The inferior vena cava (IVC) syndrome as the initial manifestation of newly diagnosed gastric adenocarcinoma: a case report

Abstract

Introduction: Vena cava compression is a relatively rare initial manifestation of underlying malignancy. The superior vena cava syndrome, which is characterized by facial plethora, jugular venous distension, and arm swelling, is a well-known entity associated with bronchogenic carcinoma. Less common is the compression of the inferior vena cava. To the best of my knowledge, this is the first reported case of newly diagnosed gastric adenocarcinoma presenting initially as the inferior vena cava syndrome. The unique aspect about this case is that it highlights a rare presentation before diagnosis of gastric adenocarcinoma.

Case presentation: A 56-year-old Malaysian woman with a past medical history of iron deficiency anemia presented with lower extremity edema and progressive fatigue of 1 month's duration. She had significant worsening of leg swelling after standing for short periods of time. She also reported epigastric discomfort, which led to an additional workup, including computed tomography of the abdomen and pelvis. This revealed a 3cm×2.9cm mass in the stomach, extensive hepatic metastasis, and severe inferior vena cava compression. The patient was examined further with esophagogastroduodenoscopy, and a biopsy showed gastric adenocarcinoma.

Conclusions: This report describes a case of a patient with inferior vena cava syndrome as a unique presentation of previously undiagnosed stage IV gastric adenocarcinoma. Patients presenting with inferior vena cava syndrome should undergo prompt evaluation for underlying malignancies that have a predilection for hepatic metastasis. This case is important because earlier recognition of this syndrome can lead to earlier workup and thus detection of malignancy. Prompt initiation of treatment, including chemotherapy or vena cava stent placement, can result in improved patient outcome.

Fig. 1

Compression of the inferior vena cava by foci of hepatic metastases. Computed tomographic scan of the abdomen and pelvis with intravenous contrast shows that the inferior vena cava (green arrows) becomes progressively more compressed by the tumor superiorly to inferiorly. a Patent inferior vena cava at the level of the pancreas. d Near-complete compression of the inferior vena cava at a level of the superior portion of the kidneys. a-d Superiorly to inferiorly

Fig. 2

Adenocarcinoma involving the antrum of the stomach. Computed tomographic scan of the abdomen and pelvis with intravenous contrast shows an ill-defined 3cm×2.9cm necrotic mass. Scan also reveals omental implants and nodular extension of the gastric tumor posteriorly into the lesser sac

Fig. 3

Histologic specimens from gastric antral mass biopsy. The biopsy revealed invasive, moderately differentiated adenocarcinoma of intestinal type, with formation of glands and nests. Shown are images at various magnifications: ×10 (a), ×20 (b), and ×40 (c)

Fig. 4

Endoscopic images of gastric tumor