Diffuse large B cell lymphoma (DLBCL) is the most common histologic subtype of non-Hodgkin lymphoma (NHL) accounting for approximately 25% of NHL cases. One of the common subtype of DLBCL is primary DLBCL of the mediastinum. Case report this 65 year old female known to have diabetes and hypertension presented to our emergency department with history of epigastric pain for last 2 h. Her electrocardiogram (ECG) showed right bundle block with left posterior hemi-block representing bi-fasicular block with minimal ST segment depression in leads V4–V6. Her initial routine laboratory results revealed normal renal function, blood counts and liver profile. Her cardiac bio-markers were elevated with Troponin I of 1.22 and CPK of 35. She was admitted by the cardiology team diagnosis of non-ST elevation myocardial infarction (NSTEMI). She was started with usual anti-ischemic. Next morning she had echocardiography which revealed a large mediastinal mass on the antero-lateral aspect of the left ventricle infiltrating the basal lateral and anterior wall. This mass was encasing the origin of the great vessels and also infiltrating the left atrium occluding the Left atrial appendage and left upper pulmonary vein. It was infiltrating the Right ventricular outflow tract causing obstruction to the flow with a gradient of 52 mmHg. Cardiac MRI showed multiple cardiac masses, the largest of which was originating from the anterior mediastinum and going posteriorly then infiltrating RV and within the right ventricular out-flow tract (RVOT) causing significant obstruction. The magnetic resonance characteristics of the intra cardiac and extra cardiac masses were same and with features of central necrosis was highly suggestive of lymphoma. The CT scan of the chest and abdomen showed the same cardiac findings as of cardiac MRI and multiple enlarged thoracic, retroperitoneal, left common iliac lymph nodes. Patient had CT guided Lymph node biopsy from the mediastinal lymph node and was reported as Diffuse Large B-Cell lymphoma of non-germinal center subtype with anaplastic features. Bone marrow biopsy was also performed as well PET oncology to complete staging process. The case was discussed in the multi-disciplinary oncology board and planned for chemotherapy with CHOP with no need for any cardiac intervention at this moment. The care of the patient was transferred to the hematology team with close follow-up by cardiology team. He received the chemotherapy for 4 cycles and had a repeat cardiac MRI which showed the complete resolution of the intra-cardiac mass. Patients with DLBCL typically present with a rapidly enlarging symptomatic mass, most usually nodal enlargement in the neck or abdomen, or, in the case of primary mediastinal large B cell lymphoma, the mediastinum, but may present as a mass lesion anywhere in the body. The prognosis is good as the rate of remission with chemotherapy is good. The cardiac MRI can assist in diagnosis.
cardiac MRI
Cardiac MRI May Offer One-Stop Diagnostic Imaging for Pulmonary-Vein Isolation Patients
Cardiovascular magnetic resonance (CMR) imaging can accurately detect left atrial (LA) and left atrial appendage (LAA) thrombi prior to pulmonary-vein isolation (PVI), potentially sidestepping the need for a transesophageal echocardiogram (TEE), new research suggests[1].
Delayed-enhancement CMR using long inversion time (long TI DE-CMR) was able to identify all nine cases of thrombi detected by the gold-standard TEE.
Long TI DE-CMR had the best diagnostic accuracy, sensitivity, and specificity (99.2%, 100%, 99.2%), followed by contrast-enhanced MR angiography (94.3%, 66.7%, 95.2%) and standard cine-CMR (91.6%, 66.7%, 92.5%), Dr Danai Kitkungvan (Houston Methodist DeBakey Heart & Vascular Center, TX) and colleagues reported in their study, published online May 25, 2016 in JACC: Cardiovascular Imaging.
“Certainly, the results of our findings would suggest you may be able to obviate the need for getting a transesophageal echo and really within the CMR test alone do both—identify the pulmonary-vein anatomy as well as look for the presence of thrombus,” senior author Dr Dipan J Shah (also from Houston Methodist DeBakey) told heartwire from Medscape.
The current paradigm is for patients get either an MR or computed tomography (CT) scan to define the pulmonary-vein anatomy and a TEE on top of that to exclude the presence of LA or LAA thrombus.
“A diagnostic study that confidently answers two clinical questions is appealing from a practical and financial point of view,” Drs Warren Manning and Aferdita Spahillari (Beth Israel Deaconess Medical Center, Boston, MA) write in an accompanying editorial[2].
In order for this approach to become incorporated into clinical practice, however, they note that the optimal interval between CMR and PVI would need to be determined, especially for patients with atrial fibrillation (AF), in whom anticoagulation is discontinued between procedures, but that CMR “may be especially attractive for those with a relative contraindication to TEE (eg, esophageal stricture, Zenker’s diverticulum) or at higher risk for conscious sedation (eg, sleep apnea).”
Single Shot
The study included 261 patients (mean age 61.8 years; 69.4% male) who underwent multicomponent CMR imaging and TEE within 7 days (mean 1.3 days). Almost two-thirds of patients (73.6%) were on anticoagulation at the time of the CMR exam.
