Superior vena cava syndrome in children with malignancy: analysis of seven cases

Superior vena cava syndrome (SVCS) is rare in children. In Veterans General Hospital-Taipei, a total of 364 cases of SVC syndrome were diagnosed in the past 12 years. Of them only seven cases were younger than 18 years of age, ranging from 6 to 17 years, and they were all caused by mediastinal tumor. The underlying malignancy included malignant lymphoma in 4, teratocarcinoma in one and unknown in 2. The most common initial symptom was cough, followed in order of frequency by chest discomfort or neck mass. Dyspnea, orthopnea, swelling of head and neck, and venous engorgement might develop gradually within one to three weeks. Of the reported seven cases, two cases received immediate resuscitation upon arrival but expired in 1-2 hours. The other five cases received treatment with intravenous steroid as well as chemotherapy, and three cases also received committent emergent radiotherapy. Two of them expired 4 months and 2 years after treatment, respectively. Of the two surviving cases, one has received a complete course of chemotherapy and the other is still under regular chemotherapy in our hospital. Both of them are stable till now.

Gianturco self-expanding stents: clinical experience in the vena cava and large veins

Twenty-five patients with stenosis of the vena cava (21) and other large veins (4) have been treated with self-expanding Gianturco metallic stents. Eighteen patients had superior vena cava syndrome. In 17, the stricture was due to malignant superior vena cava compression recurrent after maximum tolerance radiotherapy and/or chemotherapy. In 16 of these patients there was early symptomatic relief. In 1 patient with a benign posttraumatic superior vena cava stricture, the stenosis was not relieved, and occlusion occurred after 1 month. Stenoses associated with dialysis shunts were relieved in 2 other patients. Two malignant and one benign inferior vena cava stenoses were relieved either until death, or in the benign case, for 30 months. One malignant subclavian vein obstruction occluded after 24 h due to stent misplacement and another with extrinsic mediastinal compression remained patent until death, extensive thrombus having been lysed prior to stent placement. The results of this short series suggest that the Gianturco self-expanding stent in the vena cava and large veins is easy and safe to place, and in most cases produces almost immediate palliation of the distressing effects of venous obstruction, often in a preterminal and inoperable patient.

Gianturco-Rösch expandable Z-stents in the treatment of superior vena cava syndrome

Gianturco-Rösch expandable Z-stents were used in 22 patients with superior vena cava syndrome (SVCS). Stents were placed in all patients in the SVC and in 17 patients, also into the innominate veins. Stent placement resulted in complete relief of symptoms in all patients. Twenty-one patients had no SVCS recurrence from 1 to 16 months, to their death, or to the present time. SVCS recurred only in 1 patient 9 months after stent placement due to tumor ingrowth and secondary thrombosis. Based on ours and on other reported experiences, expandable metallic stents are effective devices for treatment of the SVCS which is difficult to manage by other means.

Superior vena cava syndrome associated with lymphoma

OBJECTIVE

To evaluate the workup and treatment of children with lymphoma and superior vena cava syndrome.

DESIGN

A retrospective survey.

SETTING

State hospital serving as a secondary and tertiary referral center for pediatric oncology and pediatric cardiac surgery.

PARTICIPANTS

Eleven children aged 11 months to 12 years diagnosed as having lymphoma or T-cell acute lymphoblastic leukemia who presented with superior vena cava syndrome during an 11-year period.

INTERVENTIONS

Lymph node biopsy (two patients), thoracenthesis (five patients), bone marrow aspiration (two patients), and thoracenthesis in addition to bone marrow aspiration (two patients). All aspirates were evaluated with immunohistochemical studies. Chemotherapy was the only management intervention.

RESULTS

T-cell lymphoma or leukemia accounted for nine cases and Hodgkin's disease for two cases. Respiratory symptoms occurred in 10 patients, including tracheal compression in six patients (compression was life-threatening in one patient). Diagnosis of superior vena cava syndrome was achieved in eight patients using surface-marker analysis of aspirates. The syndrome disappeared within 2 to 10 days. Seven of nine children whose conditions were diagnosed more than 1 year before this writing were alive and free of disease after mean follow-up of 37 months.

