V4) Facial and upper extremity swelling

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

  1. Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with generalized swelling.
  2. Review the DDx considerations in a patient with generalized swelling.
  3. Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with generalized swelling.


Physical Exam


Provisional Diagnosis

Select the Dx you believe is most appropriate
The patient likely has superior vena cava syndrome considering the symptom localization to the face and upper extremities and positive Pemberton maneuver. Their history including long-term smoking and constitutional symptoms suggests this would be secondary to a lung cancer.
Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

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Though their condition is not immediately life threatening, the patient requires expedited workup.

First Imaging Study

What is the first imaging study you will order?

A chest CT with IV contrast is an appropriate non-invasive initial study to assess for the presence of superior vena cava syndrome.
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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Watch our video

View the full study if you'd like to take a look yourself.

Second Imaging Study

What is the next imaging study you will order?

A staging PET CT would be the next best step. The images are not included for the purposes of this case.
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What is your Diagnosis now that you have seen the imaging results?

The clinical and imaging findings are consistent with SVC syndrome secondary to a mass that is likely from metastatic spread of lung cancer to lymph nodes.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Though the patient’s condition is not immediately life threatening, they will require further workup.

Assessment and Plan

Please provide your assessment and plan for this patient

The patient is a 60-year-old female with significant smoking history presenting with cough, constitutional symptoms, and upper body swelling. Imaging demonstrated right upper lobe masses with a large right mediastinal lymph mass consistent with metastatic disease which encases and occludes the upper SVC, leading to SVC syndrome. Oncology, pulmonology, and vascular surgery should be consulted for further evaluation.

Lessons Learned:
- SVC syndrome can present occur from intrinsic stenosis, thrombosis, or as in this case, extrinsic compression of the SVC.
- SVC syndrome is characterized on CT scan by presence of SVC occlusion, collateral vasculature (including the “hot quadrate” sign), and extensive upper body soft tissue swelling.

That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.

Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator