1355576 - B-cell lymphoma with cardiac involvement: a case report.

Description of Clinical Presentation: 26-year-old woman, smoker for 4 years. History of fever, night sweats, myalgias, arthralgias, dyspnea at rest and exacerbated in decubitus, cough, tachycardia and left chest pain. There is no weight loss. On admission, tachycardia, poorly palpable apex shock, auscultation with a hyperdynamic heart, dull noises, pericardial friction rub on the left sternal border were documented. In laboratory tests anemia, platetosis and elevated ferritin.

Diagnostic Techniques and Their Most Important Findings:

PA chest radiograph with poorly defined left radiopacity (image 1a). Transthoracic Ecardiogram showing pericardial effusion (image 1b). Computerized axial tomography showing a multilobed mass with heterogeneous density in the anterior mediastinum (image 1c).
CMR: large tumor in the anterior mediastinum (132 x 105 x 107 mm) with intermediate signal intensity in HASTE sequence (image 2a). STIR sequence shows hyperintense areas of central distribution corresponding to cystic degeneration vs necrosis (image 2b). No hypointense areas are observed on T2* (image 2c), nor fat deposits (not shown).
The tumor is in close contact with the anterior wall of the left ventricle in the basal and middle thirds (image 2d) and with the anterior wall of the right ventricle associated with hypokinesia, it compresses the infundibulum and the trunk of the pulmonary artery (image 2e). There is loss of the interface between the tumor and the heart muscle (image 2f), causing expansion of the pericardial leaves associated with pericardial effusion with septa (image 2g). In late gadolinium enhancement images, the tumor presents intense and heterogeneous enhancement with hypointense central areas and enhancement of the pericardial leaves (image 2h). An ultrasound-guided biopsy was performed, taking 6 samples (image 3a), obtaining a histopathological result compatible with a malignant tumor of small, round, blue cells compatible with type B germ cell lymphoma (image 3b and 3c).

Learning Points from this Case:

 

Primary mediastinal large B-cell lymphoma is a variety of non-Hodgkin's lymphoma, located in the mediastinum.
This lymphoma mainly affects young women, between the third and fourth decade of life.
It presents as a rapidly growing and local aggressiveness mass in the anterior mediastinum, during its evolution it infiltrates adjacent structures such as the pericardium. Pericardial effusion is frequently found.
Multimodality imaging work-up represents the best method for tumor detection and evaluation of its size and extension. On CT imaging, appears as a soft-tissue mass iso-hypoattenuating relative to the myocardium, extending along the epicardial surface wrapping and infiltrating myocardium, pericardium, great vessels, and coronary arteries.
MRI is the best choice to accurately depict the extent myocardial and pericardial infiltration. It also helps in discriminating between benign versus malignant cardiac masses emphasizing infiltration, invasion, and other signs of metastasis.