Even when the correct diagnosis of a right atrial metastatic tumor is made, there is no standard treatment. Palliative resection with variable success has been reported in cases of hemodynamic instability resulting from ball-valve thrombus syndrome and intractable heart failure, but the prognosis remains dismal.16,17 Untreated, the median survival time period of patients with metastatic HCC is 3 to 4 months.18,19 Besides surgical resection, other controversial treatments for HCC invasion of the IVC and RA include systemic chemotherapy, transcatheter arterial chemoembolization, and radiotherapy.19,20 Multimodality treatments are also under investigation. Our patient declined surgical resection and was referred for palliative radiotherapy. The patient received 50.4 Gy in 28 fractions to the gross tumor volume. Margins involved the IVC and RA, using a three-dimensional conformal approach. Following radiotherapy, the patient improved clinically, with resolution of her lower-extremity edema and marked improvement in her respiratory status. Because of the hematogenous spread of her tumor, our patient was started on sorafenib 400 mg bid. Repeat MRI showed an interval decrease in the size of the tumor and no new areas of metastasis.