HCC with tumor thrombus entering the right atrium and inferior vena cava treated by percutaneous ablation
© The Author(s). 2017
Received: 13 November 2016
Accepted: 22 February 2017
Published: 28 February 2017
In the advanced stages of hepatocellular carcinoma (HCC), a tumor thrombus (TT) can form in the portal or hepatic vein. The management of patients with advanced HCC and a TT extending into the right atrium (RA) and inferior vena cava (IVC) is extremely difficult and risky.
We report the case of a patient with HCC and a large TT (85 × 45 mm) extending into the RA through the hepatic vein and IVC, which is very rare. We performed percutaneous microwave ablation of the TT and the two intrahepatic tumors (maximum diameter, 57 mm). The treatment shrank the tumors, and the patient is in good condition and has survived for 16 months thus far. A literature review was also performed. This is the first such case to be treated with percutaneous microwave ablation.
The outcomes in this case suggest that percutaneous ablation is useful for the treatment of TT extending into the RA and IVC in patients with HCC.
KeywordsHepatocellular carcinoma Percutaneous Ablation Tumor thrombus Right atrium Case report
Hepatocellular carcinoma (HCC) is one of the most common malignant tumors and the second leading cause of cancer-related deaths . HCC is a highly progressive cancer with a high rate of metastasis. Furthermore, tumor thrombus (TT) formation in the portal or hepatic vein is common in the advanced stages of HCC . When the tumor thrombus invades the inferior vena cava (IVC) and right atrium (RA), the prognosis is usually very poor, since the condition may lead to cardiac failure or pulmonary embolization [3–5]. Furthermore, the treatment options at this stage are limited and not very effective. The general treatment of choice is major surgery with cardiopulmonary bypass, which is dangerous, risky, and expensive. In addition, many patients at this stage of HCC cannot tolerate such an operation.
We report the case of a patient with HCC associated with a tumor thrombus extending into the RA that was treated with percutaneous microwave ablation (MWA). To our knowledge, this is the first reported case in which minimally invasive percutaneous ablation was used to treat an HCC patient with a tumor thrombus in the RA.
A 73-year-old man, who had been hepatitis B virus (HBV) positive for around 40 years, was diagnosed with primary HCC and cirrhosis. He was asymptomatic at the time, and the tumor was detected during a routine examination. He was admitted to our hospital, where a physical examination revealed no abnormality. He had mild hypertension, which was well controlled. He had received no treatment for HCC before admission to our hospital.
Patients with RA tumor thrombus usually have a poor prognosis. Sudden death can occur due to right heart failure or pulmonary embolization. However, our patient refused surgical treatment. We therefore offered him the option of percutaneous MWA to which he consented.
Only 0.67–4.1% of HCC patients develop a tumor thrombus extending into the RA [6, 7]. In our patient, the accessory hepatic vein was invaded by the tumor all the way up to the RA. This is a very rare condition that carries a dismal prognosis, as it is associated with a high risk of systemic metastasis, acute pulmonary embolism, and heart failure [8–10].
The management of patients with advanced HCC and a tumor thrombus extending into the RA is difficult and risky. The prognosis is dismal if only supportive care is provided (median survival, 5 months) . Surgical extraction of the thrombus and resection of the tumor appears to be the only effective treatment option. However, this is a major open surgery that commonly requires cardiopulmonary bypass [11–16]. Moreover, the operation involves incising the subcostal arch, RA, IVC, and all the way down to the hepatic venous root site . Our patient refused surgery and preferred to undergo minimally invasive treatment. In the past, surgeons could extract only the tumor thrombus, owing to technical limitations and the post-operative survival was a mere 1–9 months (mean, 6 months) [4, 17]. With improvements in surgical techniques, it is now possible to simultaneously resect both the intrahepatic tumor and the RA tumor thrombus [18, 19]. The mean survival of patients after this operation, which involves cardiopulmonary bypass, has been reported to be 20 months (range, 18 days to 56 months) . These results indicate the benefits of surgical treatment. However, patients with advanced HCC complicated with tumor thrombus in the IVC and RA are usually elderly and may not tolerate major open surgery to extract the thrombus. More over, there is a high risk of operative failure and complications related to general anesthesia in these patients. The high expense of major operations is also a factor.
TACE does not improve survival in HCC patients with tumor thrombus . Here, we used TACE to label the tumor margins and help precisely ablate the thrombus and tumor masses. TACE and ablation therapy are minimally invasive; they do not require systemic anesthesia and can be tolerated by almost all HCC patients. Moreover, ablation therapy can be repeated to treat large tumors, multiple nodules, and tumor recurrences. This therapy has become increasingly important in the management of HCC, and is the treatment of choice in many other conditions . Therefore, we decided to attempt ablative therapy in our patient. Since MWA is known for its larger ablation volumes, shorter duration, and resistance to the heat-sink effect as compared with radiofrequency ablation, we considered that using MWA would lessen the number of puncture procedures and thus reduce the risk of bleeding and ablation failure.
The intra-operative complications in our patient were mild and transient. No vascular thrombosis related with the ablation was observed. Abundant blood flow was present to dissipate the heat generated during ablation, and thus, the IVC was protected from being damaged by thermal ablation. The post-operative biloma and bile track infection in our patient were controlled within 10 days by using drainage and medical care. The patient has thus far survived for 16 months. He is in a good condition and is being routinely followed up.
A potential severe complication of our treatment is pulmonary embolism due to dislodgement of the ablated thrombus. However, this complication was not observed in our patient and has not yet been reported in the literature.
To our knowledge, this is the first report of the use of percutaneous ablation therapy for the management of an HCC patient with a tumor thrombus in the IVC and RA. The results in this patient indicate that this treatment may have comparable efficacy to conventional open surgery with less local trauma and without the need for general anesthesia.
Percutaneous ablation therapy might represent a useful and promising therapeutic modality for HCC patients with tumor extension into the RA and IVC, including patients with advanced tumors and older patients. Large-scale clinical trials of HCC patients with RA/IVC tumor thrombosis treated with percutaneous ablation are ongoing in China.
Body mass index
Hepatitis B virus
Inferior vena cava
Transcatheter arterial chemoembolization
We adhered to CARE guidelines in this case report.
This study is supported by Beijing Natural Science Foundation (7142078), Funding for High-level Talents in Beijing Municipal Health System (2014-3-088), National Twelve-Five Key Technology Support Program (2012BAI15B08) and the National Natural Science Foundation of China (H1617/81472328).
Availability of data and materials
All data generated or analyzed during this study are included in this published article.
WL: collected all references and wrote the draft. YW: responsible for pathology. YW and WFG: collected all data of the clinical. WL and JSZ: offered the conception and design, revised and discussed the meaning of the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Ethics approval and consent to participate
Written informed consent was obtained from the patient for publication of this case report and accompanying images. You’an Hospital Ethics Committee has approved this study.
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