Journal of Cancer Research and Therapeutics Medknow Publications on behalf of the Association of Radiation Oncologists of India (AROI) ISSN: 0973-1482 EISSN: 1998-4138 Vol. 6, Num. 3, 2010, pp. 401-402

Journal of Cancer Research and Therapeutics, Vol. 6, No. 3, July-September, 2010, pp. 401-402

Letter to the Editor

An unusual presentation of non-Hodgkin lymphoma: Cardiac involvement

Hassan Errihani¹, Rhizlane Belbaraka¹, Nabil Ismaili¹, Mohammed Cherti²

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

Correspondence Address:Rhizlane Belbaraka, Department of Medical Oncology, National Institute of Oncology, Avenue Allal Alfassi, Rabat, Morocco, r_belbaraka@yahoo.fr

Code Number: cr10102

PMID: 21119292

DOI: 10.4103/0973-1482.73329

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.

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

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