All TEE and CMR studies were interpreted by two experienced readers blinded to clinical history and results of other imaging studies. Interobserver agreement was highest in long TI DE-CMR (κ=0.91), followed by cine-CMR (κ=0.85) and contrast-enhanced MR angiography (κ=0.83).
One of the study’s primary objectives was to see whether long TI DE-CMR, which is available on most cardiac MR scanners and does not require special software or hardware, can be performed in patients with AF or irregular heart rhythms, Shah said. It is performed with a single-shot acquisition technique 10 minutes after contrast administration and “essentially acquires each image within one single heartbeat. So the lack of being able to hold their breath or the presence of irregular heart rhythms really doesn’t compromise the image quality for this particular technique,” he added.
The diagnostic accuracy of CMR was slightly less but not significantly different in patients with AF vs those in sinus rhythm using long TI DE-CMR (98.2% vs 100%; P=0.174), contrast-enhanced MR angiography (93.6% vs 94.7%; P=0.789), and cine-CMR (88.1% vs 94.1%; P=0.113).
While an important consideration, the editorialists write, “there were very few thrombi, and the study was underpowered to detect a difference. Furthermore, the diagnostic ability of CMR to detect right atrial or right atrial appendage thrombi was not assessed.”
The investigators acknowledge that, “unlike TEE, which could provide anatomical and physiological data such as LAA-emptying velocity, the evaluated CMR components in our study could provide only anatomical data.”
The longer time required for CMR is also a common criticism, but this could be brought down—albeit not as short as for cardiac CT—if CMR protocols were tailored to assess PV anatomy and LA/LAA thrombi. CMR also provides valuable data for PVI without exposing patients to radiation, they note.
Shah agreed further studies are needed to confirm the results but observed that they currently use CMR on all patients prior to PVI.
Cardiac MRI May Offer One-Stop Diagnostic Imaging for Pulmonary-Vein Isolation Patients
Cardiovascular magnetic resonance (CMR) imaging can accurately detect left atrial (LA) and left atrial appendage (LAA) thrombi prior to pulmonary-vein isolation (PVI), potentially sidestepping the need for a transesophageal echocardiogram (TEE), new research suggests[1].
Delayed-enhancement CMR using long inversion time (long TI DE-CMR) was able to identify all nine cases of thrombi detected by the gold-standard TEE.
Long TI DE-CMR had the best diagnostic accuracy, sensitivity, and specificity (99.2%, 100%, 99.2%), followed by contrast-enhanced MR angiography (94.3%, 66.7%, 95.2%) and standard cine-CMR (91.6%, 66.7%, 92.5%), Dr Danai Kitkungvan (Houston Methodist DeBakey Heart & Vascular Center, TX) and colleagues reported in their study, published online May 25, 2016 in JACC: Cardiovascular Imaging.
“Certainly, the results of our findings would suggest you may be able to obviate the need for getting a transesophageal echo and really within the CMR test alone do both—identify the pulmonary-vein anatomy as well as look for the presence of thrombus,” senior author Dr Dipan J Shah (also from Houston Methodist DeBakey) told heartwire from Medscape.
The current paradigm is for patients get either an MR or computed tomography (CT) scan to define the pulmonary-vein anatomy and a TEE on top of that to exclude the presence of LA or LAA thrombus.
“A diagnostic study that confidently answers two clinical questions is appealing from a practical and financial point of view,” Drs Warren Manning and Aferdita Spahillari (Beth Israel Deaconess Medical Center, Boston, MA) write in an accompanying editorial[2].
In order for this approach to become incorporated into clinical practice, however, they note that the optimal interval between CMR and PVI would need to be determined, especially for patients with atrial fibrillation (AF), in whom anticoagulation is discontinued between procedures, but that CMR “may be especially attractive for those with a relative contraindication to TEE (eg, esophageal stricture, Zenker’s diverticulum) or at higher risk for conscious sedation (eg, sleep apnea).”
Single Shot
The study included 261 patients (mean age 61.8 years; 69.4% male) who underwent multicomponent CMR imaging and TEE within 7 days (mean 1.3 days). Almost two-thirds of patients (73.6%) were on anticoagulation at the time of the CMR exam.
All TEE and CMR studies were interpreted by two experienced readers blinded to clinical history and results of other imaging studies. Interobserver agreement was highest in long TI DE-CMR (κ=0.91), followed by cine-CMR (κ=0.85) and contrast-enhanced MR angiography (κ=0.83).
One of the study’s primary objectives was to see whether long TI DE-CMR, which is available on most cardiac MR scanners and does not require special software or hardware, can be performed in patients with AF or irregular heart rhythms, Shah said. It is performed with a single-shot acquisition technique 10 minutes after contrast administration and “essentially acquires each image within one single heartbeat. So the lack of being able to hold their breath or the presence of irregular heart rhythms really doesn’t compromise the image quality for this particular technique,” he added.
