Right atrial tumour thrombus in hepatocellular carcinoma: a case report and literature review of anticoagulation dilemmas

Abstract

Tumour thrombus (TT) extending from the hepatic vein (HV) to the inferior vena cava (IVC) and right atrium (RA) is rare and associated with poor prognosis. The role of anticoagulation in such cases remains controversial, particularly in Child-Pugh C cirrhosis. A 55-year-old Malay male with Hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) and TT extending to the RA was initiated on apixaban due to concerns for risk of thromboembolism. The patient had Child-Pugh class C cirrhosis with a MELD score of 20. Apixaban treatment was not associated with any bleeding complications or any survival or symptomatic benefit, and the patient succumbed to disease progression within nine weeks. HCC with extensive vascular TT portends a poor prognosis. Anticoagulation in such cases should be individualized by considering the Khorana score, presence of varices, and bleeding risk. Further studies are needed to establish evidence-based strategies.