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Grand Rounds - Hammersmith Hospital: New approach to superior vena caval obstruction Mechanical clearance of thrombus may help

BMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6945.1697 (Published 25 June 1994) Cite this as: BMJ 1994;308:1697
  1. L Robinson,
  2. J Jackson
  1. Hammersmith Hospital, London W12 0NN.**

    Superior vena caval obstruction is a well recognised complication of bronchogenic carcinoma, with distressing clinical sequelae secondary to oedema of the soft tissues, larynx, and central nervous system. Conventionally it has been treated with radiotherapy and adjuvant chemotherapy or surgery with varying degrees of success.

    Case history

    A 56 year old white woman presented with a 10 week history of progressive oedema of the face and upper limbs followed by a one week history of worsening dyspnoea and dry cough. She denied any other symptoms. In her history she was noted to have mild asthma controlled by inhaled bronchodilators but she was otherwise well. She had smoked 20 cigarettes a day for about 40 years and had a red florid complexion with severe oedema of the face, chest wall, and upper limbs. The jugular veins were non-pulsatile and greatly distended. She was tachypnoeic at rest with a respiratory rate of 30/min, a monophonic wheeze in the right upper zone, and bilaterial pleural effusions. Neurological examination confirmed a right Horner's syndrome. Cardiovascular and abdominal examinations showed no abnormality.

    Chest radiography showed a coin lesion in the right upper lobe with associated hilar and mediastinal lymphadenopathy and small bilateral pleural effusions; this was confirmed by computed tomography of the thorax. Pleural aspiration and biopsy, bronchoscopy, and anterior mediastinotomy did not give a diagnosis but confirmed the presence of a hard thrombosed superior vena cava with dilated venous collaterals. Cytological investigation of sputum confirmed the diagnosis of squamous cell carcinoma of the bronchus.

    The tumour was inoperable, so to relieve the obstruction and palliate her symptoms, she had radiotherapy at a dose of 20 Gy in five fractions over five days with concurrent oral dexamethasone. Unfortunately, her oedema seemed to get worse. Venography showed numerous opacified collateral veins around both shoulders and the chest wall …

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