Mediastinal lymphoma with cardiac involvement mimicking acute coronary syndrome: a case report

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Abstract

Lymphomas constitute a heterogeneous group of cancers characterized by uncontrolled clonal proliferation of lymphoid cells. They may arise in lymph nodes and extranodal organs and tissues. Primary mediastinal large B-cell lymphoma is a rare and aggressive subtype of B-cell lymphomas, accounting for approximately 2%–3% of all non-Hodgkin lymphomas.

This article presents a clinical case of primary mediastinal lymphoma with cardiac involvement in a 66-year-old female patient. The initial signs of the disease mimicked acute coronary syndrome, including chest pain, dyspnea, and cardiac rhythm disturbances. Diagnostic evaluation revealed a rapidly progressive mediastinal tumor invading the pericardium and myocardium, confirmed using modern imaging modalities (echocardiography, cardiac magnetic resonance imaging, and computed tomography) and pathological examination. Despite intensive treatment, the patient’s condition deteriorated rapidly, resulting in a fatal outcome.

This case highlights the diagnostic challenges associated with cardiac and pericardial involvement in mediastinal lymphomas and demonstrates the necessity of a multidisciplinary approach in the management of such rare and aggressive diseases.

About the authors

George M. Shaginyan

City Clinical Hospital No. 1 named after N.I. Pirogov

Author for correspondence.
Email: namegeorge1@gmail.com
ORCID iD: 0000-0001-9289-6104
SPIN-code: 4271-2309
Russian Federation, Moscow

Olga V. Stukalova

National Medical Research Center of Cardiology named after Academician E.I. Chazov

Email: olgastukalova@mail.ru
ORCID iD: 0000-0001-8377-2388
SPIN-code: 4261-0827

MD, Cand. Sci. (Medicine), Assistant Professor

Russian Federation, Moscow

Andrei V. Sherashov

Endocrinology Research Centre

Email: sherashovmd@yandex.ru
ORCID iD: 0000-0003-2220-5990
SPIN-code: 1477-3266
Russian Federation, Moscow

Alexandra S. Shilova

City Clinical Hospital No. 1 named after N.I. Pirogov

Email: a.s.shilova@gmail.com
ORCID iD: 0000-0002-4092-5222

MD, Cand. Sci. (Medicine)

Russian Federation, Moscow

Dmitry Yu. Shchekochikhin

City Clinical Hospital No. 1 named after N.I. Pirogov; Sechenov First Moscow State Medical University (Sechenov University)

Email: agishm@list.ru
ORCID iD: 0000-0002-8209-2791
SPIN-code: 3753-6915

MD, Cand. Sci. (Medicine), Assistant Professor

Russian Federation, Moscow; Moscow

Anait A. Oganesyan

City Clinical Hospital No. 1 named after N.I. Pirogov

Email: talilen@mail.ru
ORCID iD: 0000-0003-1896-023X
SPIN-code: 6531-2957
Russian Federation, Moscow

Zainab M. Magomedova

City Clinical Hospital No. 1 named after N.I. Pirogov; Sechenov First Moscow State Medical University (Sechenov University)

Email: magomedova.zainab.97@mail.ru
ORCID iD: 0000-0001-6753-1525
SPIN-code: 5271-4915
Russian Federation, Moscow; Moscow

Ekaterina S. Pershina

City Clinical Hospital No. 1 named after N.I. Pirogov; Sechenov First Moscow State Medical University (Sechenov University)

Email: pershina86@mail.ru
ORCID iD: 0000-0002-3952-6865
SPIN-code: 7311-9276

MD, Cand. Sci. (Medicine)

Russian Federation, Moscow; Moscow

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2. Fig. 1. Results of magnetic resonance imaging of the heart: a — T1-weighted images, the pathological formation has an isointense signal relative to the myocardium. Tumour masses are detected in the pericardial cavity with spread to the left ventricular myocardium in the apex, apical segments, as well as the anterior and inferior walls (white arrows); b — T2-weighted images, hyperintense signal from the formation relative to the myocardium (white arrows); c, d — post-contrast T1- and T2-weighted images, heterogeneous accumulation of contrast agent in the formation is noted (white arrows); e, f — T1-mapping images (before and after contrast administration), showing heterogeneous hyperintense signal from pathological foci (white arrows); g — late gadolinium enhancement (delayed phase), accumulation of contrast agent is visualised in both the visceral and parietal layers of the pericardium (white arrows).

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3. Fig. 2. Electrocardiogram: sinus rhythm, heart rate 81 beats per minute, normal position of the electrical axis of the heart, ST segment elevation in leads V3–V4 up to 2 mm, negative T wave in leads II, III and aVF, biphasic T wave in V2–V3.

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4. Fig. 3. Coronary angiography results: a — the left coronary artery trunk has an irregular contour, extensive stenosis up to 90% of the right interventricular artery in the proximal segment (yellow arrow), stenosis of the intermediate artery more than 99% in the proximal segment (orange star), extensive stenosis of the circumflex artery more than 90% in the proximal segment from the mouth, distal bed without haemodynamically significant stenosis (blue arrow); b — after administration of vasodilators, positive dynamics of antegrade blood flow in the left coronary artery, significant increase in the proximal lumens of the right interventricular artery (yellow arrow) and circumflex artery (blue arrow).

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5. Fig. 4. Results of computed tomography of the chest organs with intravenous contrast: a — diffuse solid tumour masses with uneven and blurred contours (white arrows) are detected in the pericardial cavity, with a density of up to 50 HU and a slight accumulation of contrast in the delayed phase up to 75 HU; the structure of the masses is heterogeneous due to hypovascular areas; b — the pathological structures described above spread in a sleeve-like manner from the walls of the ascending aorta to the diaphragmatic surface of the pericardium (white lines). RA — right atrium; RV — right ventricle; LA — left atrium; LV — left ventricle.

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6. Fig. 5. Results of computed tomography of the abdominal organs with intravenous contrast: spread of the tumour process to the diaphragm and into the subdiaphragmatic space above the left lobe of the liver (white arrows).

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7. Fig. 6. Heart macro specimen: on the cut surface, the tumour tissue is represented by greyish-white and yellowish areas with a soft, sometimes homogeneous and necrotic consistency; foci of haemorrhage and necrosis are observed in some areas. The myocardium is thickened due to infiltration and has a heterogeneous structure in the affected areas, with foci of greyish-white infiltration spreading along the vessels and intermuscular septa.

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8. Fig. 7. Microscope slides of myocardium (a–c) and bronchus (d) (stained with haematoxylin and eosin): a — diffuse tumour lymphoid infiltrate with massive areas of necrosis is detected in the myocardial wall (magnification ×5); b — infiltration of the myocardium with tumour lymphoid cells (magnification ×10); c — at higher magnification, the lymphoid infiltrate is represented by medium and large cells with rounded-oval nuclei and moderately expressed cytoplasm (magnification ×40); d — ingrowth into the bronchial wall of lymphoid infiltrate of similar structure (magnification ×5).

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