Primary cardiac lymphoma

Systemic Diseases and Heart Block

Systemic diseases can cause heart block owing to the involvement of the myocardium and thereby the conduction system. Younger patients (<60) with heart block should be evaluated for an underlying systemic disease. These disorders are classified into infiltrative, rheumatologic, endocrine, and hereditary neuromuscular degenerative diseases. Cardiac amyloidosis owing to amyloid fibrils and cardiac sarcoidosis owing to noncaseating granulomas can infiltrate the conduction system leading to heart block. Accelerated atherosclerosis, vasculitis, myocarditis, and interstitial inflammation contribute to heart block in rheumatologic disorders. Myotonic, Becker, and Duchenne muscular dystrophies are neuromuscular diseases involving the myocardium skeletal muscles and can cause heart block.

Case report: Surgical resection of a primary cardiac diffuse large B-cell lymphoma and reconstruction of involved right heart structures

INTRODUCTION AND IMPORTANCE

Lymphoma can either be Hodgkin or non-Hodgkin (NHL) with diffuse large B cell lymphoma (DLBL) being a type of the latter with an aggressive behavior. Although NHL involvement of the heart in late stages is not uncommon, disease that primarily originates from the heart is rare and therefore poses a diagnostic challenge.

CASE PRESENTATION

Herein, we report the case of a 52-year-old patient who presented to the hospital with non-specific signs and symptoms and was found to have a heterogeneous echogenic irregular mass across the tricuspid valve in the right atrium and right ventricle. The majority of the mass was located in the right atrium, with the tip attached to the right ventricular free wall near the tricuspid annulus. Initially thought to be an atrial myxoma but later confirmed histologically to be diffuse large B cell Lymphoma, and the patient underwent right atrial mass resection, followed by chemotherapy. The patient showed improvement following treatment.

CLINICAL DISCUSSION

Primary cardiac lymphoma (PCL) is a rare form of lymphoma that is confined exclusively to the heart and/or pericardium, without the involvement of other lymph nodes or extra-nodal tissues or organs. Pathological analysis confirms PCL as either non-Hodgkin's lymphoma (NHL) or Hodgkin's lymphoma (HL). PCL accounts for approximately 1.3 % of primary cardiac tumors and 0.5 % of extra-nodal lymphomas.

CONCLUSION

Our case report provides valuable insights for clinicians to better understand this uncommon disease and reduce the incidence of misdiagnosis.

Systemic Diseases and Heart Block

Systemic diseases can cause heart block owing to the involvement of the myocardium and thereby the conduction system. Younger patients (<60) with heart block should be evaluated for an underlying systemic disease. These disorders are classified into infiltrative, rheumatologic, endocrine, and hereditary neuromuscular degenerative diseases. Cardiac amyloidosis owing to amyloid fibrils and cardiac sarcoidosis owing to noncaseating granulomas can infiltrate the conduction system leading to heart block. Accelerated atherosclerosis, vasculitis, myocarditis, and interstitial inflammation contribute to heart block in rheumatologic disorders. Myotonic, Becker, and Duchenne muscular dystrophies are neuromuscular diseases involving the myocardium skeletal muscles and can cause heart block.

Serous fluids and hematolymphoid disorders

Diagnosing hematolymphoid neoplasm by evaluating fine-needle aspiration (FNA) cytology sample is controversial and requires experience and clinical skills. This concept becomes more challenging when evaluating hematolymphoid neoplasm in body fluid. Differentiating between low-grade lymphoma and reactive lymphocytes is often difficult by morphology alone as reactive lymphoid cells may acquire activation morphology from being exposed to different cytokines within the body fluid. However, in most cases there are specific features that may aid in differentiating small reactive from non-reactive lymphocytes including the round shape of the nucleus, the absence of visible nucleoli and the presence of fine clumped chromatin. In large cell lymphoma and leukemia cells involvement of body fluid this concept becomes less challenging. Large cell lymphoma and leukemia cells tend to have large size nuclei, less mature chromatin, and visible nucleoli with and without cytoplasmic vacuoles. However, to reach accurate diagnosis and subclassification, the utilizing of flow cytometry, to confirm monoclonality, and other ancillary studies such immunocytochemistry, cytogenetics and molecular studies is needed. This review article will be incorporated finally as one of the chapters in CMAS (CytoJournal Monograph/Atlas Series) #2. It is modified slightly from the chapter by the initial authors in the first edition of Diagnostic Cytopathology of Serous Fluids.

