A Case of Classic Hodgkin Lymphoma With Biventricular Myocardial Involvement

Pericardial disease occurs in approximately 5–25% of patients with classic Hodgkin lymphoma, representing a minority overall but occurring more frequently in patients with bulky mediastinal disease, whereas direct myocardial invasion is rarely reported. We report the case of a 31-year-old male with International Prognostic Score (IPS)-7 score of 4, stage IVB classic Hodgkin lymphoma, nodular sclerosis subtype, who initially presented with multiple mediastinal masses with tumor infiltration of both ventricles—the first documented case of biventricular myocardial involvement with multiple cardiac masses. Myocardial involvement was diagnosed clinically and radiographically on concordant multimodality imaging and supported by response to lymphoma-directed therapy; no myocardial biopsy was performed, and histologic confirmation of classic Hodgkin lymphoma was obtained from a left axillary lymph node excisional biopsy. He received one cycle of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy prior to pathology confirmation, then six cycles of brentuximab plus doxorubicin, vinblastine, and dacarbazine (A + AVD). A marked morphologic response followed the single initial CHOP cycle, and a significant metabolic response was seen after two subsequent A + AVD cycles. He completed therapy without cardiac rupture despite major tumor burden, though during treatment he required hospitalization for a syncopal episode associated with extensive great vessel thrombosis and paradoxical hypotensive bradycardia. The thrombosis was considered most consistent with an advanced-stage, early-treatment lymphoma-associated hypercoagulable state, although a contribution from antecedent vascular compression could not be excluded.