Right-sided heart failure caused by a mediastinal lymphoma infiltrating the right atrium and ventricle

    Authors

    Abstract

    **Introduction**: Primary cardiac lymphomas are very rare, representing only 0.5% of all lymphomas and 1-2% of all heart tumors. Cardiac involvement from systemic lymphomas is more common, comprising 10-20% of all lymphomas. Secondary cardiac lymphomas most frequently affect the pericardium, and then the myocardium. The patient’s symptoms are based on the area of cardiac involvement. **Case report:** 79-year-old women was hospitalized due to shortness of breath, fatigue, and lower extremity edema. A transthoracic echocardiogram (TTE) showed a mass infiltrating the myocardium of the right atrium and the right ventricle causing systolic dysfunction of the right ventricle (TAPSE 5 mm, s’0.05 m/s). A thoracic computed tomography (CT) showed a mass in the anterior mediastinum, measuring 5 x 7.5 cm infiltrating the myocardium of the right atrium and ventricle. An endobronchal ultrasound (EBUS) guided biopsy was performed and tissue samples confirmed the diagnosis of diffuse large B cell lymphoma (DLBCL) of the mediastinum, bone marrow infiltration was nonexistent. Immunochemotherapy treatment (R-CEOP) was started and the patient’s symptoms significantly improved during the course of treatment. A follow-up thoracic CT showed that the mass had significantly reduced in size after 4 cycles of therapy, and now measuring 2.1 x 6.2 cm. A control TTE showed only moderate thickening of the right atrium and right ventricle myocardium (14 mm in width), with a normal systolic and diastolic RV function (TV E/A – 1.4). **Conclusion**: In this case, the patient presented with signs and symptoms of right heart failure due to an infiltrating mass. Histology confirmed diagnosis of a DLBCL of the mediastinum. The patient was treated with immunochemotherapy, her symptoms improved, and by the end of treatment she was asymptomatic. The majority of the literature details patients with the rarer primary cardiac lymphoma. (1-3) The involvement of the right atrium and ventricle as a direct extension from an intrathoracic tumor mass in our patient resulted in a heavily impaired right heart systolic function, as a first symptom of the disease, and was completely resolved with treatment.

    Keywords

    lymphoma, heart failure

    DOI

    https://doi.org/10.15836/ccar2018.463

    Literature

    1. Chim CS, Chan AC, Kwong YL, Liang R. Primary cardiac lymphoma. Am J Hematol. 1997 Jan;54(1):79–83. https://doi.org/10.1002/(SICI)1096-8652(199701)54:1<79::AID-AJH13>3.0.CO;2-5
    2. McDonnell PJ, Mann RB, Bulkley BH. Involvement of the heart by malignant lymphoma: a clinicopathologic study. Cancer. 1982 Mar 1;49(5):944–51. https://doi.org/10.1002/1097-0142(19820301)49:5<944::AID-CNCR2820490519>3.0.CO;2-C
    3. Meng Q, Lai H, Lima J, Tong W, Qian Y, Lai S. Echocardiographic and pathological characteristics of cardiac metastasis in patients with lymphoma. Oncol Rep. 2002 Jan-Feb;9(1):85–8. https://doi.org/10.3892/or.9.1.85
    Cardiologia Croatica
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    Right-sided heart failure caused by a mediastinal lymphoma infiltrating the right atrium and ventricle

    Extended Abstract
    Issue11-12
    Published
    Pages463
    PDF via DOIhttps://doi.org/10.15836/ccar2018.463
    lymphoma
    heart failure

    Authors

    Ivica KristićORCIDKlinički bolnički centar Split, Split, Hrvatska
    Nikola Crnčević*ORCIDKlinički bolnički centar Split, Split, Hrvatska
    Velimir PivacORCIDKlinički bolnički centar Split, Split, Hrvatska
    Mijo MeterORCIDKlinički bolnički centar Split, Split, Hrvatska
    Diana BajoKlinički bolnički centar Split, Split, Hrvatska
    Ivica VukovićORCIDKlinički bolnički centar Split, Split, Hrvatska

    *Correspondence email: crni179@hotmail.com

    Abstract

    **Introduction**: Primary cardiac lymphomas are very rare, representing only 0.5% of all lymphomas and 1-2% of all heart tumors. Cardiac involvement from systemic lymphomas is more common, comprising 10-20% of all lymphomas. Secondary cardiac lymphomas most frequently affect the pericardium, and then the myocardium. The patient’s symptoms are based on the area of cardiac involvement. **Case report:** 79-year-old women was hospitalized due to shortness of breath, fatigue, and lower extremity edema. A transthoracic echocardiogram (TTE) showed a mass infiltrating the myocardium of the right atrium and the right ventricle causing systolic dysfunction of the right ventricle (TAPSE 5 mm, s’0.05 m/s). A thoracic computed tomography (CT) showed a mass in the anterior mediastinum, measuring 5 x 7.5 cm infiltrating the myocardium of the right atrium and ventricle. An endobronchal ultrasound (EBUS) guided biopsy was performed and tissue samples confirmed the diagnosis of diffuse large B cell lymphoma (DLBCL) of the mediastinum, bone marrow infiltration was nonexistent. Immunochemotherapy treatment (R-CEOP) was started and the patient’s symptoms significantly improved during the course of treatment. A follow-up thoracic CT showed that the mass had significantly reduced in size after 4 cycles of therapy, and now measuring 2.1 x 6.2 cm. A control TTE showed only moderate thickening of the right atrium and right ventricle myocardium (14 mm in width), with a normal systolic and diastolic RV function (TV E/A – 1.4). **Conclusion**: In this case, the patient presented with signs and symptoms of right heart failure due to an infiltrating mass. Histology confirmed diagnosis of a DLBCL of the mediastinum. The patient was treated with immunochemotherapy, her symptoms improved, and by the end of treatment she was asymptomatic. The majority of the literature details patients with the rarer primary cardiac lymphoma. (1-3) The involvement of the right atrium and ventricle as a direct extension from an intrathoracic tumor mass in our patient resulted in a heavily impaired right heart systolic function, as a first symptom of the disease, and was completely resolved with treatment.

    Literature

    1. 1.
      Chim CS, Chan AC, Kwong YL, Liang R. Primary cardiac lymphoma. Am J Hematol. 1997 Jan;54(1):79–83.DOI
    2. 2.
      McDonnell PJ, Mann RB, Bulkley BH. Involvement of the heart by malignant lymphoma: a clinicopathologic study. Cancer. 1982 Mar 1;49(5):944–51.DOI
    3. 3.
      Meng Q, Lai H, Lima J, Tong W, Qian Y, Lai S. Echocardiographic and pathological characteristics of cardiac metastasis in patients with lymphoma. Oncol Rep. 2002 Jan-Feb;9(1):85–8.DOI