Introduction: Superior vena cava (SVC) syndrome which is defined as the obstruction of blood flow through the SVC vein, often affecting patients with malignancy especially small cell lung cancer (SCLC) and is potentially an emergent condition needing prompt management. It is an ominous sign with poor prognosis and a mean of 8-10 months survival rate.&nbsp;Case presentation: Here we present a middle-aged man who presented with fascial swelling and dyspnea with final diagnosis of advanced SCLC. Combination of multiple chemotherapy regimen, prophylactic brain radiation with administration of anticoagulant drugs were performed for him leading toward extension of his survival to 28 months.&nbsp;Conclusion: These therapeutic approaches may lead to extending the survival in patients with SVC syndrome and SCLC

Akhondzadeh, Neda

Haseli, Sara

Keshavarz, Pedram

English

Advanced Journal of Emergency medicine

ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e79 Keshavarz et al 
   
 1 Copyright © 2020 Tehran University of Medical Sciences 
This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). 
 
 
Case Study DOI: 10.22114/ajem.v0i0.250 
Extending Survival in a Patient with Extensive Stage of Small Cell Lung 
Cancer Presenting with Superior Vena Cava Syndrome as an Initial 
Symptom: A Case Study 
  
Pedram Keshavarz1*, Sara Haseli1, Neda Akhondzadeh2 
 
1. Department of Radiology, Medical Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. 
2. Department of Emergency Medicine, Poursina Clinical Research Development Unit, Guilan University of Medical Sciences, Rasht, Iran. 
 
*Corresponding author: Pedram Keshavarz; Email: keshavarz.p2390@gmail.com 
Published online: 2019-12-17 
Abstract  
Introduction: Superior vena cava (SVC) syndrome which is defined as the obstruction of blood flow through 
the SVC vein, often affecting patients with malignancy especially small cell lung cancer (SCLC) and is 
potentially an emergent condition needing prompt management. It is an ominous sign with poor prognosis 
and a mean of 8-10 months survival rate. 
Case presentation: Here we present a middle-aged man who presented with fascial swelling and dyspnea 
with final diagnosis of advanced SCLC. Combination of multiple chemotherapy regimen, prophylactic brain 
radiation with administration of anticoagulant drugs were performed for him leading toward extension of 
his survival to 28 months.  
Conclusion: These therapeutic approaches may lead to extending the survival in patients with SVC 
syndrome and SCLC. 
Key words: Single-Case Studies as Topic; Small Cell Lung Carcinoma; Superior Vena Cava Syndrome; 
Survival 
Cite this article as: Keshavarz P, Haseli S, Akhondzadeh N. Extending Survival in a Patient with Extensive Stage of Small Cell Lung 
Cancer Presenting with Superior Vena Cava Syndrome as an Initial Symptom: A Case Study. Adv J Emerg Med. 2020;4(3):e79. 
INTRODUCTION
Superior vena cava (SVC) syndrome is defined as 
the obstruction of blood flow through the SVC vein 
(1). It is a kind of oncology emergency needing 
prompt management (2). Its symptoms such as 
fascial erythema, swelling and edema are 
secondary to upstream increase in venous 
pressure resulting from SVC vein occlusion 
leading to venous drainage impairment in the 
head and neck (3). It can potentially propel to 
cerebral edema and intracranial hypertension or 
airway compromise secondary to laryngeal edema 
(4). SVC syndrom usually affects patients with 
malignancy especially those with small cell lung 
cancer (SCLC) due to its central location and 
associated lymphadenopathy causing pressure 
effect over SVC vein (5). Although the underlying 
disease is somewhat sensitive to chemotherapy 
and radiotherapy, full recovery is often difficult to 
achieve. Here we present a middle-aged man who 
presented with SVC syndrome with final diagnosis 
of advanced SCLC who underwent several 
therapeutic methods leading toward extension of 
his survival to 28 months. 
CASE PRESENTATION 
A 54-year-old man presented with facial swelling, 
erythema and dyspnea lasting for 4 weeks. He also 
had productive cough with occasional bloody 
sputum. His past medical history was positive for 
25-year cigarette smoking (50 packs a year). On 
physical exam he was a man with body mass index 
(BMI) of 24 and blood pressure of 115/75 mmHg, 
heart rate of 85 beats per minute, respiratory rate 
of 19 per minute and O2 saturation of 90% on 
room air. Facial plethora, neck swelling, purple 
discoloration of the face and neck with prominent 
external jugular veins and some collateral vessels 
on his face, neck and upper thoracic area were 
found (Figure 1). Other parts of physical 
examinations were unremarkable. Chest X-ray 
was requested which showed lobulated 
mediastinal widening and “S-golden sign” in right 
lung representative of concomitant right hilar 
mass and upper lobe atelectasis. Elevation of the 
right hemi-diaphragm was also seen with 
“juxtaphrenic peak sign” secondary to upper lobe 
atelectasis (Figure 2). 
Contrast enhance computed tomography (CT) 
scan of the chest was performed which revealed a 
large mass about in right side of upper 
mediastinum extending to the right hilum. It 
causes significant narrowing and encasement of 
ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e79 Keshavarz et al 
   
