A 28 year old plumber presented with 11 year history of worsening head and neck symptoms. In the year 2000 he was diagnosed with anaplastic large cell lymphoma of the neck and axillae. He was treated with 6 cycles of chemotherapy. Five separate Hickman lines were used, three were right sided and two were left sided. Over the years he developed worsening exercise tolerance and gradually he became unable to perform the physical demands of his job. He complained of dull headaches, he developed worsening fascial and neck swelling and on three different occasions he had epistaxis. Bending forward for 5–10 min after manual exercise, precipitated presyncopal symptoms and on two occasions he lost consciousness. For the last 6 months prior to his outpatient visit he stopped working because of the severity of his symptoms. On examination the patient had a plythoric engorged face. There were varicose veins visible over the sternum and the right anterior axillary line. There were also...
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