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Original Article

Primary Cardiac Lymphoma


An Analysis of Presentation, Treatment, and Outcome Patterns

Adam Petrich, MD1,2,3; Soung Ick Cho, MD4; and Henny Billett, MD2,3

BACKGROUND: Primary cardiac lymphoma (PCL) represents a rare subset of non-Hodgkin lymphoma, characterized
by poor outcomes. The authors aimed to construct a framework of known clinical presentations, diagnostic
features, disease complications, treatment, and outcomes to improve prognostication. METHODS: Individual patient
data were obtained from defined cases of PCL (1949-2009) and systematically analyzed. RESULTS: The authors
report results of a review of 197 cases of PCL, with half of all cases reported since 1995. Survival was affected by 4
factors: immune status, left ventricular involvement, presence of extra-cardiac disease, and arrhythmia. Median
overall survival (OS) for immunocompromised and immunocompetent was 3.5 months (m) and not reached,
respectively (HR 0.29, 95% CI, 0.13-0.68; P .004). LV involvement was uncommon (26%) and associated with
an OS of only 1m, whereas patients free of LV involvement had a median OS of 22m (HR 0.28, 95% CI, 0.12-0.64; P
.002). Patients with extra- cardiac disease had shorter median OS compared with those without (6m vs 22m, HR
0.49, 95% CI, 0.26-0.91; P
.02). Those patients with an arrhythmia of any type had a median OS that was not reached (n 55), whereas those
without rhythm disturbances (n 41) had median OS of 6m (HR 0.51, 95% CI, 0.29-0.91; P .024). Overall
response rate to therapy was 84%, with long-term OS over 40%. CONCLUSIONS: The current study presents the
largest analy- sis of PCL to date. The data demonstrate that PCL is now more frequently diagnosed premortem
and appears to have reasonable response rates. Lack of LV involvement and the presence of arrhythmias are
associated with improved survival. Cancer 2011;117:5819. VC 2010 American Cancer Society.

KEYWORDS: primary cardiac lymphoma, extra nodal lymphoma, non-Hodgkin lymphoma, immunocompromise.

Cardiac involvement of disseminated lymphoma is common, with between 9% and 24% incidence having been
reported on autopsy series,.1-3 Primary cardiac lymphoma (PCL), however, occurs with far lower frequency. Defined as
extranodal lymphoma involving only the heart and/or pericardium, it was first assigned a distinct pathological
categoriza- tion in 1978 on the basis of 4 cases that composed only 0.5% of a series of extranodal lymphomas.4
Applying the same definition, PCL was discovered in only 0.05% of a series of over 12,000 autopsies.5 In 1996, citing
the well recognized difficulty in assessing the precise location of the lymphoid cell(s) at the time of incipient clonal
expansion, the Armed Forces Institute of Pathology broadened the inclusion criteria to include those cases of lymphoma
presenting with cardiac manifestations, particularly if the bulk of disease was found in the heart or pericardium.6-9
A review of primary malignant tumors of the heart published in 1949 attributes the first recognized case to a
1939 report in a German publication.10,11 Since then, accumulated knowledge of PCL has been derived mainly from
isolated case reports, both pre- and postmortem, although series with as many as 9 cases have been published.12
It has been recognized that the incidence of extranodal NHL increased during the latter part of the 20th century
in both the United States and elsewhere.13,14 This has been attributed to multiple possible factors, including improved
diag-
nostic techniques, increased population of immunosuppressed patients, exposure to environmental toxins, and the
advent of the human immunodeficiency virus (HIV).15 With the discovery of HIV and its role in NHL in the early
1980s, authors began to distinguish reports of PCL vis-a-vis immune status, observing that PCL was more
commonand increasing in incidencein the immunocompromised population.7,16-18 Published reviews to date have
encompassed up to 9 HIV-positive patients and 38-48 immunocompetent patients, where a more recent study
reviewed 68 patients without regard to immune status.12,19-21

