Initial Management of Superior Vena Cava Obstruction

Introduction

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.

Assessment / monitoring

Obtain full history including:

• Details of known malignancies and their treatment.
• The development of new or worsening respiratory symptoms, arm swelling and headaches, and rapidity of onset.
• Co-morbidities
• Medication including use of and contraindications to corticosteroids and anticoagulation.

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:

• Is there a relative contraindication for radiotherapy? For example previous chest / mediastinal radiotherapy? Is the patient able to lie reasonably flat?
• What is the patient's performance status? (0=normal activity, 1=restricted daily activity, 2=ambulatory and self caring, out of bed >50% of the day, 3=capable of limited self care, in bed >50% time, 4=unable to self care, chair/bed-bound).
• Is stenting procedure available? (This is performed by interventional radiology.)

Guideline reviewed and updated November 2020