Article Text

Non-surgical CHOP cures right ventricular outflow obstruction
  1. J P J Halcox
  1. Department of Cardiology, St Bartholemew’s Hospital, West Smithfield, London EC1A 7BE, UK
  1. Dr Halcox.

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A 27 year old banker was referred by his general practitioner with constitutional symptoms and a murmur. He had a four month history of weight loss, lethargy and dry cough. On examination there was a systolic thrill and a loud ejection murmur in the pulmonary area.

Chest radiography suggested a large anterior mediastinal mass, which was confirmed by thoracic computed tomography (CT). Echocardiography showed a 2.5 × 1.5 cm mass in the right ventricular outflow tract (RVOT) (fig 1) and colour flow mapping showed turbulent flow around its free edge. Flow velocity through the RVOT, assessed by continuous wave Doppler, was 4 m/s estimating a pressure gradient of 64 mm Hg (fig2). The right ventricle was mildly dilated and an anterior extracardiac soft tissue mass was seen.

Figure 1

Parasternal short axis echocardiogram. RVOT, right ventricular outflow tract; PV, pulmonary valve; AV, aortic valve; ESTM, extracardiac soft tissue mass .

Figure 2

Continuous wave Doppler interrogation across the RVOT showing a peak velocity of 4 m/s (pressure gradient of 64 mm Hg).

CT guided biopsy failed to get suitable tissue for analysis but a sample was obtained mediastinoscopically, histology of which confirmed sclerosing mediastinal non-Hodgkin’s lymphoma.

The patient was treated with six cycles ofcyclophosphamide, doxorubicin—formerlyhydroxydaunorubicin, vincristine—oncovin, andprednisolone (CHOP) chemotherapy with excellent clinical and radiological response.

Repeated echocardiography one month after treatment showed complete resolution of the RVOT mass (fig 3) with normal spectral and colour Doppler assessment.

Figure 3

Repeat parasternal short axis scan one month after completion of chemotherapy showing resolution of the RVOT mass and reduction in extracardiac soft tissue shadowing.

Discussion

The differential diagnosis of an intracardiac mass includes vegetation, thrombus, and both primary and secondary neoplasm. Although the pericardium is the most usual site for cardiac secondary tumours, myocardial deposits are not infrequent. Lymphoma is noted as one of the more common tumours to spread to the myocardium.1-3 The RVOT is a well recognised site of cardiac involvement with lymphoma.4 5

Our case illustrates the value of echocardiography in the assessment of such patients. The effect of an appropriate regimen of chemotherapy is clearly demonstrated with complete resolution of the tumour echocardiographically and radiologically.

Acknowledgments

I thank Ms D Harrington and Ms S Fergey for producing these informative images.

References

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