Initial Management of Superior Vena Cava Obstruction
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, 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 http://www.intranet.woscan.scot.nhs.uk/, under guidelines and protocols, then acute oncology guidelines.
Assessment / monitoring
The initial assessment includes:
- 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
- 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? E.g. Previous chest / mediastinal radiotherapy? Is the patient able to lie reasonably flat?
- 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)
- Availability of stenting (performed by interventional radiology)
Treatment / drug therapy
- 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 (unless swallowing problems then IV) 8 mg twice daily (morning and lunchtime) with gastroprotection if appropriate (e.g. omeprazole oral 20mg daily or lansoprazole oral 30mg once daily if appropriate).
- This may be commenced while 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 on LMWH for VTE in cancer on StaffNet, Clinical Guideline Electronic Resource Directory and search in the 'Haematology' section).