Review Question - QID 100839

The patient described in the question stem and pictured in the image suffers from superior vena cava syndrome, which in an older active smoker, is most likely secondary to lung cancer (bronchogenic carcinoma).

Superior vena cava syndrome (SVCS), or superior vena cava obstruction, is usually the result of the direct obstruction of the superior vena cava by malignancies such as compression of the vessel wall by right upper lobe tumors or thymoma and/or mediastinal lymphadenopathy. Presentation includes headache, dizziness, dyspnea, and distension of neck veins, plus position-dependent facial edema seen in this man. The most common malignancy that causes SVCS is bronchogenic carcinoma. Retinal hemorrhage and stroke may be complications of SVCS. A Pancoast tumor is a bronchogenic carcinoma situated in the upper lobe of the lung and can cause superior vena cava syndrome as well as the signs and symptoms typical of Horner's syndrome (ptosis, anhidrosis and miosis) via compression of the sympathetic chain.

According to Jones and Detterbeck a Pancoast tumor is an uncommon primary brochogenic carcinoma that produces upper extremity pain and Horner's syndrome. These symptoms are due to compression of the SVC and sympathetic chain respectively.

According to Rice et al. the most common cause of SVC syndrome is malignancy. They also discuss that patients with small cell lung cancer are more likely to develop SVC syndrome as compared to those with large cell lung cancer.

Figure A shows the before (left) and after (right) images of a man with SVCS. Note that the edema seen in the picture to the left resolves after he stands upright during the day, somewhat overcoming the venous obstruction.

Illustration A is a chest radiograph showing lung carcinoma obstructing the SVC and causing SVCS.

Incorrect Answers:
Answer 1: Congestive heart failure would be less likely to produce this degree of position-dependent facial edema and distended neck veins.
Answer 3: Diuretic therapy would not cause distension of neck veins.
Answer 4: Edema from a Type I hypersensitivity reaction would not be position dependent nor chronic over several weeks.
Answer 5: Subclavian steal syndrome describes atherosclerosis/obstruction of blood flow in the subclavian artery. Blood is then "stolen" from the cerebral circulation via the vertebral arteries giving patients symptoms such as syncope and dizziness particularly during exertion.