JOURNAL OF COMMUNITY HOSPITAL INTERNAL MEDICINE PERSPECTIVES
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CLINICAL IMAGING
A case of right atrial thrombus secondary to hepatocellular carcinoma Sushil Ghimire, MD1, Smith Giri, MD2*, Mohamed Morsy, MD2, Inyong Hwang, MD2 and Shadwan F. Alsafwah, MD, FACC2 1
Department of Medicine, Reading Health System, Reading, PA; 2Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
*Correspondence to: Smith Giri, Department of Medicine, University of Tennessee Health Science Center, 956 Court Avenue, Room H314, Memphis, TN 38163, USA, Email: [email protected] Received: 29 February 2016; Accepted: 22 April 2016; Published: 6 July 2016
67-year-old African American male with a past medical history of hypertension and seizure disorder presented with a week history of abdominal pain, poor appetite, and nausea. The patient had also noticed bilateral leg swelling for the last several weeks that was worse toward the end of the day and resolved upon propping up his legs. He has a history of heavy alcohol use as well as 20 pack-year history of smoking. At presentation, he was afebrile with stable vital signs. Physical examination revealed a thin appearing male in no apparent distress. Scleral icterus was present. Lung and heart examination was within normal limits. Abdominal examination revealed a vague right upper quadrant mass with no tenderness or guarding/rigidity. A complete blood count was within normal limits. Comprehensive metabolic panel was notable for mildly elevated bilirubin at 1.1 mg/dl, elevated aspartate aminotransferase at 220 IU/ml, alanine aminotransferase at 34 IU/ml, and alkaline phosphatase at 138 IU/ml. A computed tomography of the abdomen showed a large invasive, poorly marginated, irregularly enhancing, 14-cm mass occupying the right lobe of the liver with tumoral invasion of the inferior vena cava and right atrium. A subsequent magnetic resonance imaging of the abdomen showed a 15-cm right liver mass with features suggestive of hepatocellular carcinoma. Alfa-fetoprotein was mildly elevated at 10.1 ng/ml. Further evaluation with a transthoracic echocardiography revealed a right atrial mass 23 cm in diameter along with Inferior Venacava (IVC) dilation and obstruction (Fig. 1 and Video 1). The patient was deemed to be a nonsurgical candidate based on the vascular spread of his malignancy. He was followed up in the hematologyoncology clinic with an intention of starting systemic chemotherapy with sorafenib, given his excellent performance status.
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Fig. 1. Transthoracic echocardiographic image (short axis view) showing large right atrial mass from tumor extension in the patient (shown by arrow).
Video 1. Transthoracic echocardiographic video clip (apical four-chamber view) showing large right atrial mass from tumor extension in the patient.
Journal of Community Hospital Internal Medicine Perspectives 2016. # 2016 Sushil Ghimire et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), permitting all noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6: 31443 - http://dx.doi.org/10.3402/jchimp.v6.31443
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(page number not for citation purpose)
æ
CLINICAL IMAGING
A case of right atrial thrombus secondary to hepatocellular carcinoma Sushil Ghimire, MD1, Smith Giri, MD2*, Mohamed Morsy, MD2, Inyong Hwang, MD2 and Shadwan F. Alsafwah, MD, FACC2 1
Department of Medicine, Reading Health System, Reading, PA; 2Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
*Correspondence to: Smith Giri, Department of Medicine, University of Tennessee Health Science Center, 956 Court Avenue, Room H314, Memphis, TN 38163, USA, Email: [email protected] Received: 29 February 2016; Accepted: 22 April 2016; Published: 6 July 2016
67-year-old African American male with a past medical history of hypertension and seizure disorder presented with a week history of abdominal pain, poor appetite, and nausea. The patient had also noticed bilateral leg swelling for the last several weeks that was worse toward the end of the day and resolved upon propping up his legs. He has a history of heavy alcohol use as well as 20 pack-year history of smoking. At presentation, he was afebrile with stable vital signs. Physical examination revealed a thin appearing male in no apparent distress. Scleral icterus was present. Lung and heart examination was within normal limits. Abdominal examination revealed a vague right upper quadrant mass with no tenderness or guarding/rigidity. A complete blood count was within normal limits. Comprehensive metabolic panel was notable for mildly elevated bilirubin at 1.1 mg/dl, elevated aspartate aminotransferase at 220 IU/ml, alanine aminotransferase at 34 IU/ml, and alkaline phosphatase at 138 IU/ml. A computed tomography of the abdomen showed a large invasive, poorly marginated, irregularly enhancing, 14-cm mass occupying the right lobe of the liver with tumoral invasion of the inferior vena cava and right atrium. A subsequent magnetic resonance imaging of the abdomen showed a 15-cm right liver mass with features suggestive of hepatocellular carcinoma. Alfa-fetoprotein was mildly elevated at 10.1 ng/ml. Further evaluation with a transthoracic echocardiography revealed a right atrial mass 23 cm in diameter along with Inferior Venacava (IVC) dilation and obstruction (Fig. 1 and Video 1). The patient was deemed to be a nonsurgical candidate based on the vascular spread of his malignancy. He was followed up in the hematologyoncology clinic with an intention of starting systemic chemotherapy with sorafenib, given his excellent performance status.
A
Fig. 1. Transthoracic echocardiographic image (short axis view) showing large right atrial mass from tumor extension in the patient (shown by arrow).
Video 1. Transthoracic echocardiographic video clip (apical four-chamber view) showing large right atrial mass from tumor extension in the patient.
Journal of Community Hospital Internal Medicine Perspectives 2016. # 2016 Sushil Ghimire et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), permitting all noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6: 31443 - http://dx.doi.org/10.3402/jchimp.v6.31443
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