 2 Copyright © 2020 Tehran University of Medical Sciences 
This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). 
 
 
the SVC vein and right pulmonary artery. 
Elevation of the right hemi diaphragm was 
demonstrated with linear atelectasis at basal 
segments of the right lung representative of 
phrenic nerve invasion by the mentioned large 
mass (Figure 3).  In visualized part of abdomen, 
there was enhancing heterogeneous mass 
involving the left adrenal gland suggestive of 
metastasis. Based on imaging findings advanced 
stage of lung cancer with metastasis (T4N2M1) 
was diagnosed.  
Trucut biopsy was done under guide of CT scan. 
The final histopathologic result confirmed SCLC. 
Chemotherapeutic regimen was prescribed 
including 14 cycle platinum doublets protocol, 
Cisplatin and Etoposide. SVC syndrome associated 
symptoms improved significantly after the third 
chemotherapy session.  
Ten sessions of the whole brain radiotherapy 
were done prophylactically. The patient had no 
neurological symptoms at time of brain radiation 
and subsequent brain magnetic resonance 
imaging (MRI) revealed no intracranial metastasis. 
Whole body positron emission tomography scan 
(PET-scan) was done to determine the response to 
treatment after the 8th chemotherapy. It showed a 
central 18 F-FDG avidly uptake mass in right 
upper lobe representative of primary SCLC (SUV 
max=8.3). Right para-tracheal 18 F-FDG-avidly 
uptake metastatic adenopathy was seen (SUV 
max=6.6). Another FDG avid uptake mass within 
the right adrenal gland was also note (SUV=6.2) 
(Figure 4). 
According to PET-scan no new metastasis was 
occurred and partial response to treatment was 
achieved. SVC syndrome symptoms reappeared 
after cessation of chemotherapy regimen. 
Chemotherapeutic regimen was changed to 
Ifosfamide – Etoposide therapeutic protocol. 
Intravenous anticoagulant medication was also 
prescribed. The patient’s syndrome responded 
well with new chemotherapeutic protocol. After 
that patient presented with bilateral pleural 
 
Figure 1: Neck and upper chest appearance of the patient. 
Engorgement and dilation of the superficial veins and 
extensive venous collateral circulation in the chest wall 
with also bilateral external jugular vein prominence and 
purple discoloration of neck and upper thorax is seen (red 
arrows) 
 
 
Figure 2: The chest x-ray of the patient. AP chest x-ray 
shows lobulated mediastinal widening and “S-golden sign” 
in right lung representative of concomitant right hilar mass 
and upper lobe atelectasis. (red arrow) elevation of right 
hemi-diaphragm is also seen (yellow arrow) with 
“juxtaphrenic peak sign” secondary to upper lobe 
atelectasis. 
 
