A 64-year-old man complains of cough, increasing shortness of breath, and headache for the past 3 weeks. He has mild hypertension for which he takes hydrochlorothiazide; he has smoked 1 pack of cigarettes a day for 40 years. On examination you notice facial plethora and jugular venous distension to the angle of the jaw. He has prominent veins over the anterior chest and a firm to hard right supraclavicular lymph node. Cardiac examination is normal and lungs are without rales. Peripheral edema is absent.
What is the most likely cause of his condition?A. Long-standing hypertension
This patient presents with the superior vena cava (SVC) syndrome. Such patients have jugular venous distension but no other signs of right-sided heart failure. They have prominent facial (especially periorbital) puffiness and may complain of headache, dizziness, or lethargy. SVC syndrome is caused by a malignant tumor 90% of the time. Lung cancer and lymphoma, both of which are often associated with bulky mediastinal lymphadenopathy, predominate. Gastric cancer often metastasizes to the supraclavicular nodes (most often on the left, the so-called Virchow node) but does not usually affect the mediastinal nodes to this degree. Prompt diagnosis is necessary to prevent CNS complications or laryngeal edema. Sensitive tumors (lymphoma, small cell lung cancer) may be treated with chemotherapy, while most other cell types are treated with radiation therapy. Hypertension, emphysema, and nephrotic syndrome do not cause SVC syndrome.