You are a young #medicine resident in a busy emergency when a 26/โ๏ธ walks in with ๐๐ป
C/o cough and respiratory distress + facial swelling x 7days. He is unable to sleep as the symptoms โคด๏ธ on lying down ๐ฎ
What do you do next?
You read this thread๐๐ป
#medtwitter
1/18
C/o cough and respiratory distress + facial swelling x 7days. He is unable to sleep as the symptoms โคด๏ธ on lying down ๐ฎ
What do you do next?
You read this thread๐๐ป
#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 ๐๐ป
Damnnnnn ๐ฎ๐ฎ๐ฎ
What's that ??
#MedTwitter
2/18
Damnnnnn ๐ฎ๐ฎ๐ฎ
What's that ??
#MedTwitter
2/18
That is a massive mass in the neck and the mediastinum, also B/L CP angles are blunted ๐ฎ๐ฎ
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 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 โก๏ธ compresses the SVC โก๏ธ obstructed blood flow โก๏ธ SVC obstruction โก๏ธ reduced venous return โก๏ธ symptoms of SVC syndrome !
Can anything other than a tumour l/t SVC syndrome??
Continue reading ๐๐ป
#medtwitter
4/18
Tumour โก๏ธ compresses the SVC โก๏ธ obstructed blood flow โก๏ธ SVC obstruction โก๏ธ reduced venous return โก๏ธ symptoms of SVC syndrome !
Can anything other than a tumour l/t SVC syndrome??
Continue reading ๐๐ป
#medtwitter
4/18
YES !!
Infact the first ever case of SVC syndrome (way back in 1757) was secondary to a syphilitic aneurysm๐ฎ
Other causes:
โขThrombus
โขCentral venous catheters
โขRetrosternal goitre
โขAortic aneurysm
โขMediastinal fibrosis (post infections)
#medtwitter
5/18
Infact the first ever case of SVC syndrome (way back in 1757) was secondary to a syphilitic aneurysm๐ฎ
Other causes:
โขThrombus
โขCentral venous catheters
โขRetrosternal goitre
โขAortic aneurysm
โขMediastinal 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 syndrome๐๐ป
1. Lung cancer (SCLC/NSCLC)
2. Lymphoma (NHL > HL)
3. Thymoma
4. Germ cell tumours
#medtwitter
6/18
Let's list out the malignancies that frequently cause SVC syndrome๐๐ป
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 swellingโ
Dyspnoeaโ
Headacheโ
Coughโ
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 ๐๐ป
7/18
Facial swellingโ
Dyspnoeaโ
Headacheโ
Coughโ
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 ๐๐ป
7/18
A QUICK RECAP ๐๐ป
โขSVC syndrome is an ๐๐
โขP/w facial swelling, headache, cough
โขMost often d/t MALIGNANCY
โขOther causes - CVC/thrombus
โขUrgent imaging & Rx is a must
Now let's learn how to manage it ๐ช๐ป
#medtwitter
8/18
โขSVC syndrome is an ๐๐
โขP/w facial swelling, headache, cough
โขMost often d/t MALIGNANCY
โขOther causes - CVC/thrombus
โขUrgent imaging & Rx is a must
Now let's learn how to manage it ๐ช๐ป
#medtwitter
8/18
It's gonna be a TEAM EFFORT ๐ช๐ผ
You need the help of your intervention radiologist & radiation oncologist !!
Call them up, STAT ๐
#medtwitter
9/18
You need the help of your intervention radiologist & radiation oncologist !!
Call them up, STAT ๐
#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 position๐๐ป
Start some diuretics & maybe some corticosteroids (may make diagnosis difficult but can be life saving)
#medtwitter
10/18
Raise the head end of the bed and start supplemental 02
Patients feel most comfortable in the upright position๐๐ป
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
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 syndrome๐ช๐ผ
Intervention radiology to the rescue๐๐ป
#medtwitter
12/18
Stenting has an advantage, histology isn't obscured & symptom relief is quick! This is the best Rx for life threatening SVC syndrome๐ช๐ผ
Intervention radiology to the rescue๐๐ป
#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 ๐๐ป
#medtwitter
13/18
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 ๐๐ป
#medtwitter
13/18
So we can say that the management depends on:
โขSeverity of SVC syndrome
โขMost likely underlying disease
โขAvailability of intervention radiologist
โขAvailability of RT
#medtwitter
14/18
โขSeverity of SVC syndrome
โขMost likely underlying disease
โขAvailability of intervention radiologist
โขAvailability of RT
#medtwitter
14/18
You suspect a lymphoma here, what would you do ?
1๏ธโฃGeneral supportive measures
2๏ธโฃTry to establish a diagnosis before bombarding w/ steroids/RT
3๏ธโฃEndovascular stenting >> RT here because the former can help with symptom relief and diagnosis won't be obscured
15/18
1๏ธโฃGeneral supportive measures
2๏ธโฃTry to establish a diagnosis before bombarding w/ steroids/RT
3๏ธโฃEndovascular 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:
1๏ธโฃ SVC syndrome isn't severe (i.e no laryngeal oedema/CNS symptoms)
2๏ธโฃ Diagnosis is already established
#MedTwitter
16/18
1๏ธโฃ SVC syndrome isn't severe (i.e no laryngeal oedema/CNS symptoms)
2๏ธโฃ Diagnosis is already established
#MedTwitter
16/18
Summary:
1๏ธโฃStart 02 and elevate bed for all
2๏ธโฃCall in intervention radiology and RT
3๏ธโฃIf severe SVCs, stenting >>RT
4๏ธโฃIf 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
1๏ธโฃStart 02 and elevate bed for all
2๏ธโฃCall in intervention radiology and RT
3๏ธโฃIf severe SVCs, stenting >>RT
4๏ธโฃIf 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 ๐๐ป
I hope you learnt something new, I did
#MedTwitter
Just one more tweet ๐๐ป
I hope you learnt something new, I did
#MedTwitter
Just one more tweet ๐๐ป
Just a follow up to get you all motivated !!
This is the same guy, post successful management of his symptoms ๐๐ป๐ช๐ผ
He was diagnosed w/ large B cell lymphoma (MYC, BCL2 rearranged)
This is post C1 R-CHOP ๐๐ป
#MedTwitter
End.
This is the same guy, post successful management of his symptoms ๐๐ป๐ช๐ผ
He was diagnosed w/ large B cell lymphoma (MYC, BCL2 rearranged)
This is post C1 R-CHOP ๐๐ป
#MedTwitter
End.
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