Patient Presentation
A previously healthy 34-year-old woman presented with shortness of breath and B symptoms including fever, night sweats, and weight loss. Diagnostic workup revealed a large mediastinal mass, and biopsy at an outside hospital demonstrated diffuse large B-cell lymphoma (DLBCL). Upon review at Temple University Hospital, pathology findings were most consistent with primary mediastinal large B-cell lymphoma, a subtype of large B-cell lymphoma.
The patient was admitted for urgent initiation of aggressive multiagent chemotherapy with R-EPOCH. However, during her initial hospitalization, she developed chest pain and concerning changes on her electrocardiogram showing ST elevations, a pattern associated with heart attack.
A Life-Threatening Discovery
Coronary angiography ruled out artery blockages, but cardiac MRI and echo revealed something more alarming: the lymphoma had extensively invaded the heart muscle itself, infiltrating both ventricular apices and the tricuspid valve annulus.
This presentation is both rare and dangerous, explains Eman Hamad, MD, Director of the Cardio-Oncology Program at Temple University Hospital. While cardiac involvement can occur in some lymphoma cases, extensive myocardial invasion carries a very high mortality rate.
“There was great danger that the tumor would cause perforation of her heart and cause death,” she says.
A Collaborative Treatment Plan
In addition to danger from the cancer, the treatment itself also posed severe risks. As chemotherapy broke the tumor down, it could cause tumor lysis syndrome (a cascade of metabolic complications) or cause the weakened heart wall to rupture.
Dr. Hamad collaborated with Michael Bromberg, MD, PhD, Chief of the Section of Hematology at Temple University Hospital, to develop a specialized treatment plan, modifying the R-EPOCH regimen and initiating treatment in the intensive care unit with extraordinary precautions in place.
ICU-Based Chemotherapy
The patient remained in the ICU for more than a month during her first chemotherapy cycles. The team established comprehensive monitoring, including continuous cardiac telemetry to monitor heart rhythms, arterial and central venous access to detect hemodynamic instability, and daily echocardiograms during the first two cycles to assess for pericardial effusion and potential tamponade – indicators of micro perforations or inflammatory response to therapy.
During this time, an ECMO machine remained on standby to provide heart-lung support if needed.
A Successful Course
After tolerating the first two chemotherapy cycles, the patient was transferred to a telemetry unit for continued monitoring during her third cycle. Serial imaging showed encouraging progress, with shrinking of both the tumor itself and the pericardial effusion.
Once stabilized, the patient was allowed to return home between treatment cycles, returning to the hospital for approximately one week at a time for each subsequent chemotherapy session. She eventually completed all seven chemotherapy cycles, and follow-up cardiac MRI demonstrated a dramatic reduction in the myocardial invasion.
“She has made significant improvement and remarkable resolution of the tumor attacking her heart,” Dr. Hamad says.
What Providers Should Know
Early recognition of cardiac involvement in mediastinal DLBCL is critical for therapeutic planning and risk stratification. Patients presenting with chest pain, ECG changes, or cardiac symptoms should be referred immediately for advanced cardiac imaging.
In patients with extensive myocardial invasion, standard outpatient or floor-based chemotherapy protocols may be insufficient.
“ICU-based chemotherapy administration with multidisciplinary oversight and multimodal imaging can facilitate early identification and management of treatment-related complications,” Dr. Hamad says.
The case demonstrates that even in patients with severe cardiac involvement from lymphoma, aggressive monitoring, individualized treatment plans, specialized expertise and multidisciplinary care can lead to good outcomes, she adds.