SQUAMOUS CELL CARCINOMA PRESENTING WITH OBSTRUCTION OF THE SUPERIOR VENA CAVA AND CENTRAL AIRWAYS

Abstract

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: One mechanism by which cancer causes morbidity/mortality is by mass effect with distortion, compression, or occlusion of nearby anatomical structures. Within the chest, tumors can exert these effects on the airways and vascular structures. This case illustrates the need for urgent intervention in a patient presenting with severe compression of multiple intrathoracic structures. CASE PRESENTATION: A 54 year-old man with chronic tobacco use and limited exposure to healthcare presented to the hospital with gradually progressive shortness of breath over several months, followed by facial swelling, severe wheezing, and recurrent syncope over the past few days. Exam was remarkable for facial flushing and diffuse inspiratory/expiratory wheezing. Laryngoscopy was performed, which did not suggest critical airway edema. Computed tomography (CT) of the chest demonstrated a large right-sided suprahilar mass, with severe compression of the superior vena cava (SVC) and right mainstem bronchus (RMB) and bronchus intermedius, narrowing of the right pulmonary artery and vein, and complete collapse of the right upper lobe. The patient underwent urgent placement of an 11x59mm balloon-expandable covered stent within the SVC, after which the patient reported improvement in facial swelling but minimal improvement in dyspnea. Next, he underwent bronchoscopy, which demonstrated significant extrinsic compression within the right mainstem bronchus; transbronchial needle aspirates of lymph nodes from Stations 4R and 7 were obtained, from which pathology results were consistent with squamous cell carcinoma (SCC). Because of the degree of bronchial compression, and the need for chemotherapy and radiation therapy which could temporarily cause tumoral inflammation and worsen compression/collapse of the right lung, bronchoscopy was repeated, and this time a 12x40mm self-expandable partially-covered stent was placed within the right mainstem bronchus. After this, the patient reported significant improvement in dyspnea, and was discharged to home in stable condition. DISCUSSION: This case describes pulmonary SCC presenting with symptoms of acute SVC syndrome and central airway compression. Lung cancer associated with either of these conditions has dramatically increased morbidity/mortality. In malignant SVC syndrome, stent placement has been shown to reduce SVC pressure and improve symptoms; there is moderate risk of stent re-obstruction. Though not free of risks, endobronchial stent placement can prevent the impending occlusion of a central airway, when surgical or endobronchial resection/debulking is not possible. In recent years, there have been numerous advances in the technology and variety of endobronchial stents for multiple indications. CONCLUSIONS: Malignant extrinsic compression of the SVC and central airways is associated with high morbidity/mortality and can be managed urgently and safely with stent placement. Reference #1: Avasarala SK, Freitag L, & Mehta AC. Metallic endobronchial stents: A contemporary resurrection [published online ahead of print December 11, 2018]. CHEST. doi:10.101/j.chest.2018.12.001. Reference #2: Niu S, Xu YS, Cheng L, & Cao C. Stent insertion for malignant superior vena cava syndrome: Effectiveness and long-term survival. Vascular and Interventional Radiology 2017, 122: 633-638. Reference #3: Mudambi L, Miller R, & Eapen GA. Malignant central airway obstruction. Journal of Thoracic Disease 2017, 9(10): 1087-1110. DISCLOSURES: No relevant relationships by Gabriel Ryan, source=Web Response