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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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