we have reported a 78 year old man with complaint of abdominal pain and vomiting . in patients
preoperative evaluation for surgical management of an intra - abdominal mass , a large intracardiac mass has found incidentally during the echocardiography .
pathologic biopsy of right atrial mass that has removed by open heart surgery shown : non hodgkin - b cell lymphoma .
the patient has treated by chop chemotherapy regiment successfully and after completion of treatment , there was complete response .
gross tumor formation in any of the cardiac chambers has been rare , particularly at the time of presentation and diagnosis of lymphoma ( 2 ) .
symptoms were usually very subtle and non - specific , particularly in the setting of co - existing comorbidities ( 3 )
. as imaging modalities and treatment options for lymphoma have improved , more unusual disease presentation might be observed more frequently . in this article
we have reported a 78-year - old man with an incidental large cardiac mass whose symptoms was abdominal pain and vomiting in the setting of pre - operative evaluation for surgical management of intra - abdominal mass .
a 78-year - old man has affected by abdominal pain , vomiting and weakness and has evaluated at june 2013 .
studying his medical history , he had hip joint replacement surgery , then in initial physical examination has shown no significant finding , except a few tenderness on the middle abdominal quadrant . in laboratory assessment , complete blood count , renal function tests - alkaline phosphatase and lactate dehydrogenase were normal , but hemoglobin and transaminases were abnormal as follows : hb = 9.1 mg / dl , ast = 71 u / lit , alt = 656 u / lit . in abdominal ct scan , there was a 71  61 mm mass at the aortic bifurcation in favor of tumoral lesion or adenopathy .
ecg had no significant and specific changes and in echocardiography , a large mass with diameter of 74  60 mm has seen in right atrium ( figure 1 ) and lv ejection fraction was 65% .
also , in thoracic sections of ct scan , an intra - cardiac mass has seen ( figure 2 ) .
bases on these new findings management of the patient has changed to cardiac surgery and open heart surgery has recommended and performed at august 2013 .
pathologic examination of removed cardiac mass has reported as below after immunohistochemistry study : hmb 45 and ck : negative ; cd20 : positive .
compatible with non - hodgkin lymphoma in favor of b - cell origin ( figures 3 and 4 ) .
he has referred to oncologist after recovery of heart surgery ( september 2013 ) . in evaluation of medical history and further physical examination , he had no history of fever and sweating , but weight loss of 2 - 3 kg during recent weeks .
karnowsky performance status was 80% . at physical examination , he had an adenopathy of 2  1 cm at left jugulodigastric chain , and the another of 3  1 cm at left supraclavicular area and physical exam was normal otherwise . in bone marrow biopsy ,
the patient has planned to treat by r - chop chemotherapy regimen ( rituximab - cyclophosphamide - doxorubicin - vincristine - prednisolone ) .
he could not provide rituximab due to economic problems , therefor he has received only chop regimen .
after first cycle of treatment , cervical adenopathies have disappeared and at the end of seventh cycle , imaging of the neck , chest and abdominopelvic cavity by ct scan had no positive finding of disease but the patient has not satisfied to undergo bm biopsy for second time .
patient treatment has completed after eight cycles of chop chemotherapy regimen at february 2014 , but he was in good condition , without any evidences of disease after six months of follow up .
cardiac masses have been arising from the heart or pericardium , were potentially lethal whether defined as benign or malignant .
metastatic deposits have represented the vast majority of cardiac malignancies ; the common primary malignancies sources have included cancers of lung , esophagus and breast as well as lymphoma , leukemia and melanoma ( 5 ) .
cardiac involvement as an initial presentation of malignant lymphoma was a rare occurrence ( 2 ) .
secondary involvement of the heart has seen in 8.7 - 27.2% of documented clinical case of lymphoma ( 2 , 6 , 7 ) . despite its life - threatening nature ( 8) , the cardiac manifestations of lymphomatous involvement of the heart
these symptoms and signs might include arrhythmias , pericardial effusion or tamponade , tumor embolization and obstruction of blood flow and valvular dysfunction .
these symptoms have related on tumor location , size , growth rate , degree of invasion and friability . in the present case and many other reports the majority of intracavital tumors have occurred on the right site of the heart , the reason for which has yet been to be found ( 1 , 11 ) .
plain chest radiographs lack sensitivity and specificity as an initial diagnostic tool but could demonstrate cardiomegaly or specific chamber enlargement .
echocardiography was the first non - invasive study for examining the chambers of the heart and pericardium ( 12 ) but trans esophageal echocardiography ( tee ) was a more sensitive technique for assessing patients ( 13 ) .
ct scan and mri with gadolinium contrast injection were useful tools for demonstrating morphology , location , extension of disease , blood flow and cardiac function ( 14 , 15 ) .
fdg - pet imaging has recently reported to reveal previously unsuspected cardiac involvement ( 16 , 17 ) .
although traditionally this has required a thoracostomy , less invasive procedures has recently been available such as tee - guided biopsy , endomyocardial biopsy , or percutaneous intracardiac biopsy with combined fluoroscopy and tee or pericardial fluid sampling ( 18 , 19 ) .
the available literature suggested systemic chemotherapy was the only effective therapy ( 18 ) and the majority of cases have treated with combination chemotherapy with varying results ( 20 , 21 ) .
there was an improvement in response and survival rates by adding of monoclonal therapies to chemotherapy ( 22 ) .
radiation therapy has indicated in cardiac mass that progresses despite chemotherapy and its adverse side effects have been pericarditis , cardiomyopathy , diastolic dysfunction , conduction defects and coronary artery disease .
cardiac involvement was rare as an initial presentation of malignant lymphoma and has often been subclinical .
these tumors have seen more common in the right site of the heart and tee , ct scan and mri with gd were effective tools in assessment of patients .
pathologic diagnosis would be essential to management of cardiac masses and the only effective treatment has been chemotherapy .
 introduction : cardiac involvement as an initial presentation of malignant lymphoma has been a rare occurrence.case presentation : we have reported a 78 year old man with complaint of abdominal pain and vomiting . in patients 
 preoperative evaluation for surgical management of an intra - abdominal mass , a large intracardiac mass has found incidentally during the echocardiography . 
 pathologic biopsy of right atrial mass that has removed by open heart surgery shown : non hodgkin - b cell lymphoma . 
 bone marrow biopsy was taken and was positive for lymphomatous involvement.conclusions:the patient has treated by chop chemotherapy regiment successfully and after completion of treatment , there was complete response . 
Introduction:
Case Presentation:
Conclusions:
1. Introduction
2. Case Presentation
3. Discussion