A 65-Year-Old Patient with Superior Vena Cava Syndrome and Bone Metastases

Abstract

A 65-year-old man was referred to the emergency department because of hoarseness and progressive swelling of the neck and face. The clinical examination revealed visible collateral veins on the upper thoracic cage wall. A computed tomography (CT) scan of the chest and upper abdomen showed a bilobar mass in the right upper lobe of the lung that was suspicious for malignancy ( Fig. 1). In addition, there were multiple enlarged mediastinal lymph nodes, poorly defined vertebral body densities in vertebrae T2 and T3 that were suspicious for bone metastasis (Fig. 2), and a small right-sided pleural effusion. The examination of bronchoscopic biopsy specimens revealed squamous cell lung cancer, and the clinical stage was cT2aN2M1b according to the TNM 7 classification.Dilatation and stent placement in the superior vena cava (SVC) was performed first because of the symptomatic SVC syndrome. Over a few days, this resulted in rapid symptomatic improvement.There were no other metastases on conventional imaging, and therefore an 18 F-fluorodeoxyglucose positron emission tomography CT ( 18 F-FDG PET-CT) scan was performed to discuss a potential oligometastatic approach at our multidisciplinary tumor board. It revealed the highly hypermetabolic rightsided lung tumor, the mediastinal lymph node metastases, but surprisingly no sign at all of vertebral body metabolic activity. Moreover, the CT scan no longer showed any vertebral body abnormality (Fig. 3). The patient subsequently started concurrent chemoradiation therapy for a tumor with final clinical staging cT2aN2M0. DiscussionThe SVC-initially nearly completely obstructed by the mediastinal lymph nodes-resumed a normal flow pattern after the successful stent placement. The initial CT scan suggested that the sclerotic vertebral body metastases were most likely caused by increased density of the contrast-filled vertebral venous plexus in response to the obstructed SVC. This image returned to normal after the SVC obstruction was treated, with regression of the collateral venous flow in the (hemi-) azygos vein system. There was also no increased 18 F-FDG uptake on the PET-CT scan.SVC syndrome is a frequent complication of primary lung cancer, as are osseous lesions detected on a staging CT scan. When SVC syndrome develops, multiple venous collateral pathways also develop, including uncommon ones, such as breast, brain, and liver venous networks. 1 Paravertebral collateral flow is a more common finding, but until now only a few case reports have described contrast-enhanced lesions inside the vertebrae. [2][3][4] In one retrospective study, Kim et al. 5 reviewed CT scans of patients with patients with SVC syndrome and unusual vertebral body enhancement. In these 13