Hepatocellular carcinoma mimicking an atrial mixoma

A 60-year-old female (P.G.) suffering from palpitations and dyspnoea was referred first to trans-thoracic echocardiography; then she was referred to trans-oesophageal echocardiography that indicated the presence of a right atrial mass that was classified as atrial mixoma (Supplementary material online, Movie S1). Because of the low cardiovascular risk, the patient was then referred to 64-slice Cardiac CT (CCT) to exclude the presence of obstructive coronary artery disease prior to open heart surgery. Cardiac CT showed normal coronary arteries (Panels A and B). Cardiac CT also showed the atrial mass (Panels C–F, arrowheads). The atrial mass was freely moving in the atrial cavity, but it was continuous with inferior vena cava and hepatic veins (Supplementary material online, Movies S2–S4). The mass was mixed and featured a vascularized part and a thrombotic part. Based on these early findings, the CCT investigation was immediately followed by a thoraco-abdominal CT in order to stage the disease. The final CT diagnosis was HepatoCellular Carcinoma (HCC) with ascending thrombotic infiltration of hepatic veins and inferior vena cava, extending into the right atrium (Panel G arrowheads). The patient underwent complex surgery with mixed approach (thoracic and abdominal) in an attempt to resect the hepatic mass and preserve the inferior vena cava connections. Atrio-caval thrombectomy was performed with complete clearance of the thrombus up to the right sovrahepatic-caval exit. Simultaneously, the neoplastic liver mass was removed by right hepatectomy, together with right phrenectomy and right adrenalectomy, because of a neoplastic involvement of also these structures. Pathological examination confirmed the diagnosis of HCC. The patient survived surgery and was well for 2 years. After then she died for a local recurrence of HCC. In case of cardiac masses, CT has a comprehensive ability to assess coronary arteries and thoracic anatomy. Cardiac CT findings. CT coronary angiography (Panels A and B) showed normal coronary arteries. The atrial mass was evident in the right atrium; in particular at the level of ostium of the inferior vena cava in the axial plane (Panels C and D; arrowheads) and two-chamber long axis for the right ventricle (Panels E and F; arrowheads), both in arterial (Panels C and E) and venous (Panels D and F) phases. The extended CT investigations showed the hepatic mass (Panel G; arrowheads) in the right lobe with ascending tumoural thrombosis in the inferior vena cava. Supplementary material is available at European Heart Journal online.