A Case of Malignant Superior Vena Cava Syndrome Presenting as Syncope

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Mediastinum SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Superior Vena Cava Syndrome (SVCS) is a constellation of clinical symptoms and signs caused by either extrinsic compression or SVC thrombosis. Lung Cancer is the most common cause of SVCS. We present an uncommon case of malignant SVCS presenting with syncope. CASE PRESENTATION: A 55-year-old male presented to the emergency department after passing out in his niece’s parked car. He had lightheadedness and blurred vision before the witnessed, one minute, syncopal episode. He denied any previous history of syncope, heart disease or seizure. He endorsed having progressive neck pain and swelling over the past six months, a twenty-two pounds weight loss over the past year and a forty year pack history of tobacco smoking. Physical examination revealed normal vital signs except for heart rate of 105 bpm. Multiple solid, non-mobile masses were noted on the neck and the chest wall (Figure 1). Distended superficial veins were observed on the diffusely swollen right upper extremity. Significant clubbing was noted in all extremities. Routine syncope workup was unremarkable. CT scan of the neck and chest with intravenous contrast showed the presence of a speculated nodule in the right upper lobe, a large right neck mass, evidence of venous collaterals and soft tissue edema, and extensive upper mediastinal lymphadenopathy significantly narrowing the SVC (Figure 2). Surgical incisional biopsy of a chest wall mass was performed. Histology and immunohistochemistry studies (Figure 2) along with the clinical and radiographic findings confirmed the diagnosis of malignant SVCS secondary to stage IV (T4 N3 M1) poorly differentiated adenocarcinoma of lung origin. Imaging of the brain revealed no evidence of metastases. The patient was hemodynamically stable and with no significant cardiorespiratory compromise. Combined palliative treatment with radiation and chemotherapy was elected. Two years later, the patient continues to maintain good functional capacity. DISCUSSION: This is a case of malignant SVCS presenting uncommonly as syncope. Proper diagnosis, grading, and staging of malignant SVCS are key to its management. Worrisome signs like laryngeal or cerebral edema might warrant an emergent placement of an endovascular stent. Our patient’s SVCS was secondary to stage IV lung adenocarcinoma and was severe based on proposed grading system by Yu et al. Patient has responded well to palliative radiation and chemotherapy. CONCLUSIONS: Accurate diagnosis and staging of SVCS are necessary and help determine the modality and goal of therapy. Reference #1: Wilson, L. D. (2007, 05). Superior Vena Cava Syndrome with Malignant Causes. NEJM, 356(18), 1862-1869. Reference #2: Yu, J. B. (2008, 08). Superior Vena Cava Syndrome—A Proposed Classification System and Algorithm for Management. Journal of Thoracic Oncology, 3(8), 811-814. DISCLOSURE: The following authors have nothing to disclose: Mahrous Abo Hassan, Yahya Kurdi, Xiaoyi Yu, Eric Speakman, Rupesh Raina, Harish Kakarala, Osei-Tutu Owusu No Product/Research Disclosure Information