DISCUSSION:
One of the frequent and serious manifestations of advanced malignancies
is pericardial involvement, which includes various degrees such as
pericarditis, pericardial effusion, pericardial tamponade, and
constrictive pericarditis(4). Symptomatic effusion mostly presents with
tachycardia, dyspnea (our patient’s chief complaint), and
echocardiographic characteristics of right heart failure, but it can
also occur asymptomatically (5,6).
Pericardial effusion rises mainly from blockage of the lymphatic and
venous drainage of the pericardium which is caused by adjacent
compression, direct tumoral infiltration, or via hematogenous spread.
Pericardial effusions in cancer patients can also be triggered by
chemotherapy and radiotherapy. Other complications like infections and
autoimmune diseases, can also cause pericardial effusion in these
patients(4,7). The typical findings on electrocardiogram are sinus
tachycardia and low voltage defined as maximum QRS amplitude
<0.5 mV in the limb leads. New-onset atrial fibrillation can
be present. Electrical alternans, characterized by beat-to-beat
alternation in the QRS complex, represent the swinging of the heart in
the pericardial fluid(3). Echocardiography is considered to be the
primary imaging modality for pericardial effusion, and it is recommended
to be done before, during and after treatment to monitor the
patient(1,2).
Lymphoma is a haematological malignancy that emerges from the clonal
proliferation of lymphocytes at different maturation stages. It presents
with fatigue, night sweats, enlarged painless lymph nodes, and weight
loss. Lymphoma is classified into 2 major subgroups: Hodgkin (10%) and
non-Hodgkin lymphoma (90%) (2). Lymphomas involving the mediastinum
have a wide age range, and occur in both pediatric and adult
populations(11).
Chen et al compared pediatric and adult lymphomas involving the
mediastinum, and reported that pediatric patients had a higher incidence
of T-LBL/T-ALL, prevalence of dyspnea, stage IV tumors frequency, and
relative tumor diameter, compared to adults. They were also more likely
to be male(12).
Cardiac and pericardial involvement of lymphoma is extremely rare. It
accounts for 0.5% of cardiac involvement and 1% of all extranodal non
hodgkin lymphomas. It is more common in high-grade lymphomas,
particularly double-hit/triple-hit subtypes, and shows a poor prognosis,
as in other malignancies(6). Bertog et al. studied 163 patients
diagnosed with constrictive pericarditis, and lymphoma was the aetiology
in only 2 of the patients (9). In another study, out of 8 patients
undergoing pericardiectomy for malignant constrictive pericarditis, only
one was diagnosed with lymphoma(10). This unlikeliness has sometimes led
to incorrect approaches and treating patients with multiple
pericardiocenteses or management according to other diagnoses like
tuberculosis(13).
On the other hand, malignancy involving the pericardium is usually a
late secondary feature(8). In a case study-based systematic review on
lymphoma-associated cardiac tamponade, Shareef et al evaluated 52 cases
aged 9 to 95 (median 52), out of which 49 patients had non-Hodgkin
lymphoma, and observed that most of these patients were diagnosed with
lymphoma prior to hospital presentation (80.8%) (4). They also reported
that the median overall survival of patients with lymphoma and cardiac
tamponade is 4 months, and there is no significant difference between
lymphoma diagnosis before or after this complication.
A chest x-ray identifies an anterior mediastinal mass mostly when it is
very large (bulky disease) and produces mediastinal widening. It
demonstrates tumour bulk and pleural effusion. Chest computed tomography
(CT) scans are examined for precise tumour location, presence of
necrosis, pulmonary parenchymal involvement, chest wall invasion, and
more assessment of pleuropericardial effusion(14,15). Definitive
diagnosis is achieved via biopsy and histopathological examination, and
treatment begins after complete staging according to Ann Arbor
classification.