A Life-Threatening Presentation of Primary Small Cell Colorectal Non-Hodgkin Lymphoma as Cardiac Tamponade and Its Challenging Management

Abstract

Colorectal NHL is quite aggressive and rare, forming only less than 1% of all cases of colorectal cancer. The pericardium is an extremely rare first site of metastasis. Cardiac tamponade can be a life-threatening initial presentation. We report a 55-year-old lady who presented with severe shortness of breath, intermittent abdominal pain and altered bowel habits. She had low blood pressure with congested neck veins. Her echocardiogram showed pericardial and cardiac infiltration with tumour mass; a large pericardial effusion with signs of cardiac tamponade. There was no safe window for percutaneous drainage, and the patient was not physically fit for surgical drainage. A multidisciplinary approach was used to diagnose and manage the case involving a cardiologist, gastroenterologist, pathologist, radiologist and oncologist. CT scans of the whole body showed a large rectosigmoid mass infiltrating the uterus and adnexa. Flexible sigmoidoscopy showed a large bleeding mass at the rectosigmoid junction. The biopsy confirmed small cell non-Hodgkin lymphoma (NHL). Urgent three cycles of chemotherapy were commenced over a period of 5 weeks ( one cycle of CVP; two cycles of CHOP). The patient showed significant symptomatic improvement. A five-week follow-up echocardiogram showed that the d pericardial tumour had disappeared and only a small rim of pericardial effusion. Effusion did not recollect in her follow-up echocardiography. A year later, she was referred to the palliative care team due to the further spreading of her lymphoma. In conclusion, colorectal small cell NHL might initially present as cardiac tamponade. Urgent initiation of chemotherapy can be a treatment option whenever a drainage procedure is unsafe.