THINK OUTSIDE THE BOX

Abstract

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: In the world of oncology, superior vena cava (SVC) syndrome and cardiac tamponade occurring together are infrequent. Although it's rare, clinicians should be looking for all life-threatening oncological emergencies and manage them emergently. CASE PRESENTATION: A 62-year-old male with recently diagnosed metastatic small cell lung cancer complicated with SVC syndrome treated with four cycles of cisplatin and etoposide with good response presented with acute dyspnea. He was hemodynamically stable but tachypneic and maintaining good oxygen saturations. A computerized tomography (CT) scan of the chest showed an increase in the size of the right lung mass compressing SVC, right main pulmonary artery, and proximal right upper lobe bronchus along with severe pericardial effusion. An emergent echocardiogram revealed tamponade physiology. He underwent emergent pericardiocentesis and drained 470 cc of fluid which was positive for malignant cells. He was scheduled for radiation and second-line chemotherapy but developed pneumonia and septic shock. The family opted for comfort care and he expired soon thereafter. DISCUSSION: Malignancy related pericardial effusions are due to secondary metastases to the pericardium, direct invasion of the pericardium, previous radiation or concurrent infection. Diagnosis is by echocardiogram as the clinical picture is not classical most of the time [1]. Irrespective of the mechanism, emergent pericardiocentesis should be performed. Pericardial drain placement, systemic chemotherapy, and radiation can be tried to prevent reaccumulation [2]. External compression of SVC leading to SVC syndrome can be suspected clinically but CT scan with contrast confirms it. Emergent treatment with an endovascular stent is indicated for hemodynamic instability, airway compromise, and elevated intracranial pressure. Radiation therapy is effective but symptom relief is delayed [3]. CONCLUSIONS: This case alerts fellow physicians regarding two major oncological emergencies where accurate diagnosis and urgent intervention is mandated. Also, in the absence of a clinical suspicion identification of one can lead to an overlooked diagnosis of the other. It is always a good approach to keep the differentials broad and failure to recognize and treat either of the two may result in a grave outcome. Reference #1: Asif S, Mahmood M, Pauly RR. Concurrent Cardiac Tamponade and Superior Vena Cava Syndrome: A Concerning Situation. Cureus. 2019 Mar;11(3). Reference #2: Soler-Soler J, Sagristà-Sauleda J, Permanyer-Miralda G. Management of pericardial effusion. Heart. 2001 Aug 1;86(2):235-40. Reference #3: Halfdanarson TR, Hogan WJ, Madsen BE. Emergencies in hematology and oncology. InMayo Clinic Proceedings 2017 Apr 1 (Vol. 92, No. 4, pp. 609-641). Elsevier. DISCLOSURES: No relevant relationships by Ammar Ali Ashfaq, source=Web Response No relevant relationships by Neelima Manda, source=Web Response No relevant relationships by Nishanth Thalambedu, source=Web Response