411 AN UNEXPECTED (AND UNDESIRED) ECHOCARDIOGRAPHIC FINDING IN A PATIENT WITH RIGHT-SIDED CHEST PAIN


 A 71-year-old man, former smoker, without other cardiovascular risk factors nor previously known cardiological history, was admitted to our emergency department for nonproductive cough and right-sided chest pain, worsened by inspiration. ECG documented reduced peripheral QRS voltages. Echocardiography was performed, revealing the presence of an inhomogeneous, hyperechoic neoformation involving the lateral wall of the right ventricle (RV), dislocating the right coronary artery, protruding into the cavity towards the intraventricular septum and reaching the sub-valvular apparatus of the tricuspid valve, without any hemodynamic interference. Pericardial effusion was also documented (maximum 20 mm around the atrioventricular groove), without signs of cardiac tamponade. For better mass characterization, a computed tomography (CT) scan and a cardiac magnetic resonance (CMR) were performed, confirming the presence of a solid neoformation involving the RV and pericardial effusion, also showing right pleural effusion. Furthermore, right hilar and subcarinal lymphadenomegaly with compression of the bronchi was observed. A positron emission tomography (PET) scan showed areas of increased 18-fluorodeoxyglucose (18FDG) uptake in supra- and infra diaphragmatic lymph nodes, adrenal glands, bones, and lungs. Due to the clinical suspicion of a lymphoproliferative neoplasm, corticosteroid therapy was started.
 Before a diagnostic lymph node biopsy could be performed, the patient had a syncopal episode due to cardiac tamponade, requiring pericardiocentesis. During hospitalization, continuous heart monitoring revealed intermittent third-degree atrioventricular block, so a permanent pacemaker was implanted. Finally, an excisional lymph node biopsy was obtained, and a diagnosis of diffuse large B-cell lymphoma was established. Treatment with Prednisone, Cyclophosphamide, Vincristine, nonpegylated liposomal Doxorubicin, and Rituximab (R-COMP) was promptly started. Seven months later, after five cycles of chemotherapy, complete remission was documented by PET scan, and the cardiac mass was no longer evident at echocardiography.
 Metastatic involvement of the heart is a relatively frequent event in oncologic patients, with an estimated prevalence of 8% at autopsy. Lymphoproliferive neoplasms have a not negligible rate of heart mestastatization (9,4%). Neoplastic invasion secondary to lymphoma tends to infiltrate the myocardium, typically causing arrhythmias and conduction disturbances.
 Diagnostic evaluation relies upon echocardiography, CT and CMR. PET/TC is of paramount importance to assess the malignant nature of the mass, to stage the disease and to evaluate the response to chemotherapy. Metastatic cardiac involvement typically occurs as a late manifestation of disseminated lymphoma and the prognosis is usually poor; however, survival is increasing thanks to new chemo-immunotherapy strategies.