Figure 1. (A) . Trans-esophageal echocardiographic image of the cardiac mass showing the large atrial mass originating from the right sided atrial septum and protruding through the tricuspid valve and into the Right Ventricle. (B) . Pulse Wave Doppler showing the pressure gradient across the tricuspid valve with a mean gradient of 10 mmHg and a peak of 14 mmHg and some obstruction to the outflow tract (C) . Contrast enhanced CT image demonstrates a pedunculated low attenuation right atrial mass from the inter-atrial septum extending through the tricuspid valve in the right ventricle. Axial (D).and sagittal (E) T2 weighted MR images demonstrate same pedunculated, smooth bordered, right atrial mass arising from the inter-atrial septum projecting into the right ventricle. Also, moderate pericardial effusion.
Fig 1 ( F) H&E (40X objective) The tumor shows a moderate cellularity of pleomorphic cells with mitotic activity (arrow) with myxoid matrix, prominent dilated capillaries, and areas of necrosis (left edge, asterisk) accounting for more than 50% of the tumor volume. The tumor did not show evidence of maturation, being negative for desmin, S100, myogenin and CD34 and only focally positive for smooth muscle actin. The tumor shows positive Fig 1(G) MDM2 and Fig 1(H) CDK4 Immunostains Fig 1 (I) The specimen was a 70g, 7.3 X 5.0 X 4.4cm smooth surfaced mass partly surrounded by a thin pseudo capsule. The cut surface shows hyperemic and myxoid pale yellow areas.
Figure 2(A) Axial CT image showing the pre-operative gross tumor volume (GTV) and planning target volumes (PTV) for the different doses (25.2Gy, 41.4Gy and 54Gy) using IMRT
Figure 2(B) Dose volume histograms for the various tumor target volumes and normal structures after IMRT 54Gy/30fr was delivered with concurrent chemotherapy.