Systemic Diseases and Heart Block

Systemic diseases can cause heart block owing to the involvement of the myocardium and thereby the conduction system. Younger patients (<60) with heart block should be evaluated for an underlying systemic disease. These disorders are classified into infiltrative, rheumatologic, endocrine, and hereditary neuromuscular degenerative diseases. Cardiac amyloidosis owing to amyloid fibrils and cardiac sarcoidosis owing to noncaseating granulomas can infiltrate the conduction system leading to heart block. Accelerated atherosclerosis, vasculitis, myocarditis, and interstitial inflammation contribute to heart block in rheumatologic disorders. Myotonic, Becker, and Duchenne muscular dystrophies are neuromuscular diseases involving the myocardium skeletal muscles and can cause heart block.

Primary Cardiac Lymphoma Manifesting as Complete Heart Block

Primary cardiac tumors are exceedingly rare with variable clinical manifestations. This case involves a patient presentation of symptomatic complete heart block and cardiac imaging revealing a right atrial mass invading the myocardium consistent with Burkitt lymphoma on histopathology. The patient received definitive bradytherapy with a pacemaker and chemotherapy for the primary cardiac lymphoma. After three cycles of chemotherapy, the right atrial mass regressed significantly with restoration of atrioventricular conduction and no pacing burden. Primary cardiac lymphomas infrequently manifest as atrioventricular block and this case highlights cardiac masses as a potential etiology when evaluating new conduction disturbances and bradyarrhythmias.

Cardiac Lymphoma

Lymphoma of the heart and pericardium may develop in up to 25% of patients with disseminated nodal disease, but primary cardiac lymphoma is rare. The majority are diffuse large B-cell lymphomas, which arise in immunocompetent older individuals, men twice as often as women. Subsets are found in immunocompromised patients, including those with HIV-AIDS or allograft recipients. Cardiac lymphomas tend to arise in the wall of the right heart, especially right atrium, with contiguous infiltration of epicardium and pericardium. Pericardial implants and effusions are common. The disease is often multifocal in the heart, but cardiac valves are usually spared.

Complete Resolution of Tumor Burden of Primary Cardiac Non-Hodgkin's Lymphoma

Primary cardiac tumors are a rare set of benign and malignant neoplasms found in the heart or pericardium. We describe a patient presenting with nonspecific symptoms and ultimately diagnosed with primary cardiac non-Hodgkin's lymphoma (PCL). Our patient had extensive tumor in the right ventricle, which extended into the right atrium and right ventricular outflow tract. The tumor also encased the right coronary artery, which manifested as ischemic changes on EKG and cardiac MRI. The patient was treated with chemotherapy and achieved complete remission, with dramatic and full resolution of the mass on repeat echocardiography in nine weeks. More studies are needed to understand the optimal management and prognosis of patients with PCL.

Primary cardiac lymphoma: two cases and a review of literature

Background

Primary cardiac lymphoma is one of the rarest tumours of the heart. It belongs to the extra-nodal non-Hodgkin’s lymphomas. The most common type of this tumour is diffuse large B cell lymphoma. Usually, right atrium and right ventricle are involved. This tumour is fatal unless diagnosed and treated in time. In this article two female patients who were diagnosed with primary cardiac lymphoma and treated at our clinic are described. The first patient went to remission after the treatment, while the second patient died. The goals of this article are to show the difficulties of diagnosing and treating this disease, the role of cardiac surgery in its treatment and to raise awareness of this disease.

