Benign superior vena cava syndrome with uncontrolled pleural effusion by calcified mediastinal lymphadenopathy: surgical management

Abstract

This report describes a rare case of benign superior vena cava syndrome (SVCS) accompanying recalcitrant pleural effusion developed secondary to extrinsic compression by anthracotic calcified mediastinal lymphadenopathy which was corrected by surgical bypass graft. An 81-year-old female presented with recalcitrant pleural effusion for several months despite of medical treatments. SVCS developed progressively without any other radiological evidence of malignancy or active infection on initial chest computed tomography (CT). A follow-up chest CT scan taken one month later revealed a poorly-defined mass-like lesion encasing the SVC. Near total collapse of the SVC due to circumferential compression by massive anthracotic calcified lymph nodes was noted in the surgical fields. A bypass graft was performed using an artificial vessel instead of endovascular treatment because of severe adhesion. The abrupt SVCS and uncontrolled pleural effusions completely disappeared after surgical correction.

Keywords: Superior vena cava syndrome (SVCS); mediastinal lymphadenopathy; pleural effusion.

Figure 1

Chest CT scan before and after surgical management. (A,B) Initial contrast-enhanced chest CT scans show narrowed contrast-filled SVC (white arrow) due to surrounding soft tissue (black arrows) and bilateral pleural effusion. Right (R) brachiocephalic vein is more contrast-enhanced compared to left (L) brachiocephalic vein because intravenous iodine contrast material was injected into the right arm; (C,D) follow-up CT scans obtained 40 days after initial CT scan show complete occlusion of SVC by soft tissue (white arrow) and multiple collateral veins (arrowheads) in the mediastinum and chest wall. Iodine contrast material was injected in to the left arm, but left brachiocephalic vein (L) shows poor contrast-enhancement due to venous stasis caused by SVC obstruction. The patient underwent surgery, and the soft tissue occluding SVC was confirmed as anthracotic lymph node. (E,F) Post-operative follow-up CT scan shows patent SVC (white arrow). SVC, superior vena cava.

Figure 2

Surgical correction. (A) Enlarged lymph nodes between SVC, at the level where azygos vein (white arrow) branches out, accompanied with heavy calcification and adhesion (black arrow); (B) instead of removing the mass encasing SVC, bypass graft was placed using artificial vessel. SVC, superior vena cava.