Superior Vena Cava Obstruction (SVCO) is an oncological emergency and any patients should be discussed with a Registrar or above immediately, and with the local Respiratory team or on-call Oncology team at the Beatson (Appendix 6 for contact details), as soon as possible to guide investigation and management.
SVCO results from the compression of the superior vena cava by either a tumour arising in the right main or upper lobe bronchus or mediastinal lymphadenopathy. Initially it is diagnosed clinically in the presence of neck and facial swelling and distended veins over the anterior chest wall. There may also be swelling of one or both arms and symptoms of dyspnoea and headache. Malignancy is the commonest cause (>90%), most typically lung cancer, lymphoma, metastatic disease, mesothelioma and thymoma. Where relevant the West of Scotland guideline on the Management of Newly Presenting Patients with a Mediastinal Mass Causing Airway Compromise' may be helpful. See the WoSCAN intranet site (NHS network access is required) and search for guideline under Guidelines and Protocols section, then Acute Oncology Guidelines subsection.
Obtain full history including:
Examine for distended external and internal jugular veins, collateral veins on the anterior chest wall, facial, arm and neck swelling, and conjunctival redness.
The investigation of choice is a contrast enhanced spiral or multi-slice chest CT (CTPA). This defines tumour extent, and often the site of occlusion or stenosis and the extent of any thrombus formation. Impending SVCO can be an incidental finding on CT.
Confirmation of diagnosis by histology may involve fine needle aspirate of palpable nodes, bronchoscopy, or CT guided biopsy. Seek advice from Respiratory or Oncology as soon as possible to guide investigation and management.
In addition to above, questions that may influence whether the patient should be considered for SVC stent or chemotherapy / radiotherapy are:
Treatment is initially to alleviate symptoms and (when known) directed at the underlying cause. Ensure that the patient has no life-threatening symptoms (e.g. associated stridor) and is fit enough for active treatment. If no contraindication to corticosteroids, commence dexamethasone oral (IV if swallow problems) 8 mg twice daily (morning and lunchtime) with gastroprotection if appropriate (e.g. omeprazole oral 20mg daily or lansoprazole oral 30mg once daily). Dexamethasone may be commenced whilst waiting for CT if clinical suspicion of SVCO is high. If CT confirms SVCO continue dexamethasone and seek urgent advice. As symptoms improve, dose may be gradually reduced over several weeks. If symptoms do not improve after 7 days consider stopping. If the CT scan shows no SVCO, then stop dexamethasone.
Other treatments frequently used are radiotherapy, stent insertion and chemotherapy and will depend on clinical scenario. If thrombus is present, consider anticoagulation if no contraindications (see guideline titled 'Treatment and Secondary Prophylaxis of Venous Thrombosis in Patients with Malignant Disease' on NHSGGC StaffNet / Acute / Venous Thromboembolism / Diagnosis & Treatment (link only active if accessing via NHS computer).
Guideline reviewed and updated November 2020