Case reports

In this article two female patients who were diagnosed with primary cardiac lymphoma and treated at our clinic are described. The first patient went to remission after the treatment, while the second patient died.

Conclusions

Primary cardiac lymphoma is a very rare disease. At the moment the most effective treatment is chemotherapy. Palliative surgery may be necessary to correct hemodynamics when venous blood flow to the lungs is disturbed.

Recurrent primary cardiac lymphoma on aortic valve allograft: implications for therapy

Primary malignant cardiac lymphomas associated with grafts are extremely rare: to our knowledge, only 6 cases of prosthesis-associated B-cell lymphoma have been reported. Ours is the first report of recurrent diffuse large B-cell lymphoma associated with aortic valve allografts. We treated a 60-year-old man who presented in early 2007 with aortic valve endocarditis. He underwent aortic valve replacement with an allograft; the resected native valve showed active endocarditis without tumor. In January 2011, the patient underwent repeat aortic valve replacement because of symptomatic aortic regurgitation. The explanted valve specimen displayed diffuse large B-cell lymphoma. In September 2011, the patient presented with fever and a mass around the aortic valve. He died in January 2012. On autopsy, the explanted replacement valve displayed recurrent diffuse large B-cell lymphoma. The recurrent lymphoma on a new graft leads us to believe that this tumor is more aggressive than had been thought. We propose early systemic chemotherapy, in addition to tumor resection, for the possibility of a better prognosis. We discuss our patient's case and review the relevant medical literature.

Primary cardiac lymphoma: clinical, histologic, immunophenotypic, and genotypic features of 5 cases of a rare disorder

Primary lymphomas of the heart are rare and frequently are diagnosed at autopsy. Modern imaging technology now permits early diagnosis and treatment. This report describes the clinical, histologic, immunophenotypic, and molecular genetic findings for 5 patients with malignant lymphoma restricted to the cardiac muscle, with or without pericardial involvement. All patients were women, with ages ranging from 40 to 68 years (median 55 y). The right atrium was involved in all cases with the left atrium, right ventricle, and pericardium affected in 1 case each. Clinical presentation included pericardial effusions associated with precordial pain, dyspnea, and bradycardia. Electrocardiographic changes included junctional rhythm, incomplete right bundle branch block and ST and T waves abnormalities, and ST segment elevation and first-degree atrioventricular block with intermittent complete heart block. In all cases, biopsy or resection of the lesion or cytologic examination of the pericardial fluid established a diagnosis. All tumors were of B-cell phenotype and included 4 cases of large cell lymphoma and one unclassifiable small cell lymphoma. In 2 cases, a follicular center cell origin was supported by reactivity of the neoplastic cells for CD10 and bcl-6 and by bcl-2 gene rearrangement by molecular analysis. One patient died shortly after diagnosis due to cerebral infarction. Two patients are alive without disease after chemotherapy with CHOP after 120 and 192 months. One patient underwent chemotherapy with CHOP and rituximab, and shows persistent cardiac involvement by lymphoma but with a decrease in tumor burden at 7 months of follow-up. One patient was lost to follow-up. Clinical outcome is variable; however, early diagnosis in conjunction with effective treatment (surgery and/or chemotherapy) may result in an excellent prognosis. Primary cardiac lymphoma should be included in the differential diagnosis of a right atrial mass.

