SESSION TYPE: Cancer Student/Resident Cases
PRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM
INTRODUCTION: Inferior vena cava (IVC) syndrome is a rare disease process due to obstruction of the IVC, primarily from infradiaphragmatic causes1. We present a unique case with supradiagphramatic etiology of locally invading non-small cell lung cancer (NSCLC) causing IVC syndrome.
CASE PRESENTATION: A 47-year-old male with a significant smoking history and family history of gastrointestinal malignancy, presents with right shoulder pain, lower extremity pain and swelling progressively worsening over the last eight months. The patient admits to a history of weight loss and anorexia over same time period. He denies chest pain or dyspnea. Physical examination reveals a thin built male with minimal abdominal ascites, no hepatomegaly and no signs of heart failure, other than bilateral leg swelling and tenderness. Chest X-ray shows an ill-defined opacity at the right lung base with right hemi-diaphragm elevation. Chest CT reveals a large supradiaphragmatic mass (Figure 1), compressing the upper inferior vena cava (Figure 2). Video assisted thoracic surgical biopsy shows a poorly differentiated non-small cell lung cancer. Due to tumor location and involvement of the IVC, the patient was not considered a surgical candidate and was referred to oncology for further treatment options.
DISCUSSION: IVC syndrome is a clinically rare condition characterized by abrupt onset of ascites, lower extremity edema, hepatomegaly, and proteinuria due to inferior vena cava obstruction1. Reported in limited literature, the etiologies are primarily infradiaphramatic such as renal cell carcinoma and hepatic metastasis1. This case is unique due to the supradiaphragmatic location of the obstructing mass. This results in additional symptoms including referred shoulder pain and right hemi-diaphragm elevation resulting from right phrenic nerve irritation. Among the case reports describing NSCLC causing venous obstruction, the majority have been associated with superior vena cava (SVC) syndrome2. In both SVC and IVC syndromes, collateral circulation pathways begin to form due to chronic blockage. Hence, rapidity of symptoms depend on two competing factors: rate of tumor progression and rate of formation of collateral circulation1,2.
CONCLUSIONS: To our knowledge, this is the first case report describing a supradiaphragmatic etiology associated to IVC syndrome. Due to the anatomical proximity of the IVC and lung base, we should be cognizant of its possibility in the setting of lung cancer.
1) Sonin AH et al. Obstruction of the inferior vena cava: a multiple-modality demonstration of causes, manifestations, and collateral pathways. RadioGraphics. 1992.
2) Wilson LD et al. Clinical practice. Superior vena cava syndrome with malignant causes. New England Journal of Medicine. 2007.
DISCLOSURE: The following authors have nothing to disclose: Pulin Shah, Kathir Balakumaran, Sanjay Singh, Gregory Thibodeau
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