Corresponding author: Adam Petrich, MD, Division of Hematology, Department of Oncology, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY 10467;
Fax: (718) 798-7474; apetrich@montefiore.org
1
Department of Oncology, Montefiore Medical Center, Bronx, New York; 2Division of Hematology, Department of Medicine, Montefiore Medical Center, Bronx,
New York; 3Albert Einstein College of Medicine, Bronx, New York; 4Department of Medicine, Jacobi Medical Center, Bronx, New York
DOI: 10.1002/cncr.25444, Received: December 28, 2009; Revised: March 22, 2010; Accepted: April 19, 2010, Published online October 4, 2010 in Wiley Online
Library (wileyonlinelibrary.com)
Cancer
581 February 1, 2011 Cancer February 1, 581
2011
Original Article Primary Cardiac Lymphoma/Petrich et al

We present here an analysis of 197 cases of primary For analyses of factors affecting survival times,
cardiac lymphoma. We have reviewed the cases for multi- patients were included only if they were diagnosed
ple discreet variables in an effort to establish patterns to
these disparate presentations, treatments, and
outcomes to develop a rationale for prognostication in
this disease.

MATERIALS AND METHODS


PubMed searches using the terms primary, extranodal,
cardiac, and lymphoma were used to identify published,
potentially eligible case reports and case series. Works
cited by each of these reports were also evaluated to
iden- tify any cases that may have been missed.
Articles were excluded if 1) the reported patients
failed to meet the current definition of PCL, defined as
cardiac involvement of non-Hodgkin lymphoma,
present upon initial lym- phoma diagnosis, without
evidence of disease elsewhere as evidenced by a lack of
tumor encountered after a) both computed tomography
of the body and bone marrow biopsy, b) autopsy, or c)
an extensive search as reported by the author(s); 2) if
insufficient information was provided to make a
judgment of the diagnosis; or 3) if the source article
could not be located.
Analyses were performed using Excel (Microsoft
Corp, Redmond, Wash), in which all patient data were
tabulated. Variables sought included demographic
information, immune status, clinical presentation, radio-
graphic and other diagnostic characteristics,
disease complications, therapy rendered, therapeutic
response, survival, and cause of death. The year of
estimated diagno- sis for each patient was assessed
according to when the re- spective report was submitted
(or year from publication if submission date not
provided), and subsequently adjust- ing for survival
achieved at the time of report (eg, in the case of a
patient with 5-year survival reported in 1995, the year of
diagnosis was estimated to be 1990). Echocardio-
graphy results were assumed to be transthoracic,
unless otherwise specified. Any response categorization
provided (eg, complete response, refractory disease) was
assumed to be accurate, even if supporting data were
not provided. Where such categorization was not
provided, either a conclusion was drawn from
supporting data or, if these were lacking, it was
considered unknown. Cases that met criteria for an
unconfirmed complete response (CRu) were grouped
with complete responses (CR). All statistical analyses and
graphing were performed using Prism 5.0 (Graphpad
Software, La Jolla, Calif).
Original Article Primary Cardiac Lymphoma/Petrich et al
premortem and had reported survival data. Otherwise, cases, 26 were HIV- positive (41%). Global immune
unless specified, each percentage presented is of the status was not mentioned in 119 cases (60%). Apart from
entire HIV, 2 patients were oth- erwise reported as
197-patient cohort. immunocompromised. Of these 2, 1 report does not
provide the nature of the immunocom- promise,32
RESULTS whereas the other patient was on chronic corti- costeroids
Literature Search Results A total of 190 articles and methotrexate for treatment of rheumatoid
containing case reports were identified. Of these, 13 arthritis.33 Performance status was given in only 3 instan-
articles were excluded, as they were not available in ces, making any assessment of this variable as a
English. Another predictor of outcome (including as a component of the
11 articles were excluded for the following reasons: a) Interna- tional Prognostic Index) impossible.20,34 Half
reported patients failed to meet either definition of PCL of all cases included in our analysis were reported
(as provided above; 6 articles reporting on a total of 14 within the last 15 years.
patients22-27); b) insufficient information was provided
Presentation
about a given patient to make such a judgment (2
Presenting complaints were provided for every patient
articles reporting on 1 patient each2,28); or c) the
included in our analysis (Table 1). Dyspnea was by far
source article could not be located (3 articles with
the most common presenting symptom, affecting 64%.
unknown number of case reports).29-31 This provided a Constitutional complaints and chest pain were the next 2
total of 166 articles, reporting 197 unique cases, for most common symptoms, at 26% and 24%, respectively.
inclusion in our analysis.
Ten patients presented with superior vena cava (SVC)
syndrome. Of 178 patients for whom pertinent
Population
informa- tion was reported, 47% were in congestive heart
Of the 197 patients in our analysis, the male-to-female
failure.
ra- tio was 1.94, with a median age of 63. Although
In cases where the presenting heart rhythm was
patients ranged in age from 9 to 90 years old, only 5 were
described, 56% (83 of 149) had an arrhythmia other
17 years of age or younger. HIV status was not
than sinus tachycardia/bradycardia. The 2 most
mentioned for 133 cases (68%), and of the remaining 64
common
Table 1. Presenting Symptoms and Clinical Findings in Primary Cardiac Lymphoma