Primary cardiac lymphoma

Primary cardiac lymphoma (PCL) has rarely been reported in Chinese populations. PCL mostly occurs in the right atrium. The clinical manifestations may be variable and are attributed to its location, the presence of congestive heart failure, pericardial effusion, arrhythmia, and cardiomegaly. The prognosis is usually poor because it is usually found too late and therefore, clinicians should be aware of PCL. Imaging examinations are the best methods for initial diagnosis and include echocardiography, computed tomography (CT) scan, magnetic resonance imaging (MRI), and radioisotope scan. However, the final diagnosis is made by pathology, such as cytologic examination of the effusive fluid and tissue biopsy. Because the tumors are difficult to resect, the main treatment for the disease is chemotherapy, which can be successful. Here, we report a 58-year-old man who had a tumor measuring 8 x 5 cm in the right atrium. By clinical staging, including chest X-ray, echocardiography, CT scan of the abdomen, MRI of the heart, whole body tumor Gallium scan, and gastrointestinal series, no metastatic lesion or involvement was found in other parts of the body. Pathologic findings including cytology of pericardial effusion and heart tumor biopsy revealed the case as a diffuse large B-cell lymphoma. After chemotherapy with COP (cyclophosphamide + vincristine + prednisone) and CHOPBE (COP + doxorubicin + bleomycin + etoposide) regimens, the intracardiac tumor had disappeared, but the patient survived for 12 months in total, despite additional radiotherapy over the pericardial lesions. It was presumed that because the tumor was very large and involved all 3 layers of the heart, it did not respond as well to the therapy as expected.

Cardiac presentation of ALK positive anaplastic large cell lymphoma

Cardiac involvement as an initial presentation of malignant lymphoma is a rare occurrence. We report the case of an immunocompetent 29-year-old male who presented with syncope and arrythmias secondary to a ventricular cardiac mass. Transcutaneous cardiac biopsy was non-diagnostic, therefore an open cardiac biopsy was performed from which a provisional diagnosis of a cardiac inflammatory pseudotumour was made. Six months after presentation, he developed several subcutaneous lesions with systemic symptoms. Histological and immunophenotypic review of the initial cardiac biopsy revealed features consistent with a diagnosis of CD30, ALK1 positive anaplastic large cell lymphoma (ALCL). Despite intensive treatment with combination chemotherapy, there was significant progression of disease, and he died 11 months after diagnosis. The overall prognosis of cardiac lymphoma remains poor, which may be due to the often late presentation of the tumour. To our knowledge, this is the first reported case of a cardiac ALK positive ALCL. Although rare, cardiac presentation of ALCL should be added to the list of differential diagnoses of cardiac lymphomas.

Cardiac involvement by malignant lymphoma: a clinicopathologic study of 25 autopsy cases based on the WHO classification

As cardiac involvement by malignant lymphoma (ML) is relatively uncommon and antemortem diagnosis is difficult, details of this condition remain to be elucidated. To clarify clinicopathologic features of cardiac lymphoma (CL), 25 autopsy cases were studied. Each was rediagnosed according to the World Health Organization (WHO) classification, and clinicopathologic characteristics were investigated by tumor phenotype. The study subjects were 13 males and 12 females with a mean age of 53.4 years. All cases were secondary CL and were not diagnosed as CL before death; 14 cases (56%) were of B-cell and 11 (44%) of T-cell (including natural killer cell) phenotype. Nasal and nasal-type natural killer/T-cell lymphomas (NKTLs) accounted for five (20%). Cardiac manifestation was evident in eight (32%), with hematogenous infiltration as the most common pattern of tumor spread. Some B-cell CLs (n=3) were complicated by cardiac tamponade and heart failure (HF), and T-cell CLs (n=5), including three nasal NKTLs, also featured arrhythmia and sudden death. The incidence of T-cell phenotype was significantly elevated for CLs (p<0.05), especially for CLs with cardiac manifestation (p<0.01), compared with that for MLs in general. Our results indicate that T-cell lymphomas, compared with B-cell lymphomas, invade the heart more frequently and aggressively and are associated with a variety of cardiac manifestations. Where cardiac involvement is suspected, aggressive diagnostic procedures are warranted, especially with MLs having a T-cell phenotype. In cases of nasal NKTL, particular attention is necessary.

