Cardiac involvement in disseminated diffuse large B-cell lymphoma, successful management with chemotherapy dose reduction guided by cardiac imaging: A case report and review of literature

Abstract

BACKGROUNDSecondary cardiac involvement by lymphoma has received limited attention in the medical literature, despite its grave prognosis. Although chemotherapy improves patients’ survival, a subgroup of treated patients dies suddenly due to myocardial rupture following chemotherapy initiation. Reducing the initial chemotherapy dose with dose escalation to standard doses may be effective in minimizing this risk but the data are limited. We report on the successful management of a patient with disseminated diffuse large B-cell lymphoma (DLBCL) involving the heart using such approach.CASE SUMMARYAn 18-year-old male presented to our hospital with six months history of progressive dyspnea, orthopnea and cough. On physical examination, the patient was found to have a plethoric and mildly edematous face, fixed elevation of the right internal jugular vein, suggestive of superior vena cava obstruction, and a pelvic mass. Investigations during admission including a thoracoabdominal computed tomography (CT) scan with CT guided biopsy of the pelvic mass, echocardiography and cardiac magnetic resonance imaging led to the diagnosis of disseminated DLBCL with cardiac involvement. The patients were successfully treated with chemotherapy dose reduction followed by dose escalation to standard doses, under the guidance of cardiac imaging. The patient completed chemotherapy and underwent a successful bone marrow transplant. He is currently in remission and has a normal left ventricular function.CONCLUSIONImaging-guided chemotherapy dosing may minimize the risk of myocardial rupture in cardiac lymphoma. Data are limited. Management should be individualized.

Acute kidney injury and cardiac arrhythmia as the presenting features of widespread diffuse large B-cell lymphoma

“…This group noted that this particular presentation had not been previously described based on their literature review 7. Other publications have reported symptomatic cardiac involvement and attempts made for treatment purposes, but the findings are still poorly studied overall 8 , 9 , 10. Encouragingly, some of these studies outline successful treatment with varied chemotherapy regimens.…”

Cardiac lymphoma with early response to chemotherapy: A case report and review of the literature

“…Sometimes, cardiac involvement in disseminated lymphoma is widespread, affecting not only the pericardium but also the myocardium, diffusely. 8 Some case reports showed uncommon presentations like massive cardiac infiltration mimicking restrictive cardiomyopathy. 6 , 8 – 10 …”

“… 8 Some case reports showed uncommon presentations like massive cardiac infiltration mimicking restrictive cardiomyopathy. 6 , 8 – 10 …”

Secondary Cardiac Lymphoma Presenting as Sick Sinus Syndrome and Atrial Fibrillation Which Required Leadless Pacemaker Implantation

“…Primary cardiac lymphoma is a very rare tumor that is confined to the heart and pericardium and accounts for 1.3% to 3% of all primary cardiac tumors ( 4 ). In contrast, secondary metastatic involvement of the heart from extra cardiac tumors is 20-40 times more common than primary cardiac tumors ( 4 ), and secondary cardiac involvement of lymphoma is found in 8.7-25% of documented clinical cases of lymphoma ( 1 ).…”

“…Secondary cardiac involvement of lymphoma is relatively common, reported in 8.7-25% of documented clinical cases of lymphoma ( 1 ). Nevertheless, manifestations of cardiac involvement of lymphoma are often subclinical, thus, cardiac involvement as an initial presentation of malignant lymphoma is rare ( 2 , 3 ).…”