 
Figure 3: Axial contrast-enhanced computed tomography 
scan (CT scan) of upper mediastinum revealed large mass 
(green arrows) with pressure effect and encasement over 
compression of the SVC (red arrows) and extending to right 
hilum. 
 
ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e79 Keshavarz et al 
   
 3 Copyright © 2020 Tehran University of Medical Sciences 
This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). 
 
 
effusion which pleurodesis with bleomycin was 
performed. After two years, the patient presented 
with neurologic symptoms including seizure and 
slurred speech. Subsequent brain MRI found 
multiple intracranial metastasis. Unfortunately, 
despite all therapeutic modalities, the patient was 
expired almost 28 months after initial 
presentation.  
DISCUSSION 
SVC syndrome usually presents in patients with 
underlying malignancy, leads to an ominous 
prognosis; but it sometimes responds to 
chemotherapy with or without radiotherapy (6, 
7). CT-scan is a valuable modality for detection of 
possible underlying malignancy in patients 
presenting with SVC syndrome (8).  
SCLC accounts for 20-25% of all lung cancer cases. 
Due to its central location and associated 
lymphadenopathy, causing pressure effect over 
SVC vein, it can cause SVC syndrome (5). It is an 
aggressive form of lung cancer with tendency 
toward dissemination and early metastasis (9). 
Limited-stage of SCLC is cured by combination of 
chemotherapy with radiation therapy; in about 
20% of the patient’s cure can be achievable in 
early stages. The mean survival rate for patients 
with limited-stage of the disease is nearly 18 
months (10). SCLC cases presenting at advanced 
stage of the disease are primarily treated with 
chemotherapy, with a high initial response rate of 
about 70% and a complete response rate of about 
30% but with a median survival time of 
approximately 10 months (11, 12).  
Nowadays platinum and etoposide combination is 
the accepted standard chemotherapeutic regimen 
(13). Thoracic radiotherapy (TRT) is another 
accepted therapeutic method for patients with 
limited stage of the disease (14). Adding TRT 
would improve the survival rate approximately 
5% in comparison to chemotherapy alone. TRT 
performed simultaneously with chemotherapy is 
more effective than sequential therapy (15). 
Furthermore, the survival benefit is greater if TRT 
is given earlier in the course of chemotherapy 
(16). Patients with SCLC whose symptoms persist 
or progress after first-line chemotherapy have a 
high mortality rate. Second-line therapy may 
produce a modest clinical benefit. Few studies 
have revealed that there is usually partial 
response to the SCLC after the first line of 
chemotherapy; but, unfortunately, we see the 
tumor regression infrequently, and most cases 
usually need second line therapy (17, 18).  
In a case report from the Netherland the authors 
reported a SCLC case with paraneoplastic 
nephrotic syndrome who had a 7-month survival 
rate. They present the same picture of our case 
(but they didn't start a prophylactic brain 
radiotherapy for the patient at all) and after 5 
months of first line chemotherapy, the patient had 
a brain metastases and then expired after two 
months (19); this is in contrast to our results 
about the survival rate. 
In another case from China, the authors presented 
a patient with transformed SCLC from lung 
adenocarcinoma with metastasis to the brain and 
then liver during the chemotherapy treatment 
cycles. They also did not do the prophylactic brain 
radiation in the first time that the diagnosis was 
confirmed, and finally they saw rapid progression 
of the tumor to other organs like brain and liver 
and the patient died within a short period of time 
(20).   
Although the combination of SVC syndrome and 
SCLC leads to survival rate of less than 8 months, 
here we report a case in which combination of 
multiple chemotherapy regimen, prophylactic 
brain radiation with administration of 
anticoagulant drugs contributed to the 
improvement of survival to 28 months. 
CONCLUSIONS 
Multiple combination of chemotherapeutic 
regimen with radiation therapy, prophylactic 
brain radiotherapy, and anticoagulant 
administration can leads to extending the survival 
in patients with SVC syndrome and SCLC, and may 
provide bright horizons in the treatment of similar 
patients. 
 
