Subclavian thrombosis in a patient with advanced lung cancer: a case report
Paul Zarogoulidis
0
Eirini Terzi
0
Georgios Kouliatsis
0
Vasilis Zervas
0
Theodoros Kontakiotis
1
Alexandros Mitrakas
0
Kostas Zarogoulidis
0
0
University Pulmonary Department, Oncology Unit, G Papanikolaou Hospital
,
Thessaloniki
,
Greece
1
University Pulmonary Department, Bronchoscopic Unit, G Papanikolaou Hospital
,
Thessaloniki
,
Greece
Introduction: Lung cancer is now considered the most common cause of death among cancer patients. Although target biological regimens have emerged in recent years for non-small cell lung carcinoma, the survival and quality of life of patients with this condition still remain low. The five-year survival rate for all stages of lung cancer is 17% or less. Case presentation: We describe the case of a 53-year-old Caucasian woman who was diagnosed with advanced stage IIIa (T2aN2M0) non-small cell lung carcinoma (adenocarcinoma) and underwent a complete left upper lobectomy three years ago. After two and a half years of follow-up, she suddenly presented with facial edema and venous distension and was immediately treated for superior vena cava syndrome. Because of a diagnostic check, a major clot was detected in the right subclavian vein. Our patient was informed about treatment options, and she was taken to the catheterization laboratory for percutaneous stenting of the superior vena cava to restore superior vena cava patency. Conclusion: Lung cancer has a vast number of complications. Superior vena cava syndrome and thrombosis should be considered upon the presentation of a patient with obstructive symptoms. In this case report, even though we expected the clot to be on the side of the former lesion, it was present on the opposite side. Treatment should also start immediately in these patients with clinical suspicion of thrombosis to avoid further complications, even in cases with a differential diagnosis problem. Finally, although patients with non-small cell lung carcinoma have a high incidence of thromboembolic events, anticoagulant treatment is given only as maintenance therapy after a first event occurs.
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Introduction
Lung cancer is one of the leading causes of death in the
European Union, with an incidence of approximately
180,000 cases per year [1]. Superior vena cava syndrome
(SVCS) is a well-known manifestation of benign and
malignant tumors of the upper mediastinum, that causes
obstruction of blood flow through the superior vena
cava (SVC) [2] in approximately 1.7% to 4% of patients
with lung cancer [2,3]. Most of the cases are caused by
compression of the SVC by tumors; pure intravascular
thrombosis is extremely uncommon and only 0.04% of
hospitalized adults have been diagnosed with
cancerrelated SVC thrombosis [3,4]. Percutaneous treatment
via stenting is an accepted strategy as a palliative
approach for patients with SVCS if it is impossible to
treat the underlying disease, most commonly a
metastatic tumor, and when the patient is highly
symptomatic [5]. This report discusses a rare case of SVCS by
cancer-related thrombosis treated with endovascular
stenting, resulting in complete restoration of blood flow
and immediate relief of symptoms without any
complications.
Case presentation
A 53-year-old Caucasian woman consulted our
department complaining of progressively worsening facial
swelling and a feeling of tension in the head, which
she had first experienced eight days previously and had
gradually worsened. Our patient had a history of locally
advanced lung cancer (stage T2aN2M0-IIIa). It was first
diagnosed three years before as a left upper lobe mass
attached to the mediastinum and was treated with left
upper lobe complete resection. The pathologic
examination revealed poorly differentiated adenocarcinoma. Our
patient was subsequently treated with six cycles of
taxane and platinum chemotherapy and radiotherapy at the
primary site. It was decided to initiate a complete
chemotherapy regimen for locally advanced lymph node
disease N2. After two and a half years of follow-up, our
patient was diagnosed with progressive disease (left
supraclavicular nodes and sternum bone metastases),
and at the time of examination, she was not receiving
any treatment. Her physical examination revealed facial
edema and thoracic and upper limb venous distension
(Figure 1). The differential diagnosis included central
venous obstruction or thrombosis, including SVCS. A
chest radiograph showed no progression of the disease
in either hemithorax at the time of symptom
presentation (Figure 2). Her blood examination results were as
follows: white blood cell count 5770/mm3, hemoglobin
8.4 g/dL, platelets 253 104/mm3, glucose 92 mg/dL,
creatine 1.23 mg/dL, aspartate aminotransferase 20IU/L,
alanine aminotransferase, 10IU/L, alkaline phosphatase
107IU/L, lactate dehydrogenase 382IU/L, albumin 2.8 g/
dL, total bilirubin 0.6 mg/dL, sodium (Na+) 141.4 mEq/
L, potassium (K+) 4.3 mEq/L, calcium (Ca2+) 8.9 mg/dL,
uric acid 4.1 mg/dL, international normalized ratio
(INR) 0.94, and D-dimers 4300 (...truncated)