Superior Vena Cava

Obstruction
By Dr. Sumayya Latif
 Epidemiology and Etiology
Malignant etiologies (85% to 95% of cases)
a. Lung cancer 80%
• about 1/2 of small cell type
• SVC syndrome --> 5%
b. Malignant lymphoma 15%
• High-grade histology
• Hodgkin lymphoma or low-grade nodular lymphomas rarely cause
SVC obstruction.
c. Other etiologies.
Metastatic disease (breast adenocarcinoma or testicular seminoma),
sarcomas, and other malignancies
Benign etiologies (<15%)
a. Mediastinal fibrosis

b. Thrombosis of vena cava

c. Benign mediastinal tumors

1. Aneurysm of aorta or right subclavian artery
2. Dermoid tumors, teratomas, thymoma
3. Goiter, sarcoidosis
 Pathogenesis
1. Obstruction and thrombosis
• Compression from tumor growing in mediastinum
• Thrombosis due to stasis or vascular tumor

2. Collateral circulation
Rapid progression, no time for collateral
development

3. Incompetent internal jugular vein valves

 Presentation
ØOnset is typically insidious over weeks and results in the
development of compensatory collateral venous channels
in the territory of the SVC
ØSymptoms are worse on bending forwards
• SOB (50%)
• Neck and face swelling (40%)
• Swelling of trunk and upper extremities (40%)
• Conjunctival suffusion
• Headache
• Nasal congestion
• Epistaxis
• Dizziness
• Syncope
 Examination
• Non-pulsatile raised JVP
• Neck and thoracic veins distension
• Neck, face, arm edema
• Tachypnea
• Plethora of face and cyanosis
• Occasionally sudden occlusion occurs and the patient
becomes acutely unwell
• Fundoscopic examination: Retinal veins dilatation
• Dullness to percussion over the sternum
• Laryngeal stridor and coma are grave signs
 Investigation
Earlier symptoms and less severe respiratory distress:
ØCXR
ØCT scan
ØHistological Daiagnosis
• CT-guided FNAC or biopsy
• Bronchoscopy
• Sputum cytology
• Biopsy of enlarged neck nodes.
• Mediastinoscopy or thoracoscopy
Full-blown SVC syndrome & severe respiratory distress,
ØEmergency therapy without tissue diagnosis
 Treatment
Initial management:
• Sit the patient up
• Give O2 if required
• Steroids (e.g. dexamethasone 12–16 mg daily in
divided doses) with PPIs
• Superior vena caval stent --> in patients who
require urgent symptom relief, and this will often
allow time to establish a tissue diagnosis.
• Thrombosis should be appropriately treated if
present
• Chemotherapy:
üLymphoma,
üGerm cell tumor
üSCLC
• Radiotherapy:
Mainstay of treatment with other solid tumors
ØPatients with NSCLC and severe SVCO should be
offered a stent first.

•
 Radiotherapy
Patient preparation, positioning and
Immobilization:
• Patient lies supine, with a head rest and arms by
the side
• If the patient is unable to lie flat: the sitting
position can be used with arms by the side
Localization and target volume:
Simulated treatment fields or, where available, CT
planning is used with the target volume to cover the
SVC, tumor and mediastinum
Dose:
Poor performance status and prognosis
• 10 Gy/ single Fx
• 16 Gy/ 2 Fx
• Field size is limited to 12 × 12 cm.
• Quick symptom relief with minimal visits to the radiotherapy
department

