1. The post-intubation chest x-ray reveals deviation of the endotracheal tube leftward.
2. Given the patient’s presentation and tracheal deviation suggesting a possible mass, a chest CT with IV contrast was performed.
3. This CT reveals a large right sided mass and the diagnosis of SVC (superior vena cava) syndrome.
SVC syndrome is caused by either invasion or external compression of the SVC by a contiguous pathologic process: mass, lymph nodes, other mediastinal structures or thrombosis. The most common cause is malignancy: #1 Lung Cancer and #2 Lymphoma – together they represent 94% of cases. The most common presenting symptom is shortness of breath. Symptom onset depends on the speed of SVC obstruction onset. Malignant disease can arise in weeks to months.
This image reveals a patient who presented with progressively enlarging veins over the anterior chest wall. A diagnosis of right-sided superior sulcus (Pancoast) tumor compressing the SVC was made.
Patients may present with venous distention of the neck or chest wall, cough, arm swelling or cyanosis as well as facial swelling or “head fullness” – exacerbated by bending forward or lying down. Pemberton’s sign is the development of most of these symptoms when the arms are raised above the head.
Timely identification of the cause is essential. Radiographic studies are useful – with the most common findings being a widened mediastinum or pleural effusion. Chest CT with IV contrast is the preferred study. Up to 60% of patients with SVC syndrome related to neoplasm do not have a known diagnosis of cancer. Current strategies aim at accurate diagnosis of underlying etiology before therapy. Treatments include radiation, chemotherapy and intraluminal stents.
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