PMC4021862_01
Initial transthoracic echocardiography (TTE) study showing no structural abnormalities on all views. A 4-chamber view. Regular ventricles and atria, no suspicious masses can be identified. Intact mitral and tricuspid valvular apparatus. B Parasternal long axis showing a regular, non obstructed left ventricular outflow tract. Left Atrium, mitral valve with anterior and posterior leaflet, left ventricle, aortic valve and ascending aorta. No ventricular wall dyskinesias, no obstructions. C Aortic root and left atrial diameter measurement. 35,5 mm versus 38.5 mm D Parasternal short axis. Mitral valve level showing intact valvular apparatus, no vegetations can be identified.
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F1
The patient's cardiologist could not detect any structural abnormalities on transthoracic echocardiography (Figure 1A 4-chamber view, Figure 1B parasternal long axis, Figure 1C aortic root and left atrial diameter measurement, Figure 1D parasternal short axis).
Magnetic resonance imaging demonstrating no evidence of mediastinal lymphadenopathy. A Axial view, T2 weighted images showing both pericardial and bilateral pleural effusions, right greater than left. Right ventricular wall irregularities and right greater than left intracavitary tumor formation, partially obstructing the right atrial and the right ventricular flow. B Sagittal view, T2 weighted images evidencing intracavitary tumor formation and both pericardial and bilateral pleural effusions. No evidence of mediastinal lymphadenopathy could be observed.
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F2
A magnetic resonance imaging (MRI) scan revealed heterogeneity of the right atrium right ventricle and left atrium and raised concerns of a possible extensive mass (Figure 2A axial view and Figure 2B sagittal view).
Repeat transesophageal echocardiography (TEE) study. A 5-chamber view. Tumor formation in both left and right sided cardiac structures, mitral and tricuspid valves are affected. Of note, both, the right atrium and the right ventricle are significantly obstructed. B Mid-esophageal 4-chamber view confirming extensive tumor formation and showing significant involvement of the mitral valve leaflets. Both, the right atrium and the right ventricle are severely obstructed. C Mid esophageal long axis confirming mitral valve involvement. D 4-chamber view, with cut apex. Tumor formation on mitral valve, however mitral valve apparatus does not appear to be diffusely infiltrated or misconfigured.
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F3
A transthoracic echocardiogram (TEE) was performed only 3 weeks after the initial transthoracic echocardiography study (Figure 3A 5-chamber view, Figure 3B mid-esophageal 4-chamber view, Figure 3C mid esophageal long axis, Figure 4D, 4-chamber view and additional file 1: Video 1) and revealed a right atrial and right ventricular soft tissue density, diffusely infiltrating both the lateral right atrial wall and free wall of the right ventricle with multisegmental dyskinesias, highly suspicious for a malignant neoplasm.
Histology. Complete destructive replacement of the myocardial wall by a diffuse large B cell lymphoma that demonstrated plasmacytoid differentiation and blasts.
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F4
Frozen sections were sent for histopathologic evaluation and revealed complete destructive replacement of the myocardial wall by a diffuse large B cell lymphoma that demonstrated plasmacytoid differentiation (non-Hodgkin's lymphoma, Figure 4).
PMC4021862_02
Magnetic resonance imaging demonstrating no evidence of mediastinal lymphadenopathy. A Axial view, T2 weighted images showing both pericardial and bilateral pleural effusions, right greater than left. Right ventricular wall irregularities and right greater than left intracavitary tumor formation, partially obstructing the right atrial and the right ventricular flow. B Sagittal view, T2 weighted images evidencing intracavitary tumor formation and both pericardial and bilateral pleural effusions. No evidence of mediastinal lymphadenopathy could be observed.
1749-8090-9-14-2.jpg
PMC4021862_02_1749-8090-9-14-2.jpg
F2
A magnetic resonance imaging (MRI) scan revealed heterogeneity of the right atrium right ventricle and left atrium and raised concerns of a possible extensive mass (Figure 2A axial view and Figure 2B sagittal view).
Repeat transesophageal echocardiography (TEE) study. A 5-chamber view. Tumor formation in both left and right sided cardiac structures, mitral and tricuspid valves are affected. Of note, both, the right atrium and the right ventricle are significantly obstructed. B Mid-esophageal 4-chamber view confirming extensive tumor formation and showing significant involvement of the mitral valve leaflets. Both, the right atrium and the right ventricle are severely obstructed. C Mid esophageal long axis confirming mitral valve involvement. D 4-chamber view, with cut apex. Tumor formation on mitral valve, however mitral valve apparatus does not appear to be diffusely infiltrated or misconfigured.
1749-8090-9-14-3.jpg
PMC4021862_02_1749-8090-9-14-3.jpg
F3
A transthoracic echocardiogram (TEE) was performed only 3 weeks after the initial transthoracic echocardiography study (Figure 3A 5-chamber view, Figure 3B mid-esophageal 4-chamber view, Figure 3C mid esophageal long axis, Figure 4D, 4-chamber view and additional file 1: Video 1) and revealed a right atrial and right ventricular soft tissue density, diffusely infiltrating both the lateral right atrial wall and free wall of the right ventricle with multisegmental dyskinesias, highly suspicious for a malignant neoplasm.
Histology. Complete destructive replacement of the myocardial wall by a diffuse large B cell lymphoma that demonstrated plasmacytoid differentiation and blasts.
1749-8090-9-14-4.jpg
PMC4021862_03_1749-8090-9-14-4.jpg
F4
Frozen sections were sent for histopathologic evaluation and revealed complete destructive replacement of the myocardial wall by a diffuse large B cell lymphoma that demonstrated plasmacytoid differentiation (non-Hodgkin's lymphoma, Figure 4).
PMC4021862_03
Histology. Complete destructive replacement of the myocardial wall by a diffuse large B cell lymphoma that demonstrated plasmacytoid differentiation and blasts.
1749-8090-9-14-4.jpg
PMC4021862_03_1749-8090-9-14-4.jpg
F4
Frozen sections were sent for histopathologic evaluation and revealed complete destructive replacement of the myocardial wall by a diffuse large B cell lymphoma that demonstrated plasmacytoid differentiation (non-Hodgkin's lymphoma, Figure 4).
PMC4021862_04