Correspondence

Vena Caval Obstruction by Tumor

N Engl J Med 1994; 330:575February 24, 1994

Article

To the Editor:

In the September 30 issue the Image in Clinical Medicine 1 was alleged to be that of the superior vena cava syndrome. It showed the torso of a man with dilated superficial veins converging on the superficial inferior epigastric veins at the groin. The patient was also noted to have distended neck veins, but minimal facial edema. The veins of the patient's arms also appeared to be distended, and the ones of the upper part of the chest less so.

Although the patient probably had a partial obstruction of the superior vena cava, he must have had a serious obstruction of the inferior vena cava. If the superior vein was obstructed and the inferior one open, the veins of the most inferior portion of the abdominal wall should have been less distended rather than more so. Without belaboring the physics of the problem, the end of the vessel near the high-pressure source has a higher pressure, whereas the end near the lower-pressure sink has a lower pressure. The image and the accompanying legend indicate that the pressure in the inferior vena cava was greater than that in the superior.

Robert C. Luckey, M.D.
471 Williams, Suite 4, Richland, WA 99352

1 References

1. 1

   Kovacs RG, Aguayo SM. Superior vena cava syndrome. N Engl J Med 1993;329:1007-1007
   Full Text | Web of Science | Medline

To the Editor:

The Image in Clinical Medicine in the September 30 issue shows massive engorgement of collateral subcutaneous veins of the chest and abdomen due to small-cell lung cancer. The patient was treated with radiotherapy, with transient improvement of venous dilatation, but he died some weeks later.

We suspect that radiotherapy was given in the belief that it is the treatment of choice in any patient with the superior vena cava syndrome due to a malignant tumor1,2. Yet there are data in the literature indicating that in certain instances a combination of chemotherapy and radiotherapy yields a higher response rate than radiotherapy alone3-5. On the basis of these data and our own experience, we suggest that chemotherapy should always be included in the treatment of superior vena cava syndrome due to malignant tumors, and in particular to small-cell lung cancer.

G.P. Stathopoulos, M.D.
E. Michailakis, M.D.
N.A. Malamos, M.D.
Hippokration Hospital, Athens 11528, Greece

5 References

1. 1

   Perez CA, Presant CA, Van Amburg AL III. Management of superior vena cava syndrome. Semin Oncol 1978;5:123-134
   Web of Science | Medline

2. 2

   Schraufnagel DE, Hill R, Leech JA, Pare JA. Superior vena caval obstruction: is it a medical emergency? Am J Med 1981;70:1169-1174
   CrossRef | Web of Science | Medline

3. 3

   Dombernowsky P, Hansen HH. Combination chemotherapy in the management of superior vena caval obstruction in small-cell anaplastic carcinoma of the lung. Acta Med Scand 1978;204:513-516
   CrossRef | Web of Science | Medline

4. 4

   Maddox AM, Valdivieso M, Lukeman J, et al. Superior vena cava obstruction in small cell bronchogenic carcinoma: clinical parameters and survival. Cancer 1983;52:2165-2172
   CrossRef | Web of Science | Medline

5. 5

   Urban T, Lebeau B, Chastang C, Leclerc P, Botto MJ, Sauvaget J. Superior vena cava syndrome in small-cell lung cancer. Arch Intern Med 1993;153:384-387
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Although we agree that the pressure in the inferior vena cava of this patient must have been increased, it is difficult to estimate whether the increase in pressure in the inferior vena cava was greater than that in the superior vena cava. Granted, when the superior vena cava is rapidly occluded, the predominant signs and symptoms are facial plethora and engorgement of the neck veins associated with dyspnea and headache. However, when the obstruction worsens gradually, an extensive collateral circulation may develop. The azygos venous system is still considered the most important alternative route of circulation, but there are other important collateral systems such as the internal thoracic veins, lateral thoracic veins, and the subcutaneous veins that were engorged in the patient. We also agree that most patients with the superior vena cava syndrome due to cancer should be considered for chemotherapy.

Samuel M. Aguayo, M.D.
Ronald G. Kovacs, R.B.P.
Atlanta Veterans Affairs Medical Center, Decatur, GA 30033