Acute pulmonary embolism as the first manifestation of hepatocellular carcinoma

We report a case of a 56-year-old man admitted to the Emergency Department of a Hospital in Sao Paulo with dyspnea, hypoxemia and pleural effusion due to pulmonary embolism as the first presenting sign of hepatocellular carcinoma.CT angiography of the chest confirmed bilateral pulmonary embolism with tumor thrombus invasion of the inferior vena cava and right atrium.The patient was not aware of previous chronic liver disease.Anticoagulant therapy with low-molecular weight heparin was administered.Due to a high risk of complications in a cardiovascular surgery intervention, the medical team decided to start palliative treatment for the HCC with sorafenib.Patient was discharged after 5days of anticoagulation without any respiratory complaint, using enoxaparin (1mg/ kg, q12h).Patient was readmitted to hospital 6months after the diagnosis of HCC with acute upper gastrointestinal hemorrhage and died due to its complications.Liver cancer is the sixth most prevalent cancer, and patients with cirrhosis are at highest risk for developing hepatocellular carcinoma.Thus, these patients should be screened with abdominal ultrasound every 6months, aiming a diagnosis in early stages.A therapeutic option for a thrombus that invades inferior vena cava and the right atrium is surgery, but most patients would not tolerate such procedure due to advanced hepatic dysfunction.In a palliative scenario, sorafenib is a first line treatment option.