假性急性冠状动脉综合征表现的纵隔淋巴瘤伴心脏受累：临床病例

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淋巴瘤是一组异质性恶性肿瘤，其特征为淋巴细胞的克隆性失控增殖。该类肿瘤既可发生于淋巴结，也可累及结外器官和组织。原发性纵隔大B细胞淋巴瘤是一种罕见且侵袭性较强的B细胞淋巴瘤亚型，约占全部非霍奇金淋巴瘤的2–3%。

本文报道了一例66岁女性原发性纵隔淋巴瘤伴心脏结构受累的临床病例。疾病的初始表现模拟急性冠状动脉综合征，表现为胸痛、呼吸困难及心律失常。诊断过程中发现纵隔肿瘤快速进展，并侵及心包及心肌，该结果经现代影像学检查方法（超声心动图、心脏磁共振成像、计算机断层扫描）及病理形态学研究结果证实。尽管接受了强化治疗，患者病情仍迅速恶化，最终导致死亡。

该病例突显了纵隔淋巴瘤累及心脏及心包时的诊断困难，并强调了在此类罕见且高度侵袭性疾病的诊治过程中采用多学科协作策略的必要性。

作者简介

George M. Shaginyan

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

编辑信件的主要联系方式.
Email: namegeorge1@gmail.com
ORCID iD: 0000-0001-9289-6104
SPIN 代码: 4271-2309
俄罗斯联邦, 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 代码: 4261-0827

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

俄罗斯联邦, Moscow

Andrei V. Sherashov

Endocrinology Research Centre

Email: sherashovmd@yandex.ru
ORCID iD: 0000-0003-2220-5990
SPIN 代码: 1477-3266
俄罗斯联邦, 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)

俄罗斯联邦, 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 代码: 3753-6915

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

俄罗斯联邦, 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 代码: 6531-2957
俄罗斯联邦, 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 代码: 5271-4915
俄罗斯联邦, 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 代码: 7311-9276

MD, Cand. Sci. (Medicine)

俄罗斯联邦, 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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