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LETTER TO THE EDITOR
Year : 2010  |  Volume : 6  |  Issue : 3  |  Page : 401-402

An unusual presentation of non-Hodgkin lymphoma: Cardiac involvement


1 Department of Medical Oncology, National Institute of Oncology, Rabat, Morocco
2 Department of Cardiology, IBN SINA Hospital, Rabat, Morocco

Date of Web Publication29-Nov-2010

Correspondence Address:
Rhizlane Belbaraka
Department of Medical Oncology, National Institute of Oncology, Avenue Allal Alfassi, Rabat
Morocco
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.73329

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How to cite this article:
Errihani H, Belbaraka R, Ismaili N, Cherti M. An unusual presentation of non-Hodgkin lymphoma: Cardiac involvement. J Can Res Ther 2010;6:401-2

How to cite this URL:
Errihani H, Belbaraka R, Ismaili N, Cherti M. An unusual presentation of non-Hodgkin lymphoma: Cardiac involvement. J Can Res Ther [serial online] 2010 [cited 2020 Sep 22];6:401-2. Available from: http://www.cancerjournal.net/text.asp?2010/6/3/401/73329

Sir,

A 41-year-old man without any significant medical history was hospitalized in cardiology service for progressive dyspnea, palpitation and continuous weight loss for two months. On admission, the patient had an ECOG performance status equal to 1. Physical examination revealed tachycardia with a pulse rate of 95 beats per minute, a blood pressure of 140/80 mmHg, and a murmur due to pericardial friction. Clinical examination showed an axillary left node measuring 2 cm. Chest X-rays showed left pleural effusion without cardiac hypertrophy. Electrocardiogram showed a microvoltage. Bi-dimensional transthoracic echocardiography [Figure 1] revealed a nonobstructing mass fixed to the right atrium, without any vegetation, measuring 60 × 40mm, and a second lesion attached to the left atrium measuring 50 × 45 mm; with normal left ventricular fonction and free right ventricular. Chest computed tomography confirmed tow cardiac mass attached to the atriums, and showed multiple mediastinal nodes, and pleural and pericardial effusion. Laboratory investigations showed a normal blood formule. Blood cultures and viral serologies (EBV, VHB, VHC, and HIV) were negative. Biopsy of the axillary node with histological and immunohistochemistry studies showed DLBCL according to the Revised European-American Classification of Lymphoid Neoplasms/World Health Organisation classification of lymphoid neoplasms (REAL/WHO). [1] Most of the neoplasic cells were positive for CD-20. Computed tomography of the abdomen and pelvis was normal. A bone marrow biopsy showed no abnormalities. The patient was staged IV according to the Ann Arbor Staging system. The patient received standard Rituximab 375 mg/m2 on day 1, Cyclophosphamide 750 mg/m2 on day 1, Doxorubicine 50 mg/m2 on day 1, Vincristine 1.4 mg/m2 on day 1, and prednisone 50 mg/m2 on day to 5, (RCHOP) regimen. A bidimensionnal echocardiography after 4 chemotherapy courses showed the complete disappearance of the right and left atrials tumor [Figure 2] and a normal clinical cardiac exam. He received 8 cycles of standard chemotherapy with complete clinical and radiological response. He remained disease free, until now, 8 months after the end of chemotherapy.
Figure 1: Atrial mass at initial diagnosis

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Figure 2: Transthoracic echocardiography after 4 cycles of chemotherapy

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Secondary involvement of the heart cavity by non-Hodgkin lymphoma is more frequent than primary cardiac non-Hodgkin's lymphoma and represents the third most common malignant tumour of the heart in autopsy studies. [2] The disease may involve all cardiac structures, but lesions of the right heart and particularly the right atrium are predominant. [3] Clinical manifestations are usually non-specific and appear at a late stage, reflecting diffuse involvement. Cardiac involvement as an initial presentation of malignant lymphoma is a rare occurrence. [4]

Three mechanisms can be suggested to explain heart tissue involvement: direct neighbouring extension of the tumor from a primitive mediastinal site, retrograde flow through the cardiac lymphatics and hematogenous spread. [3] In our case, retrograde lymphatics or hematogenous spread was suspected because there was no direct invasion to the epicardium.

The prognosis of cardiac involvement lymphoma remains poor due to diagnostic delay and advanced stage of organ infiltration. However, nowadays, the addition of rituximab to the CHOP protocol increases the overall survival rate. [5] Our patient achieved complete and successful response after the end of the 8 cycles of chemotherapy with rituximab.

 
 > References Top

1.Harris NL, Jaffe ES, Stein H, Banks PM, Chan JK, Cleary ML, et al. A revised European-American classification of lymphoid neoplasms: A proposal from the International Lymphoma Study Group. Blood 1994;84:1361-92.  Back to cited text no. 1
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2.Mioulet D, Braem L, Heno P, Paule P, Peloni JM, Bonnet D, et al. Cardiac extension of a non-Hodgkin lymphoma revealed by an atrial flutter. Ann Cardiol Angeiol (Paris) 2009;58:117-21.   Back to cited text no. 2
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3.McDonnell PJ, Mann RB, Bulkley BH. Involvement of the heart by malignant lymphoma: A clinicopathologic study. Cancer 1982;49:944-51.   Back to cited text no. 3
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4.Ban-Hoefen M, Zeglin MA, Bisognano JD. Diffuse large B cell lymphoma presenting as a cardiac mass and odynophagia. Cardiol J 2008;15:471-4.  Back to cited text no. 4
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5.Morillas P, Quiles J, Nuρez D, Senent C, Martύnez S, Fernaρdez JA, et al . Complete regression of cardiac non-Hodgkin lymphoma. Int J Cardiol 2006;106:426-7.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]


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