Abstract
BACKGROUND: Multimodality imaging plays a key role in the evaluation of cardiac masses, although histopathology remains the gold standard for definitive diagnosis. In rare cases, obtaining tissue can be challenging or even impossible. CASE SUMMARY: We present a patient with a highly vascularized intra- and extracardiac mass, raising strong suspicion for cardiac angiosarcoma. The case was challenging given significant hemorrhagic risk associated with the tumor's extensive vascularization, which limited the options for obtaining tissue diagnosis. Chemotherapy was started based on imaging characteristics. DISCUSSION: Cardiac tumors with lack of tissue diagnosis and anatomical considerations pose significant challenges. This case demonstrates the need for personalized decision-making in rare and aggressive malignancies where standard diagnostic pathways may not be feasible. TAKE-HOME MESSAGES: Multimodality imaging has a crucial role in the assessment of cardiac tumors. Tissue diagnosis is usually feasible, but in selected cases it can be challenging or not possible.