Symptom/Findings Current Ikeda, Anghel, Ceresoli,


Study 200435 200421 199720
N5197 N540 N556 N548
Dyspnea (%) 64 50 46 NR
Arrhythmia (%) 56a 10 18 12
CHF (%) 47b 7 28 52
Constitutional Complaints (%)c 26 NR NR NR
Chest Pain (%) 24 NR 13 17
Pericardial effusion (%) 58d NR 30 NR
Pericardial mass (%) 30d 37 NR NR
Tamponade (%) 20b 7 NR 12
Peripheral Edema (%) 9 10 26 NR
SVC Syndrome (%) 5 2 5 8

All values given as percentages of the entire study cohort, unless otherwise specified.
CHF,congestive heart failure; SVC,superior vena cava; NR,not reported.
a
n149.
b
n178.
c
Constitutional complaints include fever, chills, sweats, and weight loss.
d
n183.

abnormalities were atrial arrhythmias and 28 cases (15%) reported neither transthoracic (TTE) nor
atrioventricular transesophageal echocardiography (TEE) results, and 13
(AV) block, at 23% and 22%, respectively. Interestingly,
20 of 33 reported cases of AV block (61%) were
complete. In addition, 16 patients had either left or
right bundle branch block, and 8 suffered ventricular
arrhythmias.
In keeping with previous reports,35 right heart
involvement was far more common than left heart in
this population. A total of 179 patients had described
chamber involvement (vs pericardial involvement only),
of which
92% had either the right atrium (RA) or right
ventricle (RV) involved. Only 7% of these patients
had left-side involvement in the absence of right-side
involvement. The order of rate of chamber involvement
was RA > RV
> left atrium (LA) > left ventricle (LV). Other
commonly involved structures included the intra-
atrial septum (41%) and the SVC (25%). Of 183
patients with appro- priate information, 107 had
pericardial effusions (58%),
53 had masses involving the pericardium (30%), and 38
patients had both (21%). Of those with a pericardial
effu- sion, 34% demonstrated tamponade physiology.

