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
Nice margins on that.
C
D
C) CT guided Per-cutaneous Needle Biopsy
most likely to be a case of SVCS, caused by a tumor on the lung due to long term smoking..this compressed mechanically the SVC or thrombosis results due to cancerous infiltration..
the most probably answer is> C) CT guided Per-cutaneous Needle Biopsy.. then plan for treatment
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.
D) Video-Assisted Thoracoscopic Surgery (VATS)
CT guided Per-cutaneous Needle Biopsy shouldnt be done for fear of massive bleeding if it is of the highly vascular benign type of tumor
i think c
ct guided per cutaneous needle biopsy
CT guided Per-cutaneous Needle Biopsy…
c
d
C
CT guided Per-cutaneous Need Biopsy. Helpful especially if smaller nodules related to small cell carcinoma of the lung are involved. A tissue specimen from the lung nodule is often needed for optimal treatment. It is the technique of choice to establish a tissue diagnosis of malignancy.
VATS!
its a case of superior venacaval obstruction. Ans may be d
CT guided percutaneous needle biopsy
c) CT guided percutaneous needle biopsy.treatment would be given after nature of tumor determined.
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
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
i would agree w/ sara ,this mass in the upper lung zone should be dx first ,then do treament.
D
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!
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
CT guided per cutaneous needle biopsy
VATS is the the answer because it will solve the problem all the way,diagnosis and therapy.
I think its c there is no clue to start radio or chemo nor vats so is will go with see…suy is smoking pack from last 45 years
Answer C.
The patient has features suggestive of Superior Vena CAVA syndrome. SVC syndrome can occur from several causes – NSCLC, SCLC, germ cell tumors, Non-hodgkin’s lymphoma etc. Chest X-RAY show Right lung Apical lobe tumor. His smoking history as well as the tumor appearance on the X-RAY is suggestive of Pancoast tumor. Most Pancoast tumpors tend to be NSCLC ( Squamous predominantly) rather than SCLC. Pancoast tumors can present with brachial plexopathy, horner’s syndrome and sometimes, SVC syndrome (SVC can be obstructed especially, in case of right sided superior sulcus or pancoast tumor) . The usual treatment for SVC syndrome is Radiation therapy however, in case of SVC syndrome due to SCLC, Lymphomas and Germ Cell Tumors –Chemotherapy is the preferred option since these tumors quickly respond to Chemotherapy. However, the first step is obtaining a histological diagnosis and because of its location, a Pancoast tumor is easily amenable to percutaneous needle biopsy under CT guidance.
Option. A is incorrect. In the past, SVC syndrome was considered a potentially life-threatening emergency. It is no longer considered as an emergency and emergent radiation therapy is not appropriate for most patients. Histological diagnosis and full diagnostic work-up must be performed first in order to obtain accurate diagnosis of underlying etiology before therapy. Emergent treatment must be considered in SVC syndrome only if there is significant stridor secondary to laryngeal edema or central airway obstruction. Presence of Stridor should be considered as a true medical emergency and patient should be intubated and then, Radiation therapy must be instituted.
Answer C.
The patient has features suggestive of Superior Vena CAVA syndrome. SVC syndrome can occur from several causes – NSCLC, SCLC, germ cell tumors, Non-hodgkin’s lymphoma etc. Chest X-RAY show Right lung Apical lobe tumor. His smoking history as well as the tumor appearance on the X-RAY is suggestive of Pancoast tumor. Most Pancoast tumpors tend to be NSCLC ( Squamous predominantly) rather than SCLC. Pancoast tumors can present with brachial plexopathy, horner’s syndrome and sometimes, SVC syndrome (SVC can be obstructed especially, in case of right sided superior sulcus or pancoast tumor) . The usual treatment for SVC syndrome is Radiation therapy however, in case of SVC syndrome due to SCLC, Lymphomas and Germ Cell Tumors –Chemotherapy is the preferred option since these tumors quickly respond to Chemotherapy. However, the first step is obtaining a histological diagnosis and because of its location, a Pancoast tumor is easily amenable to percutaneous needle biopsy under CT guidance.
Answer. A is incorrect. In the past, SVC syndrome was considered a potentially life-threatening emergency. It is no longer considered as an emergency and emergent radiation therapy is not appropriate for most patients. Histological diagnosis and full diagnostic work-up must be performed first in order to obtain accurate diagnosis of underlying etiology before therapy. Emergent treatment must be considered in SVC syndrome only if there is significant stridor secondary to laryngeal edema or central airway obstruction. Presence of Stridor should be considered as a true medical emergency and patient should be intubated and then, Radiation therapy must be instituted.