The presence of a mass in the right heart chambers poses a major problem both in diagnosis and in the risk of embolism distally. Its presence gives rise to investigations both on the nature and the cause mainly attributed to primary cardiac malignancies, on the thrombi which can form locally in the right atrium or migrate from the venous circulation: they are more present in the atrium. right than in the right ventricle.

However, the medical context of our patient orients from the outset, taking into account the clinical semiology of HCC, a cardiac mass which is very probably of a metastatic malignancy 3. The most probable etiology of a cardiac mass is certainly thrombus or vegetation, however the clinical setting provides diagnostic clues. Thus, if a cardiac mass represents a tumor, its etiology can often be determined by considering four factors: a) likelihood based on histology; b) the patient's age at the time of presentation; c) the location of the tumor; and d) non-invasive tissue characterization. Using this approach, and integrating clinical data, a precise diagnostic strategy is generally possible without the need for percutaneous or surgical biopsy 4.

This leads us, taking into account the clinical examination, biochemical biological results, serological, tumor markers, imaging of our patient, to suggest primary liver cancer. As for metastasis, it would be due to the contributing factors reported in Table 1. The very proximity of the liver to the right cardiac chambers via the inferior vena cava is an important element of predilection of the cardiac site.

In comparison, kidney tumors have the particularity of having in 5 to 10% of cases a venous tumor extension with in particular an involvement of the inferior vena cava that can go up into the right atrium 5; and thrombus tumors in the chambers of the heart are discovered incidentally through radiological and ultrasound examinations performed for a variety of reasons.6 There is a classification of cardiac masses according to their cause, which includes primary and secondary neoplastic masses. In the latter, we classify the metastatic masses by direct extension, by hematogenous route, by lymphatic route and by venous route among which cancers of renal, adrenal, thyroid, pulmonary and hepatic origin (Table 2) 4, like of our patient.

The current diagnosis of HCC is based on the following criteria: HCC proven by cytology or histology or diagnostic according to the following characteristics: if nodule less than 1 cm, increase in size during follow-up by ultrasound every three months; if nodule greater than 1 cm, diagnosis of HCC in the presence of a typical image (hypervascularized nodule in the arterial phase with wash-out in the portal or late phase); in other cases, do a liver biopsy 7. And the development of multi-strip CT allows the acquisition of increasingly precise images. The sensitivity and specificity of multi-strip CT are identical to that of magnetic resonance imaging (MRI) 8.

Thanks to CT, we were able to study the different masses (cardiac, IVC and HSV) on their possible nature and measure their size, thus making the link with the primary cancer of the liver of our patient.

According to the author F. Aboukhoudir et al, in 2017, I quote "the finding of a right atrial mass coming from the inferior vena cava must always make us think of renal or adrenal carcinoma" 9; this thesis would now be called into question according to the case of our patient whose HCC is now one of the carcinomas to be evoked in front of a right atrial mass from IVC (and especially VSH).

The biopsy of this tumor being able to be essential to specify the type of primary cancer of the liver and for the continuation of the therapeutic management of our patient, we had referred the patient in a department of Gastroenterology, with a follow-up in collusion on the cardiac plane.

Considering the causes of the spread, we recommend that a non-invasive cardiac assessment be performed like TTE in any elderly person with the triad of anorexia, wasting and asthenia.