1353877 - The Masquerader: Hepatocellular Carcinoma Metastasis to the Left Ventricle Appearing as a Hypertrophic Cardiomyopathy Variant

This 64 year old male presented to the emergency department complaining of dyspnea, increased chest discomfort. Having a history of ischemic cardiomyopathy, diabetes, hepatocellular carcinoma, and known lung and brain metastasis, the patient underwent diagnostic exams including CT Brain, CT chest (PE protocol), and MRI exams of the brain and cervical spine. The brain exams showed new hemorrhagic lesions as well as previously treated lesions. The CT chest showed increased hilar lymphadenopathy and sub segmental pulmonary embolism. Additionally, on the CT there were large pulmonary nodules as well as a new left ventricular wall mass. The patient underwent an echocardiogram with contrast that showed severely dilated LV and concentric remodeling while the RV was within normal limits. Also noted was a filling defect at the inferior and inferior mid wall, similar to that seen on the CT scan. The echo was compared to a CMRI performed in 2020 that identified hypertrophied inferior-septal papillary muscle. However, this echo could not exclude a mass. The question presented: Was this an intracardiac mass, apical hypertrophy, or a prominent, hypertrophied papillary muscle? A cardiac MRI was recommended for further clarification/delineation of this hypertrophied LV apex.

Methods:

The CMRI exam showed the following:

Moderately dilated left ventricular size by 3D volumetric analysis with BSA normalization LV ED Volume Index= 126 mL/m². Severely reduced left ventricular systolic function. 3D LVEF= 32%. Increased myocardial mass index= 103 g/m². Mitral inflow patterns were consistent with impaired relaxation.

Results:

There was a 33 x 33 x 49 mm intra-myocardial mass found in the apical inferior/inferolateral wall. Global hypo kinesis with abnormal septal motion due to known LBBB. Normal right ventricular size and systolic function. RVEF= 53 %. The triple inversion images obtained, showed abnormal, increased signal (edema) within the mass area. Late gadolinium enhancement (LGE) imaging was performed and was abnormal. There was patchy LGE uptake involving the apical mass. The LGE images showed no evidence of infarction. The CMRI images mimicked what normally would be considered an apical hypertrophic cardiomyopathy, compatible with apical “spading”, masquerading as apical hypertrophy variant.

Conclusion:

This new apical mass that was not seen previously on the 2020 CMR. The T2 and LGE findings and its intra-myocardial nature indicate this is most likely metastatic disease. As compared to the study from 2020, the LVEF has decreased. The apical mass is new.

Review of the literature, most hepatocellular carcinoma metastasize to the right atrium/ right ventricle and or the inferior vena cava. Metastasis to the left ventricle is extraordinarily rare, with only 5 cases reported in the literature.