Diagnosis
The first cases using echocardiography36 and nuclear
imaging37 were both reported for cardiac lymphoma
cases in 1981. This may have dramatically improved the
ability
to detect PCL: 64% of cases (14 of 22) occurring
before or during 1981 were diagnosed only at
autopsy; since then, that figure has dropped to 15%
(27 of 175). Only
of these were reported before 1981. In our series, TTE than 10% each: 13 cases of Burkitt, 10 cases of T-cell
had a sensitivity of 73% for right atrial involvement (n lymphoma,
108) and 55% for right ventricular involvement (n 8 cases of small lymphocytic lymphoma, and 2 cases of
86). Using TEE added to the findings of TTE in 19 of 36 plasmablastic lymphoma. The remainder (51 cases, 26%)
cases (53%). remained unspecified by the authors. These data agree
with the findings of previous authors, who noted
DLBCL as the predominant histology since the early
Pathology to mid-
Tissue diagnoses were made in 43% with minimally inva- 1980s,2,38 irrespective of HIV status.
sive biopsy techniques 36% at surgery, leaving Tumor dimensions were reported in 81
autopsy diagnoses accounting for the final 21%. Of instances, and, of these, 21 (26%) had disease greater
those who underwent surgery, 48% had surgery than 7.5 cm and 7 (9%) greater than 10 cm.
performed on an urgent/emergent basis; 56% Immunohistochemistry (IHC) was consistent with the
underwent partial or com- plete tumor resection at the predominance of B-cell disease in those tested; only 3
time of surgery. cases (of 88 reported) were CD-20 negative, of which 2
By far, the most common NHL subtype was were T-cell histology and 1 plasmablastic. Values for
diffuse large B-cell lymphoma (DLBCL), with 113 KI-67 were reported in 13
reports. Other reported subtypes constituted fewer
instances, with a median value of 80%. Just over 10% Therapy
(10 of 98) of patients had bone marrow involvement, A total of 142 patients were treated by any modality
with over half of all reports not including this (72% of all patients, 91% of those diagnosed premor-
information. tem). The most common modality was chemotherapy,
It was observed that 112 of 163 patients (68%) met which was administered to 89% of those treated.
strict criteria for PCL (see Methods above), with the Surgi- cal resection (either partial or complete) was
remainder of reports lacking sufficient information to undertaken in 28% and radiotherapy performed for
make such a judgment. HIV status seemed to affect the 20%, with a median dose of 34.8 Gy (range 15-59
likelihood of meeting these criteria: only 26% of HIV- Gy). A total of
positive patients (5 of 19) were free of extracardiac 23 patients received combined up-front
lymphoma (ie, met a loose, but not strict chemoradiation, with another 2 patients having
definition of PCL), whereas 76% of HIV-negative received both treatments asynchronously. Only 2
patients (28 of patients received radiation with- out any sort of
37) and 74% of those with unknown HIV status (79 of systemic chemotherapy,46,47 making a substantive
107) had disease limited to the heart and/or comparison of combination therapy versus radiation
pericardium at the time of initial diagnosis. alone impossible. High-dose chemotherapy, followed
by autologous stem cell transplant or allogenic
Laboratory Data transplant, was given in 4 patients and 1 patient,
These data were most remarkable for elevations in respec- tively. Heart transplant was reported for
lactate dehydrogenase (LDH). Sixty-six reports included another. Based upon the supposition that diagnostic
LDH values, of which 92% were above their respective rates improved with advances in imaging, a parallel
reference ranges, with a mean of 770 IU/L (range 228- analysis of treat- ment trends was undertaken. This
4820 for the elevated levels described). The exact LDH analysis demonstrated that, before and during 1981
determinations of patients noted to have normal (when echocardiography was first reported as a
levels were not detailed.20,39-42 Anemia affected 27 of diagnostic tool for a case of PCL), only 41% of
53 patients, with a mean hemoglobin of 11.4 g/dL. patients (9 of 22) were treated by any modality. Since
There were too few reports of levels of creatine 1981, 79% of all patients (133 of
phosphokinase (CPK), cardiac-specific enzymes, uric 168) have received treatment (for 7 patients it was
acid, or erythrocyte sedi- mentation rate (ESR) for unclear whether treatment was given).
analysis. Anthracycline-containing regimens, primarily CHOP,
were given to 89% (97 of 109) of those patients
Complications receiving chemotherapy. The use of rituximab first
Of all patients included in the analysis, 57% had died occurred in
by the time of reporting, and the cause of death was 2001 and, since that year, has been given to 38% of
provided for 71% (80 of 113). The most common patients with non-Tcell histology (23 of 61). A
cause of death was heart failure, at 40%. This was median of 6 cycles of chemotherapy was administered
followed by sepsis or other severe infection (26%) and to the 67 patients for whom such data were reported.
progression of lym- phoma (23%). Of the 21 cases in One fatality from tumor lysis syndrome was
which infection was the cause of death, 12 patients reported.48 Taken together with the 12 patients who
(57%) had received chemo- therapy, although the link had received chemo- therapy and developed sepsis, this
between treatment and death from infection was is indicative of a treat- ment-related mortality (TRM)
generally not specified. As mentioned above, over half of as high as 10% (13 of
all patients with PCL presented with an arrhythmia, 126) for chemotherapy. Management of heart failure
which was fatal in 11% of such cases (9 of and arrhythmias arising as complications of PCL was
83). Four patients presented with sudden cardiac mentioned in only isolated case reports; therefore, no
death.23,36,43,44 such data were collected or analyzed.
A total of 12 patients presented with embolic
phenomena attributed to PCL, including 7 episodes of Response and Survival Patterns
pulmonary embolism (PE) and 4 episodes of cerebrovas- Of the 142 patients treated by any modality, 92 had a
cular accident (CVA). PE was fatal in 4 instances, CVA partial (PR) or complete response (CR) documented; 26
in 1. Although tamponade physiology was noted in 36 reports did not provide response data. This translates to
cases (see Presentation above), in only 1 of these cases an overall response rate (ORR) of 79% for cases
was it described as fatal.45 with available data and a CR of 59%, which compares
favor- ably to the 38% CR reported in a 2004 review
of 40
Table 2. Therapeutic Management and Overall Survival in
Primary Cardiac Lymphoma

