Current literature suggests that the incidence of cardiac involvement by lymphoma as identified by autopsy varies widely, ranging from 8.7% to 20%. Historically, many cases might have been clinically undetected; however, improved imaging techniques increasingly identify cardiac involvement incidentally. In addition, newer agents resulting in improved cancer therapy outcomes might alter the prevalence and location of metastatic deposits to include more unusual disease sites, including intracardiac locations1,2. We present a case of cardiac lymphoma metastases in a patient with previous history of NHL.
A 45-year-old woman with previous history of diffuse large B cells non-Hodgkin lymphoma (NHL) presented to our echocardiography lab with shortness of breath as well as swelling of the neck and face both worsening in past 8 weeks.
A multimodality imaging approach allowed to diagnose an intracardiac lymphoma.
A bulky right atrial mass (∼7 cm × 5 cm) was observed adjacent to the tricuspid valve (Figures 1 and 2 and Supplementary material online, Figure S1A and Videos S1 and S2) creating a valvular obstruction (mean gradient 10 mmHg). The mass appeared to infiltrate the free wall of the inflow tract of the right ventricle and to compress it towards the interventricular septum (Figure 1). This contributed to generate the above-mentioned atrioventricular obstruction.
Figure 1.
Parasternal short-axis view at echocardiogram.The mass infiltrates the free wall of the inflow tract of the right ventricle and compress it towards the interventricular septum (green arrows). This contributes to generate the right atrioventricular obstruction. The pericardial effusion is also depicted (PERICARDIUM). LV, left ventricle; RA, right atrium; RVOT, right ventricle outflow tract.
Figure 2.
Cine four-chamber at cardiac magnetic resonance imaging. The right atrium mass (∼7 cm × 5 cm), adjacent to the tricuspid valve, creates valvular obstruction (*). It involves the superior vena cava input into the atrium (**), the free wall of the inflow tract of the right ventricle together with the relative pericardial leaflet (***). LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
A moderate pericardial effusion was also depicted (Figure 1 and Supplementary material online, Video S5).
Inferiorly the mass infiltrated the superior vena cava inlet into the right atrium, and superiorly the aortic root wall (Supplementary material online, Figures S1B and S2A and Video S3). The right coronary artery appeared to be compressed within the mass (Supplementary material online, Figure S2B) which possibly explained the first-grade atrioventricular block observed on the 12-lead ECG.
The short tau inversion recovery (T2 STIR) sequences (Supplementary material online, Figure S2D) showed high contrast enhancement, consistent for oedema and hypervascularization of the mass. Besides, phase-sensitive inversion recovery (T1 PSIR) sequences (Supplementary material online, Figure S2C) revealed a heterogeneous pattern of late gadolinium enhancement, indicating intralesional fibrosis and/or necrosis2,3.
Computed tomography scan (Supplementary material online, Figure S1D) demonstrated a diffused lymphatic retroperitoneal and splenic localization of the mass.
Finally, the bone marrow biopsy results were consistent with a medullar localization of the tumour.
The patient was initially treated with a cycle of R-CHOP regimen and referred to the National Cancer Institute for further course of care.
The imaging techniques were complementary in allowing us to make the operative diagnosis of intracardiac lymphoma and to begin a specific antiproliferative therapy early after diagnosis, sparing the patient potentially life-threatening procedures.
Supplementary material
Supplementary material is available at European Heart Journal - Case Reports online.
Consent: The author/s confirm that written consent for submission and publication of this case report including image(s) and associated text has been obtained from the patient in line with COPE guidance.
Conflict of interest: none declared.
Supplementary Material
Contributor Information
Stefano De Vita, Cardiac Imaging Lab, Luigi Sacco University Hospital, Via GB Grassi 74, 20157 Milan, Italy.
Marina Petullà, Cardiac Imaging Lab, Luigi Sacco University Hospital, Via GB Grassi 74, 20157 Milan, Italy.
Manfredo Cerchiello, Cardiac Imaging Lab, Luigi Sacco University Hospital, Via GB Grassi 74, 20157 Milan, Italy.
Alberto Barosi, Cardiac Imaging Lab, Luigi Sacco University Hospital, Via GB Grassi 74, 20157 Milan, Italy.
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