A CONFOUNDING CASE OF SUPERIOR VENA CAVA SYNDROME

Abstract

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Superior Vena Cava Syndrome (SVCS) results from obstruction of blood flow through the superior vena cava (SVC). It can either be due to malignant obstruction caused by direct invasion of tumor into the SVC, or by external compression of the SVC by thoracic or mediastinal structures. Face or neck swelling is one of the commonest findings in SVCS and might be mistaken for an allergic reaction.Here, we present a case of a patient who presented with SVCS due to malignancy which was initially misdiagnosed as angioedema. CASE PRESENTATION: A 72-year-old Caucasian female with a medical history of hyperlipidemia presented to the emergency department (ED) with facial & neck swelling and dyspnea for 6 weeks. The swelling was more prominent in the morning and decreased as the day progressed. Before the presentation, she went to urgent care and was treated with antibiotics for 2-3 weeks. Despite that, her symptoms persisted, and she went to an otolaryngologist, an allergist & an immunologist who treated her with antihistamines and steroids for possible angioedema. Since it was not getting better, she came to the ED. She did not report fever, night sweats, cough, weight loss, or fatigue. She had a 30 pack-year smoking and 10-year vaping history. On presentation, vitals and laboratory investigations were normal. Physical examination was significant for facial edema and erythema in the malar area. There was no swelling in the upper extremities. The chest radiograph was normal. Computed tomography revealed confluent right paratracheal lymphadenopathy measuring 3 x 4 cm in aggregate extending to the right hilum. She underwent endobronchial ultrasound with a transthoracic needle aspiration biopsy. Pathology results were diagnostic for squamous cell carcinoma (SqCC) of the lung positive for P63 and CK5/6. She underwent radiation therapy and chemotherapy with paclitaxel and carboplatin that provided relief to the symptoms. DISCUSSION: SVCS can be challenging to diagnose and can be mistaken as inflammatory, infectious, or allergic conditions (1). Our patient did not have any constitutional symptoms suggestive of malignancy. On physical examination, she had facial swelling but did not have upper extremity swelling. The absence of upper extremity swelling; one of the commonest symptoms, seen in one-third of SVCS patients (2), made the diagnosis difficult. Significant smoking and vaping history prompted us to get further imaging and biopsy which ultimately lead to diagnosis. Evidence suggests that amongst lung cancers, small cell lung cancer is most likely to cause SVCS (3), however, our patient was diagnosed with SqCC which was also unique in our case. CONCLUSIONS: SVCS can be a life-threatening condition and warrants a timely diagnosis. Our case demonstrates that suspicion for SVCS should be high in patients with a significant smoking history presenting with facial swelling unresolved with angioedema treatment. REFERENCE #1: Rochelle Tonkin, Christopher Sladden. What lies downstream? A case of superior vena cava syndrome presenting in the dermatology clinic: A case report. SAGE Open Medical Case Reports. https://doi.org/10.1177/2050313X20919618 REFERENCE #2: Armstrong BA, Perez CA, Simpson JR, Hederman MA. Role of irradiation in the management of superior vena cava syndrome. Int J Radiat Oncol Biol Phys. 1987;13(4):531-539. doi:10.1016/0360-3016(87)90068-x REFERENCE #3: Wei S, Liu J, Li X, et al. A retrospective stenting study on superior vena cava syndrome caused by lung cancer. Thorac Cancer. 2020;11(7):1835-1839. doi:10.1111/1759-7714.13461 DISCLOSURES: No relevant relationships by Ghulam Aftab, source=Web Response No relevant relationships by Sidharth Bhasin, source=Web Response No relevant relationships by Sanya Chandna, source=Web Response No relevant relationships by Monarch Shah, source=Web Response No relevant relationships by Abi Watts, source=Web Response