Figure 4: Frontal view of positron emission tomography 
scan (PET-Scan) showed an avidly uptake 18F-FDG mass 
lesion in the right upper lobe and the right para-tracheal 
that are primary lung mass and its metastatic para-tracheal 
lymph node respectively (red arrow) and another mass in 
the right adrenal gland (blue arrow) 
 
ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e79 Keshavarz et al 
   
 4 Copyright © 2020 Tehran University of Medical Sciences 
This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). 
 
 
ACKNOWLEDGEMENTS 
The authors would like to thanks the staff of the 
radiology department of Shiraz University of 
Medical Sciences for their kind cooperation in 
gathering data. 
AUTHORS’ CONTRIBUTION 
All the authors fulfil the criteria of authorship 
based on the recommendations of the 
International Committee of Medical Journal 
Editors (ICMJE). 
CONFLICT OF INTEREST 
None declared  
FUNDING 
None declared 
REFERENCES 
1. Ho YJ, Yeh CH, Lai CC, Huang JC, Chuang LH. ExPRESS miniature glaucoma shunt for intractable 
secondary glaucoma in superior vena cava syndrome-a case report. BMC Ophthalmol. 2016;16:125. 
2. Bajwa R, Cheema A, Khan T, Lerner W, Bauer T, Frasco F. A Drooling Man: A Case of Superior Vena 
Cava Syndrome. Am J Respir Crit Care Med. 2018;197:A4121. 
3. Danjoux C, Tsao M, Barnes E, Chow E. Superior vena cava syndrome. J Pain Manag. 2015;8(4):283-7. 
4. Zimmerman S, Davis M. Rapid Fire: Superior Vena Cava Syndrome. Emerg Med Clin North 
Am. 2018;36(3):577-84. 
5. Sfyroeras G, Geroulakos G. Superior Vena Cava Syndrome. Vascular Surgery: Springer; 2018. 
6. Dimakakos E, Micha F, Charpidou A, Gkiozos I, Tsagkouli S, Kiagia M, et al. Superior vena cava 
syndrome in lung cancer patients: How to prevent its venous thromboembolism complications. Thromb 
Res. 2018;164:S237. 
7. Noaparast M, Zebardast J, Namvari A. The Patency Rate of Endovascular Procedure in Patients with 
Superior Vena Cava Syndrome Caused by Intravenous Catheterization: A Case Series and Longitudinal 
Study. Adv J Emerg Med. 2020;4(In Press). 
8. Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and 
evolving etiology. Medicine (Baltimore). 2006;85(1):37-42. 
9. Kocak MZ, Aktas G, Erkus E, Atak B, Duman T, Savli H. Superior Vena Cava Syndrome and Multiple 
Venous Thrombosis in a Patient with B Cell Lymphoma. Althea Med J. 2018;5(1):12-5. 
10. Drews RE, Rabkin DJ, Eidt JF, Collins KA. Malignancy-related superior vena cava syndrome. 
UpToDate, Waltham, MA. 2016. 
11. Coutinho AD, Shah M, Lunacsek OE, Eaddy M, Willey JP. Real-world treatment patterns and 
outcomes of patients with small cell lung cancer progressing after 2 lines of therapy. Lung Cancer. 
2019;127:53-8. 
12. Alvarado-Luna G, Morales-Espinosa D. Treatment for small cell lung cancer, where are we now?—a 
review. Transl Lung Cancer Res. 2016;5(1):26-38. 
13. Reck M, Luft A, Szczesna A, Havel L, Kim SW, Akerley W, et al. Phase III randomized trial of 
ipilimumab plus etoposide and platinum versus placebo plus etoposide and platinum in extensive-stage 
small-cell lung cancer. J Clin Oncol. 2016;34(31):3740-8. 
14. Cook RF, Miller YE, Bunn Jr PA. Small cell lung cancer: etiology, biology, clinical features, staging, and 
treatment. Curr Probl Cancer. 1993;17(2):69-141. 
15. Slotman BJ, van Tinteren H, Praag JO, Knegjens JL, El Sharouni SY, Hatton M, et al. Use of thoracic 
radiotherapy for extensive stage small-cell lung cancer: a phase 3 randomised controlled trial. Lancet. 
2015;385(9962):36-42. 
16. Palma DA, Warner A, Louie AV, Senan S, Slotman B, Rodrigues GB. Thoracic radiotherapy for 
extensive stage small-cell lung cancer: a meta-analysis. Clin Lung Cancer. 2016;17(4):239-44. 
17. Vanhees S, Paridaens R, Vansteenkiste J. Syndrome of inappropriate antidiuretic hormone associated 
with chemotherapy-induced tumour lysis in small-cell lung cancer: case report and literature review. 
Ann Oncol. 2000;11(8):1061-5. 
ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e79 Keshavarz et al 
   
