Swelling Upon Waking: Is It SVC Syndrome?

If you spend enough time in oncology, you find certain patients will touch you and stay with you forever. I always hope I have had an equally positive effect on them during our time together.

One young woman reminds me of this. She was a new patient to our clinic. I was told by some of our staff that she sometimes had some "moments." I wasn't sure what that meant -- I usually keep an open mind and heart and make my own conclusions later.

I cared for this 46-year-old woman on several occasions. And I learned not only that she had a new diagnosis of non-small cell lung cancer, but also that she had family issues that seemed to have been there for a while. This caused some anxiety for this patient, and it must have explained some of the "moments" she had with our ancillary staff. I never saw any of these moments. She and I had a genuine connection, and I could tell she did not have many people in her life who genuinely listened to her.

On one follow-up appointment, she brought her sister with her. Usually, she came alone. That morning, she got out of the shower and noticed her right eye drooping (ptosis). The right side of her face was slightly swollen. She did not have any pain, but she did have some increased fatigue and intermittent dizziness. Her cough also seemed to be worse. Her physical exam revealed tachycardia, anisocoria, and bilateral neck swelling. She had a mediport in place on the left side of her chest. I suspected superior vena cava (SVC) syndrome, and I quickly collaborated with one of our physicians. The physician, who also suspected Horner syndrome (nerve involvement), agreed with ordering a CT of the head, neck, and chest.

SVC syndrome is something that is seen in 75 to 85 percent of people with malignancies. It is most commonly seen with:

• Lung cancer patients (80 percent), especially those with small cell lung cancer
• Lymphoma patients (with mediastinum involvement)
• Patients with central venous catheters (mediports) or pacemakers
• Patients who have had previous radiation treatment to the mediastinum area.

SVC is caused usually by a tumor, thrombus, or enlarged lymph node that compresses or obstructs the superior vena cava, which is responsible for the vital venous drainage of the head, neck, and upper extremities. An abnormality, such as SVC syndrome, will result in increased venous pressure to the affected area(s) and/or decreased cardiac output. This is considered a structural emergency in oncology.

Early signs and symptoms of SVC include facial swelling upon rising, dyspnea, neck and thoracic vein distention, redness and edema in conjunctivae, nonproductive cough, hoarseness, and the "stoke sign" that is signified by the swelling of the neck, arms, and hands. This young woman was exhibiting some of these.

Late signs and symptoms include irritability, tachycardia, severe headache, dizziness, syncope, Horner syndrome, changes in mental status, decreased blood pressure, visual disturbances, blurred vision, stridor, and/or congestive heart failure. She also exhibited some of these signs.

Fortunately, her CT scans showed nothing new and ruled out SVC syndrome. However, her scans did find a mass on the right internal jugular vein and progression of her disease due to this mass increasing in size since her last scans and since starting chemotherapy.

It was the holiday season when I saw this patient next. I admitted her to the hospital for disseminated shingles. Her sister was with her on that visit, too, and I suspected they had mended the previous strain in their relationship. The day after I admitted this patient, her sister stopped by the clinic to see me. She confirmed that the family had mended, and she told me that the patient had decided to initiate hospice care. Her family was in agreement, and I was grateful they were there for her.

Her sister came by to thank me for all the time, care, and compassion I showed with her sister. I was touched, because I knew this was such a difficult time for the patient and her newly healed family. Next to a holiday tree in my office, I had a small statue of a bear that I had just brought into my office that day. I asked the sister if she would give this knickknack to the patient to let her know I was thinking of her. The sister grabbed me hard with a hug and started crying into my shoulder. Thinking about it brings me to tears today. Her sister passed about two weeks later.