CT and MR imaging findings of malignant cardiac tumors

This article reviews CT and MRI features of malignant cardiac and pericardial tumors, most of which originate from the lung, breast, melanoma, leukemia, or lymphoma through lymphatic, hematogenous, transvenous, and direct pathways. Although echocardiography establishes the diagnosis in most cases, CT and MRI provide additional physical, spatial, and functional information that further aids the evaluation of metastases. For instance, CT provides superior resolution for detecting calcification or fat, while MRI with its direct multiplanar ability more completely characterizes the heart, pericardium, mediastinum, and lungs. MRI also helps elucidate the pathophysiological effects of these tumors on cardiac function through gated cine-loop sequences. Beyond tumor characterization, both modalities can help confirm diagnosis through the addition of contrast, which helps distinguish tumor from myocardium, thrombus, and blood flow artifact. Ultimately, MRI best facilitates surgical planning and posttreatment follow-up in large part because of its unparalleled ability to locate and delimit these tumors.

Primary lymphoma of the heart: case report and literature review

Primary cardiac lymphoma (PCL) is a rare and usually fatal neoplasma. A case of PCL in a 78-year-old man who complained of exertional dyspnea and peripheral edema is presented. Echocardiography revealed a mass in the right atrium and a diagnosis of low-grade B-cell lymphoma was obtained with the surgically resected tumor. The lesion appeared to have originated in the right atrium and involved the right ventricle. The patient died of bronchopneumonia 8 months after the initial consultation. The present case and 39 patients with PCL reported between 1995 and 2002 were reviewed. Forty patients showed various and non-specific symptoms such as dyspnea, edema, arrhythmia and pericardial effusion. Primary cardiac lymphoma occurred slightly more often in male patients (M : F = 23:17) and in the elderly in general (mean age, 67 years), with lesions found in the following locations, listed in order of frequency: right atrium, pericardium, right ventricle, left atrium, left ventricle, and other sites. Antemortem diagnosis was obtained in 37 of the 40 patients. Thirty-seven cases were of B-cell lineage and two cases were of T-cell lineage. Complete remission was obtained in only 15 of the 40 patients. Although PCL antemortem diagnoses have been made in the majority of recent cases, the prognosis still remains poor.

Primary cardiac Burkitt lymphoma in a child

Primary cardiac lymphoma (PCL) is a rare and usually fatal malignancy, seldom reported in children. This report describes the case of a 10-year-old boy who presented with multiple intracardiac masses which, when biopsied, proved to be small non-cleaved cell (Burkitt's) lymphoma. The first two cycles of chemotherapy according to the LMB 96 protocol were given under close cardiological supervision, with good response. The treatment was then continued with full-dose chemotherapy, without any cardiological complication. The patient who was treated by chemotherapy alone remains in complete remission 36 months after the end of treatment and can presently be considered as cured, without late cardiac effect.

An Unusual Cause of New-onset Atrial Flutter: Primary Cardiac Lymphoma

Primary cardiac lymphoma is a rare disease with a high mortality rate due to the advanced stage of myocardial involvement at presentation. The diagnosis is extremely difficult to make because of the rarity of the disease, variability of clinical manifestations, limited noninvasive diagnostic techniques available, and difficulties and/or delays in the use of invasive measures. The incidence of the disease is increasing, especially among immunocompromised patients, with those suffering from acquired immunodeficiency syndrome accounting for the greatest increase. We report the case of an immunocompetent 76-year-old black woman who presented with near-syncopal episodes. Transthoracic echocardiogram revealed a right atrial mass. Surgical resection was performed, and a diagnosis of large B-cell non-Hodgkin's lymphoma was made. Primary cardiac lymphoma should be considered in any patient with a cardiac mass. Prompt diagnosis and treatment of primary cardiac lymphoma is imperative for survival.

A unique atrial primary cardiac lymphoma mimicking myxoma presenting with embolic stroke: a case report

An immunocompetent 29-year-old male presented with an embolic stroke from an unusual primary cardiac lymphoma. The cardiac lesion consisted of a polypoid, left atrial, mural fibrin thrombus with anaplastic tumor cells lining the surface of the clot. Histologic, immunophenotypic, and molecular characterizations were consistent with a diagnosis of CD30+ large B-cell lymphoma with anaplastic cytology. While tumor emboli from invasive primary cardiac lymphomas have been reported, this noninvasive fibrin thrombus-associated lymphoma appears to be unique and previously unreported.

