these patients usually have a short life span because of pulmonary embolism , heart failure , or cancer progression . and therefore , early detection of intracavitary tumor thrombus and effective surgical resection are important factors of survival prolongation . herein we report an echocardiographic detection of the right atrial mass in two cases of hepatocellular carcinoma . a 61-year - old man , with a history of niddm ten years previously , was admitted due to epigastric pain , indigestion , and malaise . on admission , he had a regular pulse rate , was normotensive and relatively well - looking . abdominal ultrasonogram favored a hepatoma of the right lobe with a right hepatic vein thrombus(fig . two - dimensional echocardiographic examination and transesophageal echocardiogram were performed , showing a large right atrial mass(fig . the ivc had a tumor , which appeared to be continuous with the right atrial mass . one year prior to admission , she had began suffer - ing from an abdominal fullness and weakness . laboratory examinations manifested serum alt of 391iu / l , serum ast of 341iu / l , alkaline phosphatase of 279iu / l , gamma glutamyl transferase of 298iu / l , alpha - fetoprotein of more than 7000ng / ml and alpha 1-antitypsin of 410mg / dl . abdominal computed tomography revealed an ill - definded large inhomogeneous mass filling the entire right lobe of the liver with underlying liver cirrhosis and tumor thrombus in the upper portion of the ivc and the right atrium ( fig . a 61-year - old man , with a history of niddm ten years previously , was admitted due to epigastric pain , indigestion , and malaise . on admission , he had a regular pulse rate , was normotensive and relatively well - looking . abdominal ultrasonogram favored a hepatoma of the right lobe with a right hepatic vein thrombus(fig . two - dimensional echocardiographic examination and transesophageal echocardiogram were performed , showing a large right atrial mass(fig . the ivc had a tumor , which appeared to be continuous with the right atrial mass . one year prior to admission , she had began suffer - ing from an abdominal fullness and weakness . laboratory examinations manifested serum alt of 391iu / l , serum ast of 341iu / l , alkaline phosphatase of 279iu / l , gamma glutamyl transferase of 298iu / l , alpha - fetoprotein of more than 7000ng / ml and alpha 1-antitypsin of 410mg / dl . abdominal computed tomography revealed an ill - definded large inhomogeneous mass filling the entire right lobe of the liver with underlying liver cirrhosis and tumor thrombus in the upper portion of the ivc and the right atrium ( fig . hepatoma , testicular teratoma and smooth muscle sarcoma may cause the right atrial tumor growth through the inferior vena cava , . especially , hepatocellular carcinoma is known for its tendency to grow in the venous system . but , the most common sites of metastasis are the regional lymph nodes and the lungs . the incidence of metastatic involvement of the heart in hepatoma ranges from 1.5 to 18.3% . however , such cardiac metastasis occur through the lymphatic system or by infiltrating from neighboring organs , such as the lung and breast . therefore , cardiac metastases occur mainly in the pericardium and myocardium . intracavitary cardiac metastasis or tumor invasion is an uncommon form of secondary cardiac malignancy , and metastasis to the right atrium is even less common ( 0.674.8% ) . a report by hanfling showed that intracardiac tumor thrombus occur from above the pulmonary vein to the left cardiac cavities , and from below the superior and inferior vena cava to the right cavities . tumor implantation to the right ventricle without right atrial involvement and extensive myocardial invasion is unusual in hepatoma . the left atrial involvement is probably related to tumor growth from the pulmonary veins following massive metastasis to the lung , direct invasion of the atrial septum or tumor implantation via subclinical right - to - left shunt through the patent foramen ovale . lei et al . reported unusual patterns of cardiac metastasis in three cases of hepatocellular carcinoma : one patient was noted to have a large right ventricular tumor mass with intracavitary growth and myocardial invasion : the second had massive pulmonary and left atrial metastasis ; and the third patient had a right atrial tumor mass with concomitant right ventricular and left atrial involvement . in the past , antemortem diagnosis of right atrial tumor thrombi in patients with primary hepatoma was difficult , and such cases were reported by angiography . okuda described the angiographic findings of the right atrial tumor thrombi from the liver;thread and streak sign . recently , ekg - gated magnetic resonance imaging(mri ) , computerized tomography(ct ) , transthoracic echocardiogrphy and transesophageal echocardiography are available to detect the right atrial tumor thrombus from hepatoma . transthoracic echocardiography can be considered the first step in case of suspected cardiac masses , but it in sometimes limited by the thoracic conformation and not always discriminant . the resolutive diagnosis in possible thanks to mri . therefore , mri can be considered the second step in the imaging of cardiac masses . ct is limited by the only axial or para - axial scans with low quality reconstructions , worsened in these cases by respiratory and cardiac movements . transesophageal echocardiography is semi - invasive , so esophageal varices were relative contraindication to transesophageal echocardiography . chua and colleagues reported two cases of right atrial tumor associated with hepatoma diagnosed by two - dimensional echocardiography . molinari et al . reported that mri compared to ct in the intracardiac spread of hepatocellular carcinoma . therefore , abnormal cardiac sounds and murmurs subsequantly develop . when the tumor thrombus is mobile , this symptom is termed the ball - valve thrombus syndrome . according to kato , 3 percent(5 of 156 ) of hepatocellular carcinoma cases had right atrial metastasis , and these patients had edema in the legs , venous dilatation in abdominal wall , ascites , and dyspnea;secondary budd - chiari syndrome . because of the high risk of sudden death from tricuspid valve obstruction in patients with mobile right atrial mass , prompt diagnosis and surgical intervention may prolong the patient s life . despite progress in liver surgery , hepatocellular carcinoma with a tumor thrombus extending into the right atrium has been considered beyond the reach of resection . although sporadic reports of successful diagnosis have been published , surgical removal has rarely been reported . similar procedures have been carried out by ehrlich , hill and hetzer , and miller . these patients who have hepatoma and intracardiac extending mass usually die within a short period because of pulmonay embolism , heart failure or cancer progression . there is ittle doubt that prompt diagnosis and surgical intervention relieved suffering and prolonged life .