Eur J Cardiothorac Surg 2001;19:724-725
© 2001 Elsevier Science NL
Intraluminal biopsy of a superior vena cava mass
C.S. Carra,
R. Rawlinsa,
K.M. Browna,
J.F. Reidyb,
C.R. Camerona
a Department of Thoracic Surgery, Guy's Hospital, St. Thomas Street, London, SE1 9RT, UK
b Department of Interventional Radiology, Guy's Hospital, St. Thomas Street, London, SE1 9RT, UK
Received 6 September 2000;
received in revised form 7 February 2001;
accepted 28 February 2001.
Corresponding author. Department of Cardiac Surgery, St. Thomas' Hospital, Lambeth Palace Road, London, UK. Tel.: +44-20-79289292; fax: +44-20-79554858
e-mail: noahalkh{at}talk21.com
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Abstract
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A number of methods have been devised for the biopsy of intracaval tumour masses but all risk damage to the cava and tumour dissemination. We report on a case in which the tumour mass was almost entirely within the superior vena cava and describe an ‘endoscopic’ technique for biopsy.
Key Words: Intraluminal biopsy • Superior vena cava mass
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1. Introduction
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A number of methods have been devised for the biopsy of intracaval tumor masses including transcatheter aspiration [1], brush biopsy [2] and scoop biopsy [3]. These methods risk damage to the cava and tumor dissemination. The use of endoscopy biopsy forceps has been described for inferior vena cava (IVC) tumor [4–5] but not for superior vena cava (SVC) tumor. We describe a technique for biopsy in which the tumor mass was almost entirely within the SVC.
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2. Case report
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A 57-year-old man had presented with a 6 month history of pain, weakness and numbness of the right arm initially thought to be secondary to a brachial plexus injury. He then developed a right subclavian vein thrombosis and subsequent SVC obstruction. He had no significant past medical history but was an ex-smoker.
Chest X-ray suggested a right paratracheal mass and contrast computerized tomography (CT) showed a mass in the right neck infiltrating between the trachea and oesophagus extending into the right brachial plexus. The SVC was markedly enlarged with an intraluminal mass and no external compression (Fig. 1). Mediastinoscopy was not performed due to the possibility that the nodes may be adherent to the mass within the SVC and the potential for trauma to it. Positron emission tomography showed abnormal uptake behind the right clavicle and upper mediastinum with areas of uptake in the liver and spine, however ultrasound of the liver showed no macroscopic lesions. Since the bulk of the tumor was within the SVC biopsy of this mass was thought to be the only safe approach.
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Fig. 1. CT scan of the chest showing a large mass occupying the SVC with contrast seen running in from the left.
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Venography confirmed an endoluminal mass (Fig. 2), and a transvenous biopsy via a right femoral vein approach using a long 8F sheath was performed. Under fluoroscopy a guidewire was passed beyond the mass so localising the medial extent of the tumor and minimising the risk of intimal damage. The sheath was inserted up against the mass and endoscopy biopsy forceps were pushed into the mass for tissue retrieval. The procedure went uneventfully with four good specimens obtained.
Histology confirmed a large cell carcinoma probably of pulmonary origin. The patient was anticoagulated but unfortunately 5 days later became confused and dyspnoeic progressing to a respiratory arrest from which he was not resuscitated. Post-mortem examination was not performed.
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3. Discussion
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The choice of biopsy method has to balance the potential risks as well as the potential for positive histology. With intracaval tumors there is a risk of dissemintation. Aspiration techniques produce small samples, but scoop biopsy from the SVC has been shown to produce good sample size [3]. Intracaval endoscopy biopsy forceps have been used in the IVC [4–5] but do not appear to have been used in the SVC. This patient had no other lesions suitable for safe conventional biopsy, and evidence of dissemination, therefore despite his poor clinical state the biopsy procedure was uncomplicated yielding definitive histology. His subsequent death was sudden and probably unlikely to be related to the procedure. This report shows that intracaval ‘endoscopic’ biopsy can be an effective means of obtaining a biopsy specimen involving freely available equipment.
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References
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Abstract
1. Introduction
