An unusual case of fulminant heart failure

A 51-year-old patient presented with a 10-day history of breathlessness and back pain. Significant background his- tory included human immunodeficiency virus-2 and hepatitis C virus infections. Physical examination showed end-inspiratory crackles and muffled cardiac sounds and his blood test showed an increased aspartate aminotransferase level (500 IU/L), ala- nine aminotransferase level (654 IU/L), and lactate dehydroge- nase level (2354 IU/L). His chest radiograph confirmed pulmo- nary edema, and the echocardiogram showed severe pericardial effusion (2.5 cm). A computed tomography scan of the chest showed an incidental finding of a 5-cm liver mass at the liver dome. The patient was admitted to the intensive care unit to undergo percutaneous drainage of his pericardial effusion, and he died a few hours later of acute heart failure unresponsive to cardiovascular support. The patient underwent a post-mortem examination. The liver and the heart are shown in Figures A and B, respectively. Figure A shows a multifocal liver tumor ranging in size from 1 to 7 cm maximum. The heart, the pericardium, and the aortic arch were widely involved by metastatic deposits (Figure B). A section of the vertebral bones and the lungs also showed further small metastatic deposits. Initial histology of the liver lesions and the heart showed small-cell carcinoma (SmCC) (Figure C, tumor cells between myocardial cells, H&E, original magnification, 100). We performed immunohisto- chemistry on the pulmonary deposits to rule out a primary pulmonary SmCC. No positivity was seen for thyroid transcrip- tion factor-1, caudal type homeobox transcription factor 2, CK7, CK20, chromogranin, synaptophysin, or CD56. Immuno- histochemical stains for hepatocyte paraffin 1 (Figure D), car- cinoembryonic antigen, and -fetoprotein showed a strong pos- itivity and TTF-1 negativity. On the basis of the macroscopic framework and immunohistochemical features, a diagnosis of metastatic SmCC of the liver was made. Cardiac metastases from hepatocellular carcinoma are very uncommon.1 Hepatic SmCCs are even more uncommon: to our knowledge, only 13 cases have been reported.2 They usually present with locally advanced or metastatic disease, and no disease-free survivors have been reported to date. Interestingly, they do not show any association with chronic liver disease or with hepatitis C/hepatitis B viruses, and high fetoprotein levels also seem to be uncommon.