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Abstract

Introduction: First described in 1757 [1], Superior vena cava syndrome (SVCS) is an array of symptoms caused by the impairment of blood flow through the SVC to the right atrium. Symptoms include dyspnea, coughing, and swelling of the face, neck, upper trunk, and extremities [2]. Most commonly seen in small cell lung cancer, only a small percentage of non small cell lung cancer (NSCLC) patients, 1%, develop the syndrome. Case: A 78-year-old male, diagnosed 3 weeks prior with locally advanced NSCLC of the right lung, was being set up for systemic chemotherapy treatments when he presented to the emergency department with increasing shortness of breath over a week. He was in moderate respiratory distress. His O2 sat was 95% on 100% O2 via non re-breather mask. His chest exam revealed decreased breath sounds bilaterally but clear. CTA chest to rule out pulmonary emboli was negative for emboli but significant for increase in the size of a mediastinal mass with evidence of superior vena caval obstruction (figure 1,2). Clinically, he had evidence of SVC obstruction with upper extremity edema, facial edema, increased collateral veins in his neck, anterior and posterior chest. He was admitted to ICU and started on IV methylprednisolone 125mg with diuretics. Radiation oncology performed decompressive external beam radiation to improve his respiratory status by delivering 300 cGy utilizing AP/PA fields to the right upper lobe and mediastinum. This was repeated for a total of 900 cGy in 3 fractions. The patients O2 requirements decreased to 6l O2 via nasal cannula. His dyspnea markedly improved. Discussion: SVCS occurs in approximately 15,000 persons in the United States each year [3]. While in the past, causes were primarily infectious they are now predominantly malignant causes. In a 2006 study, 78 patients with SVCS were studied over 5 years. Malignancy was the etiology in 60% of the cases, and bronchogenic carcinoma was the most common. Small cell and NSCLC accounted for 17 (22%) and 19 (24%) cases, respectively, but a higher percentage of patients with small-cell lung cancer developed the syndrome (6% vs 1%) [2]. We present a case of a patient with NSCLC who developed SCVS, successfully treated with radiation. Conclusion: This case illustrates that given the rarity of the number of patients with NSCLC who develop SVCS, prompt recognition and treatment is vital in leading to successful improvement in symptoms and reduction in O2 requirements.