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Case history

image A 71-year-old man presented to A&E with rapidly increasing shortness of breath. He had a 3 month history of a cough with haemoptysis. He had noticed some overall weight loss and felt that his face and neck were becoming swollen. His medical history included chronic obstructive pulmonary disease and hypertension. He lived alone and independently.

On examination he was noted to have distended veins to his neck and chest and a swollen face. A chest X-ray was performed that showed a right upper lobe opacity. Clinical suspicion was of superior vena cava obstruction (SVCO) secondary to malignancy.

How might SVCO present?

What underlying causes should be considered in a differential diagnosis of SVCO?

How should this patient be managed?

What are the potential complications of SVCO?

Who would be involved in this patient’s care?

How might SVCO present?

The superior vena cava is the second largest vein in the body. It is formed by the right and left brachiocephalic veins – draining the head, neck and upper limbs – and is joined by the azygous vein – draining the thorax – before it enters the right atrium at the level of the hilum. SVCO occurs when the vessel is occluded by extrinsic compression or luminal obstruction within the vessel, e.g. due to tumour invasion or thrombus, impairing venous return from the upper body to the right atrium, leading to congestion. Although considered an oncological emergency, symptoms of SVCO depend on the speed of onset and location of the obstruction. If patients have a slow-growing obstruction, symptoms may be minimal, as venous return from the upper body can be maintained through the collateral azygous vein, internal mammary vein, epigastric and thoracic veins. Symptoms are generally worse if the obstruction is below the level of the azygous vein, as this is the most efficient collateral system.

SVCO can usually be diagnosed clinically on the basis of characteristic symptoms (Table 25.1). These classically include swelling of the face, neck and upper limbs, distended neck veins and shortness of breath. Symptoms may be exacerbated on coughing, bending or lying down, owing to an increase in venous pressure, and may be exaggerated by lifting both arms above the head.

Table 25.1Signs and symptoms of SVCO.

What underlying causes should be considered in a differential diagnosis of SVCO?

The aetiology of SVCO may be malignant or benign (Figure 25.1). Prior to the introduction of antibiotics, tuberculosis and syphilitic aortic aneurysm were the most frequent cause. Today, malignancy is behind most cases of SVCO, with lung cancer ...

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