CONCLUSIONS

(1) A specific diagnosis can be achieved in most children with superior vena cava syndrome and lymphoma; (2) Thoracic computed tomographic scans are essential, identifying minute pleural effusions that can aid diagnosis; (3) Anesthetic hazard is related only to severe tracheal compression; (4) Chemotherapy achieves excellent symptomatic relief; and (5) Long-term survival, without disease, is achievable.

[Gianturco expandable metallic stents in the treatment of superior vena cava syndrome caused by lung cancer]

Treatment of superior vena cava syndrome (SVCS) caused by advanced lung cancer is still controversial. We inserted Gianturco expandable metallic stents (GEMS) in 5 patients with SVCS due to the extension of lung cancer. GEMSs were introduced intravenously through the catheter after intraluminal balloon dilation of the stenotic sites. SVCS was successfully and easily relieved by this method without any significant complication. GEMS placement seems to be a useful alternative to bypass grafting procedure for the treatment of SVCS.

Use of balloon-expandable stents to treat experimental peripheral pulmonary artery and superior vena caval stenosis: preliminary experience

Current therapy of congenital or acquired stenoses of the peripheral pulmonary arteries and superior vena cava are frequently ineffective. This report describes our initial experience with the use of a balloon-expandable stainless steel stent to treat experimentally created branch pulmonary artery and superior vena cava stenosis. Fifteen adult mongrel dogs had surgically created stenoses of either a branch pulmonary artery and/or superior vena cava. A balloon-expandable stainless steel (0.076 mm), 3 cm long, intravascular stent was used in all animals. Stents were successfully placed in 13 of 15 dogs (nine with branch pulmonary stenosis and four with superior vena caval stenosis) with hemodynamic and angiographic relief of the stenoses in all. In three animals, successful stent placement was not accomplished because the distal right pulmonary artery was found to be totally obstructed in two and in one dog with combined vena cava and pulmonary stenosis the distal right pulmonary artery was so severely stenotic that the stenosis could not be crossed. Repeat catheterization performed 6 months following stent placement documented persistent gradient relief and angiographic evidence of unobstructed flow through the stent without thrombus formation and with patent side branch vessels. Our preliminary results suggests that balloon-expandable stents are a potential therapy for the treatment of branch pulmonary artery and superior vena cava stenoses.

Case report: superior vena cava obstruction complicated by central venous thrombosis--treatment with thrombolysis and Gianturco-Z stents

Expandable wire stents can provide effective palliation of superior vena cava obstruction (SVCO). We describe a case of SVCO unresponsive to radiotherapy and chemotherapy, which was complicated by extensive central venous thrombosis. Successful thrombolysis occurred with low-dose streptokinase allowing subsequent stent placement.

Intravascular stents in the management of superior vena cava syndrome

Superior vena cava syndrome can be effectively palliated with the use of intravascular stents. Adjunctive modalities which may be utilized prior to stent placement are thrombolytic therapy and balloon angioplasty. Six patients with an underlying malignancy were treated with these modalities. Complete resolution of symptoms occurred in five patients, and partial resolution occurred in the sixth. Two of the patients who had initial, complete resolution of symptoms had recurrences. One involved rethrombosis of the superior vena cava which occurred twice and required percutaneous thrombectomy, and the second involved restenosis requiring a percutaneous transluminal angioplasty of the SVC just distal to the stent. Both of these patients with second procedures, again, had complete resolution of symptoms. Intravascular stents are a valuable additional treatment of superior vena cava syndrome.

Vena caval and central venous stenoses: management with Palmaz balloon-expandable intraluminal stents

Palmaz balloon-expandable intraluminal stents (BEISs) were used to treat vena caval and adjacent central venous obstructions that failed to respond to conventional balloon angioplasty. An initial series included seven patients: five had superior vena cava (SVC) syndrome due to a malignant neoplasm and/or radiation therapy, one had dialysis access-related stenosis of the subclavian vein, and one had inferior vena cava (IVC) and bilateral common iliac vein obstruction due to abdominopelvic radiation therapy for Hodgkin disease. Treatment produced clinical benefit in all seven patients. Patency was achieved with stents placed across stenoses of the SVC, IVC, and brachiocephalic and subclavian veins. One stent placed in a left common iliac vein was oval and was shown to be occluded on a follow-up computed tomographic scan, suggesting that compression between the right common iliac artery and the spine was responsible. Although caution is recommended in placement at possible compression sites, BEISs can be used to treat obstructions of the vena cava and major central veins.

