Critical Care Medicine-Hematologic and Oncologic Disorders>>>>>Oncological Syndromes
Question 2#

A 65-year-old man with a diagnosis of small-cell lung cancer presents to the emergency with complaints of hoarseness, shortness of breath, and swelling of his face and right arm. His vital signs are:

On examination, he is stridorous and unable to speak in full sentences. ECG is notable for sinus tachycardia and a chest x-ray reveals widened mediastinum.

What is the most appropriate next step in management?

A. Endotracheal intubation
B. Catheter-based venography
C. CT venography
D. Radiation therapy

Correct Answer is A

Comment:

Correct Answer: A

The patient has superior vena cava syndrome (SVCS) from malignancy with life-threatening symptoms (eg, stridor, respiratory distress) and require immediate stabilization (endotracheal intubation to secure the airway, circulatory support), followed by definitive intervention (endovenous recanalization, mechanical thrombectomy, SVC filter placement).

Radiation therapy is no longer recommended as the first-line treatment. SVCS occurs in response to mechanical obstruction of the SVC due to external compression, tumor invasion into the vessel, or internal obstruction. Malignancy is the most common cause of SVCS, with lung cancer and non-Hodgkin lymphoma as the most common types of associated malignancy. Dyspnea is the most common presenting symptom. Other symptoms may include facial, neck, and arm swelling, hoarseness, stridor, chest pain, and dysphagia. Physical examination findings in patients with SVCS include facial, neck, and arm edema, engorged neck veins, stridor, and in severe cases, obtundation due to increased intracranial pressure and brain swelling.

Chest radiography and ECG provide nonspecific information in patients with SVCS. Chest radiograph may show widened mediastinum and ECG commonly shows sinus tachycardia. CT venography provides information about the location and extent of the obstruction, and catheter-mediated thrombolysis can be performed concurrently with the imaging.

References:

  1. Zimmerman S, Davis M. Rapid fire: superior vena cava syndrome. Emerg Med Clin North Am. 2018;36:577-584.
  2. Breault S, Doenz F, Jouannic AM, Qanadli SD. Percutaneous endovascular management of chronic superior vena cava syndrome of benign causes: long term follow-up. Eur Radiol. 2017;1:97-104.
  3. McCurdy MT, Shanholtz CB. Oncologic emergencies. Crit Care Med. 2012;40:2212-2222.