Primary cardiac and pericardial neoplasms: radiologic-pathologic correlation

Primary cardiac and pericardial neoplasms are rare lesions and include both benign and malignant histologic types. Myxoma is the most frequent primary cardiac neoplasm, but other benign tumors include papillary fibroelastoma, rhabdomyoma, fibroma, hemangioma, lipoma, and paraganglioma. Cardiac sarcoma represents the second most common primary cardiac neoplasm. Lymphoma can also affect the heart primarily. Pericardial tumors that affect the heart include benign teratomas and malignant mesotheliomas. Patients affected with cardiac or pericardial neoplasms often present with cardiovascular compromise or embolic phenomena and exhibit cardiomegaly at chest radiography. Benign cardiac tumors typically manifest as intracavitary, mural, or epicardial focal masses, whereas malignant tumors demonstrate invasive features and may involve the heart diffusely. Benign lesions can usually be successfully excised, but patients with malignant lesions have an extremely poor prognosis.

A case of primary cardiac B cell lymphoma associated with ventricular tachycardia, successfully treated with systemic chemotherapy and radiotherapy: a long-term survival case

We experienced a long-term survival case of primary cardiac lymphoma (PCL) demonstrating ventricular tachycardia (VT) as an initial sign, which was related to localized myocardial damage by lymphoma cells. A 70-year-old woman with sustained VT was admitted to the Kofu Municipal Hospital. VT ceased with the administration of disopyramide intravenously. The origin of the VT was the free wall of the right ventricular outflow tract (RVOT) as observed by electrocardiography on admission. A solitary mass in the free wall of the RVOT was found by echocardiography, chest computed tomographic scanning and magnetic resonance imaging. There was no evidence of extracardiac involvement. The patient was histologically diagnosed as PCL by endomyocardial biopsy. Chemotherapy started immediately after the diagnosis and the mass showed a marked reduction in size. After 8 cycles of chemotherapy, radiotherapy was performed. Pericardial thickness in the free wall of the RVOT developed without severe side effects. Complete remission has been maintained for 30 months after the initial diagnosis, and no recurrence and arrhythmias have been detected during the follow-up period. It was demonstrated that rapid diagnosis and chemotherapy followed by radiotherapy for PCL achieved better survival.

Successful treatment of a patient with cardiac lymphoma who presented with a complete atrioventricular block

A patient with primary cardiac lymphoma, which is very rare, generally is regarded to have a poor prognosis. We herein report a patient with cardiac lymphoma who was treated successfully by systemic chemotherapy and radiotherapy using a pacemaker to control the complete atrioventricular (A-V) block. A 70-year-old man had a syncope caused by a complete A-V block. An echocardiogram, a computed tomographic scan, and magnetic resonance imaging of his chest showed a cardiac tumor. At this time, a biopsy of the cardiac tumor disclosed malignant lymphoma (diffuse large cell type, B cell type). The patient was thus treated with systemic chemotherapy and radiotherapy and, as a result, achieved a complete remission with a disappearance of the A-V block. Recently, several successful outcomes involving primary cardiac lymphoma have been reported because of the progress in diagnostic techniques including echocardiography, computed tomographic scanning, and magnetic resonance imaging, as well as improvement in the therapy of malignant lymphoma. Our clinical experience indicated that an early and accurate diagnosis combined with the appropriate therapy can thus help in obtaining a long survival in patients with primary cardiac lymphoma.

Primary cardiac lymphoma in an immunocompetent woman

We report a fatal primary cardiac non-Hodgkin's lymphoma in a 62 years old immunocompetent woman presenting with tamponade and complete atrioventricular block. CT-scan, echocardiography and autopsy examination showed a tumor largely infiltrating the heart without extracardiac involvement. A surgical biopsy revealed high grade B-cell non-Hodgkin's lymphoma with a misleading myelomonocytic CD68 (KPI) expression. Polymerase Chain Reaction analysis revealed a clonal rearrangement of the immunoglobulin heavy chain gene and confirmed the B-cell origin of the lymphoma. Our report also emphasizes the role of immunohistochemical and molecular techniques in the diagnosis.