Patients with localised disease and better performance status

• 36 Gy / 12 Fx over 2.5 wks
• Tumor and symptomatic control will be prolonged
ØOccasionally radiotherapy may be given with radical intent in
appropriately selected patients such as those with NSCLC whose
disease can be encompassed in a radical volume
 Response
• Improvement within 3 to 7 days
• Complete response:
75% lymphoma
25% lung cancer
Raised ICP
Intracranial contents are:
• BRAIN
• CSF
• BLOOD
•
Etiology: due to increased volume
of I/cranial contents
• Space-occupying effect of intracranial tumours,
which are most often metastatic
• Intracranial haemorrhage
• Cerebral oedema following intracranial surgery
or radiotherapy
• Venous sinus thrombosis
• Intracranial infection in an immunosupressed
patient
 Neurological Symptoms
1. Headache: usually worse on waking in the morning
and is relieved by vomiting
2. Nausea and vomiting: usually worse in the morning
3. Drowsiness: most important clinical feature
4. Papilledema: is due to transmission of the raised
pressure along the subarachnoid sheath of the
optic nerve.
5. Sixth nerve palsy: diplopia, false localizing sign
6. Seizures
7. Behavioral changes
 Systemic Signs
Cushing’s Triad:
• Bradycardia
• Hypertension
• Respiratory irregularity
 Investigation
• CT scan of the brain: detect brain metastases
• MRI: Greater sensitivity for detecting small
metastases, meningeal disease and fourth
ventricle obstruction
• Histological Diagnosis:
Biopsy inappropriate in frail patient with multiple
metsand other possible sites of mets
 Management
• Assess and manage ABC
• Provide high-flow O2
• Document GCS and monitor it
• Head elevation: to 30 degree
• Dexamethasone 12–16 mg daily in divide doses
with PPIs
• Mannitol: 0.5–1 g/kg IV over 15 minutes.
• Avoid fluid overload
• Analgesia: for headache
• VP shunting
• Treat infection
• Platelet transfusion: thrombocytopenia
• Avoid hypotonic maintenance fluids
If <=3 brain mets:
• For specific anti-cancer treatment, seek a
neurosurgical opinion
• Stereotactic radiotherapy
Multiple mets
WBRT:
• Mobile patients
• Responding to steroids
Dose: 30 Gy/10 Fx or 12 Gy/ 2Fx
•
Bleeding
 Etiology
• Bleeding is more likely to occur in patients treated with anticoagulants.
Massive haemoptysis:
• Lung cancer
• Endobronchial metastases from carcinoid, breast, kidney, sarcoma and colon
cancers.
“It is defned as expectoration of more than 100 mL of blood in a single episode
during 24–48 hours.”
Associated with:
• respiratory difficulty
• airway obstruction,
• anaemia
• hypovolaemic shock.
• It may also be associated with coagulation disorder, thrombocytopenia or fungal
infection
Haematemesis,
• approx 2–5% of upper GI bleeding is related to
malignancy
• Benign disease (peptic ulcer disease, oesophagitis,
gastritis, duodenitis)
• Mallory–Weiss tears may be secondary to vomiting
induced by chemotherapy, renal failure or advanced
malignancy
• The Rockall score is a risk assessment tool for GI
haemorrhage
Rockall score: >= 6 --->predicted mortality of around
50%.
Rockall Scoring
• Haematuria
• Malignant tumours involving the genitourinary tract
• Most commonly in renal, bladder and prostate cancer.
Patients may present with:
• Asymptomatic haematuria,
• Associated symptoms related to the underlying cancer
• Severe pain caused by clot retention.
 Investigations
• Maintain ABC
• CBC, clotting screen, RFTs, LFTs, Blood group
• CT scan or endoscopy (e.g. bronchoscopy, upper or
lower GI endoscopy, cystoscopy): to establish
diagnosis and identify the site of bleeding
• Urine or sputum microscopy and culture
 Treatment
For patients who require active resuscitation/
intervention:
• Secure airway, breathing and circulation;
• Fluid resuscitation:
ü0.9% NaCl
üColloid (Hemaccel)
to restore blood pressure and urine output, which
can be monitored by measuring the central venous
pressure (CVP)
• Patients with Hb < 10.0 g/dL--> Blood transfusion
• Comorbids
• Tranexamic acid (with caution in haematuria
because of the risk of clot retention)
• Specifc measures for a bleeding disorder
vPlatelet transfusion
vVitamin K
vFresh frozen plasma
 Site-specific interventions:
Haemoptysis – bronchoscopy/radiotherapy
Haematemesis:
• Drug therapy (e.g. proton pump inhibitors, somatostatin)
• endoscopic therapy (e.g. direct injection of adrenaline into
bleeding ulcers, effective in 90%),
• fibrin glue
• human thrombin
• Heat and mechanical devices
• Radiotherapy to the tumour bed:
• 8 Gy/ 5 Fx over 1 week.
Hematuria:
• Radiotherapy to the prostate or bladder:
• 8 Gy/ single Fx (or a planned volume for radical treatment);
• Cystoscopy with electrocautery/laser
Renal tumors bleeding:
• Renal artery embolism
Carotid blow out:
• Terminal phase of advanced malignancy with massive and
uncontrollable bleeding
• I/V midazolam and diamorphine provides rapid sedation
and palliation