September 2016 Imaging Case of the Month

Michael B. Gotway, MD  

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA 

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Clinical History: A 64-year-old woman presents with a several month history of slowly worsening shortness of breath and dry cough, with worsening exercise limitation. Laboratory data, include white blood cell count and serum chemistries were within normal limits. Oxygen saturation on room air was 93%.

Frontal and lateral chest radiographs (Figure 1) were performed. Previous frontal and lateral chest radiographs, performed 7 years prior to presentation, are shown for comparison.

Figure 1. Frontal (A) and lateral (B) chest radiography. Frontal (C) and lateral (D) chest radiography performed 7 years prior are shown for comparison.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of seven panels)

1. Frontal and lateral chest radiography appears normal
2. Frontal and lateral chest radiography bilateral linear and reticular abnormalities
3. Frontal and lateral chest radiography shows abnormally increased lung volumes
4. Frontal and lateral chest radiography shows bilateral hilar enlargement
5. Frontal and lateral chest radiography shows developing pleural thickening

Cite as: Gotway MB. September 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016;13(3):114-22. doi: http://dx.doi.org/10.13175/swjpcc088-16 PDF

Medical Image of the Week: Superior Vena Cava Syndrome

Figure 1. Thoracic CT in soft tissue windows. Panels A, B, C and G show extensive collateral circulation along the right chest wall especially subcutaneous vessels and subcapsular hepatic vessels during contrast injection in the right arm (arrows). There are also prominent right hepatic and capsular enhancing vessels with vascular shunt within the posterior subcapsular right hepatic lobe. Panels D, E, F and I show extensive collateral circulation on the left side when the contrast is injected (on a different admission) in the left arm (arrows). Panel H shows absent blood flow in the totally thrombosed SVC stent.

Superior vena cava (SVC) syndrome results from obstruction of blood flow in the SVC. Most cases are secondary to malignancy, the most common being lung cancer or non-Hodgkin lymphoma. Other less encountered etiologies include fibrosing mediastinitis and thrombosis associated with intravascular devices (1,2). Here, we present a case of advanced lung cancer undergoing chemo-radiation therapy who presented with typical symptoms of SVC syndrome including progressive shortness of breath and facial swelling/ fullness over weeks to months. His chest CT scan showed SVC obstruction due to his tumor mass (Figure 1). The patient underwent stenting and improved partially for sometime. However, he returned again with worsening symptoms over a few weeks with discovery of SVC in-stent thrombosis. He was started on therapeutic enoxaparin and his symptoms improved partially with time.

Huthayfa Ateeli, MBBS¹, Kawanjit Sekhon, MD² and Dena K. L'Heureux, MD³.

¹Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy Medicine; ²Department of Medicine, Internal Medicine Residency Program, Main Campus; and ³Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy Medicine, University of Arizona, Southern Arizona VA Health Care System, Tucson, AZ USA

References

1. Wilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes. N Engl J Med. 2007 May 3;356(18):1862-9. [CrossRef] [PubMed] 
2. Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and evolving etiology. Medicine (Baltimore). 2006 Jan;85(1):37-42. [CrossRef] [PubMed] 

Cite as: Ateeli H, Sekhon K, L'Heureux DK. Medical image of the week: superior vena cava syndrome. Southwest J Pulm Crit Care. 2016;13(2):99-100. doi: http://dx.doi.org/10.13175/swjpcc065-16 PDF