was present

A chest x-ray film showed a small right pleural effusion, and ventricular premature contractions were place on the ECG. Alphafeto protein was extremely high (743800 ng/ml) Serum glutamate oxaloacetic transaminase (496-U) serum glutamate pyruvate transaminase (66K-U) lactate dehydrogenase (542W-U) total bilirubin (24 mg/dl) and alkaline phosphatase (160K-A) were elevated. The viral marker experiments showed the patient to be an HB virus carrier with negative HBe antigen.

Abdominal echogram favored HCC of the right hepatic lobe with portal vein tumor thrombus. The upper gastrointestinal x-ray series and barium enema were normal. The CT scan (Fig 1A) upon admission revealed a broad cheap density area with necrosis of the right hepatic lobe, tumor within the inferior vena cava (IVC) and the right atrium (RA), and dilatation of the azygos vein. brace dimensional echocardiography (Fig 2) onward admission revealed an immobile right atrial tumor lead into each othered to tumor within the IVC, with a fine granular repercussion of sound pattern. The right atrial tumor showed a layered be sounded back pattern on M-mode echocardiography. Selective celiac angiography (Fig 3) showed tumor sailing crafts of the right hepatic lobe typical of HCC The threads and streaks sign, which indicates feeder tubes of the tumor thrombus derived from the main tumor, was observ from the hepatic vein to the IVC and RA. The right ramus of the portal vein was completely cloged on portography. Immobile tumor of the IVC, a filling lack of the RA, and markedly lay opened upward collateral veins were set up on inferior cavography. The patient was then diagnosed as having HCC complicated on the secondary Budd-Chiari syndrome, appropriate to true tumor thrombus of the venous scheme and was treated with chemoembolization therapy using an oily suspension of Lipiodol (10 ml) doxorubicin (Adriamycin) (30 mg) and mitomycin C (10 mg)

After therapy, the ascites, pleural effusion, and dilated superficial veins resolv Liver function was markedly improved and alphafeto protein decreased to 315220 ng/ml forward CT scan taken 14 days after the therapy (Fig 1B) necrosis of the tumor thrombus within the IVC and RA was originate Two-dimensional echocardiography 55 days after the therapy (Fig 4) showed diminished RATT forward multiple scannings, but the internal reverberate pattern of the tumor thrombus was scarcely altered. Seven month after therapy, the patient died with respiratory and hepatic failure. Anticoagulation therapy was not performed, and obvious pulmonary embolism was not observ either symptomatically or roentgenographically from one extremity to the other of his course.

DISCUSSION

In spite of the progres of therapy for HCC when it is complicated by means of RATT, the prognosis has not improved.[3] Lung metastasis is far higher in HCC complicated on RATT than in cases without it.[4] The particular complications reported for RATT are pulmonary infarction to be ascribed to separation of the tumor thrombus,[5] the ball valve thrombus syndrome[6] and the secondary Budd-Chiari syndrome[7] Therefore, the antemorten diagnosis of RATT is important.

Diagnostic regularitys for the RATT associated with the HCC include echocardiography,[1,2] angiography,[8] and radioisotope scintigraphy.[9] However, no echocardiographic changes of the tumor thrombus before and after transarterial embolization therapy have been reported previously. This is the first report of of the like kind changes. In our case, the tumor within the IVC and RA was not embolism, yet the true tumor thrombus because of selective celiac angiographic and inferior cavographic findings, and the diminishing of the authentic tumor thrombus after chemoembolization therapy was clearly finded by echocardiography, but necrosis of the tumor thrombus shown by dint of CT was barely evident forward echocardiography. Though the mechanism of the diminution of RATT is idea to be necrosis and fragmentation, fragmentation is unlikely because a pulmonary embolic incident was not detected clinically from beginning to end his course.