Extensive-stage small-cell lung cancer with malignant superior vena cava syndrome

What happened, in summary

This man was originally diagnosed at age 66 with extensive-stage small-cell lung cancer. He also had idiopathic pulmonary fibrosis with a usual interstitial pneumonia pattern, chronic obstructive pulmonary disease, a heavy smoking history, and deep-vein thrombosis treated with apixaban. His lung cancer was first treated with carboplatin plus etoposide, followed by amrubicin as second-line therapy. Carboplatin and etoposide were later tried again as third-line treatment, but he developed drug-induced pneumonitis. With no further anticancer drug options, his care shifted to best supportive care as the tumors gradually enlarged. At age 68, he was admitted with diffuse facial swelling and swelling of both upper arms. He required oxygen by nasal cannula, but blood tests did not suggest another cause such as low albumin, heart failure, or venous thrombosis. Imaging showed a larger right hilar mass and severe narrowing of the superior vena cava from tumor compression, leading to malignant superior vena cava syndrome. Radiation was considered difficult because of his interstitial pneumonia, so the care team chose an endovascular procedure to relieve the obstruction quickly. Through the femoral and internal jugular veins, a guidewire was passed across the narrowed segment, a self-expanding bare-metal stent was placed, and balloon angioplasty widened the most narrowed area. Venography confirmed better blood flow through the superior vena cava. The venous pressure fell, and his facial and arm swelling improved. Apixaban was continued to help prevent stent clotting. He was discharged on hospital day 7 and was able to spend time at home without recurrent superior vena cava syndrome or stent-related complications. He died from worsening lung cancer about 2 months after discharge.