The Oedematous Mr H

1
The Oedematous Mr H
Student Grand Round 09.12.2003
The Oedematous Mr H
Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
2
The Oedematous Mr H
HISTORY

• Mr H 58 yr old taxi driver
• PC
• 3/12 Hx persistent productive cough, with yellow
  sputum production
• HPC
• Abx relieved symptoms initially, however cough
  returned coinciding with flu jab
• Pt was sent for CXR subsequently referred to
  Rapid Access Chest Clinic
• Symptoms/ signs on presentation
• Cough and sputum production
• 7 kg weight loss over 3/12
• Fatigue over 2/52, which has stopped Pt working
• Difficulty swallowing solids over 3-4/52
• 6/7 Hx facial swelling mild headache
• SOB
• Worsens at night, but no orthopnea (sleeps with
  2 pillows)
• Onset after walking 100 yards

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
3
The Oedematous Mr H
HISTORY

• PMH
• Rheumatic fever as a child
• Early 1980s Frozen shoulder, treated
  conservatively
• Mid 1980s
• Dx Diabetes Mellitus Type II following 1yr Hx
  paraesthesia on dorsal aspect of both feet
• Blood tests also highlighted some degree of
  liver dysfunction, managed conservatively Pt ?
  alcohol intake
• August 1999 MI
• May 2000 MI
• Angina drug managed
• Stress headaches
• ºAllergies
• DH
• Lanspoprazole 30mg od
• Asprin 75mg od
• Isosorbide Mononitrate 10mg bd
• GTN spray
• Fenofibrate 267mg od

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
4
The Oedematous Mr H
HISTORY

• SE
• CVS - Angina (drug managed), nil of note
• Resp - Difficulty with full inspiration
  taking a full deep breath in
• GI - ? appetite
• - Weight loss since onset of cough
• GU - nil of note
• MSS - nil of note
• CNS - Peripheral neuropathy 2º to Diabetes
• THREADS

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
5
The Oedematous Mr H
HISTORY

• FH
• Two sons one daughter (1st marriage).
• Now remarried, with one step son.
• Significant FHx Diabetes Heart Failure on
  mothers side.
• Father died aged 64 of lung Ca, mother died in
  late 80s of Heart Failure.
• SH
• Lives with 2nd wife, in 4th floor flat in
  Clapham.
• Flat does have lift but Pt likes to walk where
  possible.
• No problems with ADL.
• Smoked 20/day for 50years currently trying to
  stop but has had many previous failed quit
  attempts.
• Drinks 5-6pints/wk, but previous Hx v heavy
  drinking (14 bottles whiskey/wk).

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
6
The Oedematous Mr H
OBSERVATIONS EXAMINATION

• Obs
• PR - 85
• RR - 20
• BP - 130/80
• Temp - 36C
• BM - 6.6
• General - Facial swelling and significant
  periorbital oedema
• Large palpable R cervical LN, palpable
  axillary LN
• Nicotine stained hands
• CVS - NAD
• Resp - Bronchial breathing RUL posteriorly with
  decreased air entry.
• GI - No palpable masses, liver, kidneys or
  spleen.
• Neuro - NAD
• JACCOL

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
7
The Oedematous Mr H
SUMMARY AND IMPRESSION

• Summary
• Mr H is a 58 year old taxi driver
• Presented with Hx cough SOB over 3/12
• O/E Bronchial breathing RUL posteriorly with ?
  air entry and palpable R cervical LN
• Co-morbidity Diabetes mellitus and ischaemic
  heart disease
• Has a 50 pack year history and has been a heavy
  drinker
• Clinical impression prior to any Ix
• Probable bronchial Ca, with cervical LN
  involvement and Superior Vena Cava Obstruction
  (SVCO)
• Chronic infection
• Plan
• Admit Pt
• FNA of cervical LN to determine histology

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
8
The Oedematous Mr H
MANAGEMENT

• Admitted to ward under c/o Dr Rees
• Immediate management 8mg of dexamethasone b.d.
• Further tests
• CXR
• Blood test
• FNA cervical LN- SCLC confirmed by other
  histological tests
• CT scan thorax and abdomen
• Bone scan

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
9
The Oedematous Mr H
CXR
Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
10
The Oedematous Mr H
CT 1
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C. Tucker, I. Rajkomar R. Green
11
The Oedematous Mr H
CT 2
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C. Tucker, I. Rajkomar R. Green
12
The Oedematous Mr H
BONE SCAN
Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
13
The Oedematous Mr H
MANAGEMENT

• 21/11
• Started on chemotherapy etoposide 100mg b.d.
• 23/11
• Generally well
• Stable
• Symptoms improved
• Discharged

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
14
The Oedematous Mr H
LUNG CANCER

• Most common cause of cancer death worldwide.
• Malesgtgtfemales.