 5 Copyright © 2020 Tehran University of Medical Sciences 
This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0). 
 
 
18. Horino T, Takao T, Yamamoto M, Geshi T, Hashimoto K. Spontaneous remission of small cell lung 
cancer: a case report and review in the literature. Lung Cancer. 2006;53(2):249-52. 
19. Boon E, Vrij A, Nieuwhof C, Van Noord J, Zeppenfeldt E. Small cell lung cancer with paraneoplastic 
nephrotic syndrome. Eur Respir J. 1994;7(6):1192-3. 
20. Jiang S-Y, Zhao J, Wang M-Z, Huo Z, Zhang J, Zhong W, et al. Small-cell lung cancer transformation in 
patients with pulmonary adenocarcinoma: A case report and review of literature. Medicine 
(Baltimore). 2016;95(6):e2752. 
 
 
 
 
 
 
 
 
 


Extending Survival in a Patient with Extensive Stage of Small Cell Lung Cancer Presenting with Superior Vena Cava Syndrome as an Initial Symptom: A Case Study

Frontiers in Emergency Medicine (E-Journal)

ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e79 Keshavarz et al     1 Copyright © 2020 Tehran University of Medical Sciences This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0).   Case Study DOI: 10.22114/ajem.v0i0.250 Extending Survival in a Patient with Extensive Stage of Small Cell Lung Cancer Presenting with Superior Vena Cava Syndrome as an Initial Symptom: A Case Study   Pedram Keshavarz1*, Sara Haseli1, Neda Akhondzadeh2  1. Department of Radiology, Medical Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. 2. Department of Emergency Medicine, Poursina Clinical Research Development Unit, Guilan University of Medical Sciences, Rasht, Iran.  *Corresponding author: Pedram Keshavarz; Email: keshavarz.p2390@gmail.com Published online: 2019-12-17 Abstract  Introduction: Superior vena cava (SVC) syndrome which is defined as the obstruction of blood flow through the SVC vein, often affecting patients with malignancy especially small cell lung cancer (SCLC) and is potentially an emergent condition needing prompt management. It is an ominous sign with poor prognosis and a mean of 8-10 months survival rate. Case presentation: Here we present a middle-aged man who presented with fascial swelling and dyspnea with final diagnosis of advanced SCLC. Combination of multiple chemotherapy regimen, prophylactic brain radiation with administration of anticoagulant drugs were performed for him leading toward extension of his survival to 28 months.  Conclusion: These therapeutic approaches may lead to extending the survival in patients with SVC syndrome and SCLC. Key words: Single-Case Studies as Topic; Small Cell Lung Carcinoma; Superior Vena Cava Syndrome; Survival Cite this article as: Keshavarz P, Haseli S, Akhondzadeh N. Extending Survival in a Patient with Extensive Stage of Small Cell Lung Cancer Presenting with Superior Vena Cava Syndrome as an Initial Symptom: A Case Study. Adv J Emerg Med. 2020;4(3):e79. INTRODUCTIONSuperior vena cava (SVC) syndrome is defined as the obstruction of blood flow through the SVC vein (1). It is a kind of oncology emergency needing prompt management (2). Its symptoms such as fascial erythema, swelling and edema are secondary to upstream increase in venous pressure resulting from SVC vein occlusion leading to venous drainage impairment in the head and neck (3). It can potentially propel to cerebral edema and intracranial hypertension or airway compromise secondary to laryngeal edema (4). SVC syndrom usually affects patients with malignancy especially those with small cell lung cancer (SCLC) due to its central location and associated lymphadenopathy causing pressure effect over SVC vein (5). Although the underlying disease is somewhat sensitive to chemotherapy and radiotherapy, full recovery is often difficult to achieve. Here we present a middle-aged man who presented with SVC syndrome with final