Patients (Pts) with lymphoma are at high risk of cardiovascular events for the cardiotoxic effects of therapies and direct involvement of the heart. Autopsy series, indeed, indicate that cardiac localization may be observed in 10 – 25% of DLBCL Pts. The presence of cardiac mass, in DLBCL poses further complexity to the management beyond myocardial chemotherapy-related cardiotoxicity for the possible unfavorable/unpredictable evolution of the lymphoma mass (arrhythmias, AV block, myocardial ischemia, pericardial effusion and cardiac tamponade). We report the case of pt. with diffuse DLBCL, and multiple cardiac locations discovered, incidentally, on total body PET performed for disease stratification.
A 72-year-old woman with worsening asthenia and advanced stage non-GCB DLBCL presented multiple cardiac radiotracer uptake at 18FDG PET. The basal echocardiogram evidenced a roundish pedunculated mass at the level of the outflow tract of the right ventricle (24 x 22 mm) with significant obstruction of the RVOT, an oval formation at right ventricular apex with possible myocardial infiltration and a further mass in the right atrial site. Mild (< 1 mm) circumferential pericardial effusion, finally, was appreciated. No other notable alterations .
After multi-disciplinary discussion, the patient underwent R-COMP based induction regimen, thus substituting conventional doxorubicin (R-CHOP) with non-pegylated liposomal doxorubicin in order to reduce the risk of acute cardiotoxicity. The first cycle was administered as inpatient under close cardiac monitoring, that was subsequently carried on before each cycle. No embolic and/or mechanical complications occurred. The response to chemotherapy was excellent: after the first cycle a substantial reduction in size of the cardiac masses was observed and after 3 cycles a complete resolution of the same was observed. Interim response evaluation by 18FDG PET after cycle 3 upheld early ultrasound observations by displaying a complete disappearance of pathological uptake.
In the case of patients with advanced DLBCL, multi-imaging evaluation enable appropriate assessment of cardiac conditions, including possible cardiac location and nature of masses. The personalized multidisciplinary management allows a tailored management of complex cases that enables both the achievement of treatment goals and the avoidance of acute complications