Risk factors

• Un-modifiable
• Gender
• Race
• Genetic predisposition

• Modifiable
• Smoking
• Passive smoking
• Pollution
• Exposure to occupational carcinogens
• Diet

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
15
The Oedematous Mr H
SMALL CELL LUNG CANCER

• 15-20 of all lung ca
• Central/hilar tumours which arise from
  Kulchitsky cells
• Rapid onset
• Aggressive course
• Widespread metastasis
• Extremely sensitive to chemotherapy
  radiotherapy

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
16
The Oedematous Mr H
SCLC

• Symptoms
• Cough
• Chest pain
• Haemoptypsis
• Wheezing
• Anorexia
• Weight loss
• Distant spread
• No symptoms

• Signs
• Reduced BS
• Dullness to percussion
• Hepatomegaly
• Lymphadenopathy
• Clubbing
• SVCO

• Paraneoplastic syndromes in SCLC
• SIADH
• Ectopic Cushing's
• Rare neurological syndromes

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
17
The Oedematous Mr H
SCLC

• Investigations
• CXR
• FBC
• UE
• Bone scan
• CT (to include liver adrenals)
• LFTs

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
18
The Oedematous Mr H
SCLC

• Treatment
• Surgery - limited in value except in limited
  stage disease.
• Radiation - limited as curative, but useful in
  prophylaxis or as palliative treatment.
• Chemotherapy - combination therapy better than
  single agent therapy, standard combinations CDV,
  PE, CAVE, alternating EP and CAV
• Palliative treatment - for progressive
  non-curable SCLC.

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
19
The Oedematous Mr H
SUPERIOR VENA CAVA SYNDROME

• Occurs when the vena cava is occluded.
• Obstruction - External (e.g. tumour,
  lymphadenopathy)
• - Intra-luminal (e.g. tumour, thrombosis).
• Malignancy ? 90 of SVCS cases. SVCS poor
  prognostic indicator.
• Advanced lung cancer, specifically small cell
  carcinoma (SCLC), accounts for 75 of malignant
  SVCS causes.
• Other malignant causes Non-Hodgkins (and more
  rarely, Hodgkins) lymphoma, and mediastinal
  metastases from Breast Ca, Kaposis sarcoma,
  thymoma, fibrous mesothelioma and germ cell
  cancers.
• Non malignant causes goitre, aortic aneurysm
  and granulomatous infection secondary to TB.
• Iatrogenic causes venous thrombosis due to
  central line fibrosis due to mediastinum
  radiotherapy.

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
20
The Oedematous Mr H
SUPERIOR VENA CAVA SYNDROME
Patients with cancer at increased risk of SVCS

• Patients with small cell lung cancer or, less
  frequently, non-small cell lung carcinoma (e.g.
  squamous cell carcinoma) and those with right
  lung involvement.
• Patients with non-Hodgkins lymphoma.
• Male patients aged 50-70 years who have primary
  or metastatic tumours of the mediastinum.
• Patients with breast carcinoma and mediastinal
  metastasis, Kaposis sarcoma with mediastinal
  involvement, thymoma, fibrous mesothelioma, and
  germ cell neoplasms.
• Patients with central venous catheters and
  pacemaker catheters.
• Patients who have received previous radiation
  therapy to the mediastinum.
• Patients with cancer who have comorbid conditions
  such as tuberculosis, histoplasmosis, or aortic
  aneurysm.

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
21
The Oedematous Mr H
SUPERIOR VENA CAVA SYNDROME

• Common presenting symptoms of SVCS
• Dyspnoea (most common symptom) and
  non-productive cough.
• Swelling of the face, arms, fingers, or neck
  (usually the first sign, often subtle).
• Feeling of fullness of the head.
• Difficulty buttoning shirt collars (Stoke's
  sign) women also may experience breast swelling.
• Dysphagia and hoarseness.
• Chest pain.
• Later symptoms that may occur include
• Life-threatening symptoms of respiratory
  distress, such as orthopnoea.
• Headache, visual disturbances, dizziness, and
  syncope.
• Lethargy, irritability, and mental status
  changes.

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
22
The Oedematous Mr H
SUPERIOR VENA CAVA SYNDROME

• Common clinical signs elicited on examination
• Oedema of the face, neck, upper thorax, breasts,
  and upper extremities.
• Prominent venous pattern (i.e., dilated veins of
  face, neck, and thorax).
• Jugular vein distension.
• Periorbital oedema and redness and oedema of
  conjunctivae.
• Facial plethora (ruddy complexion of face or
  cheeks).
• Compensatory tachycardia.
• Clinical signs indicating progression of SVCS
• Cyanosis of the face or upper torso.
• Engorged conjunctivae.
• Mental status changes.
• Tachypnoea, orthopnoea, stridor, and respiratory
  distress.
• Stupor, coma, seizure, and death.

