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Cardiac Lymphoma
 
Published on 2014-06-09 by WALID GHARZUDDINE
 
 
History and Findings
 

The case below is not about an echocardiographic curiosity as it is about the achievements of modern day oncology and the effectiveness of chemotherapy.

 

 

A 37 year old male presented with symptoms of palpitations, in addition to fever and night sweats of three months duration. His referring physician had diagnosed him with atrial flutter and a right atrial mass was diagnosed by echocardiography. After admission positron emission tomography (PET scan) was requested in addition to  a repeat transthoracic echocardiography. Figure 1 shows the appearance on PET scan of a large mediastinal mass infiltrating the heart. Videos 1 and 2 represent the initial studies showing left atrial and right atrial masses.

Biopsies were performed and the diagnosis of B cell lymphoma was made. He was started on a regimen consisting or Rituximab, Adriamycin, Cyclophosphamide, Bleomycin, Vinblastine, and Prednisone. After only two cycles of treatment 3weeks apart, there was a remarkable regression of the mediastinal and cardiac tumors 

 Videos 3 and 4 show the remarkable regression of the atrial tumors with disappearance of the left atrial mass and a significant decrease in size of the right atrial mass. This is appreciated on a regular CT scan done (fig. 2).

 
 
 
video 1 | video 2 | video 3 post therapy | video 4 post therapy
 
 
       
 
 
Discussion
 

Lymphoma deposits represent 13.6% of metastatic tumors to the heart.1 As imaging modalities and treatment options for lymphoma improve, more unusual disease presentations may be observed more frequently.

Lymphomatous involvement of the heart, previously a rarity, is now being reported with greater frequency. Extranodal lymphomas are increasingly seen with acquired immunodeficiencies such as HIV or after bone marrow and solid organ transplantation. The increased incidence might be partly a result of increased clinical awareness, improved imaging techniques, and a change in cellular biology.

Two-dimensional echocardiography is regarded as the primary diagnostic imaging technique for the evaluation of cardiac
masse, with a diagnostic sensitivity of 93% for trans-thoracic echocardiography and 97% for trans-oesophageal
echocardiography. Nuclear medicine techniques previously employed to detect cardiac tumours include blood pool imaging and gallium or thallium scintigraphy . [18F]FDG-PET/CT has been shown to be more accurate than CT in the evaluation of lymphomas and other tumors, especially in the follow-up of patients  previously treated with chemotherapy and/or radiotherapy. [18F]FDG-PET/CT may have the advantage of detecting the tumour or metastases at an early stage.

References:

1. Lam KY, Dickens P, Chan AC. Tumors of the heart. A 20-year experience with a review of 12,485 consecutive autopsies. Arch Pathol Lab Med 1993;117:1027–31.

2. A Mallia, LL Travaini, G Trifiro and G Paganelli. Detection of a cardiac mass by [18F]FDG-PET/CT: ecancer 2009, 3:152

 
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