A 65-year-old woman smoker with a long history of malignancy was referred to our Center due to the evidence of an intracardiac mass at transthoracic echocardiography (TTE). Her past medical history included pulmonary adenocarcinoma treated with right lobectomy and lymphadenectomy, right nephrectomy due to clear cell renal carcinoma and total gastrectomy for adenocarcinoma. The TTE revealed a hyperechogenic thickening at the apex of the right ventricle (RV) without clear evidence of pathological mass. CMR showed a 20 × 28 mm intramyocardial mass localized at the apex of the RV (Fig. 1a). Due to previous history of malignancy there was a high suspicion of cardiac metastatic secondarism. Patient underwent percutaneous EMB of the RV mass under fluoroscopic and ICE guidance. The RV apical mass was visualized and five biopsies were performed (Fig. 1b and c; Additional file 2: Movie 2). No pericardial effusion was present at the end of the EMB (Fig. 1d). Pathologic specimens demonstrated no evidence of malignancy permitting to avoid open-chest surgical removal of the mass. The patient was safely discharged the day after EMB procedure and followed-up in outpatient clinic.

A 54-years-old male, with previous history of liver transplant related to hepatocellular carcinoma (HCC) and HBV-cirrhosis, presented to our center for severe dyspnea. TTE demonstrated a 23 × 27 mm multi-lobed mass in the right ventricular outflow tract (RVOT) involving the pulmonary trunk. CMR imaging and contrast-enhanced CT also confirmed the intracardiac mass detected by TTE (Fig. 2a and b). Patient was scheduled for EMB under ICE guidance. Clear visualization of the mass was rapidly obtained permitting accurate evaluation of size and intracardiac extension (Fig. 2c). Four biopsies were then taken from the right ventricular side under close ICE guidance (Fig. 2d and e; Additional files 3 and 4: Movie 3 and 4). Histopathological analyses showed a poorly differentiated carcinoma characterized by a highly cellular proliferation rate. The pleomorphic epithelioid cells organized in cords of variable thickness resembles dysmorphic hepatocytes with large amounts of cytoplasm. Immunohistochemically studies demonstrate the presence of cytocheratins MNF, Glutamine Syntetase and Heat-shock protein 70, confirming the diagnosis of a metastatic HCC. Successful complete surgical removal of the intracardiac mass confirmed the diagnosis of HCC metastasis.

A 77-years-old male with history of diabetes, myocardial infarction with reduced left ventricular ejection fraction and cerebrovascular disease was referred for an occasional finding of right ventricular mass. TTE showed a dishomogeneous mass that infiltrates the RV from the base to the apex with the only exclusion of the RVOT. CT scanning and CMR highlighted an irregular and frayed voluminous mass of 12 × 7.6 cm with a thickness of 5.5 cm extending along the free wall of the RV to the tricuspid annulus (Fig. 3a and b). The heterogeneity nature of the intracardiac mass permitted to show the importance of ICE guidance in EMB procedures. Indeed, it was possible to selectively guide the bioptome into the different areas of the mass obtaining optimal samples (Fig. 3c-e). Histopathological analyses showed solid sheets and nests of large pleomorphic lymphoid cells, with abundant cytoplasm, conspicuous cleaved nuclei with multiple nucleoli, many atypical mitotic figures and apoptotic cells. Immunohistochemical analyses revealed a B-cell large lymphoma with strong expression of CD20, CD45 but negative for CD10 and CD3. The proliferation rate was approximately 95%, as shown in the Mib1 stain. A fluorescent in situ hybridization (FISH) study showed no evidence of MYC translocation ruling out Burkitt like lymphomas. All these findings confirm the diagnosis of diffuse large B cell lymphoma. After diagnosis the patient was scheduled for a multichemotherapy regimen and is currently under treatment.