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A 76 year old man was admitted with a four month history of progressive swelling of both legs and abdominal distension. He was icteric with bilateral pitting oedema to both groins. His abdomen was distended with prominent superficial vasculature and evidence of ascites. The jugular venous pressure was not raised. The chest x ray showed a normal cardiac silhouette with clear lung fields. An ultrasound scan revealed a well demarcated mass of 10 cm diameter within the right lobe of the liver. Initial blood tests revealed an elevated bilirubin of 41 μmol/l but normal α fetoprotein at 2 kU/l (normal range 0–8 kU/l). A liver biopsy confirmed the mass to be a well differentiated hepatocellular carcinoma. Transthoracic and transoesophageal echocardiography showed a mass (5 cm × 4 cm) within the right atrium protruding from the inferior vena cava (AV, aortic valve; LA, left atrium; RA, right atrium; T, tumour). A contrast enhanced computed tomographic (CT) scan of the upper abdomen showed that the tumour extended into the inferior vena cava and was contiguous with the right atrial mass. Multiple nodes were visualised surrounding the porta hepatis. The patient received palliative treatment and died 10 months after the date of presentation. Unlike tumours originating from the kidney, it is unusual to find an hepatocellular carcinoma extending from its origin to within one of the cardiac chambers.
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