대한흉부영상의학회 Weekly Chest Cases

Case No : 795 Date 2013-01-21

Courtesy of KY Lee / Korea University Ansan Hospital
Age/Sex 43 / F
Chief ComplaintChest discomfort and dyspnea (Onset: 2 weeks ago)

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chest PA

Diagnosis With Brief Discussion

Diagnosis: Cardiac involvement of non-Hodgkin lymphoma(diffuse large B cell type)
Radiologic Findings: Chest PA shows cardiomegaly and minimal amount of right pleural effusion. On the enhanced chest CT, there is infiltrative soft tissue mass in the anterior mediastinum, encasing aorta and its branching vessels, SVC, trachea, both hilums, and heart. Diffuse enlargement of all ventricular and atrial walls is also noted. 20 months before, the patient was taken cardiac MR due to same symptom. MR images of short axis view show marked wall thickening of both atrium and ventricles. The thickened myocardium is seen as homogeneous SI on T1WI and T2WI with diffuse heterogeneous enhancement on T1CE. Large amount of pericardial effusion is combined. The diagnosis of diffuse large B-cell lymphoma was made by US-guided neck lymph node biopsy at right supraclavicular fossa.
Brief Review: Lymphoma of the heart and pericardium is usually present as one aspect of disseminated disease and rarely occurs as a primary malignancy. It accounts for 1.3% of primary cardiac tumors and 0.5% of extranodal lymphomas. Although secondary cardiac involvement by lymphoma is more common than primary involvement, to our knowledge fewer than 100 cases have been described in the English-language literature, mostly as case reports or in small case series. Secondary cardiac involvement of a malignant lymphoma is usually a late manifestation of the disease; therefore, cardiac failure as the initial presentation is extremely rare.
However, whether the lymphoma is primary or secondary, there are no differences in imaging findings between the two. Cardiac lymphomas are most commonly diffuse large cell lymphomas and frequently manifest as an ill-defined, infiltrative mass. Diffuse involvement pattern is uncommon. Atrial location is typical; the right atrium is most often affected. Pericardial thickening or effusion is often a common early feature of disease. Infiltration of atrial or ventricular walls with extension along epicardial surfaces is also a notable feature.
At CT, lymphomas commonly appear as an infiltrating epicardial or myocardial mass that is often isoattenuating to hypoattenuating relative to myocardium. Heterogeneous enhancement after administration of intravenous contrast material is routinely demonstrated. A curious feature of cardiac lymphoma is the tendency of the tumor to extend along the epicardial surfaces of the heart, primarily encasing adjacent structures including coronary arteries and the aortic root.
MR imaging best depicts the extent of myocardial and pericardial infiltration, primarily due to its superior capacity for tissue characterization and high spatial resolution. Masses can be relatively hypointense on T1-weighted images and hyperintense on T2-weighted images. However, the appearance can be variable, and the presence of isointense signal relative to cardiac muscle is not uncommon. Contrast enhancement is frequent and may be homogeneous or heterogeneous. Delayed-enhancement imaging with nulling of normal myocardium also aids in identifying the extent of tumor.
References: 1. Jean Jeudy, Jacobo Kirsch, Fabio Tavora, et al. Cardiac Lymphoma: Radiologic-Pathologic Correlation. RadioGraphics, 2012;32:1369-1380
2. Eun Young Kim, Yeon Hyeon Choe, Kiick Sung, et al. Multidetector CT and MR Imaging of Cardiac Tumors, Korean J Radiol 2009;10:164-175
3. W.-K. Leea, V.A. Duddalwarb, H.C. Rouse, et al. Extranodal lymphoma in the thorax: cross-sectional imaging findings. Clinical Radiology, 2009;64:542-549
4. Toshiji Ishiwata, Norihiro Harada1, Ryo Ko, et al. Malignant lymphoma with diffuse cardiac involvement detected by multiple imaging examinations: a case report. Aquatic Biosystems, 2012, 6:193.
Keywords: Vascular, Lymphproliferative disorder, Lymphoma,

