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Logo of thijTexas Heart Institute JournalSee also Cardiovascular Diseases Journal in PMCSubscribeSubmissionsTHI Journal Website
 
Tex Heart Inst J. 2010; 37(4): 492–493.
PMCID: PMC2929867

Diffuse Large B-Cell Lymphoma in an Aortic Valve Allograft

Raymond F. Stainback, MD, Section Editor
Department of Adult Cardiology, Texas Heart Institute at St. Luke's Episcopal Hospital, 6624 Fannin St., Suite 2480, Houston, TX 77030

A 60-year-old man with a history of aortic valve (AV) replacement with a cryopreserved allograft for aortic stenosis presented with signs and symptoms of acute left ventricular failure. Transthoracic echocardiography revealed severe AV regurgitation, and the patient subsequently underwent AV replacement with a mechanical prosthesis for the degenerative insufficiency of his prosthetic allograft. The explanted valve was noted to have vegetation-like lesions (Fig. 1). A histopathologic examination showed extensive involvement of the valvular tissue with a large-cell malignant neoplasm (Fig. 2A). The malignant cells stained strongly for CD20 (Fig. 2B) with an aberrant expression of CD43; they were negative for CD3, which suggested large B-cell lymphoma as the diagnosis. A nuclear Ki 67 positivity of 0.80 to 0.90 also raised the possibility of Burkitt's lymphoma, but the diagnostic criteria were not met. The patient's blood counts were normal, and a bone-marrow biopsy showed no evidence of lymphoma. Positron emission tomography of the head, chest, abdomen, and pelvis also yielded negative results. The patient tested negative on screening for human immunodeficiency virus, but he was not tested for Epstein-Barr virus. Two years later, he died of Staphylococcus aureus tricuspid valve endocarditis and severe pneumonia.

figure 23FF1
Fig. 1 Gross examination of the excised aortic valve showed multiple vegetation-like growths.
figure 23FF2
Fig. 2 A) Light microscopy with routine staining of valve vegetations shows a mildly pleomorphic large-cell neoplasm with a vesicular chromatin pattern and a brisk mitotic rate (H & E, orig. ×40). B) The malignant cells stained strongly ...

Comment

Primary malignant cardiac tumors are rare (0.002%–0.3% in autopsy series),1,2 and cardiac lymphomas comprise 1.5% to 5% of all primary malignant cardiac tumors.2 To the best of our knowledge, this is the 1st report of a patient with diffuse large B-cell lymphoma in a prosthetic AV allograft. Transfer of neoplastic tissue from donor to recipient in our patient is highly unlikely, because the valve had been in place for 10 years before his presentation.

Observation in animals has indicated that surgical polymeric materials are carcinogenic in 7% to 50% of exposures.3 In a MEDLINE® search of English-language articles for prior reports of Dacron-associated cardiac malignancies in human beings, we found only 3 cases, all of which involved prosthetic mitral valve malignancy.2,4,5 We wonder if the Dacron in our patient's graft caused the neoplastic transformation. Given the large number of grafting procedures performed annually, such risk in human beings appears to be negligible.

Footnotes

Address for reprints: Nishith K. Singh, MD, Department of Internal Medicine, Southern Illinois University School of Medicine, 701 N. First St., Springfield, IL 62794–9636

E-mail: ude.demuis@hgnisn

References

1. Braunwald's heart disease: a textbook of cardiovascular medicine. Braunwald E, Zipes DP, Libby P, editors. 6th ed. Philadelphia: Saunders; 2001.
2. Durrleman NM, El-Hamamsy I, Demaria RG, Carrier M, Perrault LP, Albat B. Cardiac lymphoma following mitral valve replacement. Ann Thorac Surg 2005;79(3):1040–2. [PubMed]
3. Weiss WM, Riles TS, Gouge TH, Mizrachi HH. Angiosarcoma at the site of a Dacron vascular prosthesis: a case report and literature review. J Vasc Surg 1991;14(1):87–91. [PubMed]
4. Grubitzsch H, Wollert HG, Eckel L. Sarcoma associated with silver coated mechanical heart valve prosthesis. Ann Thorac Surg 2001;72(5):1739–40. [PubMed]
5. Holtzman E, Schiby G, Segal P, Priel I. Malignant fibrous histiocytoma complicating mitral valve replacement. J Am Coll Cardiol 1986;7(4):956–60. [PubMed]

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