the main therapeutic approach is adrenalectomy and extraction of the tumor from the inferior vena cava and the right atrium .
this requires a precise evaluation of the extent of spread of the tumor , a meticulous pre - operative planning and a combined team including general and cardiac surgeons and a cardio - pulmonary bypass team .
jugular venous pulse and heart sounds were normal . a soft murmur compatible with tricuspid regurgitation was heard .
abdominal ultrasound revealed a cirrhotic liver with an enlarged portal vein , splenomegaly and ascites .
a large uniform , echodense , immobile mass ( area- 3.3 cm ) , attached to the interatrial septum was seen in the right atrium ( figure 1 ) .
the inferior vena cava was mildly enlarged and an elongated mass attached to its wall was seen .
the patient was operated and combined cardiac and abdominal procedures were performed , monitored by transesophageal echocardiography , which did not add any additional information .
inferior vena cava and right atrium were exposed and a large mass extending from the hepatic portion of the inferior vena cava to the right atrium was removed .
postoperative course was complicated by massive bleeding and coagulopathy and the patient died few hours after the operation .
we describe a rare case of adrenocortical carcinoma that extended to the inferior vena cava and the right atrium .
tumors that affect the right atrium include primary neoplasms and secondary tumors such as hypernephroma , hepatoma , testicular sarcoma and melanoma .
adrenal carcinoma may also extend to the renal veins and the inferior vena cava , usually accompanied by a thrombus .
most of the described cases of adrenal carcinomas extending to the right atrium including the present case were right - sided [ 4,6,7,9 - 15 ] .
this is explained by the direct course of the right adrenal vein to the inferior vena cava .
other forms of cardiac involvement include infiltration of the inter - atrial septum , and a malignant pericardial effusion .
the main clinical manifestations of vena caval and right atrial extension of the tumor include peripheral edema , ascites and hepatomegaly as in our case .
a patient with bouts of dyspnea and cyanosis due to a patent foramen ovale and a right atrial tumor was described .
due to the tendency of the tumor to disseminate , a precise pre - operative assessment is essential .
evaluation should involve various additional modalities such as ct , [ 4,6 - 8 ] venography and mri .
echocardiography is a very useful tool in the assessment of cardiac tumors [ 5,7,8,10,13,16,17,19 - 22 ] . in the present case
transthoracic echo identified the cardiac involvement , leading to change in the operative approach by adding cardiac surgeons to the operation .
transesophageal echo can provide high quality images of the inferior vena cava and right atrial involvement , and direct the surgeons in the removal of the neoplasm from both sites . in cases in which a good quality transthoracic study is positive for cardiac involvement
, transesophageal study can be performed only intraoperativlely , to monitor and direct surgery in the operative arena .
a patent foramen ovale should be looked for before putting the patient on by - pass .
we suggest that adrenal carcinoma , although very rare , should be included in the differential diagnosis of right atrial tumors .
once an adrenal tumor is detected , the work - up should include echocardiography , which is of a paramount importance in the evaluation of cardiac involvement , operative planning and follow - up .
none declared . there are no financial or other relations that could lead to a conflict of interest .
 backgroundadrenocortical carcinoma is a rare , highly malignant tumor 
 . cardiac involvement of the tumor is very rare . 
 echocardiography facilitates the evaluation of the cardiac involvement of the tumor.case presentationwe describe a patient with an adrenal tumor . 
 transthoracic echo showed its extension into the right atrium . accordingly , a combined abdominal and cardiac operation was performed , monitored by transesophageal echocardiography.conclusionthis case highlights the importance of echocardiography in revealing the cardiac involvement by this tumor and in planning the operative procedure . 
Background
Case Presentation
Conclusions
Competing interests
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