Superior vena cava syndrome with tumor-induced hepatisation of the lung

Case contributed by Dr Jörgen Strömberg

Presentation

Progressive dyspnea. Diagnosed with metastatic right upper lobe lung cancer in last 1.5 years.

Patient Data

Age: 75 years
Gender: Male

Exam at time of diagnosis (1.5 years previously)

CT

Large lobulated soft tissue mass in the right upper lobe. Metastatic nodules in the middle and lower right lobes. Enlarged lymph nodes in the mediastinum and right lower hilum. Enlargement of the left adrenal, raising suspicion of metastasis. The low attenuating liver lesions were unchanged since older exams, and therefore judged to be non-metastatic.

Stent in the ascending aorta from previous vascular intervention. Occlusion of the infrarenal aorta (only partially depicted). Subcutaneous emphysema from recent tracheostomy procedure.

The tumor in the right upper lobe is now significantly larger with direct growth into the upper mediastinum. The superior vena cava is engorged and almost completely obstructed by surrounding tumorous tissue, which also obstructs the azygos vein. Enlarged, contrast-filled venous collaterals are seen in the right anterior thoracic wall. The findings are consistent with superior vena cava syndrome grade IV. 

The right main bronchus is completely occluded by tumorous tissue. Subsequently, there is no ventilation of the right lung, which appears low attenuating with a density roughly corresponding to fluid. Multiple contrast-enhancing lesions in the right lung parenchyma consistent with metastases. The left lung is adequately ventilated with several densities suspicious of parenchymal and pleural metastases. Bilateral pleural effusions.

In the upper abdomen, there is heterogeneous contrast enhancement of the liver (probably due to the early contrast phase) with at least one metastatic lesion present in segment 4. The metastasis of the left adrenal has increased in size.

Please note the appearance of the right lung on the topogram. If this patient had been examined with a plain chest radiograph, chances are that such a study would have been interpreted as a massive right pleural effusion.

Case Discussion

Hepatisation of the lung is a condition that is generally associated with infectious disease, where pus/liquid-filled bronchioli prevent normal ventilation of the lung parenchyma rendering it a characteristic low attenuation appearance. Although rare, this case shows that tumourous airway occlusion may cause the same appearance.

In addition, this case also demonstrates the typical findings of superior vena cava syndrome.

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