Question of the Week # 338

338) A 65 year old man presents to the Emergency Room with complaints of  swelling of his face and worsening cough for the past two days. Swelling increases on lying down. He has no significant past medical problems.  He smoked about 1 pack per day for the past 45 years and consumes alcohol socially. On examination, his vitals are satble with a blood pressure of 130/80 mm Hg. His face is grossly swollen and the veins over the neck, anterior chest  and the face are engorged. There is no stridor. There is no laryngeal edema. Chest is clear to auscultation bilaterally. Cardiovascular examination shows normal s1 and s2 and there is no s3 gallop . A chest X-ray is shown below:

 

Which of the following is the most appropriate next step in management?

A) Radiation Therapy

B) Chemotherapy

C) CT guided Per-cutaneous Needle Biopsy

D) Video-Assisted Thoracoscopic Surgery (VATS)

E) Endotracheal Intubation

12 Responses

  1. C

  2. C) CT guided Per-cutaneous Needle Biopsy

  3. This patient has SVC syndrome most likely secondary to a Pancoast tumor. RT (option A ) alleviates the symptomatology, which would be the next step in mgmnt.

  4. c

  5. c) CT guided percutaneous needle biopsy.treatment would be given after nature of tumor determined.

  6. A this is a tumer must be central to compreed Vena Cava so we need to allivate the symptoms first by giving the radiation it is for symptom reilief not as a treatment . percutanous guid usually for peripheral tumers that un likely cause cental or mediastinal compreesion. After reliving the symptom which is the main complaint then we can fugure out the nature of the tumer for further treatment

  7. A is the answer ,this is a tumor that must be central to compressVena Cava so we need to allivate the symptoms first by giving the radiation it is for symptom reilief not as a treatment . percutanous guid usually for peripheral tumors that unlikely cause cental or mediastinal compression. After releiving the symptom which is the main complaint then we can figure out the nature of the tumer for further treatment

  8. i would agree w/ sara ,this mass in the upper lung zone should be dx first ,then do treament.

  9. http://emedicine.medscape.com/article/460865-overview

    •A CT scan of the chest is the initial test of choice to determine whether an obstruction is due to external compression or due to thrombosis.

    Most patients with superior vena cava syndrome (SVCS) present before the primary diagnosis is established.

    Controversy often arises in the treatment of a patient with superior vena cava syndrome (SVCS) in regard to the need for pathologic confirmation of malignancy before the start of therapy.

    Treatment without an established diagnosis should be initiated only in patients with rapidly progressive symptoms or those in whom multiple attempts to obtain a tissue diagnosis have been unsuccessful


    Patients with clinical superior vena cava syndrome (SVCS) often gain significant symptomatic improvement from conservative treatment measures, including elevation of the head of the bed and supplemental oxygen.[23]


    Emergency treatment is indicated when brain edema, decreased cardiac output, or upper airway edema is present. Corticosteroids and diuretics are often used to relieve laryngeal or cerebral edema, although documentation of their efficacy is questionable.


    Radiotherapy has been advocated as a standard treatment for most patients with superior vena cava syndrome (SVCS). It is used as the initial treatment if a histologic diagnosis cannot be established and the clinical status of the patient is deteriorating; however, recent reviews suggest that superior vena cava syndrome (SVCS) obstruction alone rarely represents an absolute emergency that requires treatment without a specific diagnosis.[3, 25] ◦The fractionation schedule of radiation usually includes 2-4 large initial fractions of 300-400 cGy, followed by conventional fractionation of 150-200 cGy daily, to a total dose of 3000-5000 cGy. The radiation dose depends on tumor size and radioresponsiveness. The radiation portal should include a 2-cm margin around the tumor.
    ◦During irradiation, patients improve clinically before objective signs of tumor shrinkage are evident on chest radiography. Radiation therapy palliates superior vena cava (SVC) obstruction in 70% of patients with lung carcinoma and in more than 95% with lymphoma.


    In patients with superior vena cava syndrome (SVCS) secondary to non–small-cell carcinoma of the lung, radiotherapy is the primary treatment. The likelihood of patients benefiting from such therapy is high, but the overall prognosis of these patients is poor.[26]


    Chemotherapy may be preferable to radiation for patients with chemosensitive tumors.[26]

    • Perfect explanation!

  10. what i understand now from the previous article that according to this patient presentation and stable vitals no need to rush for managment we can start with knowing the nature of the disease so we need to get the biopsy first

  11. cc: ct guided bx

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