Keywords
superior vena cava syndrome - cancerous thrombus - squamous cell tongue cancer - pericardial
effusion
A 48-year-old man with a 6-month history of poorly differentiated squamous cell carcinoma
of the tongue presented with clinical and echocardiographic signs of cardiac tamponade.
He also demonstrated signs compatible with superior vena cava (SVC) syndrome (plethoric
face and oedematous arms bilaterally). Emergent pericardiocentesis yielded 1,200 mL
of haemorrhagic fluid, resulting in temporary clinical improvement.
Interestingly, post-drainage transthoracic sub-costal ([Fig. 1A]) and transoesophageal echocardiographic (TEE) aortic-valve short-axis ([Video 1]) views disclosed a highly mobile ball-like thrombus within the right atrium, initially
considered to be ‘en route’ to pulmonary circulation. However, TEE bi-caval view revealed
that the thrombus was actually extremely elongated, mainly located within SVC; while
its lower edge demonstrated a brisk, whip-like motion within the right atrium ([Fig. 1B], [Video 2]), vascular ultrasonography of the neck ([Figs. 1C] and [D]) illustrated that SVC thrombus was extended up to the internal jugular veins (IJVs),
which were both invaded by the surrounding metastatic lymph nodes and thrombosed.
Combined cardiovascular ultrasonography was compatible with the presence of cancerous
thrombus within SVC.[1] Computed tomography pulmonary angiography confirmed ultrasound findings, illustrating
contrast deficits (open arrows) within the right atrium ([Fig. 2A]), SVC ([Fig. 2B]), both brachiocephalic veins ([Fig. 2C]) and IJVs ([Fig. 2D]); it also disclosed sub-segmental thrombi (arrow heads) in the lower lung lobes
compatible with on-going pulmonary embolism ([Figs. 2A] and [B]). The patient received anticoagulants, however, his clinical course was complicated
by major pulmonary embolism and sepsis, and he died before resorting to surgery.
Fig. 1 Superior vena cava cancerous thrombus in transthoracic sub-costal view (A), transesophageal bi-caval view (B), right (C) and left (D) neck vascular ultrasonography (see also text).
Fig. 2 Computed tomography pulmonary angiography illustrating superior vena cava (SVC) cancerous
thrombus within right atrium (A), SVC per se (B), brachiocephalic (C) and internal jugular veins (D) (see also text).
Video 1
Cancerous thrombus in transesophageal short-axis view at the level of aortic valve
(see also text). CT, cancerous thrombus; CCA, common carotid artery; IJV, internal
jugular vein; LA, left atrium; mLN, metastatic lymph node; PE, pericardial effusion;
RA, right atrium; SVC, superior vena cava.
Video 2
Superior vena cava cancerous thrombus in transesophageal bi-caval view (see also text).
CT, cancerous thrombus; CCA, common carotid artery; IJV, internal jugular vein; LA,
left atrium; mLN, metastatic lymph node; PE, pericardial effusion; RA, right atrium;
SVC, superior vena cava.
To our knowledge, there has been no previous report about the presence of SVC cancerous
thrombosis in squamous cell tongue cancer.[2] Notably, all of the three Virchow's components[3] were present in our patient's SVC system, including metastatic[4] pericardial effusion-induced blood stasis, vascular tumour invasion and malignancy-associated
hypercoagulable state.[5] This catastrophic triad might have played a pivotal role in precipitating fatal
thrombogenesis in our rare patient. We also hypothesize that abrupt decrease of intra-pericardial
pressure after pericardiocentesis may have ‘opened the bag of Aeolus’, resulting in
thrombus prolapse within the right heart and fatal pulmonary embolism. Certainly,
case reports are of less clinical value in advancing scientific knowledge and reviewing
current therapeutic algorithms in rare diseases. However, our rare report may provide
an unusual mechanism of tongue cancer expansion, which clinicians should be familiar
with. In addition, it may highlight the clinical importance of TEE and vascular ultrasound
in early detection of occult thrombi in patients with SVC syndrome.
