• Dayong Deng, Haidi Wu, Huafang Wei, Zikai Song, Yang Yu, Chongyin Zhang, and Lei Yang.
• Department of Radiology, Jilin Provincial Cancer Hospital, Changchun, China.
• Medicine (Baltimore). 2021 Sep 24; 100 (38): e27211e27211.

RationalePulmonary embolism (PE) has diverse clinical manifestations and syncope might be the first or only symptom of PE. Tumor disease usually presents with symptoms associated with the primary site, however, PE may be the first manifestation of occult tumors.Patient ConcernsHere, we report 2 patients admitted to our hospital because of syncope. One patient had a chronic hepatitis B history of more than 20 years and the other patient had chronic heavy drinking for many years. Neither patient had been diagnosed with neoplastic disease before admission.DiagnosesClinical examinations, including laboratory tests and imaging tests upon admission demonstrated PE resulting in syncope. Furthermore, malignant hepatocellular carcinoma (HCC), inferior vena cava, and right atrium tumor thrombus were diagnosed.InterventionsThrombolysis and anti-coagulation therapy were performed immediately after the diagnosis of PE. Twenty-seven HCC patients with PE in 27 articles from 1962 to 2020 in the PubMed database were reviewed.OutcomesThe improvement was achieved that no syncope recurred after treatment of PE. The oxygen partial pressure increased and the D-dimer level decreased. The clinical characteristics of 27 HCC patients with PE were summarized and analyzed.LessonsIt is important for clinicians to be aware that occult carcinoma might be a reason for patients with PE presenting with syncope. If PE cannot be explained by common causes, such as our patient, and HCC should be highly suspected when inferior vena cava and right atrial mass are found on imaging tests.Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.

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