A woman 66 years of age was admitted to the hospital for shortness of breath with activity. She thought she had pneumonia, so she went to see her primary care physician. Turns out she was right.
They performed a chest x-ray and confirmed she did have pneumonia. However, they redirected her to the hospital that same day due to the other things seen on her x-ray.
She arrived at the hospital and a CT of the chest was performed. A large mass was noted in the upper right lobe of her lung that was compressing her superior vena cava and also demonstrated mediastinal lymphadenopathy that were varied, multiple and scattered. The CT scan also stated her pulmonary veins were being compressed by all the masses and enlarged lymph nodes in her chest.
I didn't know all of this when I arrived to the unit; all I knew is that we, in oncology, were consulted for a "lung mass." But when I looked at the CT report and obtained the history and physical from this woman it became very clear to me she was on the brink of a crisis. My physical examination confirmed my suspicions. She was experiencing superior vena cava (SVC) syndrome.
The patient reported shortness of breath and cough for the past month. She had suffered swelling in her head and neck for the past week as well as a change in her voice -- she was hoarse all the time now. Her upper arms were swollen and her breasts were engorged, her skin on her breasts was red in color and she was experiencing continual clear, nipple discharge that crusted around her nipples. When I examined her I also noticed a line of bruises right where her bra was. She had 3+ non-pitting edema from the mid-torso and up as well as visible collateral veins on the right upper part of her anterior chest. Fortunately, she had no headache or signs of a stroke… yet.
It is also important to note that she did divulge a 50-pack-a-year history of smoking but quit the day she was admitted to the hospital.
I reviewed her pathology from her biopsy and there it was: small cell lung cancer. Fortunately, she was stable (her vital signs were normal) but she was very uncomfortable due to the edema.
After visiting with her, I called our oncologist. He wanted to start chemotherapy right away that day in the form of carboplatin and etoposide. Something needed to be done quickly before this woman had a true oncologic crisis.
I will be curious to see how she looks and feels when I return to the hospital. She is someone I will never forget due to her classic presentation and symptoms of SVC syndrome. Most of the other cases I have seen had been much more subtle.
Have you seen such an extreme presentation of SVC syndrome? If so, was it similar or different than how this woman presented?