Pocket Oncology (Pocket Notebook Series), 1st Ed.

SVC SYNDROME

Eric L. Smith and Jeffrey S. Groeger

Definition

• Compression or invasion of the SVC causing increased venous pressure resulting classically in face & arm swelling, vein distension, & dyspnea (see below)

Epidemiology

• Approx. 15000 new cases diagnosed in US annually

• 60–80% a/w malignancy

Differential Diagnosis

• Thrombus: Esp in presence of indwelling catheter (Chest 2003;123:809)

• Infxn: TB, syphilis, fungal

• Fibrosing mediastinitis

• Postradiation fibrosis

• Aortic aneurysm

Diagnosis

• CT + contrast, or MRI if cannot give contrast, will determine thrombosis vs. extrinsic compression

• If extrinsic compression will need bx to confirm malignancy & obtain dx in many cases. Bx of distant LN or pleural effusion cytology may suffice.

Management

• Determined by: Severity, rapidity of onset, & underlying cause

• In general, obtain bx before XRT or chemotherapy (Clin Oncol 1997;9:83)

Exception: Sev. stridor or elevated ICP requires immediate intervention

• Tx options:

Elevate head of bed

XRT

± steroids: Dexamethasone 4 mg q6h

± loop diuretics

± chemo: If thought to be rapidly responsive (see below)

often chemo can be only tx

• Intravascular stent: Can be placed urgently in pts requiring tissue dx (Vascular 2007;15:314)

Also recommended in all pts w/malignancy thought unlikely to respond to XRT or chemo (see below) or in thrombosis

• Surgical bypass graft infrequently used, can be part of attempted curative multimodality tx if caused by thymoma

• If thrombus: Fibrinolytic + anticoagulation, consider removing any associated indwelling catheter

• SVC syndrome does not change the likelihood of cure of an underlying malignancy & should not compromise the choice of curative tx