A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 72-year-old woman is brought to the emergency department because of lethargy and weakness for the past 5 days. During this period, she has had a headache that worsens when she leans forward or lies down. Her arms and face have appeared swollen over the past 2 weeks. She has a history of hypertension and invasive ductal carcinoma of the left breast. She underwent radical amputation of the left breast followed by radiation therapy 4 years ago. She has smoked two packs of cigarettes daily for 40 years. Current medications include aspirin, hydrochlorothiazide, and tamoxifen. Her temperature is 37.2°C (99°F), pulse is 103/min, and blood pressure is 98/56 mm Hg. Examination shows jugular venous distention, a mastectomy scar over the left thorax, and engorged veins on the anterior chest wall. There is no axillary or cervical lymphadenopathy. There is 1+ pitting edema in both arms. Which of the following is the most likely cause of this patient's symptoms?
-
A
Pulmonary tuberculosisIncorrect. Pulmonary TB rarely produces SVC syndrome and would not explain the heavy-smoker risk profile with new collateral venous distention.
-
B
Constrictive pericarditisIncorrect. Constrictive pericarditis causes JVD with Kussmaul sign and pericardial knock but does not produce facial plethora or unilateral chest-wall venous engorgement.
-
C
Lung cancerCorrect. Heavy smoking and a clinical picture of SVC obstruction (facial/arm swelling, JVD, chest wall collaterals, positional headache) points to lung cancer compressing the SVC.
-
D
Nephrotic syndromeIncorrect. Nephrotic syndrome produces generalized peripheral edema but not the localized upper-body venous engorgement or collateral chest-wall veins seen here.
-
E
Right-sided heart failureIncorrect. Right heart failure causes JVD and lower-extremity edema but does not produce facial swelling, chest-wall venous collaterals, or positional headache from venous obstruction.
↑ Tap an answer to reveal the reasoning
Answer: C. A long-time heavy smoker (80 pack-years) with facial and upper extremity swelling, jugular venous distention, engorged anterior chest wall veins, and a positional headache worse when leaning forward — together comprise superior vena cava (SVC) syndrome. The most common cause of SVC syndrome in adults is intrathoracic malignancy, particularly bronchogenic lung cancer, with small cell lung cancer being the most frequent subtype because of its central tumor location near the SVC.
The heavy smoking history strongly favors a new primary lung cancer rather than recurrence of breast cancer 4 years after treatment. Patients typically present with face/arm edema, dilated chest and neck collateral veins, hoarseness (recurrent laryngeal nerve), and positional symptoms (headache worse when bending forward or supine because of impaired venous drainage). Diagnosis is confirmed with contrast-enhanced chest CT, which shows the mediastinal mass and SVC compression/thrombosis.
Management is treatment of the underlying malignancy (radiation or chemotherapy for SCLC) and endovascular stenting for relief of acute symptoms.
**Why each option:**
**A.** Pulmonary TB rarely produces SVC syndrome and would not explain the heavy-smoker risk profile with new collateral venous distention.
**B.** Constrictive pericarditis causes JVD with Kussmaul sign and pericardial knock but does not produce facial plethora or unilateral chest-wall venous engorgement.
**C.** Correct. Heavy smoking and a clinical picture of SVC obstruction (facial/arm swelling, JVD, chest wall collaterals, positional headache) points to lung cancer compressing the SVC.
**D.** Nephrotic syndrome produces generalized peripheral edema but not the localized upper-body venous engorgement or collateral chest-wall veins seen here.