Median Overall
Survival, Mo
Type of Received Not P
Therapy Received

Chemotherapy 30 (n105) 0.3 (n23) <.0001


Surgery 22 (n34) 10 (n92) .18
Radiation NR (n21) 10 (n104) .11
Chemotherapy & Radiation 22 (n19) 22a (n86) .84

N, number of patients; NR, not reached.


a
For those receiving combination chemotherapy and radiation, the compar-
ator group is those receiving chemotherapy alone, as only 2 patients
received radiation with no chemotherapy.
Figure 1. Kaplan-Meier survival curve of entire cohort (N
128) of patients for whom antemortem diagnosis was made
and survival data reported.
cases.35 These proportions are lower than the reported
71% CR in a review of cases between 1989 and 2005,
for which the total number of cases in that particular
analysis was not provided.49 Refractory disease as a best 50) were 3.5 months and not reached, respectively (Fig.
response was documented in only 16 cases, and relapse 2, Panel B; HR 0.29, 95% CI: 0.13-0.68; log-rank P
following a CR in only 12. The median time to relapse
was 7 months, with none reported beyond 12 months. .0042). The only chamber whose involvement was found
Second-line ther- apy was rarely reported, with a 42% to affect survival was the LV; the 19 patients with this
ORR (5 of 12) and 2 instances of CR.50,51, Although chamber involved incurred a median OS of only 1
surgical resection and radiation trended toward a month, whereas the 103 patients free of LV
positive impact upon survival, only chemotherapy made involvement had a median OS of 22 months (Fig. 2,
a statistically significant differ- ence (30m vs 0.3m, Panel C; HR 0.28, 95% CI: 0.12-0.64; log-rank P .
P<.0001, Table 2). There was virtu- ally no difference 0024). Those patients with an arrhythmia of any type
in survival patterns between those receiving (as defined above in Methods) had a median OS of not
chemotherapy alone and those receiving com- bined reached (n 55), whereas those without rhythm
chemoradiation. This supports a previous assess- ment disturbances (n 41) had median OS of
of lack of benefit associated with the addition of 6 months (Fig. 2, Panel D; HR 0.51, 95% CI: 0.29-0.91;
radiation therapy to chemotherapy in a smaller group of log-rank P .024).
patients.20 No effect of histology on overall survival (OS)
could be found; however, as noted, non-DLBCL histo- DISCUSSION
logy was rare. Furthermore, subtypes of DLBCL (ie, We have here presented the largest review of PCL to
germinal center vs nongerminal center) were not date. We present data that seem to indicate that PCL is
mentioned in any reports. now diagnosed with greater frequency, likely because of
The median OS of those diagnosed antemortem advan- ces in imaging, although other factorssuch as
was approximately 12 months (Fig. 1). In an effort to a larger population of HIV-positive or otherwise
deter- mine predictors of outcome, we analyzed survival immunosup- pressed patients with longer life
patterns of the 128 patients diagnosed premortem, expectancy52 may be contributing to this increase. In
for whom survival data was reported. Among them, any case, we are unable to substantiate any claim that
those who had extracardiac disease (n 32) had a incidence is rising in HIV- positive or otherwise
reported median OS of 6 months, whereas those immunosuppressed populations. Our data demonstrate a
without (ie, those who met strict criteria for PCL, n fairly even distribution of 23 cases over the years 1981 to
74) had a median OS of 22 months (Fig. 2, Panel A; 1995 (between zero and 3 reports per year), followed by
HR 0.49, 95% CI, 0.26-0.91; log-rank P .024), another 3 each in 2005, 2006, and
with all reports of survival >30 months (n 13) 2007. Regardless of trends in overall incidence, it seems
coming in those without extracardiac disease. Median that PCL in these HIV patients, as compared with
OS for those with immunocompromise (including HIV, their immunocompetent counterparts, more often
n 28) and immunocompetence (n reflects only a portion of their lymphomatous
involvement.
Figure 2. Kaplan-Meier survival curves by presence/absence of 4 variables found to significantly impact survival. Kaplan-Meier
survival curves are shown for presence/absence of extracardiac disease (Panel A; log rank P value .024),
immunocompromise; (Panel B; log rank P value .0042), LV involvement (log rank P value .0019), and arrhythmia (log rank P
value .024).

