Disorders of the Mediastinum: Student/Resident Case Report Poster - Disorders of the Mediastinum |

Heart of Lymphoma: Diffuse Large B-Cell Lymphoma Invading the Atria FREE TO VIEW

Ana Velazquez, MD; Mariana Mercader, MD; Ilan Shapira, MD
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Mount Sinai Beth Israel, New York, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):554A. doi:10.1016/j.chest.2016.08.642
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SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Mediastinum

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Cardiac masses are potentially lethal, despite the majority of them being of benign origin. The differential diagnosis of left atrial masses includes mural thrombus, benign or malignant primary cardiac tumor, and secondary involvement from extracardiac tumors. Malignant lymphoma initially presenting with cardiac involvement is very rare and usually a late manifestation of the disease, with most patients being diagnosed at autopsy.

CASE PRESENTATION: A 47 year-old male with HIV and Hepatitis B presented with 4 months of worsening productive cough and exertional dyspnea associated with subjective fevers, chills, and intermittent hemoptysis. Over that 4-month period, he had multiple admissions for pneumonia and one episode of chest pain with negative ECG and troponins at outside institution. He denied weight loss, sick contacts, and history of recent travel or tuberculosis exposure. On presentation, HR was 109bpm and exam revealed less than 1cm supraclavicular and inguinal lymphadenopathy with normal lung and cardiac exam. Chest X-ray revealed increased density along the right heart border. Chest CT scan showed a large 70x102mm soft tissue mediastinal mass invading the right atrium and right side of the left atrium, completely obstructing the superior right pulmonary vein, encasing the right main pulmonary artery, and compressing the right inferior pulmonary vein (Image 1). The mass was associated with supraclavicular, mediastinal, portal and retroperitoneal adenopathy. TTE showed vena caval inflow around the mass and elevated right ventricular pressures. Core biopsy of atrial mass revealed diffuse large B-cell lymphoma (DLBCL) with Ki-67 90%. Patient underwent 6 cycles of R-EPOCH and 4 cycles of prophylactic intrathecal methotrexate with complete resolution on follow up PET-CT (Image 2). His course was complicated by central nervous system lymphoma during 6-month follow up.

DISCUSSION: DLBCL is the most common non-Hodgkin lymphomas, and is rapidly fatal if left untreated. Cardiac involvement may occur by: contiguity from intrathoracic lesions involving the pericardium; retrograde lymphatic dissemination; or hematogenous dissemination. The spectrum of cardiac manifestations is broad, going from the absence of symptoms to heart failure, pericardial effusion or arrhythmias. Cardiac involvement as initial presentation of DLBCL is very rare, as on average cardiac disease is identified 20 months after the initial diagnosis. The correct pathologic diagnosis is essential to management of cardiac masses given advances in chemotherapy and the addition of monoclonal therapies that have resulted in improved response and survival rates.

CONCLUSIONS: This case represents an uncommon initial presentation of DLBCL with cardiac involvement. Although DLBCL is a rare cause of denovo cardiac masses, it should be considered particularly in immunocompromised patients as those with HIV or transplant.

Reference #1: O’Mahony D, et al. Clin Lymphoma Myeloma. 2008 August; 8(4): 249-252

DISCLOSURE: The following authors have nothing to disclose: Ana Velazquez, Mariana Mercader, Ilan Shapira

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