Hepatocellular Carcinoma with Intracardiac Involvementeradiology.bidmc.harvard.edu/LearningLab/gastro/Sung.pdf · Hepatocellular Carcinoma with ... stable hepatoma ... metastasis

Hepatocellular

Carcinoma with Intracardiac

Involvement

Anthony Sung, HMS IV

Gillian Lieberman, MD

Beth Israel Deaconess Medical Center

Outline

• Case presentation– Imaging

• Discussion– Epidemiology– Presentation– Pathology– Imaging– Prognosis

• Case summary

Anthony Sung, HMS IVGillian Lieberman, MD

Case Presentation – Paul N

• 71M with hepatocellular

carcinoma, dx

2004

• s/p

bland embolization

x2 and chemoembolization

x2

• Previous CT 2006: stable hepatoma retroperitoneal lymph nodes, IVC thrombosis

• Surveillance CT 2007…


CT –

Hepatoma

‘06 vs. ‘07

BWH/Centricity


CT – LN ‘06 vs. ‘07

BWH/Centricity


CT – Adrenals ‘06 vs. ‘07

BWH/Centricity


CT –

Heart ‘06 vs. ‘07Anthony Sung, HMS IVGillian Lieberman, MD

CT –

Heart ‘07Anthony Sung, HMS IVGillian Lieberman, MD

Case Presentation

• Asymptomatic

• Exam– Gen: WA, NAD

– VS: P 82R, BP 124/69– Abd: +HSM– CV: nl

S1S2, +S4, MSM at LLSB; JVP 12 cm

w/prominent A waves; trace edema b/l


Discussion ‐

Differential• Primary Tumor (<0.01%)

– Benign (75%)• Myxoma• Papillary fibroelastoma• Rhabdomyoma• Teratoma• Lipoma• Hamartoma• Fibroma

– Malignant• Angiosarcoma• Rhabdomyosarcoma• Fibrosarcoma• Leiomyosarcoma• Lymphoma• Mesothelioma


Discussion ‐




• Secondary Tumor (20x more

common than primary; 1.2‐18%)

– Isolated metastasis• Lung• Breast • Lymphoma• Leukemia• Esophagus• Stomach• Melanoma

– Direct extension• Kidneys• Testicules• Thyroid• Liver


Discussion ‐




• Thrombus• Aneurysm• Artifact




– Direct extension• Kidneys• Testicules• Thyroid• Liver


Discussion ‐




• Thrombus• Aneurysm• Artifact




– Direct extension• Kidneys• Testicules• Thyroid

•**Liver**


Discussion –

Epidemiology

• Hepatocellular

carcinoma is the most common primary liver cancer and fifth most common cancer in the world

• Portal vein involvement in 26‐80%; hepatic vein involvement in 11‐23%; IVC involvement in 2.5‐26%;

intracardiac

involvment

in 2.4‐6.3%• Direct extension (75%), isolated metastasis (25%)• Tse

et al: 18 consecutive candidates for resection of HCC

– intracardiac

involvement in 1 on TTE (6%) and 2 on TEE (11%)


Discussion ‐

Presentation

Finding % (# cases/# information available)

Age (average, range) 55, 8-83 (n=119)

Gender (male) 71% (119)

Symptoms (any) 91% (103/113)

Right heart failure 72% (81/113)

Abdominal pain or swelling 60% (62/103)

Dyspnea 37% (38/103)

Lower-extremity edema 63% (49/77)

Tachycardia 39% (30/77)

JVD 25% (19/77)

Abnormal heart sounds 25% (19/77)

Abnormal ECG 36% (21/58)

Elevated AFP 77% (40/52)


Discussion ‐

Pathology

Finding % (# cases/# information available)

New diagnosis of HCC 63% (52/83)

Satellite lesions 38% (45/119)

Extrahepatic, non-cardiovascular metastases 42% (50/119)

Lung metastases 35% (42/119)

Lymph node metastases 8% (9/119)

Pulmonary embolism 20% 924/119)


Discussion ‐

Imaging

• Angiography (1975)• Echocardiography (1980)• CT (1985)• Nuclear medicine (1985)

• MRI (1990)


Discussion ‐

Imagingn angiography CT echocardiogram MRI nuclear

1975-1979 4 100% 0% 0% 0% 0%1980-1984 1 100% 0% 100% 0% 0%1985-1989 13 38% 23% 92% 0% 8%1990-1994 19 37% 26% 84% 37% 5%1995-1999 10 20% 40% 70% 0% 10%2000-2004 25 12% 56% 80% 28% 0%2005-2007 6 17% 50% 83% 17% 0%


Discussion ‐

Angiography

• Celiac angiography– “thread and streaks”

• Vena cavography• Ventriculography

Dazai

et al., 1989.


