CRA27 A SILENT TUMOR, A STRANGED VEIN: LUNG ADENOCARCINOMA PRESENTING AS SUPERIOR VENA CAVA SUNDROME

Anis Ayishah Mohd Dali¹, Boon Hau Ng¹, Nor Safiqah Sharil^1,2, Rose Azzlinda Osman¹, Hsueh Jing Low³, Nik Nuratiqah Nik Abeed¹, Andrea Yu-Lin Ban¹
1. Respiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia.
2. Department of Anesthesiology and Critical Care, Faculty of Medicine, Universiti Kebangsaan Malaysia, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia.
3. Internal Medical Unit, Faculty of Medicine and Health Science, Universiti Sains Islam Malaysia, Nilai, Negeri Sembilan.

Introduction
Superior vena cava (SVC) syndrome is a rare but potentially life-threatening complication of lung cancer, occurring in approximately 5–10% of cases.

Case report
A 60-year-old woman presented with a four-month history of cough, haemoptysis, and breathlessness. Clinical examination revealed diminished breath sounds in the right upper lung zone and facial congestion. Computed tomography of the thorax demonstrated a right upper lobe mass with tumour thrombi extending into the right pulmonary artery and superior vena cava (figure 1). Bronchoscopy revealed a fungating mass at the main carina, extending into the right main bronchus and causing approximately 50% luminal stenosis. An endobronchial biopsy confirmed adenocarcinoma, with testing revealing an ALK mutation. Given her symptomatic SVC obstruction with a Kishi score of 5, she underwent urgent SVC stenting, leading to significant symptomatic improvement. She was subsequently initiated on Ceritinib 300 mg once daily.

Discussion
There is no universally standardised classification system for SVC obstruction. The Stanford method is commonly used to classify obstruction based on venography. The Kishi scoring system evaluates the severity of symptoms to guide management decisions. A score of ≥4 suggests the need for percutaneous stent placement, whereas a score <4 favours conservative management, considering factors such as the underlying cause, alternative treatments, and prognosis. For patients with malignancy-associated SVC syndrome, treatment options include chemotherapy, radiation therapy, surgical bypass, and endovascular therapy. Given the patient’s Kishi score of 5, the decision to proceed with stenting was considered due to the rapid improvement of symptoms. This case report describes an unusual presentation of advanced adenocarcinoma of the lung with superior vena cava syndrome, which is successfully managed with endovascular stenting.