The diagnostic accuracy of CMR was slightly less but not significantly different in patients with AF vs those in sinus rhythm using long TI DE-CMR (98.2% vs 100%; P=0.174), contrast-enhanced MR angiography (93.6% vs 94.7%; P=0.789), and cine-CMR (88.1% vs 94.1%; P=0.113).
While an important consideration, the editorialists write, “there were very few thrombi, and the study was underpowered to detect a difference. Furthermore, the diagnostic ability of CMR to detect right atrial or right atrial appendage thrombi was not assessed.”
The investigators acknowledge that, “unlike TEE, which could provide anatomical and physiological data such as LAA-emptying velocity, the evaluated CMR components in our study could provide only anatomical data.”
The longer time required for CMR is also a common criticism, but this could be brought down—albeit not as short as for cardiac CT—if CMR protocols were tailored to assess PV anatomy and LA/LAA thrombi. CMR also provides valuable data for PVI without exposing patients to radiation, they note.
Shah agreed further studies are needed to confirm the results but observed that they currently use CMR on all patients prior to PVI.
Some cardiac MRI findings predict future heart events.
Certain MRI findings can independently predict future cardiovascular events in patients with coronary artery disease or those who recently had a heart attack, but you have to be careful which ones you choose, according to a study published online January 29 in the Journal of the American College of Cardiology.
In a meta-analysis of 56 previous studies, Dutch researchers found that some cardiac MRI findings are predictive for some types of patients, while there aren’t enough data to support the prognostic power of other results.
“An important finding is that different cardiac MR features are associated with events depending on the patient population under consideration,” wrote lead author Dr. Hamza El Aidi, from the department of cardiology at University Medical Center Utrecht, and colleagues (JACC, January 29, 2014).
Benefits of cardiac MRI
As the authors noted in their study, cardiac MRI has advantages over other imaging modalities because of its high spatial and temporal resolution, its ability to visualize ischemic heart disease in one scan, and its lack of ionizing radiation. Cardiac MRI is also considered the current reference standard for evaluating ventricular function and myocardial fibrosis using late gadolinium enhancement.
“However, data on prognosis from individual studies is limited, most often due to small sample sizes and/or a low number of events in these studies,” they wrote. “Furthermore, the relative prognostic value of the available cardiac MR imaging findings is unclear.”
The researchers decided to assess cardiac MRI’s predictive power based on the following imaging features:
- Left ventricular ejection fraction (LVEF)
- Wall motion abnormalities
- Abnormal myocardial perfusion
- Microvascular obstruction
- Late gadolinium enhancement
- Presence of edema
- Presence of intramyocardial hemorrhage
Patients were divided into two groups: The first group consisted of those who had experienced a recent myocardial infarction, while the second included patients with suspected or known coronary artery disease (CAD).
The imaging findings were then correlated with “hard events” — all-cause mortality, cardiac death, cardiac transplantation, and myocardial infarction — or major adverse cardiovascular events (MACE), which included hard or other events as defined by authors of the evaluated papers. For each finding, a hazard ratio was calculated to show the association between that factor and future cardiac events in each of the two patient groups.
Paper chase
Cardiac MRI papers published before February 2013 were drawn from Medline and Embase. A total of 56 papers were found to meet the study’s criteria, representing a total population of 25,497 patients.
There wasn’t enough evidence to link cardiac MRI findings with hard events in the patients with recent myocardial infarction, according to the authors. However, findings that did demonstrate prognostic value included the following:
- In patients with a recent myocardial infarction, LVEF was an independent predictor of MACE in more than 50% of the studies, with a change in hazard ratio (HR) of 1.03 to 1.05 per 1% decrease in LVEF.
- In patients with suspected or known CAD, the following cardiac MRI findings were predictors of hard events:
- Wall motion abnormalities (HR range of 1.87-2.99)
- Perfusion defects (HR range of 3.02-7.77)
- LVEF (HR range of 0.72-0.82 per 10% increase in LVEF)
- Infarction (HR range of 2.82-9.43)
- In patients with suspected or known CAD, perfusion defects were associated with MACE (HR range of 1.76-3.21).
Important predictors
According to the authors, their study is one of the first comprehensive systematic reviews investigating the predictive abilities of different cardiac MRI findings for future cardiovascular events.
“Among patients with suspected or known coronary artery disease, inducible wall motion abnormalities and inducible perfusion defects were the most important independent predictors of hard events,” they wrote. “Other independent predictors were LVEF and infarct size.”
To better assess cardiac MRI, the authors advocated the development of reporting guidelines for prognostic studies in cardiovascular imaging.
They cited the Reporting Recommendations for Tumor Marker Prognostic Studies (REMARK), which are used for oncology, and the Prognosis Research Strategy (PROGRESS) recommendations as examples.
“In conclusion, cardiac MRI is capable of providing independent prognostic information that allows for risk stratification after myocardial infarction as well as in patients with suspected or known coronary artery disease,” they wrote.
ARYAN'S BLOG 