As noted, our analysis concurs with previous currently, to maintain PCL as a diagnostic category. The
reports indicating that PCL favors the right side of the cardiac manifestations would almost certainly affect
heart. The reason for this phenomenon remains unclear; aspects of care (eg, diagnosis, complications), compared
however, a possible, novel, anatomic explanation might with cases of systemic lymphoma without significant
be the find- ing that the thoracic duct drains lymph into cardiac involvement. Moreover, survival rates would be
the SVC, and subsequently into the right atrium and measurably impacted (Fig. 2A).
ventricle, meaning the right heart would more readily In terms of predominance of presenting
and frequently be exposed to any pre-existing nodal symptoms/ findings, our results generally agree with
lymphoma. This might also explain the finding that previous reports (Table 1). An interesting exception is
approximately a quarter of PCL patients have SVC the much higher incidence of arrhythmia that we here
involvement. However, if this hy- pothesis were correct, it report. The reason for this discrepancy is unclear, but
would seem to indicate that PCL is more of an may be the result of different inclusion criteria and/or
extranodal complication of what is presumed to be sample size differen- ces.20,21,35 We considered the
occult systemic (nodal) lymphoma, and supports the possibility that the high rate of RA involvement might
analysis above that chemotherapy offers opti- mal therapy lead to frequent interference with the function of, or
for this lymphoma. This would further lead us to posit conduction from, the sinoatrial lymph node.
that PCL, rather than being primarily cardiac, is simply However, the rates of arrhythmia were virtually
a manifestation of occult systemic lymphoma, thus identical: 58% in those with RA involvement (n
stripping the strict definition of the disease of sub- 101) and 59% in those without RA involvement (n
stantive meaning. It nevertheless seems warranted, at 39).
least
Table 3. Therapeutic Modalities for the Treatment of Extranodal Lymphomas

Site of No. Surgery Chemotherapy RT ORR Median


Lymphoma (%) (%) (%) (CRR) (%) OS (%)
Gastric55 312 77 80 19 80 (64) 71 (5 y)
Breast56 204 49 80 64 93 (89) 63 (5 y)
Testes57 373 95 75 53 86 (71) 48 (5 y)
CNS58 378 23 70 88 61 (NR) 37 (2 y)
Cardiac (Current) 142 28 89 20 79 (59) 42 (4 y)

ORR, overall response rate (%); CRR, complete response rate (%); OS, overall survival; NR, not reported.

