Facial swelling and somnolence in a patient with cancer.

A 46-year-old female patient with a history of drug abuse (now on methadone), chronic hepatitis C and heavy smoking was admitted with a 4-month history of increasing low back pain radiating to her left leg, weight loss and sweats. Examination was non-contributory. Laboratory tests showed hemoglobin 12.7 g/dl, white blood cells 18.6 10/ml (neutrophils 14.8), platelets 411 10/ml, normal electrolytes, minimal liver enzymes disturbance and Erythrocyte sedimentation rate 86mm/h. Contrast computed tomography (CT) demonstrated lytic lesions in the left iliac and sacral bones, an adjacent large soft tissue mass with multiple (necrotic) lymph nodes in the retroperitoneum and liver hilum and two 28 to 36mm liver masses. Multiple pulmonary nodules were found, as well as (necrotic) lymph nodes in the mediastinum, right lung hilum, right axilla and neck. Imaging-guided biopsy confirmed poorly differentiated adenocarcinoma of unknown primary. While considering therapeutic options, the patient suddenly developed bilateral eyelid edema (right > left), face swelling and arm edema and gradually became increasingly somnolent with venous distention in the neck and superficial chest wall veins (Figure 1). CT now revealed a mass of enlarged hypodense mediastinal lymph nodes compressing the superior vena cava (SVC) (Figure 2). Prophylactic low molecular weight heparin was