diagnosis of advanced SCLC who underwent several therapeutic methods leading toward extension of his survival to 28 months. CASE PRESENTATION A 54-year-old man presented with facial swelling, erythema and dyspnea lasting for 4 weeks. He also had productive cough with occasional bloody sputum. His past medical history was positive for 25-year cigarette smoking (50 packs a year). On physical exam he was a man with body mass index (BMI) of 24 and blood pressure of 115/75 mmHg, heart rate of 85 beats per minute, respiratory rate of 19 per minute and O2 saturation of 90% on room air. Facial plethora, neck swelling, purple discoloration of the face and neck with prominent external jugular veins and some collateral vessels on his face, neck and upper thoracic area were found (Figure 1). Other parts of physical examinations were unremarkable. Chest X-ray was requested which showed lobulated mediastinal widening and “S-golden sign” in right lung representative of concomitant right hilar mass and upper lobe atelectasis. Elevation of the right hemi-diaphragm was also seen with “juxtaphrenic peak sign” secondary to upper lobe atelectasis (Figure 2). Contrast enhance computed tomography (CT) scan of the chest was performed which revealed a large mass about in right side of upper mediastinum extending to the right hilum. It causes significant narrowing and encasement of ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e79 Keshavarz et al     2 Copyright © 2020 Tehran University of Medical Sciences This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0).   the SVC vein and right pulmonary artery. Elevation of the right hemi diaphragm was demonstrated with linear atelectasis at basal segments of the right lung representative of phrenic nerve invasion by the mentioned large mass (Figure 3).  In visualized part of abdomen, there was enhancing heterogeneous mass involving the left adrenal gland suggestive of metastasis. Based on imaging findings advanced stage of lung cancer with metastasis (T4N2M1) was diagnosed.  Trucut biopsy was done under guide of CT scan. The final histopathologic result confirmed SCLC. Chemotherapeutic regimen was prescribed including 14 cycle platinum doublets protocol, Cisplatin and Etoposide. SVC syndrome associated symptoms improved significantly after the third chemotherapy session.  Ten sessions of the whole brain radiotherapy were done prophylactically. The patient had no neurological symptoms at time of brain radiation and subsequent brain magnetic resonance imaging (MRI) revealed no intracranial metastasis. Whole body positron emission tomography scan (PET-scan) was done to determine the response to treatment after the 8th chemotherapy. It showed a central 18 F-FDG avidly uptake mass in right upper lobe representative of primary SCLC (SUV max=8.3). Right para-tracheal 18 F-FDG-avidly uptake metastatic adenopathy was seen (SUV max=6.6). Another FDG avid uptake mass within the right adrenal gland was also note (SUV=6.2) (Figure 4). According to PET-scan no new metastasis was occurred and partial response to treatment was achieved. SVC syndrome symptoms reappeared after cessation of chemotherapy regimen. Chemotherapeutic regimen was changed to Ifosfamide – Etoposide therapeutic protocol. Intravenous anticoagulant medication was also prescribed. The patient’s syndrome responded well with new chemotherapeutic protocol. After that patient presented with bilateral pleural  Figure 1: Neck and upper chest appearance of the patient. Engorgement and dilation of the superficial veins and extensive venous collateral circulation in the chest wall with also bilateral external jugular vein prominence and purple discoloration of neck and upper thorax is seen (red arrows)   Figure 2: The chest x-ray of the patient. AP chest x-ray shows lobulated mediastinal widening and “S-golden sign” in right lung representative of concomitant right hilar mass and upper lobe atelectasis. (red arrow) elevation of right hemi-diaphragm is also seen (yellow arrow) with “juxtaphrenic peak sign” secondary to upper lobe atelectasis.   