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A visual discussion of superior vena cava obstruction and superior vena cava syndrome. To be accompanied by "SVCO Lecture Notes". Discusses role of radiation, stents, and steroids (corticosteroids).
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Superior vena cava obstruction
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Case 1
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Clinical presentation
4Wilson et al. Superior Vena Cava Syndrome with Malignant Causes. N Engl J Med 2007;356:1862-9.
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Differential diagnosis
7Wilson et al. Superior Vena Cava Syndrome with Malignant Causes. N Engl J Med 2007;356:1862-9.
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Pathophysiology
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Wilson et al. Superior Vena Cava Syndrome with Malignant Causes. N Engl J Med 2007;356:1862-9.
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Findings on imaging
12Wilson et al. Superior Vena Cava Syndrome with Malignant Causes. N Engl J Med 2007;356:1862-9.
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Definitive diagnosis
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Complications of definitive diagnosis
18Dosios et al. Chest 2005; 128:1551–1556
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Management
• Is it an emergency?• Supportive care
• Definitive treamtent– Chemotherapy– Radiotherapy– Stent– Surgery
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Is it an emergency?
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Supportive care
• Elevate patient’s head• Steroids?• Loop diuretics?• Evidence???
• Special cases:– IV placement– Thrombosis
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Definitive therapy• Chemotherapy– NHL– SCLC– Germ cell tumours
• Radiotherapy
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Surgery
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Evidence
• Clinical Oncology (2002)– SCLC: relief?– NSCLC: relief?– Stent: relief?– Rapidity of response?– Relapse rates?
26Rowell et al. Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus: a systematic review. Clinical Oncology 2002; 14:338-351.
27Rowell et al. Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus: a systematic review. Clinical Oncology 2002; 14:338-351.
28Rowell et al. Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus: a systematic review. Clinical Oncology 2002; 14:338-351.
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Outcome Chemotherapy Radiotherapy Stent
Relief of symptoms (SCLC)
76.9% 70.4% (prior CT)94.4% (no CT)
95% (all)
Relief of symptoms (NSCLC)
59% 63%
Rapidity of response
7-21 days 24-72 hrs
Relapse rates 16.7% (SCLC)18.5% (NSCLC)
11% (all)
Rowell et al. Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus: a systematic review. Clinical Oncology 2002; 14:338-351.
Caveats:• Trials included in systematic review were of moderate
quality (44 non-randomized, 2 RCTs)• Small numbers of patients
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Prognosis
SVCO itself
Malignancy-relatedIs SVCO an independent prognostic factor for survival?
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Case 2
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SVCO
In distressStridor, laryngeal
edema, cerebral edema
Urgent steroids, stent, radiotherapy
Symptomatic
StentProceed to "No distress"
No distress
Obtain pathologic diagnosis
Lymphoma
Chemotherapy, radiotherapy, ±steroids
SCLC
Chemotherapy, radiotherapy
NSCLC
Radiotherapy, chemotherapy
Thymoma
Chemotherapy, surgery, then radiotherapy
Tailored treatment depending on diagnosis
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