Balloon dilatation of pacemaker induced stenosis of the superior vena cava

A 53 year old woman with symptomatic pacemaker associated superior vena cava syndrome was treated successfully with balloon angioplasty. She was well six months after the procedure.

Long-term vascular access via the inferior vena cava

A prospective evaluation of long-term venous access catheters placed via the inferior vena cava was performed to determine their efficacy as well as short- and long-term morbidity. From June 1987 to May 1989, 31 catheters were placed in 26 patients, for a total of 3,503 catheter use days. All catheters were placed via an infraumbilical approach when the more conventional supraumbilical route was technically difficult, dangerous, or impossible to be used. There were a total of 14 complications in 12 episodes (one in every 701 catheter use days), six episodes of catheter occlusion or vessel thrombosis (one in every 583 catheter use days), one catheter malfunction, one episode of cuff erosion through the skin, and one catheter that migrated through the inferior vena cava into the retroperitoneum. These results compared favorably with our experience with long-term catheters of a similar type placed via a supraumbilical approach into the superior vena cava. We conclude that the infraumbilical route for long-term central venous access is safe and technically easy and should be strongly considered in patients in whom venous access via the supraumbilical approach will be technically difficult or have a high likelihood of failure.

[Superior vena cava syndrome due to hemothorax]

A 40-year-old man suffering from chronic uremia was admitted for hemodialysis. During cannulation of the subclavian vein, 1 of the arteries of the chest was punctured and bled into the right hemithorax. A large compressing hematoma occurred near the superior vena cava and acute superior vena cava syndrome developed very rapidly despite repeated intercostal drainage. Bedside, 1-shot-venography enabled accurate diagnosis and localization of the obstruction and permitted aimed surgical intervention.

Supportive care of the lung cancer patients

The care of lung cancer patients involves a specialized team approach. Complications arising from the underlying illness or its treatment are common occurrences that must be anticipated and treated properly. Psychosocial issues commonly arise in patients and their families during the course of the illness. Caregivers skilled in helping a patient and family members come to terms with this frequently fatal disease are integral members of a multidisciplinary team of cancer specialists.

Sclerosing mediastinitis: improved management with histoplasmosis titer and ketoconazole

Recognition that many patients with benign sclerosing mediastinitis have smoldering disease responsible for failure of surgical procedures or for development of collateral circulation in patients with superior vena caval obstruction has markedly improved management of these difficult patients. Histoplasmosis complement fixation titers have been used to detect unsuspected subacute disease and to follow the therapeutic adjunctive management with ketoconazole, an oral antifungal agent. Twenty-two patients with benign sclerosing mediastinitis demonstrated a variety of symptoms relating to the area of compression: superior vena cava, 13; esophagus, 3; pulmonary artery and pericardium, 3; and trachea, 3. Histoplasmosis was documented in 12 patients. Operation is used initially for diagnosis, to rule out carcinoma, and to treat the complications: superior vena caval reconstruction, 6; tracheal decompression, 2; right middle lobectomy, 1; esophageal decompression, 2; division of tracheoesophageal fistula, 1; and release of pericardial effusion and cardiac tamponade, 1. Postcardiotomy syndrome occurred in 1 patient and wound infection in another. No deaths resulted. In 6 cases of histoplasmosis, symptoms recurred in 100% of patients and were successfully managed with ketoconazole treatment, and then clinical progress was monitored with serial histoplasmosis complement fixation studies. One patient had four superior vena caval reconstructions at an outside hospital, each 1 year apart, with symptoms recurring each time. With ketoconazole therapy alone, she has been asymptomatic for more than 2 years. Vigorous search for a fungal cause may even obviate the necessity for surgical intervention. If an operation is necessary, preoperative and postoperative use of ketoconazole has assured success.