Figure 3: Axial contrast-enhanced computed tomography scan (CT scan) of upper mediastinum revealed large mass (green arrows) with pressure effect and encasement over compression of the SVC (red arrows) and extending to right hilum.  ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e79 Keshavarz et al     3 Copyright © 2020 Tehran University of Medical Sciences This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0).   effusion which pleurodesis with bleomycin was performed. After two years, the patient presented with neurologic symptoms including seizure and slurred speech. Subsequent brain MRI found multiple intracranial metastasis. Unfortunately, despite all therapeutic modalities, the patient was expired almost 28 months after initial presentation.  DISCUSSION SVC syndrome usually presents in patients with underlying malignancy, leads to an ominous prognosis; but it sometimes responds to chemotherapy with or without radiotherapy (6, 7). CT-scan is a valuable modality for detection of possible underlying malignancy in patients presenting with SVC syndrome (8).  SCLC accounts for 20-25% of all lung cancer cases. Due to its central location and associated lymphadenopathy, causing pressure effect over SVC vein, it can cause SVC syndrome (5). It is an aggressive form of lung cancer with tendency toward dissemination and early metastasis (9). Limited-stage of SCLC is cured by combination of chemotherapy with radiation therapy; in about 20% of the patient’s cure can be achievable in early stages. The mean survival rate for patients with limited-stage of the disease is nearly 18 months (10). SCLC cases presenting at advanced stage of the disease are primarily treated with chemotherapy, with a high initial response rate of about 70% and a complete response rate of about 30% but with a median survival time of approximately 10 months (11, 12).  Nowadays platinum and etoposide combination is the accepted standard chemotherapeutic regimen (13). Thoracic radiotherapy (TRT) is another accepted therapeutic method for patients with limited stage of the disease (14). Adding TRT would improve the survival rate approximately 5% in comparison to chemotherapy alone. TRT performed simultaneously with chemotherapy is more effective than sequential therapy (15). Furthermore, the survival benefit is greater if TRT is given earlier in the course of chemotherapy (16). Patients with SCLC whose symptoms persist or progress after first-line chemotherapy have a high mortality rate. Second-line therapy may produce a modest clinical benefit. Few studies have revealed that there is usually partial response to the SCLC after the first line of chemotherapy; but, unfortunately, we see the tumor regression infrequently, and most cases usually need second line therapy (17, 18).  In a case report from the Netherland the authors reported a SCLC case with paraneoplastic nephrotic syndrome who had a 7-month survival rate. They present the same picture of our case (but they didn't start a prophylactic brain radiotherapy for the patient at all) and after 5 months of first line chemotherapy, the patient had a brain metastases and then expired after two months (19); this is in contrast to our results about the survival rate. In another case from China, the authors presented a patient with transformed SCLC from lung adenocarcinoma with metastasis to the brain and then liver during the chemotherapy treatment cycles. They also did not do the prophylactic brain radiation in the first time that the diagnosis was confirmed, and finally they saw rapid progression of the tumor to other organs like brain and liver and the patient died within a short period of time (20).   