SVC Syndrome

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					                                      SVC Syndrome
Wilson, LD et al. Superior Vena Cava Syndrome with Malignant Causes 2007;356(18):1862-9.
Key Points:
           Patients often present with facial edema, distended neck and chest veins, dyspnea,
            and cough
         2/3 of cases related to malignant conditions of which NSCLC followed by SCLC
            most common
         Treatment involves treating underlying cause and may involve other means to relieve
            obstruction
Background:
         Affects 15,000 persons per year in U.S.
         Obstruction of SVC via mediastinal mass, thrombosis  edema of head, neck, arms
Etiologies:
         1/3 non-malignant causes such as thrombosis (esp r/t IV devices like catheters and
            pacemakers), syphilitic aortic aneurysm, TB
         2/3 malignant causes:
            o 50% non-small cell lung cancer
            o 22% small-cell lung cancer
            o 12% lymphoma
            o 9% metastatic disease (usually breast)
            o 3% germ-cell
            o 2% thymoma
            o 1% mesothelioma
            o 1% other cancer
Clinical Features:
         Facial edema, ↑ neck veins, dyspnea, cough, distended chest veins most common
Evaluation:
         CT chest with contrast to evaluate SVC, PET may influence design of radiotherapy
            field, MRI may be useful if cannot tolerate contrast
         Tissue diagnosis: via sputum cytology, pleural effusion thoracentesis with cytology
            (yield 50%), bronchoscopy (yield 50-70%), transthoracic needle aspiration biopsy
            (yield 75%), mediastinoscopy or mediastinotomy (yield >90%)
Treatment:
         Treatment of underlying cause:
            o Lymphoma, small-cell, germ-cell tumors respond rapidly to chemotherapy
            o Non-small cell lung cancer: concurrent chemo + XRT for stage III or chemo for
                 stage IV w/ good performance status
         Relief of obstruction:
            o Head of bed elevation (no data to support)
            o Steroids (case reports only, especially good in lymphoma and thymoma)
            o Loop diuretics
            o Removal of catheter if associated with thrombus + anticoagulation
            o XRT: SCLC and NSCLC responsive – may not correlate w/ subj improvement
            o Systemic chemotherapy: good for lymphoma, small cell, germ cell > NSCLC
            o Intravascular stent placement: good for mesothelioma (not very chemo
                 responsive) or thrombus
            o Surgical bypass grafting: good for thymoma (not chemo or XRT responsive)
Prognosis:
         Survival among patients presenting w/ SVC obstruction does not differ significantly
            from those with same tumor type and stage without obstruction

				
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posted:8/25/2011
language:English
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