In our analysis of treatment outcomes, chemother- involvement as a risk factor, although not necessarily
apy appeared to have the greatest effect upon survival, expected, is not particularly surprising. It was subse-
although it is understood there may have been a quently noted that 77% of those patients with LV
selection bias. Those diagnosed premortem and yet not involve- ment also had right chamber involvement; those
receiving chemotherapy likely represented an extremely with LV disease may simply be a group with a higher
moribund subset of the population, with shorter overall bur- den of cardiac disease, and therefore at
survival times. Although a similar but weaker bias higher overall risk of mortality. It remains curious that
may have occurred with other treatment modalities, those presenting with rhythm disturbances actually
there was no significant difference in survival curves for survived longer than those with normal rhythms,
radiation or surgical resec- tion, compared with those not although there are at least 2 poten- tial explanations: a)
receiving these treatments. Our demonstration that those with arrhythmias more often suffered symptoms
radiation adds little to systemic chemotherapy in terms that prompted early presentation; or b) the detection
of OS is novel. The aggregate of these data regarding of arrhythmia upon presentation may have led to
different modalities supports our hy- pothesis that PCL earlier imaging and/or treatment of the affected
should be considered a systemic disease, for which population.
treatment should always include chemotherapy. We acknowledge that caution must be used in
We compared our treatment data and those of inter- preting the presented data. Within the
reported series of other extranodal lymphomas (Table 3), population of patients affected by PCL wide variations
each of which, like our cohort of patients, was entirely or exist, such as the presence and nature of comorbidities,
mainly composed of patients with DLBCL subtype. the sophistication of available diagnostic tools, and even
Chemotherapy was used more often in PCL than in treatment options. Moreover, when dealing with case
any other subtype, whereas surgery and radiotherapy reports as a source of data, there is a bias in favor of
were used comparatively less; surgical rates were on par reporting those cases with unique features and a lack of
with those observed in primary CNS lymphoma, and standardization as to what features should or should not
rates of radiotherapy similar to those in gastric be reported.
lymphoma. Though no formal statistical comparisons With this in mind, we believe that our data raise
were under- taken, the overall and complete response some questions and point out what seem to be trends in
rates in PCL seem to approach those seen in primary PCL, but fail to definitively answer most issues. Our data
lymphomas of the breast, stomach, and testes, and indicate that arrhythmias are much more common in
exceed those in primary CNS lymphoma. Similarly, the PCL than previously believed. This is particularly
OS rates are indicative of outcomes between primary relevant in terms of further data we have provided
CNS and the other 3 types of extranodal lymphoma. It indicating that the presence of arrhythmia may impact
also bears noting that multiple Kaplan-Meier survival survival. We have shown that response rates approximate
curves for PCL (Figs. 1 and 2) point to subsets of PCL those seen in other types of extranodal lymphoma, but
patients that are likely cured. with inferior overall survival (with the exception of
We have provided data in support of 4 adverse primary CNS lymphoma). Finally, we would like to note
prog- nostic factors: immunocompromise, extracardiac that PCL, though still rare, is more common than
disease, LV involvement, and the absence of arrhythmia. previously thought. By our analysis of existing reports,
The first there have been as many as 14 cases in
2 come as no surprise; immunocompetent patients would 1 year (in both 1990 and 2006), and an average of over 6
be at an overall greater health risk, and subject to higher cases per year since 1996. There are certainly others that
rates of extranodal lymphoma. The presence of LV go unreported; we have been able to find an additional
3
cases of PCL treated at our own institution (not 14. Adamson P, Bray F, Costantini AS, et al. Time trends in the
reported here) within the last 5 years. In light of the registration of Hodgkin and non-Hodgkin lymphomas in
Europe. Eur J Cancer. 2007:43;391-401.
emerging role of gene expression profiling to sub- 15. Zucca E, Roggero E, Bertoni F, Cavalli F. Primary extrano-
classify DLBCL and clarify prognosis,53,54 comparison dal non-hodgkins lymphomas. Ann Oncol. 1997;8:727-
737.
of PCL genotypic ana- lyses might be informative. With
16. Antoniades L, Eftychiou C, Petrou PM, et al. Primary car-
these concerns in mind, it may be worthwhile to create a diac lymphoma: case report and brief review of the litera-
registry of PCL patients to better standardize available ture. Echocardiography. 2009:26;214-219.
data and resolve questions regarding prognosis and 17. Monsuez JJ, Frija J, Hertz Pannier L, et al. Non-Hodgkins
lymphoma with cardiac presentation: evaluation and
appropriate management. follow-
up with echocardiography and MR imaging. Eur Heart J.
1991;12:464-467.
18. Guarner J. Brynes RK, Chan WC, Birdsong G, Hertzler G.
CONFLICT OF INTEREST DISCLOSURES Primary non-Hodgkins lymphoma of the heart in 2
The authors made no disclosures. patients with the acquired immunodeficiency syndrome.
Arch Pathol Lab Med. 1987:111;254-256.
19. Chalabreysse L, Berger F, Loire R, et al. Primary cardiac
lymphoma in immunocompetent patients: a report of 3
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