Discussion ‐

Echocardiography

• Simple, fast, safe, cheap, convenient• Image myocardium and chambers• Real‐time imaging with dynamic information

about mobility and blood flow (using doppler)

• Limited views and resolution• Limited by body habitus, operator

• TEE more sensitive; however, may be contraindicated in HCC patients with varices


Discussion ‐

TEE

http://info.med.yale.edu/intmed/cardio/imaging/techniques/echo_tee/index.html


Discussion – CT

• Fast, available, high resolution• Evaluate size, location, extent of disease

(myocardial or intraluminal

invasion) calcifications, and relationship with adjacent

structures• Screening, surveillance

• Limited planes• Radiation and contrast exposure


Discussion MRI

• More expensive• Discriminate between different tissues

– Tumor has medium signal intensity on T1– Thrombus has high signal intensity on T1

• Image multiple planes• Evaluate structural and anatomical relationships, mobility of mass,

myocardial function, and blood flow

• Goldfarb et al: 20 patients with surgically‐confirmed vena caval

tumor with thrombus extension from retroperitoneal tumors– MRI identified tumor/thrombus in 100%, delineated extent in 100%– CT identified tumor/thrombus in 100%, delineated extent in 33%.


Discussion ‐

Nuclear

• Radionuclide angiography

• [67Ga]‐citrate• [111In]‐oxine labeled

platelet scintigraphy

• PET

Shyu

et al., 1989.


Discussion ‐

Survival

Palliative (n=12) Excision (n=38) Other (n=16) Overall (n=66)

Average 3.0 months 9.1 months 10.4 months 8.3 months

1 month 75% 76% 86% 77%

6 months 17% 50% 44% 42%

12 months 0% 26% 25% 21%

24 months 0% 11% 6% 8%

48 months 0% 3% 3% 3%


Discussion – Cause of Death

Palliative (n=7) Excision (n=23) Other (n=11) Overall (n=69)

Hepatic failure 85% 35% 36% 54%

Cardiac failure 14% 9% 27% 17%

Non-cardiac metastases 0% 35% 0% 12%

Sudden death 0% 9% 18% 9%

Iatrogenic 0% 9% 9% 4%

Other 0% 4% 9% 4%


Case Presentation ‐

Imaging

• Angiography• Echocardiography• CT• Nuclear medicine

• MRI


Case Presentation ‐

ImagingAnthony Sung, HMS IVGillian Lieberman, MD

Echo

http://www.med.yale.edu/intmed/cardio/echo_atlas/views/four_chamber.html

; BWH/Centricity


MRI

http://www.med.yale.edu/intmed/cardio/echo_atlas/references/coronal_view.html;

BWH/Centricity


MRI

BWH/Centricity


Gross Specimen ‘07

BWH/OR


Follow up

Echo ‘07 Echo ‘07

BWH/Centricity


Acknowledgments

• Gillian Lieberman, MD

• Joseph Loscalzo, MD

• Susan Cheng, MD

• Raul Ramirez, MD

• Eileen Scully, MD

• Nyca

Bowen


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• http://info.med.yale.edu/intmed/cardio/imaging/techniques/echo_tee/index.html

• http://www.med.yale.edu/intmed/cardio/echo_atlas/references/coronal_view.html

• http://www.med.yale.edu/intmed/cardio/echo_atlas/views/four_chamber.html


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Hepatocellular Carcinoma with Intracardiac Involvementeradiology.bidmc.harvard.edu/LearningLab/gastro/Sung.pdf · Hepatocellular Carcinoma with ... stable hepatoma ... metastasis