Endgames Picture Quiz

An odd cause of dysphagia

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d737 (Published 11 May 2011) Cite this as: BMJ 2011;342:d737
  1. Byron Temba Theron, specialist registrar in gastroenterology,
  2. Laura Pearson, foundation year 1 in medicine,
  3. John Gillson, staff grade in haematology
  1. 1Sandwell and Birmingham NHS Trust, West Bromwich B74 4HJ, UK
  1. Correspondence to: B T Theron byrontheron{at}nhs.net

A 39 year old woman presented to the medical admissions unit with a four week history of worsening shortness of breath associated with a dry cough, plus a two week history of a pressure sensation in her neck with difficulty swallowing solids. She reported weight loss of around 3 kg and an aching sensation in both arms, although she denied any weakness or numbness. The patient was otherwise well, did not smoke, and had no relevant medical history. Her examination was unremarkable. Chest radiography was undertaken (fig 1).

Fig 1 Chest radiograph

On the basis of the chest radiograph, further investigations were requested, including computed tomography of the neck, thorax, abdomen, and pelvis (fig 2).

Fig 2 Computed tomogram of the chest

Questions

  • 1 How would you describe the chest radiography and computed tomography findings?

  • 2 What are the main differential diagnoses?

  • 3 How would you investigate this patient?

  • 4 What are the treatment options?

Answers

1 How would you describe the chest radiography and computed tomography findings?

The chest radiograph shows dramatic paratracheal and mediastinal widening. The computed tomogram of the chest shows a large superior mediastinal mass with superior vena cava obstruction and a pericardial effusion.

Long answer

Symptoms of superior vena cava obstruction can be non-specific but may signify life threatening disease. Most cases are caused by intrathoracic malignancy,1 2 3 with lung cancer (75%) and non-Hodgkin’s lymphoma (10%) constituting the bulk of cases. The incidence of vascular thrombosis has increased since the emergence of intravascular devices such as pacemakers and indwelling catheters used in haemodialysis.2 However, among oncology patients, thrombosis secondary to indwelling lines is most often caused by central catheters (portacath or Hickman line). Given the most common underlying aetiology (lung cancer), most patients with superior vena cava obstruction have an abnormal chest radiograph, with mediastinal widening and pleural effusions being the most common findings. …

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