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In general, superior vena cava obstruction, an uncommon manifestation of lung cancer, is caused by carcinoma of the bronchus, and less commonly by lymphoma, metastatic disease, and intrathoracic tumours.1 We describe a case of superior vena cava thrombosis caused by pleural metastases arising from a gastric adenocarcinoma.
A 70 year old man presented with a two month history of persistent epigastric pain, nausea, weakness, fatigue, anorexia, and progressive weight loss. He had smoked 30 cigarrettes a day for many years. An endoscopic examination and an abdominal computed tomography scan demonstrated a gastric mass located in the upper third of the stomach, with multiple adenopathies on the head of the pancreas and the coeliac trunk. Histopathological study of the mass revealed a poorly differentiated carcinoma. The patient was sent to another hospital to evaluate palliative surgery. Four weeks later the patient was admitted because of progressive dyspnoea and coughing. Physical examination revealed cyanosis and jugular venous distention. The white blood cell count was 29.4 × 109 leucocytes/litre, with a left shift, and the erythrocyte sedimentation rate was 91 mm/hour. Other laboratory data were within the normal limit. A chest x ray showed a 10 × 10 cm diameter mass in the right upper lobe. A computed tomography scan of the chest (fig 1) confirmed the presence of a multilobulated mass with a sharp edge, which filled the right upper lobe without mediastinal mass or nodes. The centre of the mass was hypodense with thick fluid density. The mass invaded the superior vena cava causing intraluminal thrombosis. Fine needle aspiration showed haematic fluid with malignant cytology. These findings suggested the presence of pleural neoplasia with the appearance of haemothorax (tumorous necrosis) secondary to metastatic carcinoma. The patient died one week later.
Pleural metastases arising from a gastric carcinoma and causing a superior vena cava obstruction by invasion and thrombosis are extremely rare. Today, up to 97% of all cases of superior vena cava obstruction have a malignant aetiology, as a result of compression by tumour, mediastinal metastases, or intraluminal thrombus formation.1 Less than 5% of cases of superior vena cava obstruction are caused by metastatic carcinoma, usually advanced breast, oesophageal, or pancreatic carcinomas.2 However, gastrointestinal carcinoma, a common tumour, rarely causes superior vena cava obstruction.3–5 In these cases, the usual mechanism is metastatic adenopathies in the mediastinum, which compress and block the superior vena cava. Up to 10% of tumours of the upper third of the stomach present mediastinal adenopathies. These metastatic adenopathies are more frequent in poorly differentiated carcinomas and those closer to the oesophagogastric junction.2 Our case is probably the first case of gastric adenocarcinoma reported with invasion and thrombosis of the superior vena cava from pleural metastases and absent mediastinal metastases.