Primary cardiac lymphoma diagnosed by percutaneous needle biopsy

We diagnosed a case of primary cardiac lymphoma using transthoracic needle biopsy. A 70-year-old man was admitted because of dyspnea. Magnetic resonance imaging revealed a tumor mass in the right ventricular free wall. We performed ultrasound guided transthoracic needle biopsy using an 18-G needle, and diagnosed as malignant lymphoma by the biopsy specimen. This method may be useful for the diagnosis of cardiac lymphoma.

Primary cardiac lymphoma in immunocompetent patients: diagnostic and therapeutic management

BACKGROUND

Primary cardiac lymphoma (PCL) is extremely rare in immunocompetent patients. Different definition criteria have been employed in published series. Prognosis is poor due to diagnostic delay and relevance of the site of disease.

METHODS

Two cases observed at the study institution are reported, with a review of 48 cases published in the literature from 1980 to 1996. Only patients with lymphoma confined to the heart and/or pericardium and those with a single and asymptomatic extracardiac site were considered for analysis.

RESULTS

Eight patients had minimal extracardiac disease. The most common presentation was unresponsive heart failure. Electrocardiography findings were not specific. PCL usually arose in the right chambers as a mass, with or without pericardial effusion (> 80%). Chest X-rays, transthoracic echocardiography, and computed tomography scans are standard in diagnostic workup, but transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI) showed a sensitivity > 90%. Cytology of pericardial effusion was diagnostic in 67% of cases. Thoracotomy was diagnostic in all cases, whereas less invasive procedures had high false-negative rates. Gross resection has no role. Early anthracycline-containing chemotherapy appears to improve survival, whereas the role of radiotherapy has not yet been defined.

CONCLUSIONS

The diagnosis of PCL should be considered in patients with a cardiac mass and/or unexplained refractory pericardial effusion. Adequate diagnostic workup, including TEE and MRI, allows confirmation of the early suspicion of PCL. In the absence of a diagnostic cytology, an open biopsy may be indicated to avoid treatment delay. There is no evidence that PCL should be treated differently from other bulky aggressive lymphomas arising at other anatomic sites.

[Primary cardiac lymphoma: presentation of a case and review of the literature]

We describe a case of primary cardiac lymphoma presenting with chest pain, complete AV block, negative T waves, and infiltration of the basal segments and right free ventricular wall on echocardiography, interpreted initially as hypertrophy. One month later the patient was readmitted with systemic disease and cardiac insufficiency. Furthermore multicentric myocardial infiltration with a nodular mass in the right atrium producing severe tricuspid stenosis was demonstrated. Surgical biopsy was performed and a high grade non-Hodgkin's lymphoma diagnosed. The patient died during the immediate post-operative period without receiving specific chemotherapeutic treatment. Reviewing the published cases, we found that primary cardiac lymphomas are fast growing tumors that infiltrate predominantly the right cavities and have limited therapeutic options.

Primary cardiac lymphoma

Primary cardiac lymphoma is a rare entity. We report on the clinicopathological features of 2 patients with primary cardiac lymphomas: one involving the right atrium resulting in intractable right heart failure, and the other involving the pericardium with massive pericardial effusion. In the first patient, sternotomy and surgical biopsy of the tumor were performed to arrive at the diagnosis. In the second patient, CT thorax and transesophageal echocardiography helped to diagnose the pericardial tumor, and cytological examination of the pericardial fluid established the pathological diagnosis of lymphoma. Combination chemotherapy (COPP) was started in both patients. The first patient died on the first day of chemotherapy due to intractable heart failure, while the second attained a partial response to chemotherapy but died of progressive disease 8 weeks later. This is followed by a literature review of 21 patients with primary cardiac lymphoma. In conclusion, the prognosis of primary cardiac tumor remains poor.

