PMC8112198_01
PMC8112198_02
CT-PET abnormal 18-FDG uptake on right ventricle thickening 3 months (SUV 4.9, DS 4) (A) and 18 months (SUV 5 - DS 4) (B, C) after ASCT. Cardiac MRI images of June 2019 (from D to F) show the persistence of the right ventricle anterior wall thickening (14x56 mm). (D) Short tau inversion recovery (STIR) T2 black blood image in short axis on the cardiac base. (E) Steady-state free precession (SSFP) balance image with T2/T1 weighting in short axis on the cardiac base. (F) IR TSET1 image for evaluation of myocardial late enhancement in short axis on the cardiac base.
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Three months after ASCT, a cardiac MRI was repeated, which resulted unchanged; a CT-PET was performed, showing abnormal 18-FDG uptake on right ventricle thickening (SUV 4.9 - Deauville score (DS) 4) -  Figure 1A . Cardiac MRIs performed on October 2018, June 2019 and November 2019 showed a substantial stability of the picture, with the persistence of the right ventricle anterior wall thickening -  Figures 1D-F . The CT-PET performed in June 2019 confirmed the abnormal 18-FDG uptake on right ventricle thickening (SUV 5 - DS 4) -  Figures 1B, C .
PMC8112198_03
Decrease in cardiac wall thickness after chemotherapy at echocardiographic evaluation (from A to F). (A, C) interventricular septum (IVS) and posterior wall (PW) thickness, 18 mm and 15 mm respectively, from parasternal long-axis and short-axis view, before chemotherapy. (B, D) IVS and PW thickness, 12 mm and 10 mm, respectively, from parasternal long-axis and short-axis view, after chemotherapy. (E, F) right ventricular lateral wall (RV-LW) thickness, 9 mm and 6 mm, respectively, from 4 chamber view; of note, pericardial effusion decreases from 18 mm to 6 mm after chemotherapy. (G) monoclonal IgM/K before starting treatment. (H) no more detectable monoclonal paraprotein after treatment. (I) histologic sample of endomyocardial biopsy, hematoxylin-eosin staining.
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An IgM/K paraprotein of 20 g/L was found on serum protein electrophoresis, with decreased IgG and IgA levels (5.4 g/L and 0.48 g/L respectively), and an altered serum free light chain ratio (serum free light chain kappa 411 mg/L, lambda 6.72, kappa/lambda ratio 61.21) -  Figure 2G . An endomyocardial biopsy showed massive cardiac infiltration by B-lymphocytes from MZL, with no signs of amyloidosis -  Figure 2I . On serum protein electrophoresis the monoclonal paraprotein was not detectable -  Figure 2H . Echocardiography showed a reduction of interventricular septum thickness (12 mm), normal function of left ventricle (ejection fraction 72%), bi- atrial mild dilatation and reduction of pericardial effusion (6mm) -  Figures 2B, D, F .