P2505 - A Rare Association of Pulmonary Embolism and Hepatocellular Carcinoma in the Setting of Multiple Tumor Thrombi: A Case Report

Ayman Elawad, MD, Mukarram Jamat Ali, MD, Ikechukwu Eze, MD, Gagan P. Singh, MD, Justice Arhinful, MD, Laiyemo Adeyinka, MD, MPH, FACG
Howard University Hospital, Washington, DC

Introduction: Acute pulmonary embolism (PE) rarely develops in patient with Hepatocellular Carcinoma (HCC) and carries a poor prognosis. The growth of tumor thrombus into IVC and the RA is rare and accounts for 1-4% of the HCC cases. Here, we present a case of a 67-year-old male who presented with bilateral pulmonary embolism (PE) and multiple tumor thrombi in IVC and RA leading to a diagnosis of HCC.

Case Description/Methods: A 67-year-old male with a past medical history of coronary artery disease status post coronary artery bypass grafting (CABG) presented with non-exertional dyspnea. Initial labs showed elevated ALT (240 IU/L), AST (155 IU/L), alkaline phosphatase (239 IU/L), and total bilirubin (1.7 mg/dL), and chronic hepatitis C (HCV RNA 6.37 log IU/ml). Given the history of CABG and presentation with dyspnea, transthoracic echocardiography was obtained, which revealed a 3.3 x 2.8 cm mass in the RA, likely thrombus; and two thrombi 2.1 x 4.0 cm and 1.7 x 2.4 cm in the IVC. On further questioning, the patient endorsed mild a history of generalized fatigue, and weight loss. Ultrasound of the liver showed a large mass 2.8 x 6.3 x 2.8 cm within the intrahepatic portion of the IVC and a contiguous isoechoic hepatic mass 4.4 cm in the right lobe of the liver. CT Angiography with and without contrast revealed bilateral PEs and a hepatic tumor mass 4.2 x 4.8 cm extending into IVC and RA. Surprisingly, tumor markers including alpha-fetoprotein were negative. Biopsy demonstrated a well-differentiated HCC. Given the high risk associated with the procedure, no surgical intervention was recommended. Currently, the patient is on guideline directed immunotherapy for stage IV HCC.

Discussion: Association of acute PE with HCC complicated with TT in IVC and RA is rare and is associated with poor prognosis, likely due to the difficulty of early diagnosis. We have described this case presenting with symptoms concerning for heart failure and PE. Ultimately, an initial cardiac workup led us to the diagnosis of PE in the setting of HCC associated with tumor thrombi in IVC and RA. Clinicians need to be cognizant of rare but fatal presentation of HCC in high-risk patients. Currently, there are no diagnostic or treatment guidelines for the management of complicated HCC patients. This case underscores the importance of early diagnoses and management of complications associated with advanced HCC.



Disclosures:


Ayman Elawad, MD, Mukarram Jamat Ali, MD, Ikechukwu Eze, MD, Gagan P. Singh, MD, Justice Arhinful, MD, Laiyemo Adeyinka, MD, MPH, FACG. P2505 - A Rare Association of Pulmonary Embolism and Hepatocellular Carcinoma in the Setting of Multiple Tumor Thrombi: A Case Report, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.