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
23
The Oedematous Mr H
SUPERIOR VENA CAVA SYNDROME
1. Dilated veins on neck and chest.
3. Oedema and conjunctival haemorrhage.
2. Jugular engorgement.
5. Tongue angiomata.
4. Suffused (flushed) face.
Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
24
The Oedematous Mr H
SUPERIOR VENA CAVA SYNDROME

• Diagnosis concerned with identifying cause of
  SVCS
• Identify obstruction of SVCS ? CXR and trunk CT.
• History indicative of diseases previously
  mentioned directly (e.g. lung cancer) or via risk
  factors (e.g. heavy smoker) ? carry out
  appropriate investigations.
• Dx Lung cancer ? sputum cytology lymph node
  biopsy/FNA histology.
• Aims
• Relief of SVC obstruction.
• Restoration of normal SVC flow and/or
  development of collateral pathways of venous
  blood flow.
• Relief of oedema and associated symptoms.
• Cure, halt or slow progression of underlying
  pathology.

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
25
The Oedematous Mr H
SUPERIOR VENA CAVA SYNDROME

• Management
• Dyspnoea Elevate head of bed, provide O2.
• IV access ? flow rate in upper thorax, arms
  and head contra-indicated for venepuncture and
  IV. Central line required.
• Fluid Fluid and electrolyte balance should be
  monitored as over-hydration may exacerbate the
  symptoms. Diuretic use also monitored.
• Blood pressure Compression on the upper arm
  from BP cuff avoided.
• Side-effects of treatment Treatment has
  multiple diverse side-effects. Many of these
  side-effects may be more uncomfortable than the
  patients own experience of SVCS. Symptomatic
  relief ? treatments more bearable.

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
26
The Oedematous Mr H
SUPERIOR VENA CAVA SYNDROME

• Treatment
• Pharmacotherapy
• Corticosteroids (prednisolone or dexamethasone)
  and diuretics used to reduce oedematous swelling,
  inflammation and fluid load.
• Thrombolysis in obstruction of SVC by thrombus.
• Anticoagulant therapy to deter
  malignancy-induced thrombus is controversial.
• Radiotherapy
• Local treatment of non-small cell lung and other
  malignancies.
• Symptom relief 85-90 patients within 3/52.
• Radiotherapy vs chemotherapy in ? SVCS symptoms
  is controversial.
• Chemotherapy
• Local and systemic treatment of malignancies.
• Most common regimen for small cell lung cancer
  is a platinum-based compound (cisplatin,
  carboplatin) with etoposide.
• Relief of symptoms usually occurs within 7-14
  days in most patients.
• Surgery
• SVC stent insertion or bypass are occasional
  interventions.
• Secondary to other modalities.

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
27
The Oedematous Mr H
SUPERIOR VENA CAVA SYNDROME

• Cochrane review
• Radiotherapy chemotherapy VS surgical stent
  insertion VS steroids.
• SVCS present at diagnosis in 10 patients with
  SCLC (small cell lung carcinoma) and 1.7 NSCLC
  (non small cell lung carcinoma).
• SCLC - chemotherapy and/or radiotherapy symptom
  relief - 77.
• - recurrence rate - 17.
• NSCLC - chemotherapy and/or radiotherapy symptom
  relief - 60.
• - recurrence rate - 19.
• Stent insertion relieved symptoms in 95, with a
  recurrence rate of 11.
• Rate of symptom relief was greater than other
  modalities.
• Primary treatment option, or best-suited for
  treatment resistant cases?
• Not sufficient evidence concerning steroids.

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
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The Oedematous Mr H
SUPERIOR VENA CAVA SYNDROME

• Outcome
• Dependent upon prognostic factors of underlying
  pathology.
• Radiotherapy with chemotherapy - 50-90
  effective in ? SVCS.
• Evidence of ? effectiveness utilising both
  modalities if disease not responsive to either
  given alone.
• 70 treated remain SVCS-free prior to death.
• Recurrence of SVCS after initial treatment ?
  poor prognosis.
• Severity and outcome of SVCS not good predictors
  of underlying pathology (e.g. tumour size,
  thrombus resolution).

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green
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The Oedematous Mr H
END OF PRESENTATION

• Questions?

Student Grand Round 09.12.2003 - Dr Rees Firm
C. Tucker, I. Rajkomar R. Green