Case History
A middle-aged man with metastatic renal cell cancer presented to the palliative care outpatient department complaining of a few days of dyspnoea and wheeze. He had previously received radiotherapy to a right upper lobe metastatic deposit that had caused haemoptysis.
On examination he had apparent swelling of his face and both arms, as well as an audible inspiratory stridor. Oxygen saturations were 98% on air and there was good air entry throughout both lungs. Permbertons sign was negative.
An urgent CT scan of his chest was organized which showed a large right upper lobe mass obstructing the superior vena cava and narrowing of the trachea at the carina. A slice is shown below:
The patient was commenced on high dose dexamethasone (16mg daily). His oncologist advised that given his previous radiotherapy to the region, there was no further scope for further radiotherapy. Unfortunately there was close access to interventional radiology for an SVC stent insertion or thoracic surgery for a bronchial stent insertion and the patient decided to not travel for this. Fortunately the dexamethasone had good effect and his symptoms settled down over the following 3 days.
The patient continued on high dose steroid for some months, increasing the dose further when swelling and stridor redeveloped a month later. Shortly after this he began to experience some agitation and paranoid thinking which was thought to be due to his steroids. He did not wish to reduce his steroid dose but his agitation settled with twice daily haloperidol. Over the following month he gradually declined with worsening swelling in his face and arms and required opioids and benzodiazepines for pain and distress.
Category: Case | Category: CT | Category: SVC Obstruction | Category: Renal Cell Cancer
