CASE COMMUNICATIONS 712 IMAJ • VOL 17 • NOVEMBER 2015 cardiovascular magnetic resonance imaging (CMRI), diffuse large B cell lymphoma, angiosarcoma IMAJ 2015; 17: 712–713 PATIENT DESCRIPTION An 88 year old woman presented to our hospital with shortness of breath, leg edema and weakness of 2 weeks duration. Her past medical history was positive for ischemic heart disease and hyperlipidemia. On admission, her vital signs were normal, jugular venous pressure was elevated, lungs were clear, heart sounds were distant, and she had signifcant leg edema without hepatosplenomegaly or lymphadenopathy. Complete blood count and biochemi- cal blood tests were normal except for mild hyponatremia and mildly elevated choles- tatic liver function tests and lactate dehy- drogenase (LDH) levels. Tumor markers (CEA, CA, 19-9, CA 72-4) were normal except for CA-125 which was mildly elevated (77 mg/ml, normal range 0–35). An electrocardiogram (ECG) demon- strated sinus rhythm with low amplitude complexes. Echocardiography showed mild peri- cardial efusion, mildly dilated right atrium and ventricle flled by a vacuolated non-homogeneous texture mass with a dense consistency (atrial part 4.5 x 4.0 cm, ventricular part 7.5 x 3.5 cm), causing a signifcant obstruction of right ventricular infow. Mid-ventricular systolic pressure gradient was estimated at 12 mmHg. Te pericardial fuid was tapped and cytology examination revealed irritated mesothelial cells. No cells suspicious for malignancy were found. CT scan of the chest, abdo- men and pelvis demonstrated the mass in the right heart invading the coronary sinus, as well as bilateral adrenal masses. CMRI demonstrated an iso-intense mass in T1 and steady-state free precession (SSFP) located between the inferior part of the right atrium and the upper part of the right ventricle, impeding the blood fow between P rimary cardiac tumors are extremely rare, with an autopsy incidence rang- ing from 0.001% to 0.03% [1]. Seventy-fve percent of the primary tumors are benign; myxomas are the most frequent lesions and account for more than half the cases. Te most prevalent primary malignant tumors are cardiac sarcomas, of which angiosar- coma is the most common in adults (37%) [2]. Conversely, cardiac lymphomas are extremely rare and afect mainly immu- nosuppressed individuals. Tey are mostly non-Hodgkin B cell type and preferentially involve the right atrium, with invasion of adjacent structures and large pericardial efusion [3]. Primary cardiac tumors pres- ent with one or more of the following: intra- cardiac obstruction, systemic embolization and constitutional symptoms, and are tra- ditionally diagnosed by echocardiogram and computed tomography (CT) scan. However, in the last few years the role of cardiovascular magnetic resonance imaging (CMRI) in identifying and characterizing these tumors has emerged. We present here the case of an elderly woman with shortness of breath in whom echocardiography revealed a large mass occupying the right atrium and ventricle. Tis mass had a typical appearance on CT and CMRI supporting the diagnosis of angiosarcoma, although pathologically it was diagnosed as difuse large B cell lym- phoma and was treated accordingly with chemotherapy. them and from the inferior vena cava. In T2 it was non-homogenous with a hyper- intense center and iso-intense (compared to the myocardium) peripheral areas. With contrast it was centrally enhanced in frst- pass perfusion and signifcantly enhanced by gadolinium [Figure 1]. Tese fndings were thought to be typi- cal for angiosarcoma due to the location, early hyper-bright heterogeneous gado- linium enhancement in T1, as well as het- erogeneous appearance with hyper-intense center in T2. However, biopsy obtained from the atrial part of the mass demon- strated fragments of tissue infltrated by a difuse lymphoproliferative process com- posed of large atypical lymphoid cells with vesicular nuclei and variably prominent nucleoli. Mitotic fgures and apoptotic bod- ies were seen. Te malignant cells stained strongly with immunohistochemical stain for CD20 and for lymphocyte common antigen (LCA) but did not stain with CD3. More than 95% of the malignant cells stained with the proliferation marker Ki67. A diagnosis of difuse large B cell lym- phoma was made. Te patient was treated with irradiation without chemotherapy because of her age, with good response. COMMENT Among primary cardiac malignant tumors, lymphomas are extremely rare and afect mainly immunosuppressed individuals. Fewer than 60 cases of immunocompetent patients have been reported since 1945 [1]. As mentioned above, they are mostly non-Hodgkin B cell type and preferentially involve the right atrium, with invasion of adjacent structures and large pericardial efusion [3]. Te distinction between pri- mary cardiac lymphoma and secondary cardiac involvement in systemic lymphoma KEY WORDS: Lymphoma of the Right Atrium and Ventricle Shmuel Chen MD PhD 1 , Karine Atlan MD 2 , Dan Gilon MD 1 , Chaim Lotan MD 1 and Ronen Durst MD 1 Departments of 1 Cardiology and 2 Pathology, Hebrew University Hadassah Medical Center (Ein Kerem Campus) Jerusalem, Israel