Right atrial mass in a patient with hepatocellular carcinoma and Budd-Chiari syndrome.

A 62-year-old male patient presented with a two-week history of weakness and shortness of breath. On physical examination, blood pressure was 120/80 mm Hg and pulse rate 92 bpm. The electrocardiogram showed sinus tachycardia. He was known to have a hepatitis B virus carrier. In transthoracic echocardiography, we observed right atrial mass. Transesophageal echocardiography (TEE) showed about 52×42 mm large mass in the right atrium (RA) originating from the inferobasal wall, with close contact to the inferior vena cava (Fig. 1, Video 1). The mass was inhomogeneous and pedunculated. Contrast-enhanced tomography (CT) and magnetic resonance imaging (MR) was performed because of the suspicion of metastatic disease. CT scan revealed a 74×72×67 mm mass in the liver, which MR confirmed a hepatocellular carcinoma (HCC) with extensive tumoral thrombus to the RA. As the mass filled the RA, and the general status of the patient was good, surgical excision was planned. After giving informed consent, the patient underwent surgery, and the tumoral thrombus was removed. The tumor was a fragile, soft but occasionally hard, yellow-grey colored, thrombus-like mass. Inferior vena cava (IVC) was not totally occluded, and there was thrombus in the hepatic veins. Pathology reported a hepatocellular carcinoma invading to the right atrial wall. Due to HCC, the patient was referred to an oncology center, and chemotherapy was started thereafter.

FIGURE 1

(A) Transesophageal echocardiography demonstrates an atrial mass measuring 52×42 mm in the right atrium (yellow arrow). (B) 3D transesophageal echocardiography with the arrow depicting right atrial mass. (C) Abdomen MR shows the hepatic mass (asterix). (D) Coronal contrast-enhanced computed tomography showing the (yellow arrow) extension of the tumor-thrombus to the right atrium.

Video 1. 3D transesophageal echocardiography demonstrating the right atrial mass (The border of the mass in the right atrium was shown with dashed lines).

Here, we describe a rare case of Budd-Chiari Syndrome (BCS), presenting with HCC, tumoral thrombus in the RA extending into the IVC. The BCS is a rare disorder characterized by a hepatic venous outflow obstruction anywhere between the hepatic veins and the entrance of the IVC into the right atrium [1-3].