Cardiac involvement of malignant lymphoma and its improvement after chemotherapy

Abstract

A 63-year-old female was admitted to the emergency room in our hospital due to chest oppression at rest. Physical examination showed no significant abnormal findings. Her heart rate was 92 beats/min and blood pressure was 158/92 mmHg. Laboratory findings showed no abnormal data. ECG on admission showed normal sinus rhythm with first-degree atrio-ventricular block and negative T wave in II, III, aVF, and low voltage in limb leads. Echocardiography revealed wall thickening in the infero-posterior segments of the left ventricle (LV) with wall motion abnormality, and wall thickening in intra-atrial septum and right atrium (Fig. 1). In echocardiograms, end-diastolic and end-systolic LV diameter, septal and posterior wall thickness, and ejection fraction were 40, 23, 9, 9 mm, and 50 %, respectively. Pulsed Doppler echocardiography showed pseudonormal pattern in transmitral flow [early diastolic and atrial wave velocity ratio (E/A) = 1.75, deceleration time = 113 ms]. Tissue Doppler echocardiography showed a ratio of early diastolic transmitral flow and mitral annulus velocity (E/E0) of 15.5. Coronary angiogram revealed no significant coronary stenosis. Computed tomography (CT) scan revealed (1) multiple masses in left iliopsoas muscle, (2) lymph node swelling in the paraaortic and right inguinal portions, and (3) wall thickening in the LV, right atrium, and intra-atrial septum. She was diagnosed as having diffuse large B cell lymphoma by biopsy from the lymph node in the right inguinal portion. Chemotherapy was performed (R-CHOP, 7 courses). Follow-up echocardiograms showed a decrease in cardiac mass after the second course of R-CHOP. ECG showed normal findings, and no apparent mass was found by CT scan. After the completion of the chemotherapy, echocardiography revealed no wall thickening and improvement in the inferior wall motion (Fig. 2). E/A was decreased from 1.75 to 0.87. E/E0 was decreased from 15.5 to 11.5. Secondary cardiac involvement of lymphoma has been reported as between 16 and 28 % of extracardiac lymphomas [1–3]. These results were obtained from autopsy studies. However, cardiac involvement is not commonly diagnosed before an autopsy [3–5] for the following reasons. It is usually asymptomatic or a nonspecific symptom in cardiac involvement in patients with lymphoma because most of the cardiac involvement of lymphoma is microscopic. ECG usually shows nonspecific findings in cardiac involvement. Symptoms and signs due to coexistent involvement of other organs may induce misdiagnosis of cardiac involvement. Myocardial or atrial wall thickening as shown in the present echocardiograms has been reported in previous reports of cardiac involvement of lymphoma [3, 4]. Infiltration of tumor cells in these lesions has been shown in the autopsy in the previous reports. Echocardiography revealed a decrease in myocardial and atrial wall thickening after 4 courses of chemotherapy, and no wall thickening after the completion of the chemotherapy, which was confirmed by CT scan. In comparison with CT, echocardiography is a completely noninvasive and feasible method. Thus, echocardiography is more useful than CT for the serial assessment of the involved mass in the heart after chemotherapy. This case shows the usefulness of echocardiography H. Ochi (&) M. Yamamoto M. Yamasaki Echocardiography Laboratory, Osaka Saiseikai Noe Hospital, 1-3-25 Furuich, Joutou-ku, Osaka 536-0001, Japan e-mail: hiroyuki18ochi@yahoo.co.jp