Fifteen-year survival of a hepatocellular carcinoma extending into the right atrium treated by surgical resection with the heart-first approach under cardiopulmonary bypass: a case report and review of the literature.

Hepatocellular carcinoma with tumor thrombus in the inferior vena cava extending into the right atrium is rare and associated with poor prognosis in most cases. Although liver resection with thrombectomy is the only curative treatment, there is no consensus on the therapeutic options for managing these rare cases. The patient was a 67-year-old man with hepatocellular carcinoma with tumor thrombus in the right atrium. In February 2003, cavo-atrial thrombectomy was first performed using cardiopulmonary bypass with heparinization and cardiac arrest. After thrombectomy, right hepatectomy was performed. The total operative time was 10 h 48 min. Moreover, the total blood loss was 7267 mL. The patient recovered uneventfully except for right pleural effusion. He was cancer-free for approximately 9 years. A new lesion in the remnant liver was detected in March 2012. He underwent transcatheter arterial chemoembolization, followed by sequential administration of sorafenib and sunitinib. Radiation therapy was also administered. Eventually, the patient expired 6 years after recurrence. Cavo-atrial thrombectomy under cardiopulmonary bypass prior to hepatectomy for hepatocellular carcinoma with tumor thrombus in the right atrium could be performed safely. Aggressive surgery with the heart-first approach and multidisciplinary treatments even after recurrence led to long-term survival.