Invasion of the cardiovascular system in childhood malignant hepatic tumors

Clinical manifestations and survival of patients with hepatocellular carcinoma and cardiac metastasis

BACKGROUND AND AIM

Antemortem diagnosis of hepatocellular carcinoma (HCC) with cardiac metastasis is uncommon. To clarify the clinical manifestation and survival of HCC patients with cardiac metastases, we initiated the present study.

METHODS

We retrospectively analyzed 48 HCC patients with metastases into cardiac cavity diagnosed antemortem. The baseline clinical characteristics, echocardiogram, treatment modality and the outcome data were collected.

RESULTS

The most common symptoms of cardiac metastasis included asymptomatic in 19 cases (39.5%), bilateral lower leg edema in 18 cases (37.5%) and exertional dyspnea in 15 cases (31.3%). The median and mean survival times from the time of diagnosis of cardiac metastasis were 102 days and 161 days, respectively. Compared with another cohort of 48 patients with age-, gender-, and stage-matched HCC patients without cardiac metastasis, the median survival in the cardiac metastasis group was similar to the control group (68 days) (P = 0.67). The cause of death was HCC in 29, hepatic failure in seven, multiple organ failure in four, gastrointestinal bleeding in three, sepsis in two, pulmonary embolism in one, respiratory failure in one, and acute myocardial infarction in one.

CONCLUSIONS

Hepatocellular carcinoma patients with cardiac metastases were in the advanced stages. These patients had limited survival from the diagnosis of cardiac metastases. The most common cause of death was related to HCC per se or the underlying liver disease. Only a few patients expired because of cardiac metastases.

Hepatoblastoma metastatic to the right atrium responding to chemotherapy alone

An 18-month-old boy presented with abdominal pain and distension. On physical examination there was a 10 x 7-cm mass in the right upper abdominal quadrant. His alpha-fetoprotein level was 175,000 IU/mL. Abdominal magnetic resonance findings revealed hepatomegaly with multiple tumor masses involving nearly all the segments of the liver (PRETEXT IV). The tumor extended through the inferior vena cava and filled 2/3 of the right atrium. Echocardiography revealed normal cardiac function. Histopathologic findings after liver biopsy were consistent with hepatoblastoma. After 6 courses of chemotherapy including cisplatin and doxorubicin (PLADO, SIOPEL protocol), the cardiac tumor regressed completely. The patient's primary tumor was then fully resected; no cardiac surgery was performed. After surgery the AFP level was 4 IU/mL and echocardiography revealed normal cardiac function with no residual tumor. The patient has been in remission for 31 months postdiagnosis.

Unresectable multifocal hepatoblastoma with cardiac extension: excellent response with HB-94 chemotherapy protocol

A 10-month-old white infant presented with abdominal distention and bilateral scrotal hernia. Imaging studies of the abdomen and thorax showed a huge liver with multiple tumor masses and calcification involving all the segments. There was thrombosis in the inferior vena cava and right atrium. alpha-Fetoprotein was 246,000 IU/mL. HB-94 chemotherapy protocol was started at once due to rapid deterioration of the patient. Surgical biopsy performed after the first IPA (ifosfamide, cisplatin, doxorubicin) course showed hepatoblastoma with macrotrabecular variant. After a second IPA course and 2 courses of carboplatin and etoposide, the boy's clinical condition was excellent with normal alpha-fetoprotein but minimal regression and increased calcification in the tumor mass. Hepatic tumor was unresectable and no surgical intervention was performed. Transplantation could not be performed because of high morbidity and mortality. Despite general agreement that complete surgical resection is the cornerstone of treatment for patients with hepatoblastoma, the patient is in remission with 100% Karnofsky score in the 43 months of diagnosis.