Non-Hodgkin's lymphoma presenting as a mediastinal mass in a 38-year-old patient with superior vena cava syndrome and extreme fatigue owing to left atrium and right ventricle outflow tract compression: the applicability of strain imaging.

DESCRIPTION A 38-year-old patient presented with recurrent presyncope, extreme fatigue, facial oedema and weight loss. Physical examination revealed a palpable painless mass in the left supraclavicular region, facial oedema and a mild meso-systolic murmur audible at the right sternal border. An echocardiogram revealed a mass anterior to the heart compressing cardiac chambers and the aortic root. The compression resulted in a right ventricle outflow tract (RVOT) with less than half its normal anteroposterior diameter and a fusiformly shaped left atrium (LA) of extremely reduced antero-posterior diameter as it was being compressed by the displaced aortic root. Acceleration of blood flow in the RVOT and LA was evident with colour flow Doppler imaging. The lower radial/longitudinal strain of basal-medium segments of anterior and lateral left ventricular walls was documented. A thoracic CT revealed a voluminous mass in the anterior mediastinum and a biopsy diagnosed a non-Hodgkin’s lymphoma (diffuse large B cell type). Figures 1–3 illustrate cardiac involvement by the mediastinal mass. The type of cardiac involvement described herein is extremely unusual, including (a) direct compression of the RVOTwith superior vena cava syndrome and presyncopes; (b) indirect compression of LA as the extracardiac mass pushes the aortic root against it, causing extreme fatigue; (c) pericardial effusion and (d) reduced systolic strain of left ventricular wall segments contiguous with the extracardiac mass translating possible infiltration or limitation of contraction by external pressure. Echocardiographic strain imaging may help quantify regional myocardial dysfunction in the case of cardiac compression by a mediastinal tumour.