LETTER TO THE EDITOR

Cardiac lymphoma: sinus pausesdisappear after chemotherapy

Maleeha Haq & Aarti Patel & Maya Guglin

Received: 4 August 2013 /Accepted: 24 August 2013 /Published online: 3 September 2013# Springer-Verlag Berlin Heidelberg 2013

Keywords Sick sinus syndrome . Cardiac lymphoma

Dear Editor,Primary and secondary cardiac lymphomas are infrequent. Wepresent a patient in whom right atrial invasion of T lympho-blastic lymphoma resulted in atrial fibrillation and multiplesymptomatic episodes of sinus arrest lasting up to 6 s. Re-duction in size of the cardiac mass and resolution of sinuspauses were noted after only 7 days of treatment with systemicchemotherapy.

A 63-year-old woman presented with dyspnea and fatigueaccompanied by B type symptoms of night sweats and fevers.On admission, she was tachypneic and tachycardic. Elec-trocardiogram revealed atrial fibrillation for which she wasstarted on digoxin with successful conversion to normal sinusrhythm. The patient also had episodes of dizziness whichcorresponded to sinus pauses lasting from 4.4 to 6.0 sontelemetry (Fig. 1). She remained hemodynamically stableand did not require placement of temporary pacer wire.Computed tomography (CT) of the chest revealed a mass inthe left chest wall, superior vena cava (SVC), and right atrium.CT abdomen/pelvis showed a left flank mass. Transthoracic

echocardiogram was remarkable for a large mass in the supe-rior portion of the right atrium measuring 42×45 mm. Leftand right ventricular systolic functions were normal. Biopsyof the left flank mass was consistent with T lymphoblasticlymphoma. Bone marrow biopsy showed no evidence ofinvolvement. Cardiac magnetic resonance imaging wasobtained which showed a 48×46×46-mm sized mass lesionarising from the anterior wall of the right atrium with exten-sion into the pericardium and SVC. A right atrial biopsy wasnon-diagnostic. The patient was started on etoposide, prednis-olone, cytarabine and cisplatin (ESHAP).

After day seven of chemotherapy, the sinus pauses hadceased and the patient noted significant improvement in hersymptoms. Furthermore, the episodes of paroxysmal atrialfibrillation with rapid ventricular rate decreased in incidenceby day nine of treatment. Cardiac CT at this time showed asignificant interval decrease in the size of the right atrial mass(30×32×35 mm). Follow-up Positron emission tomography/CT showed focal hypermetabolism in the right atrium.

Prior literature suggests that while primary cardiac lym-phoma accounts for about 1 % of primary cardiac tumors,secondary cardiac involvement by lymphoma can occur in upto 20 % of lymphoma cases [1]. Preference of right-sidedinvolvement is common [2] and infiltration of the conductivesystem can produce many types of arrhythmias includingatrial fibrillation, atrioventricular block, ventricular tachycar-dia, and ventricular fibrillation. Sick sinus syndrome, howev-er, is a rare associated finding. It is found in less than 2 % of B

M. Haq :A. Patel :M. Guglin (*)2 Tampa General Circle, University of South Florida,Tampa, FL 33606, USAe-mail: mguglin@gmail.com

Ann Hematol (2014) 93:891–892DOI 10.1007/s00277-013-1894-y

cell lymphomas and almost never in T cell lymphomas [3],which make our case particularly unique.

The success of treatment in our patient was measured by boththe reduction in size of the mass and the resolution of sinuspauses. Although the patient improved from a cardiac standpoint,her disease continued to progress at other sites. After completing2 cycles of ESHAP, she was considered for clinical trial but wasunable to enroll due to rapid deterioration and eventual death.

References

1. O’Mahony D, Piekarz R, Bandettini W et al (2008) Cardiac involve-ment with lymphoma: a review of the literature. Clin LymphomaMyeloma 8(4):249–252

2. Linhart M, Lickfett L, Hammerstingl C et al (2006) Paroxysmal atrialflutter caused by cardiac lymphoma. PACE 29:682–684

3. Suzuki T, Ishibashi S, Qin X et al (1996) Sick sinus syndrome inassociation with malignant lymphoma. Eur Heart J 17:968–969

Fig. 1 Telemetry strip showing atrial fibrillation with 4.4 s sinus pause followed by conversion to junctional rhythm

892 Ann Hematol (2014) 93:891–892