Thread by @nihardesai7

You are a young #medicine resident in a busy emergency when a 26/♂️ walks in with 👇🏻

C/o cough and respiratory distress + facial swelling x 7days. He is unable to sleep as the symptoms ⤴️ on lying down 😮

What do you do next?

You read this thread👇🏻

#medtwitter

1/18

You immediately know what's going on, you ask for an urgent chest imaging. Only a chest Xray is available and shows 👇🏻

Damnnnnn 😮😮😮

What's that ??

#MedTwitter

2/18

That is a massive mass in the neck and the mediastinum, also B/L CP angles are blunted 😮😮

This looks like a malignancy l/t superior vena cava (SVC) syndrome!

This is a medical emergency and you must know what next to do before the oncologist gets there!

#MedTwitter

3/18

This image explains what exactly happens in SVC syndrome !

Tumour ➡️ compresses the SVC ➡️ obstructed blood flow ➡️ SVC obstruction ➡️ reduced venous return ➡️ symptoms of SVC syndrome !

Can anything other than a tumour l/t SVC syndrome??

Continue reading 👇🏻

#medtwitter

4/18

YES !!

Infact the first ever case of SVC syndrome (way back in 1757) was secondary to a syphilitic aneurysm😮

Other causes:
•Thrombus
•Central venous catheters
•Retrosternal goitre
•Aortic aneurysm
•Mediastinal fibrosis (post infections)

#medtwitter

5/18

But MALIGNANCY remains the most COMMON cause by far today (we treat infections better now)

Let's list out the malignancies that frequently cause SVC syndrome👇🏻

1. Lung cancer (SCLC/NSCLC)
2. Lymphoma (NHL > HL)
3. Thymoma
4. Germ cell tumours

#medtwitter

6/18

Our patient has all the typical features of SVC syndrome !

Facial swelling✅
Dyspnoea✅
Headache✅
Cough✅

There is a severity grading score (Kishi et al) and he has "severe" SVC synd d/t laryngeal oedema.

What he thankfully doesn't have is signs of cerebral oedema 🙏🏻

7/18

A QUICK RECAP 👇🏻

•SVC syndrome is an 🆘🚑
•P/w facial swelling, headache, cough
•Most often d/t MALIGNANCY
•Other causes - CVC/thrombus
•Urgent imaging & Rx is a must

Now let's learn how to manage it 💪🏻

#medtwitter

8/18

It's gonna be a TEAM EFFORT 💪🏼

You need the help of your intervention radiologist & radiation oncologist !!

Call them up, STAT 📞

#medtwitter

9/18

But DON'T WAIT till they arrive !

Raise the head end of the bed and start supplemental 02

Patients feel most comfortable in the upright position🙏🏻

Start some diuretics & maybe some corticosteroids (may make diagnosis difficult but can be life saving)

#medtwitter

10/18

What are the Rx options beyond the general stabilisation measures?

1. Radiotherapy
2. Chemotherapy
3. Endovascular stenting
4. High dose corticosteroids
5. Anticoagulation & thrombolysis

There are pros and cons of each of these and we must choose wisely!

#medtwitter

11/18

RT/chemotherapy/high dose steroids make it very difficult to establish the diagnosis

Stenting has an advantage, histology isn't obscured & symptom relief is quick! This is the best Rx for life threatening SVC syndrome💪🏼

Intervention radiology to the rescue🙏🏻

#medtwitter

12/18

Our patient most likely has a #lymphoma, the large neck nodes point towards it.

It is a radio & chemosensitive tumour.

I'd avoid RT/chemo/high dose steroids without getting a biopsy first, again intervention radiology can help you out 🙏🏻

#medtwitter

13/18

So we can say that the management depends on:

•Severity of SVC syndrome
•Most likely underlying disease
•Availability of intervention radiologist
•Availability of RT

#medtwitter

14/18

You suspect a lymphoma here, what would you do ?

1️⃣General supportive measures

2️⃣Try to establish a diagnosis before bombarding w/ steroids/RT

3️⃣Endovascular stenting >> RT here because the former can help with symptom relief and diagnosis won't be obscured

15/18

One may omit the stenting and immediately proceed to chemotherapy here if:

1️⃣ SVC syndrome isn't severe (i.e no laryngeal oedema/CNS symptoms)

2️⃣ Diagnosis is already established

#MedTwitter

16/18

Summary:

1️⃣Start 02 and elevate bed for all
2️⃣Call in intervention radiology and RT
3️⃣If severe SVCs, stenting >>RT
4️⃣If not severe, try to establish a tissue DX (get a biopsy)

Always remember to work as a team, communication w/ RT & intervention radiology team is a must

17/18

Thank you guys for reading this 🙏🏻

I hope you learnt something new, I did

#MedTwitter

Just one more tweet 👇🏻

Just a follow up to get you all motivated !!

This is the same guy, post successful management of his symptoms 👍🏻💪🏼

He was diagnosed w/ large B cell lymphoma (MYC, BCL2 rearranged)

This is post C1 R-CHOP 🙏🏻

#MedTwitter

End.