A 46-year-old man was transferred to our emergency room for facial and upper trunk swelling and dyspnea with chest discomfort that had begun 1 month earlier. He was a 30-pack-year current smoker. On physical examination, neck vein engorgement was observed, with distended veins and edema on the upper trunk and both arms. Chest radiograph showed consolidation in the right paratracheal area that suggestive of central malignancy (Fig. 1). We performed chest computed tomography (CT) with contrast enhancement to rule out SVC syndrome. The CT revealed a soft-tissue mass in the right paratracheal area that has invaded into the SVC and extended to the right atrium with bilateral pleural effusions (Fig. 2A-C). Positron emission tomography (PET)-CT with 18F-fluorodeoxyglucose (FDG) showed increased FDG uptake, with a maximum standardized uptake value (SUVmax) of 10.6 in the SVC (Fig. 2D). It was not available to obtain tissue from the primary lesion in the right upper lung using CT-guided percutaneous core needle aspiration (PCNA). In the bronchoscopy, there was no endobronchial lesion. Therefore, we decided to perform EBUS-TBNA to obtain tissue from the intravascular mass in SVC. EBUS-TBNA was performed using an ultrasound bronchoscope with a linear scanning transducer. Under ultrasound visualization, the SVC was tightly packed by the mass and blood stream was not detected around the tumor. The tumor was punctured using a 22-gauge needle under real-time visualization (Fig. 3A). During the procedure, there was no serious bleeding or other complication. Cytopathology confirmed poorly differentiated adenocarcinoma, with TTF-1-positive immunohistochemistry (Fig. 3B). There were no epidermal growth factor receptor (EGFR) gene mutations or KRAS gene mutations. He received 4 cycles of gemcitabine-carboplatin chemotherapy for the treatment of lung cancer. Two months after the chemotherapy, chest CT showed that the tumor size was decreased and his symptoms were relieved as well (Fig. 4).
Initial lung mass in chest CT scan.