Endgames Spot Diagnosis

A patient with head and neck swelling

BMJ 2016; 355 doi: http://dx.doi.org/10.1136/bmj.i5733 (Published 16 November 2016) Cite this as: BMJ 2016;355:i5733
  1. Sarah Hancox, foundation year 2 doctor1,
  2. David Howlett, consultant radiologist1
  1. 1East Sussex Healthcare Trust, Eastbourne District General Hospital, Eastbourne, UK
  1. Correspondence to: S Hancox sarahhancox{at}nhs.net

A 50 year old man presented to the emergency department with swelling and venous engorgement of his face, arms, and upper chest. He also had increasing shortness of breath. Chest radiography showed mediastinal widening. What does the computed tomography (CT) scan show (fig 1)?

Figure1

Fig 1 Axial view of a computed tomogram of the chest with contrast

Answer

The CT scan shows a tracheal tumour causing azygous vein compression, superior vena cava obstruction, and bilateral pleural effusions (fig 2).

Figure2

Fig 2 Bilateral pleural effusions and tumour surrounding the trachea (T), compressing the azygous vein (A), and obstructing the superior vena cava. Additional contrast is visible in the chest wall collateral vessels (C)

Discussion

The CT scan confirms bilateral pleural effusions and a tumour surrounding and infiltrating the trachea (T). The tumour compresses the azygous vein (A) and directly invades the superior vena cava (S), which is thrombosed, causing superior vena cava obstruction syndrome. Additional contrast is visible in the chest wall collateral vessels (C), which is a non-specific ancillary sign. Biopsy confirmed a poorly differentiated adenocarcinoma originating in the lung. Immediate management for superior vena cava obstruction is consideration of steroids and urgent referral to the local acute oncology service.

Footnotes

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following: none.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • No consent as patient is deceased with no next of kin.

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