Cardiac tamponade due to primary pericardial lymphoma in a patient with AIDS

Cardiac tamponade due to lymphomatous involvement of the heart is a dramatic and unusual complication. Because of their nonspecific clinical presentation, these tumors are seldom diagnosed antemortem. We report the case of a patient with AIDS who presented with signs and symptoms of cardiac tamponade. Emergency pericardiocentesis followed by staging studies revealed large cell B-lymphocyte lymphoma confined to the pericardial space. With combination chemotherapy, a durable complete response was obtained. This case illustrates the potential benefit of aggressive treatment of extranodal non-Hodgkin's lymphoma in a patient with AIDS. The case is of particular interest because of the unusual development of isolated pericardial involvement as the sentinel sign of lymphoma.

Malignant lymphoma with primary cardiac manifestations: a case report

This case report describes a 29-year-old black patient presenting with right heart failure secondary to massive lymphomatous cardiac involvement. Additional sites of involvement included mesenteric lymph nodes and the small bowel. Malignant lymphoma with primary cardiac manifestations is very rare and follows an aggressive course. The importance of early diagnosis and commencement of immediate therapy is emphasized.

Primary lymphoma of the pericardium: report on a "cured" case and review of the literature

This report describes a 62-year-old man with a primary diffuse, immunohistochemically proven B-cell lymphoma of large non-cleaved cell (centroblastic) type of the pericardium. The patient responded completely to systemic chemotherapy and remains free of disease 30 months after diagnosis. The use of non-cardiotoxic drugs in divided doses as initial treatment is emphasized. In addition, the authors reviewed the literature of the last decade regarding the management and outcome of patients with primary cardiac lymphomas.

Cardiac malignant lymphoma in acquired immune deficiency syndrome

BACKGROUND

Extranodal malignant lymphomas (ML) are known to occur with increased frequency in patients with human immunodeficiency virus infection. The authors report a 30-year-old man with acquired immune deficiency syndrome (AIDS) with ML primarily involving the heart and compare the clinical and pathologic features to those of previously reported patients.

METHODS

The patient's hospital record was reviewed and pertinent clinical data were abstracted. Tissue obtained at autopsy was processed for routine light microscopic study and immunohistochemistry. A computer-assisted search of the medical literature for patients with malignant cardiac lymphoma was performed.

RESULTS

The patient's initial signs and symptoms were nonspecific, and an abnormal gallium scan suggested pericarditis. Clinically, the course was characterized by progressive heart failure. Autopsy disclosed a diffuse large cell non-Hodgkin lymphoma of B-cell phenotype with massive involvement of the pericardium and extension into the myocardium. A literature search revealed 22 patients with cardiac lymphoma associated with AIDS. Clinical findings were nonspecific, but rapid progression of cardiac dysfunction was common after symptoms appeared. Pathologically, most lymphomas were of diffuse aggressive subtypes.

CONCLUSIONS

ML of the heart is extremely rare but is being encountered with increasing frequency in patients with AIDS. The diagnosis should be considered in such patients in whom cardiovascular symptoms develop suddenly and progress rapidly.

Case report of primary cardiac lymphoma. The applications of PCR to the diagnosis of primary cardiac lymphoma

A 75-year-old man initially complained of pollakiuria and low abdominal pain, and died of massive bleeding from an exacerbated gastric ulcer. The diagnosis of primary cardiac lymphoma was made postmortem. The tumor involved only the epicardium and myocardium, which met the criteria of primary cardiac lymphoma as defined by the Armed Forces Institute of Pathology. The lymphoma consisted of large cells and expressed the B cell marker, CD20. Although chronic inflammation due to chronic renal failure was observed in the pericardium around the lymphoma, polymerase chain reaction (PCR) was conducted to detect monoclonality at the DNA level in lymphoma cells, which were shown to comprise a monoclonal population.