Introduction: Diffuse large B-cell lymphoma (DLBCL) is one of the most common subtypes of non-Hodgkin lymphoma, which often presents with B symptoms and lymphadenopathy, with multi-organ involvement seen in later stages. However, DLBCL with cardiac involvement (cDLBCL), especially those causing obstructive shock requiring emergency resection, is extremely rare. Furthermore, the use of chemotherapy for postoperative patients on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is rarely reported.
Description: A 61-year-old male presented to the emergency department with a 1-month history of shortness of breath that worsened 10 days before presentation. Imaging revealed a right atrial mass (7.4*2.6cm) extending into the right ventricle, superior vena cava, and inferior vena cava. PET-CT showed mediastinal lymphadenopathy and gastrointestinal (GI) involvement. After admission, the patient developed obstructive shock, and emergency surgery under cardiopulmonary bypass was performed. The tumor was partially removed, and histopathology showed germinal center DLBCL (Ki-67 ~80%). Postoperatively, the patient developed acute cardiogenic shock requiring VA-ECMO (total of 13 days). Multiple GI hemorrhages occurred, possibly due to intestinal involvement of the lymphoma. On day 12 of VA-ECMO, the patient was started on his first cycle of chemotherapy with rituximab, cyclophosphamide, epirubicin, and vincristine (R-CHO). Glucocorticoids were not used in this cycle to reduce GI bleeding risks. The patient responded well to the treatment as the tumor size was significantly reduced, though pneumonia and myelosuppression occurred. These complications were effectively managed with transfusions, antibiotics, supportive treatments, etc. After 51 days of intensive care, the patient’s hemodynamics and pulmonary function were stabilized, and he was transferred to a rehabilitation hospital for further treatment.
Discussion: Management of critically ill stage IV cDLBCL patients can be nuanced and challenging, as the timing for chemotherapy can be difficult to decide. Our case shows that the initiation of chemotherapy with concurrent ECMO is beneficial in patients with unstable hemodynamics. However, chemotherapy should be carefully designed and personalized to minimize the risk of infection and hemorrhage.
