Journal of Clinical Oncology, Vol 22, No 6 (March 15), 2004: pp. 1152-1153
© 2004 American Society of Clinical Oncology.
DOI: 10.1200/JCO.2004.04.151
Unusual Sites of Metastatic Involvement
CASE 1. Right Ventricular Outflow Obstruction Caused by Metastatic Hepatocellular Carcinoma
Tzu Yu Lin,
Kuan Ming Chiu,
Chen Yen Chien,
Ming Jiuh Wang,
Shu Hsun Chu
Department of Anesthesia and Surgery, Far Eastern Memorial Hospital; and Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan.
A 45-year-old man who was a chronic carrier of hepatitis B had a diagnosis of hepatocellular carcinoma 4 years ago. He had undergone a right hepatic lobectomy and a course of transarterial chemoembolization. The patient was seen regularly and was generally well until a month ago, when he began to experience shortness of breath upon exertion. The symptoms included dizziness, shortness of breath, and exertional dyspnea which worsened progressively before the current admission. The ECG and cardiac enzymes excluded the diagnosis of myocardial ischemia, and chest radiography showed multiple small nodules throughout both lung fields. The computed tomography scan of the chest revealed a large mass in the right ventricle with multiple small pulmonary nodules (Fig 1). With the diagnosis of metastatic hepatocellular carcinoma causing severe right ventricular outflow tract obstruction, open-heart surgery was done to remove the tumor for relief of the symptoms. The intraoperative transesophageal echocardiography (Fig 2) revealed that the tumor nearly occupied the whole cavity of the right ventricle and protruded into the outflow tract during systole to obstruct the pulmonary blood flow (Fig 2). The right atrium was free from tumor. A mass measuring 9.1 x 5.6 cm was found to infiltrate into the free wall of the right ventricle (Fig 3). The right atrium and the septal leaflet of the tricuspid valve was opened (Fig 4) under cardiopulmonary bypass to remove as much of the intracardiac tumor as possible. The procedure took 30 minutes. The postoperative transesophageal echocardiography showed that the right ventricle outflow tract was patent (Fig 5). Histologic examination confirmed a diagnosis of metastatic hepatocellular carcinoma. The patient was extubated 12 hours after surgery and was discharged from the hospital 6 days later. He received another two courses of chemotherapy and was well 3 months later.
The incidence of hepatocellular carcinoma in Taiwan is higher than in western countries. The higher prevalence of hepatitis B carriers in Taiwan, along with its association with chronic hepatitis, cirrhosis of the liver, and hepatocellular carcinoma, may account for the higher incidence of liver cancer in this country [1,2]. Right ventricular metastasis is extremely rare in cases of hepatocellular carcinoma. It was only reported in four other cases during the past 20 years [3,4]. Earlier, a case of carcinoma of the liver with sudden death as a result of cardiac involvement was reported [5]. The first echocardiographic diagnosis of right ventricle metastasis of hepatocellular carcinoma was reported in 1980 [6]. To the best of our knowledge, our case is the first patient who was treated with open-heart surgery to remove a hepatocellular carcinoma that had metastasized to the right ventricle. Successful treatment by transcoronary chemoembolization in a patient with right ventricle metastasis of hepatocelluar carcinoma was published in 2000 [3]. However, in our case, the huge size of the tumor and its extensive infiltration of the free wall of the right ventricle raised the concern that myocardial necrosis and free wall rupture might have developed if transcoronary chemoembolization was carried out. The surgical resection of the isolated intracardiac tumor under cardiopulmonary bypass is safe and very likely to relieve symptoms and extend the life span of the patient.
Authors' Disclosures of Potential Conflicts of Interest
The authors indicated no potential conflicts of interest.
REFERENCES
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5. Culpepper AL, von Hamm E: Primary carcinoma of the liver with extensive metastasis to the right heart, and tumor-thrombosis of the inferior vena cava. American Journal of Cancer 21:355-362, 1934
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