Oncology & Palliative Care
A 57 year old man presents to the Emergency Department with exertional dyspnoea, facial swelling and a cough. His past medical history is unremarkable except for many years of heavy smoking. On examination you find conjunctival injection, jugular venous distention and facial plethora. What is the most likely diagnosis?
Answer:
Obstruction of the superior vena cava (SVC) can be due to external pressure, involvement of the vessel by tumour tissue, or a blood clot obstructing the lumen. The most common cause is superior mediastinal pressure associated with lung cancer (over 85%). Symptoms can include dyspnoea, cough, neck and face swelling, arm swelling, dizziness, headache, disturbed vision, nausea, nasal stuffiness, stupor and syncope. Symptoms tend to be aggravated by postures which increase the venous pressure in the upper part of the body, such as bending over or lying down. Signs may include dilated veins over the arms, neck and anterior chest wall; oedema of the upper body, extremities and face; severe respiratory distress; cyanosis and engorged conjunctiva. Signs may become more pronounced when the arms are lifted above the head.Lung Malignancy
Oncology & Palliative Care / Respiratory
Last Updated: 6th September 2022
Risk factors
Risk factors for lung cancer:
- Smoking
- Asbestos exposure and other industrial lung disease
- Increasing age
- History of malignancy
- History of radiation
Clinical features
- Cough
- Shortness of breath
- Haemoptysis
- Persistent chest and/or shoulder pain
- Weight loss
- Anorexia
- Malaise
- Persistent/recurrent chest infection
- Finger clubbing
- Cervical or supraclavicular lymphadenopathy
- Thrombocytosis
Pancoast tumour
Pancoast tumour refers to a relatively uncommon situation where a primary lung cancer arises in the lung apex and invades the surrounding soft tissues. Most Pancoast tumours are non small cell cancers and most commonly squamous cell cancer. Pancoast tumors may lead to several other syndromes caused by the compression of surrounding anatomical structures.
- Horner’s syndrome (compression of the paravertebral sympathetic chain and the inferior cervical ganglion)
- Miosis
- Anhidrosis
- Ptosis
- Enophthalmos
- Superior vena cava syndrome (compression of the SVC)
- Dyspnoea
- Cough
- Headache
- Dizziness/syncope
- Disturbed vision
- Neck, face and arm swelling
- Venous distention over arms, neck and anterior chest wall
- Cyanosis
- Engorged conjunctiva
- Positive Pemberton sign
- Thoracic outlet syndrome (compression of the neurovascular bundle of the upper limb)
- Upper extremity swelling
- Diffuse arm or hand pain and paraesthesia
- Ulceration or venous or arterial gangrene
- Recurrent laryngeal nerve involvement
- Hoarse voice
- Bovine cough
- Brachial plexus involvement
- Severe pain in the shoulder or scapula
- Pain and weakness in muscles of the shoulder, arm and hand
- Phrenic nerve involvement
- Hemidiaphragm paralysis
Investigations
Most lung cancers can be identified on a plain chest X-ray, though false-negatives may occur. Other imaging techniques, especially CT, may be used, though these are generally performed following an indeterminate chest X-ray, or when the person has continuing symptoms and a normal chest X-ray. Definitive diagnosis requires biopsy, usually guided by CT or via bronchoscopy. Sputum cytology is only used in those unable to have biopsy.
Management
Patients with suspected malignancy should be referred urgently to a respiratory specialist.
Report A Problem
Is there something wrong with this question? Let us know and we’ll fix it as soon as possible.
Loading Form...
- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