Although the combination of SVC syndrome and SCLC leads to survival rate of less than 8 months, here we report a case in which combination of multiple chemotherapy regimen, prophylactic brain radiation with administration of anticoagulant drugs contributed to the improvement of survival to 28 months. CONCLUSIONS Multiple combination of chemotherapeutic regimen with radiation therapy, prophylactic brain radiotherapy, and anticoagulant administration can leads to extending the survival in patients with SVC syndrome and SCLC, and may provide bright horizons in the treatment of similar patients.  Figure 4: Frontal view of positron emission tomography scan (PET-Scan) showed an avidly uptake 18F-FDG mass lesion in the right upper lobe and the right para-tracheal that are primary lung mass and its metastatic para-tracheal lymph node respectively (red arrow) and another mass in the right adrenal gland (blue arrow)  ADVANCED JOURNAL OF EMERGENCY MEDICINE. 2020;4(3):e79 Keshavarz et al     4 Copyright © 2020 Tehran University of Medical Sciences This open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 License (CC BY-NC 4.0).   ACKNOWLEDGEMENTS The authors would like to thanks the staff of the radiology department of Shiraz University of Medical Sciences for their kind cooperation in gathering data. AUTHORS’ CONTRIBUTION All the authors fulfil the criteria of authorship based on the recommendations of the International Committee of Medical Journal Editors (ICMJE). CONFLICT OF INTEREST None declared  FUNDING None declared REFERENCES 1. Ho YJ, Yeh CH, Lai CC, Huang JC, Chuang LH. ExPRESS miniature glaucoma shunt for intractable secondary glaucoma in superior vena cava syndrome-a case report. BMC Ophthalmol. 2016;16:125. 2. Bajwa R, Cheema A, Khan T, Lerner W, Bauer T, Frasco F. A Drooling Man: A Case of Superior Vena Cava Syndrome. Am J Respir Crit Care Med. 2018;197:A4121. 3. Danjoux C, Tsao M, Barnes E, Chow E. Superior vena cava syndrome. J Pain Manag. 2015;8(4):283-7. 4. Zimmerman S, Davis M. Rapid Fire: Superior Vena Cava Syndrome. Emerg Med Clin North Am. 2018;36(3):577-84. 5. Sfyroeras G, Geroulakos G. Superior Vena Cava Syndrome. Vascular Surgery: Springer; 2018. 6. Dimakakos E, Micha F, Charpidou A, Gkiozos I, Tsagkouli S, Kiagia M, et al. Superior vena cava syndrome in lung cancer patients: How to prevent its venous thromboembolism complications. Thromb Res. 2018;164:S237. 7. Noaparast M, Zebardast J, Namvari A. The Patency Rate of Endovascular Procedure in Patients with Superior Vena Cava Syndrome Caused by Intravenous Catheterization: A Case Series and Longitudinal Study. Adv J Emerg Med. 2020;4(In Press). 8. Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and evolving etiology. Medicine (Baltimore). 2006;85(1):37-42. 9. Kocak MZ, Aktas G, Erkus E, Atak B, Duman T, Savli H. Superior Vena Cava Syndrome and Multiple Venous Thrombosis in a Patient with B Cell Lymphoma. Althea Med J. 2018;5(1):12-5. 10. Drews RE, Rabkin DJ, Eidt JF, Collins KA. Malignancy-related superior vena cava syndrome. UpToDate, Waltham, MA. 2016. 11. Coutinho AD, Shah M, Lunacsek OE, Eaddy M, Willey JP. Real-world treatment patterns and outcomes of patients with small cell lung cancer progressing after 2 lines of therapy. Lung Cancer. 2019;127:53-8. 12. Alvarado-Luna G, Morales-Espinosa D. Treatment for small cell lung cancer, where are we now?—a review. 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Extending Survival in a Patient with Extensive Stage of Small Cell Lung Cancer Presenting with Superior Vena Cava Syndrome as an Initial Symptom: A Case Study

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