Pacemaker-induced superior vena cava syndrome: report of four cases and review of the literature

Superior vena cava syndrome due to transvenous pacing leads is a rare event. We describe four cases. One occurred among 3,100 primary pacemaker insertions performed at our institution. In the other three cases the primary insertion had been performed elsewhere. Over 30 cases have been reported previously. Local infection, which preceded the development of superior vena cava syndrome in each of our four cases, and the presence of a severed retained lead, as in three of our cases, are important predisposing factors. There is no strong evidence that multiple lead insertion, if each lead remains intact, significantly increases the risk. The pathology at the site of obstruction includes thrombosis and in some cases fibrotic narrowing. Venous angiography is useful to show the site of obstruction, the extent of collateral circulation and to assess the response to treatment. Treatment should include removal of any infected pacemaker apparatus, anticoagulation and, if symptoms are of recent onset, thrombolytic therapy. Most patients improve but in those who do not angioplasty or surgical relief of the obstruction may be helpful.

Percutaneous recanalization and dilatation of a thrombotically occluded superior vena cava in a patient with a peritoneovenous shunt

A superior vena cava syndrome developed in a patient with liver cirrhosis 6 months after implantation of a peritoneovenous shunt. Local fibrinolytic therapy resulted only in a transient improvement of clinical symptoms. Persistent patency of the superior vena cava and shunt function was regained only after percutaneous recanalization and balloon dilatation of the thrombotically occluded caval vein.

[Treatment of the superior vena cava syndrome]

The author describes the results of therapy in three groups of patients (128 patients altogether) with the superior vena cava syndrome caused by a tumorous disease. All the patients were treated by radiotherapy as a main method of therapy. (200 kV, filtration 2 mm Cu) in a daily fractionation 300 r on the surface by one field, in the second period (1974-1978) 55 patients were irradiated by 60Co cobalt from two opposite fields by daily fractionation of 170-180 rad into the focus and in the third period (1984-1986) 25 patients were irradiated by 60Co cobalt from two opposite fields in 3-4 introductory daily fractions 3.0 Gy into the focus and then in normal fractionation up to the total dose planned. Immediate results of the treatment--complete disappearance of the syndrome symptoms--were the best in the 3rd group, where a complete disappearance of the symptoms was observed in 84% of patients and a partial relief in 8%. In the first period a complete disappearance of symptoms was in 54% and a partial relief in 10% of patients. The corresponding values in the second period were 74% and 11% respectively. In evaluating the survival of patients, no significant differences were found. In the first period, 50% of patients survived 12 weeks, in the second period 16 weeks and in the third one 20 weeks. One-year survival was reached by two per cent of patients in the first period, four per cent in the second period and eight per cent in the third period. The paper discusses other therapeutic possibilities and approaches in the treatment of the superior vena cava syndrome.

Pulmonary venous collaterals secondary to superior vena cava stenosis: a rare cause of right-to-left shunting following repair of a sinus venosus atrial septal defect

We describe a case of unusual pulmonary vein-to-vein collateral formation leading to systemic desaturation years following surgical repair of a sinus venosus atrial septal defect and partial anomalous pulmonary venous return from the right lung. At surgery, a single right upper lobe pulmonary vein branch was left draining high into the superior vena cava (SVC), resulting in a small left-to-right shunt. SVC obstruction developed at the site of the ASD repair and elevated venous pressure above the obstruction caused retrograde flow into the unincorporated pulmonary vein. Pulmonary vein-to-vein collaterals formed between this unincorporated vein and an adjacent pulmonary vein that had been surgically diverted to drain into the left atrium, resulting in a right-to-left shunt within the right lung. Normal pulmonary veins drain multiple bronchopulmonary segments, thus providing potential collateral pathways. Balloon angioplasty of the SVC stenosis successfully relieved the obstruction and abolished the right-to-left intrapulmonary shunt.