No. of Applicants : 99

▶ Correct Answer : 37/99, 37.4%

- GM InHospital , Korea (South) Ju Won Lee
- Kyung Hee Universitiy Hospital at Gangdong , Korea (South) Seong Jong Yun
- Konkuk university hospital , Korea (South) Jeong Geun Yi
- GHICL , France manuel toledano
- Asan medical center , Korea (South) Sang Young Oh
- University of British Columbia , Canada Amr Ajlan
- Dae-jeon Bohun Veterans Hospital , Korea (South) KI-TAE HAN
- Dongnam Institute of Radiological and Medical Sciences , Korea (South) Dae-Wook Yeh
- McGill University Health Center , Canada Alexandre Semionov
- James Paget Hospital , U.K , United Kingdom nabil mahmood
- UWO , Canada S Lee
- Az Osp Santa Maria Terni , Italy angelo carloni
- Samsung medical center , Korea (South) Hyun Su Kim
- Universite de Sherbrooke , Canada Maxime Noel-Lamy
- Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
- McGill University - Cairo University , Canada Hisham Mikhael
- McGill university , Canada Badriya Al-Qassabi
- Himeji St.Mary Hospital , Japan Yuichiro Kanie
- Khoo Teck Phuat Hospital Singapore , Singapore ashish chawla
- HUEC , Brazil Diogo Pinheiro
- Kobe City Medical Center General Hospital , Japan Yasuhisa Kurata
- Ondokuz Mayis University , Turkey Cetin Celenk
- Asan Medical Center , Korea (South) Ji Eun Kim
- Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
- Fukuyama city hospital , Japan Ryotaro Kishi
- Hanyang Medical Center , Korea (South) Kibo Yoon
- Kyoto University , Japan Akihiko Sakata
- Konkuk University Medical Center , Korea (South) Inyoung Song
- Myongji hostipal , Korea (South) Yongsuk Jang
- Asan Medical Center , Korea (South) Eunyoung Kim
- Kyungpook National University Hospital , Korea (South) Jaekwang Lim
- All India Institute of medical sciences , India Justin Moses
- clinique de SAVOIE , France, Metropolitan gay-depassier philippe
- Saint Malo , France jean-baptiste Noel
- IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
- Gangnam Severance Hospital , Korea (South) Chul Hwan Park
- HIA Legouest - METZ , France Alban Gervaise

▶ Correct Answer as Differential Diagnosis : 27/99, 27.3%

- All India Institute of Medical Sciences , India Ashish Gupta
- Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
- radiologist, aditya imaging centre , India vivek patel
- Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
- mmcri , India sangeetha srinivasan
- IRSA La Rochelle France , France Denis Chabassiere
- SNUH , Korea (South) Euijin Hwang
- SCGH , Australia Yuranga Weerakkody
- Nagasaki University Hospital, Department of Pathology , Japan TOMONORI TANAKA
- Radnet Teleradiology , Turkey Murat Ulusoy
- Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
- XiangYa hospital , China Xia Yu
- Kizawa Memorial Hospital , Japan Yo Kaneko
- SRMC , India prabhu radhan
- Asan Medical Center , Korea (South) Sang Min Lee
- Asan Medical Center , Korea (South) Hye Jeon Hwang
- Okayama University , Japan Satoko Makimoto
- Dong-A University Hospital , Korea (South) Ji-yeon Han
- Onomichi Municipal Hospital , Japan Yoshihisa Masaoka
- Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
- Radnet Teleradiology Istanbul , Turkey Armagan Sarac
- Kohka Public Hospital , Japan Akitoshi Inoue
- Fortis hospital , Mohali , India Shaleen Rana
- Hopital du Sacre Coeur , Canada Andrea Ojanguren
- jaslok hospital & research centre mumbai , India JAINENDRA JAIN
- Onomichi municipal hospital , Japan Hirofumi Mifune
- China Medical University , Ditmanson Medical Foundation Chia-Yi Christian Hospital ,Taiwan, R.O.C. , Taiwan Jun Jun Yeh

▶ Semi-Correct Answer : 4/99, 4.0%

- Myongji hospital , Korea (South) Ji Ye Lee
- Heart Center Pontica , Bulgaria VLADISLAV RUSINOV
- , Korea (South) 援
- CH de la C�te Basque , France Paul ARDILOUZE

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 795 Date 2013-01-21

Discussion

No. of Applicants : 99