Superior vena cava syndrome by cardiac tumor

CASE REPORT: A 59-year-old man with a 4-week history of dyspnea, coughing, and chest discomfort was referred to hospital for further evaluation. Moreover, he reported fever and fatigue. There were neither cardiovascular risk factors nor drug medication. 6 months earlier, a deep vein thrombosis of his left lower limb was diagnosed followed by an anticoagulation for 4 weeks. Physical examination revealed a dilatation of the neck veins with a present Kussmaul sign and a diastolic murmur at the left lower sternal border. The findings on the rest of his physical examination were unremarkable. Electrocardiography showed normal sinus rhythm, low voltage, and anterolateral T wave inversion. Initial laboratory results were remarkable for elevated lactate dehydrogenase level. Transthoracic echocardiography revealed a small pericardial effusion with a large intracardiac mass adjacent to the right atrium. Thoracic computed tomography confirmed the tumor mass and showed enlargement of mediastinal lymph nodes. The patient underwent transesophageal echocardiography-guided transvenous biopsy of the tumor. The immunohistology of the specimen revealed non-Hodgkin's lymphoma. The patient subsequently received a chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone. His clinical response after the first cycle was remarkable with total regression of the superior vena cava syndrome. After the third cycle of therapy, both tumor and pericardial effusion had disappeared. CONCLUSION: A cardiac tumor is a rare cause of a superior vena cava syndrome. Tissue biopsy is warranted to guide diagnosis and therapy. Transvenous biopsy is generally safe when guided by echocardiography.