Hepatocellular carcinoma with right atrial tumor thrombus

An 89-year-old man with history of coronary artery disease, atrial fibrillation on warfarin, and recently diagnosed primary biliary cirrhosis of unclear etiology presented to the emergency department at the behest of his daughter with 2 weeks of diarrhea, abdominal discomfort, and progressive lower extremity edema. He was a retired engineer with excellent cognitive function. Physical examination was notable for an irregularly irregular heart rhythm and bilateral lower extremity pitting edema. His abdomen was soft and non-tender, and no masses were palpated. Laboratory studies showed a creatinine level of 1.1 mg/dL, potassium 5.8 mmol/L, AST 74 U/L, total bilirubin 1.8 mg/dL, albumin 2.9 g/dL, INR 4.5, troponin 0.01 ng/mL, and BNP 497 pg/mL. A point-of-care ultrasound (PoCUS) examination to assess the etiology for his abdominal discomfort and lower extremity edema demonstrated ascites and a mobile right atrial mass (Figure 1). The patient was admitted with a diagnosis of anasarca for diuresis and potassium monitoring. However, the PoCUS identification of a right atrial mass led to subsequent imaging, including computed tomography (CT) and magnetic resonance imaging (MRI), where an infiltrative liver mass compatible with hepatocellular carcinoma as well as tumor thrombus in the inferior vena cava (IVC) and right atrium were discovered (Fig. 2, Fig. 3, respectively). Previous chest CT imaging from two months earlier did not demonstrate these findings.