Teaching Case

Male, 64 years old, heavy smoker, presented with a right upper lobe mass. Due to non-treatment and tumor extension, superior vena cava syndrome was superimposed.

On December 2000, the patient seaked for medical advice due to long-standing malaise, weight loss and periodic, non-productive cough. Among other examinations, he underwent a chest x-ray, where a right upper lobe mass was depicted. Further investigation was carried out with bronchoscopy and chest computed tomography (Fig 1). Biopsy revealed a small-cell lung carcinoma.The patient had been a heavy smoker (>40 cigarettes per day); however he refused to follow any treatment and returned home. Four months later, he presented with intense dyspnea, symptoms of respiratory infection , head-and-neck swelling and dilation of jugular veins. Laboratory tests revealed elevated WBC=28200, high ESR=165 and Glu=226mg/dl. All other parameters were normal. New chest x-ray revealed considerable amount of pleural collection and a right upper lobe atelectasis (Fig.2). Based on the imaging findings of chest x-rays and of the last chest CT available, clinical findings were typical of superior vena cava syndrome as a complication of the right upper lobe malignancy. Right transjugular venography confirmed the presence of a filling defect inside the superior vena cava due to tumor invasion (Fig 3). A Wallstent of 9 cm length and 20 mm diameter (Boston Scientific, USA) was succesfully placed (Fig 4a and 4b) with impressive amelioration of patient's clinical state.

Superior vena cava (SVC) syndrome is caused by malignant disease in 85-95% of the reported cases. The cause is bronchogenic carcinoma in about 80% of cases, with lymphoma and metastatic disease comprising 15% and 5% respectively. Mediastinal inflammation as a result of fibrosing mediastinitis and/or granulomatous disease caused by histoplasmosis infection predominate the benign causes of SVC syndrome. Recently, the use of central-venous catheters for diagnostic or therapeutic interventions is responsible for the iatrogenic thrombosis of the SVC. Various modalities of treatment have been advocated for the management of SVC obstruction. Conventional treatment of this condition is radiotherapy while chemotherapy is of little value . The results of radiotherapy are better for lymphoma than bronchogenic carcinoma. Venous bypass grafts or pericardial grafts are major operations. Nowadays, the advent of intraluminal, self-expanding stents seem to offer a satisfactory alternative. They are placed under radiologic control, through a femoral or jugular insertion, and various stent lengths can be used. Candidates unsuitable for this procedure include patients with cardiac failure, complete vessel occlusion and severe coagulopathy. A short period of anticoagulation therapy is indicated in most cases . Usually, there is rapid improvement of symptoms ,within days or even hours. Self-expanding stent placement can be considered as a safe, simple, rapidly effective, minimally invasive technique for the management of SVC obstruction.