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| CASE SNIPPET |
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| Year : 2020 | Volume
: 66
| Issue : 3 | Page : 176-177 |
Isolated intracardiac recurrence of diffuse large B-cell lymphoma successfully treated with rituximab and bendamustine chemotherapy regimen
CH Chang1, CS Lin1, CL Ho2
1 Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
2 Division of Hematology and Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| Date of Submission | 20-Dec-2019 |
| Date of Decision | 02-Mar-2020 |
| Date of Acceptance | 23-Apr-2020 |
| Date of Web Publication | 14-Jul-2020 |
Correspondence Address:
C H Chang
Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
Taiwan
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jpgm.JPGM_683_19
How to cite this article:
Chang C H, Lin C S, Ho C L. Isolated intracardiac recurrence of diffuse large B-cell lymphoma successfully treated with rituximab and bendamustine chemotherapy regimen. J Postgrad Med 2020;66:176-7 |
How to cite this URL:
Chang C H, Lin C S, Ho C L. Isolated intracardiac recurrence of diffuse large B-cell lymphoma successfully treated with rituximab and bendamustine chemotherapy regimen. J Postgrad Med [serial online] 2020 [cited 2023 Jun 6];66:176-7. Available from: https://www.jpgmonline.com/text.asp?2020/66/3/176/289766 |
A 72-year-old man with a history of diffuse large B-cell lymphoma (DLBCL) in the lumbar spine, Ann Arbor stage II status post chemotherapy with rituximab, cyclophosphamide, vincristine, and prednisolone (R-COP) and local radiotherapy, had been in complete remission for 4 years. He presented to our emergency department after experiencing exertional dyspnea for 1 week. Physical examination revealed bilateral basal rales, jugular vein engorgement, and bilateral edema of the lower limbs. Chest radiography showed bilateral pleural effusion, cardiomegaly, and pulmonary trunk engorgement. Blood investigations revealed thrombocytopenia (platelet counts of 54000/μL, normal range: 150000–400000/μL) and high levels of lactate dehydrogenase (787 U/L, normal range: 140–271 U/L) and B-type natriuretic peptide (819 pg/mL, normal level: <100 pg/mL). Room air arterial blood gas analyses revealed a PaCO2 of 27.7 mmHg (normal range: 35–45 mmHg), PaO2 of 64.1 mmHg (normal range: 75–100 mmHg) and HCO3 level of 23 mmol/L. Other laboratory data were unremarkable. After an initial diagnosis of possible acute decompensated heart failure, intravenous furosemide, and nitroglycerin were initiated. However, facial swelling and edema in upper limbs, along with worsening tachycardia, and orthopnea, developed after this therapy. Contrast-enhanced computed tomography (CECT) of the chest demonstrated soft-tissue masses impacted in the pulmonary vein, right atrium, right ventricle, and left atrium, accompanied by large amounts of pericardial effusion [Figure 1]. This led us to suspect superior vena cava syndrome caused by intracardiac tumors for which steroid treatment was initiated. A biopsy was recommended. However, as the patient refused this procedure due to his advanced age, intravenous betamethasone was prescribed, followed by the rituximab and bendamustine (RB) regimen. After 3 months, the CT of the chest revealed reduced tumor sizes [Figure 2]. Positron emission tomography revealed a positive response of DLBCL to chemotherapy as evidenced by the low fluorodeoxyglucose (FDG) uptake [Figure 3] indicating a reduction in metabolism in the tumors. The patient was free of symptoms and was referred to the outpatient department for further follow-up.. | Figure 1: Contrast-enhanced computed tomography (CECT) of the chest showing masses occupying the right atrium, right ventricle, and left atrium with extensive pericardial effusion and bilateral pleural effusion
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 | Figure 2: CT of the chest after chemotherapy with six cycles of the rituximab and bendamustine regime revealing reduced tumor sizes
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 | Figure 3: PET CT image posttreatment showing reduction of metabolic activity in the intracardiac lymphoma consistent with a response to therapy. Soft-tissue masses impacted in the heart showing little FDG uptake (SUVmax: 1.2)
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DLBCL is the most common type of non-Hodgkin lymphoma and can be cured using immunochemotherapy.[1] Although it can recur at nodal or extranodal sites, such as the gastrointestinal tract, testes, thyroid, skin, breast, bone, or brain, isolated intracardiac recurrence is extremely rare. However, most cardiac lymphomas are DLBCL and involve the right side of the heart, particularly the right atrium.[2] Approximately 5–8% of patients with DLBCL present with superior vena cava syndrome.[2] The treatment of cardiac lymphoma is not without challenges as the preferred curative protocol for a patient with a recurrent DLBCL is salvage chemotherapy—the common salvage chemotherapy regimens used are rituximab, dexamethasone, high-dose Ara-C and platinol (RDHAP), or rituximab, gemcitabine, carboplatin and dexamethasone (RGCD) or rituximab and bendamustine (RB).[2],[3],[4] This treatment is frequently followed by an autologous transplant; however, surgical intervention or autologous transplant may not be a viable option, particularly for frail or elderly patients. Hence, chemotherapy with the RB regimen may be considered to be an alternative treatment protocol for patients with recurrent DLBCL, post-R-CHOP. Our successful experience highlights the therapeutic potential of the RB regimen in patients with advanced intracardiac lymphoma, particularly in those unsuited to surgical intervention.
Declaration of patient consent
The authors certify that appropriate patient consent was obtained.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| :: References | |  |
| 1. | Wang Y, Farooq U, Link BK, Larson MC, King RL, Maurer MJ, et al. Late relapses in patients with diffuse large B-cell lymphoma treated with immunochemotherapy. J Clin Oncol 2019;37:1819-27.  |
| 2. | Jeudy J, Burke AP, Frazier AA. Cardiac lymphoma. Radiol Clin North Am 2016;54:689-710. |
| 3. | Amari K, Tago M, Katsuki NE, Fukumori N, Yamashita SI. Cardiac recurrence of diffuse large B-cell lymphoma more than a decade after attaining complete remission. Am J Case Rep 2018;19:1057-62. |
| 4. | Jonavicius K, Salcius K, Meskauskas R, Valeviciene N, Tarutis V, Sirvydis V. Primary cardiac lymphoma: Two cases and a review of literature. J Thorac Cardiovasc Surg 2015;10:138-42. |
[Figure 1], [Figure 2], [Figure 3]
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