A 50-year-old woman presenting with a three-month history of worsening shortness of breath, with associated cough, intermittent haemoptysis and weight loss. Computed tomography (CT) of the chest/abdomen shows a 10 × 8.5 cm superior mediastinal mass encasing local blood vessels and right main bronchus, extending to the right hilum, with a separate smaller right upper lobe nodule. Supraclavicular lymph node was palpable. Fine needle aspiration of the neck node shows small cell carcinoma. The patient re-presented as an emergency with worsening shortness of breath and neck swelling shortly after the scan and biopsy.
What are signs and symptoms of superior vena cava obstruction (SVCO)?
What is the differential diagnosis of SVCO?
What investigations would you perform in SVCO?
How would you manage SVCO?
The superior vena cava (SVC) is formed from the joining of the brachiocephalic veins, and drains the upper part of the body. It is a short vein found in the upper part of the mediastinum and enters the right atrium at the level of the right hilum. A left SVC occurs in 0.3% of the population and drains into the coronary sinus. The azygos vein also joins the SVC before it enters the right atrium.
Superior vena cava obstruction (SVCO) is the complete or partial blockage of blood flow through the SVC through to the right atrium. Venous return from the head, neck and arms is thus impaired.
What are the signs and symptoms of SVCO?
Often considered an oncological emergency, SVCO is rarely immediately life-threatening, unless there has been a sudden blockage.1 Onset can be insidious and collaterals (from the azygos vein) are formed. At the early stages there may be few signs or symptoms. Most commonly, the diagnosis is made on the clinical symptoms of facial/neck swelling and the finding of collaterals over the upper chest. Symptoms of SVCO are generally worse when the obstruction is below the entry of the azygos vein.
Table 32.1Signs and symptoms of superior vena cava obstruction (SVCO) |Favorite Table|Download (.pdf) Table 32.1 Signs and symptoms of superior vena cava obstruction (SVCO)
|Symptoms ||Signs |
|Breathlessness ||Stridor |
|Hoarseness ||Facial/neck/arm(s) swelling |
|Headaches, especially with bending or coughing ||Distended neck and chest veins |
|Visual disturbance - blurred vision ||Plethoric complexion |
|Dizziness ||Pemberton's sign |
|Facial/arm swelling ||Conjunctival congestion |
|Tiredness ||Confusion |
The SVC can be compressed from an extrinsic source, or be blocked by thrombus from within the vein (Table 32.2).
Table 32.2Sources of compression of superior vena cava |Favorite Table|Download (.pdf) Table 32.2 Sources of compression of superior vena cava
| ||Malignant causes ||Benign causes |
| || |
|Extrinsic compression |