A previously healthy 58-year-old man presented to the emergency department with a 4-week history of gradually progressive dyspnea, facial flushing, and night sweats. Three weeks before presentation, he received the diagnosis of acne rosacea from an outside physician and was given topical treatments, with no relief in symptoms. One week before presentation, he began to notice swelling of the face, neck, and right arm and dysphagia (initially with solids, then progressing to liquids).
On physical examination, his vital signs included a temperature of 36.7[degrees]C (98.1[degrees]F), pulse of 76 beats per minute, blood pressure of 132/79 mm Hg, respiration rate of 21 breaths per minute, and arterial oxygen saturation of 95% while breathing ambient air. The patient had a hoarse voice and facial plethora.
Neck examination (while upright) revealed fullness in the right supraclavicular fossa and internal jugular vein distention to the angle of the mandible. The patient's right hand and forearm were asymmetrically larger than the left, and skin examination revealed distended veins across his chest. The cardiopulmonary examination findings were normal.
Admission laboratory data revealed normal complete blood cell count and differential, and normal basic metabolic panel and liver function test results. ECG findings suggested a prior anterior myocardial infarction.
The patient's chest radiograph (Figure 1) and CT scan of the chest after administration of intravenous contrast material (Figure 2) are shown below.
How would you interpret these findings? How would you proceed?
MAKING THE DIAGNOSIS
The chest radiograph revealed fullness in the superior mediastinum with the trachea remaining midline. The margins of the aorta remained visible, suggesting that the mass was not in the posterior mediastinum, but was in either the anterior or middle mediastinum.
The CT scan of the patient's chest showed a soft tissue attenuation mass in the middle mediastinum, causing marked compression of the superior vena cava (SVC). Tracheal compression and hypodense lesions suggesting malignancy in the left kidney and bilateral adrenal glands were also present.
Flexible bronchoscopy with transbronchial needle biopsy was performed; however, samples revealed only inflammatory cells. A CT-guided transthoracic needle biopsy obtained tissue that was consistent with small-cell carcinoma. The diagnosis was...