Case Report
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jan 26, 2019; 7(2): 191-202
Published online Jan 26, 2019. doi: 10.12998/wjcc.v7.i2.191
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
Rabah Al-Mehisen, Maha Al-Mohaissen, Hisham Yousef
Rabah Al-Mehisen, Department of Cardiology, Security Forces Hospital, Riyadh 11481, Saudi Arabia
Maha Al-Mohaissen, Department of Clinical Sciences (Cardiology), Princess Nourah Bint Abdulrahman University Research Chair in Cardiovascular Disease in Women, Princess Nourah Bint Abdulrahman University, Riyadh 11511, Saudi Arabia
Hisham Yousef, Department of Internal Medicine, Division of Hematology/Oncology, Security Forces Hospital, Riyadh 11481, Saudi Arabia
Author contributions: Al-Mohaissen M and Al-Mehisen R designed the report; Al-Mehisen R and Yousef H collected the patient’s clinical data; Al-Mehisen R, A-Mohaissen M and Yousef H analyzed the data and wrote the paper.
Informed consent statement: Consent was obtained from the patient for publication of this report and any accompanying images and is available upon request.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
CARE Checklist (2016) statement: The CARE checklist has been filled and submitted before and is not among the resubmission requirements at the journal website.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Maha Al-Mohaissen, MBBS, SBIM, ArBIM, MRCP, Associate Professor, Department of Clinical Sciences (Cardiology), Princess Nourah Bint Abdulrahman University Research Chair in Cardiovascular Disease in Women, Princess Nourah Bint Abdulrahman University, PO Box 40847, Riyadh 11511, Saudi Arabia. mahaabdulrahman@hotmail.com
Telephone: +966-11-8238882
Received: October 15, 2018
Peer-review started: October 15, 2018
First decision: December 9, 2018
Revised: December 26, 2018
Accepted: January 3, 2019
Article in press: January 4, 2019
Published online: January 26, 2019
Processing time: 104 Days and 23.9 Hours
Abstract
BACKGROUND

Secondary 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 SUMMARY

An 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.

CONCLUSION

Imaging-guided chemotherapy dosing may minimize the risk of myocardial rupture in cardiac lymphoma. Data are limited. Management should be individualized.

Keywords: Diffuse large B-cell lymphoma; Cardiac lymphoma; Cardiac imaging; Cardiac magnetic resonance imaging; Myocardial rupture; Imaging-guided chemotherapy; Case report

Core tip: Few Clinicians are comfortable managing a patient with extensive cardiac involvement by lymphoma, due to the limited clinical experience and paucity of data on such cases. Despite the heterogeneity in management, early diagnosis and treatment may lead to remission. Decisions on management should be individualized due to the variability in the pattern and magnitude of cardiac disease. In cases with extensive involvement, reducing the chemotherapy dose with dose escalation to therapeutic levels may be safe and effective management approach. Improvements in imaging technology will likely increase the rate of pre-mortem detection of cardiac lymphoma leading to better understanding of this highly fatal condition and improved patient survival.