Vena caval obstruction, characterized by the narrowing or occlusion of the caval veins, is a common oncological emergency often precipitated by malignancies such as non-small cell lung cancer, small cell lung cancer and lymphoma

Pathophysiology

• Specific cancers that commonly precipitate this condition include:
  • Lung cancer - small cell more common
  • Lymph nodes - lymphoma, secondary to other cancer
• Obstruction can also be caused by a thrombus, or a foreign body (e.g. PICC line thrombus)

Clinical features

Symptoms

• Dyspnoea
• Orthopnoea
• Facial plethora

Signs

• Jugular venous distension
• Cyanosis
• Haemodynamic compromise
• Positive Pemberton’s test: involves lifting the arms over the head for more than 1 minute; this will precipitate facial plethora and cyanosis
• Syncope
• Coma

Investigations

• CXR: widened mediastinum, mass lesion
• CT chest: shows the location, severity, and associated pathology (e.g. malignancy or intravascular thrombosis)

Management