A bridge between the liver and the heart

A 76-year-old man was referred to the emergency department due to jaundice. Laboratory tests showed increased liver enzymes (AST 400 U/L, and ALT 380 U/L) and bilirubin 2.4 mg/dl, associated with low platelets (40000 x 10⁹/L). Due to the known history of chronic liver disease, a computed tomography (CT) was requested.

A multiphasic study of the abdomen was acquired. In the unenhanced phase (Figure 1), an inhomogeneous area of liver parenchyma was appreciable in segments 4, 7, and 8. After contrast injection, a large hyperattenuating lesion on the arterial phase was appreciable (Figure 2), growing into the middle and right hepatic veins and extending into the inferior vena cava and right atrium. A similar large lesion was also depictable in segment 5 (Figure 3). Moreover, tissue with analogous hypervascularization was present in the portal vein branches (Figure 3). On the portal venous phase, all lesions and tissue in the portal vein branches showed hypoattenuating behaviour (Figures 4, 5, and 6). Main arterial vessels were recognizable, while the main portal trunk was completely involved by the pathological tissue (Figure 7).

Hepatocellular carcinoma (HCC) is the most common malignancy in patients with chronic liver disease [1]. Its classical appearance on contrast-enhanced cross-sectional imaging includes the hypervascularization on the arterial phase (wash-in) and the hypoattenuating appearance on portal-venous or delayed phase(s) (wash-out), as in the presented case [2].

HCC is the most common liver malignancy that can spread through liver vessels, in particular the portal vein. LI-RADS classifies this special pathological entity as tumor-in-vein (LR-TIV) [3]. However, due to its vessel avidity, it can spread also in other vascular structures, in particular hepatic veins or, more rarely, in the inferior vena cava, as in our case [4,5].

The quick diagnosis of HCC is important to better address patients to the best-fitted management, according to the Barcelona Clinic Liver Cancer (BCLC) prognosis and treatment strategy [6], and to eventual emergent surgical or interventional procedures to avoid complications, for example, cardiac ones, as in the case of our patient [7]. In this setting, contrast-enhanced CT can help depict vascular invasion, especially into the portal trunk or in the hepatic veins. On the other hand, also ultrasounds, thanks to colour Doppler, can evaluate portal and hepatic vein patency [8].

The diagnosis of this case is not challenging, considering that the typical imaging features of HCC are present. Its particularity relies on the growth into the inferior vena cava and in the right atrium, thus leading to possible cardiac acute complications [9].

Considering the comorbidities and the high risk of peri-procedural complications, the patient was addressed to medical therapy (Sorafenib), to under-stage the primary liver malignancy and evaluate other strategies as a second step [10].

To allow a complete and rigorous clinical, surgical, and interventional evaluation of patients with HCC, it's important to always keep in mind that this tumour has an exceptional avidity for hepatic vascular structures and that their involvement can directly impact the management.