Superior vena cava syndrome associated with massive thrombosis: treatment with expandable wire stents

Two patients with superior vena cava syndrome (SVCS) associated with massive thrombosis were treated by means of local thrombolytic therapy and placement of modified Gianturco expandable wire stents. Treatment resulted in complete resolution of the SVCS symptoms. The combination of local thrombolytic therapy and stent placement allows a more aggressive approach to treatment of SVCS and provides longer-term palliation of symptoms even for patients with later stages of the disease.

Superior vena cava syndrome: experience in a teaching hospital

Between 1972 and 1985, 39 patients with superior vena cava syndrome were admitted to the Medical College of Georgia Hospitals. I have reviewed the hospital courses of these patients and compared clinical and laboratory findings with those reported in previous series. The syndrome was malignant in 34 patients (mean age of 50 years) and benign in five (mean age of 30 years). Duration of symptoms before diagnosis was 17 months in patients with benign disease and 18 days in those with malignant disease. Presence of symptoms for less than four weeks was associated with a high likelihood of malignancy. Invasive diagnostic procedures established a diagnosis in 33 patients, and no procedural complications occurred. Computerized tomography (CT) of the chest confirmed superior vena cava obstruction and localized the level of obstruction in all six patients in whom it was done. Information gained from venacavograms did not alter therapeutic decisions. In eight patients, establishment of a definitive histologic diagnosis altered the treatment. Treatment relieved the symptoms in 69% of the patients with malignant superior vena cava syndrome, and no patient had recurrent symptoms after therapy.

Gianturco expandable wire stents in the treatment of superior vena cava syndrome recurring after maximum-tolerance radiation

Two patients with superior vena cava syndrome (SVCS) recurring after maximum-tolerance radiation were treated by placing a Gianturco expandable wire stent (GEWS) into the obstructed superior vena cava. The SVCS symptoms rapidly disappeared and good short-term (6 months) palliation was achieved. GEWS placement is a promising therapeutic alternative for palliation of SVCS symptoms when other therapeutic modes cannot be used or are not effective.

Recanalization of occluded superior vena cava for replacement of LeVeen shunt catheter

Successful percutaneous replacement of the venous limb of a LeVeen peritoneovenous shunt with the use of angioplastic technique is reported. This method may be a first line of treatment in patients with intractable ascites and a failing shunt caused by chronic occlusion of the superior vena cava.

Thymoma presenting as a superior vena cava syndrome remission following therapy

A 45-year-old male developed myasthenia gravis 8 years ago. He received prednisone for 3 years, and resumed complete clinical remission. Five years later, he was admitted with obstruction of the superior vena cava. Invasive thymoma was diagnosed by chest X-ray and an open lung biopsy. Radiation followed by combination chemotherapy with cyclophosphamide, vincristine, and prednisone induced a complete remission. The patient remained disease-free for more than 20 months after the first admission to our department. To the best of our knowledge, superior vena cava syndrome as the presenting symptom of thymoma has never been reported previously.

Oncologic emergencies and paraneoplastic syndromes

The primary care physician must be able to recognize potentially life threatening or permanently disabling oncologic complications that may be prevented or reversed by foresight or prompt action. The physician must be able to assist the patient in treatment decisions and recognize those situations in which palliation is possible. Accurate diagnosis and treatment of oncologic emergencies and paraneoplastic syndromes may both improve the quality of life and increase the length of survival in the patient with cancer.

Superior vena caval obstruction syndrome in small cell lung cancer

In a series of 643 patients with small cell lung cancer (SCLC), 55 patients (8.6%) had signs or symptoms of superior vena caval obstruction syndrome (SVCO). Relatively long intervals from the onset of the first symptoms of SVCO to the start of therapy were observed, and invasive diagnostic procedures were safely performed in most patients. The pretreatment characteristics of patients with SVCO were not significantly different from those of patients without signs of the syndrome, and survival was similar in both groups. Patients with SVCO were usually treated first with induction chemotherapy, and prompt resolution of signs and symptoms occurred in the majority. Radiation was effective in controlling SVCO at relapse or after failure of initial chemotherapy. It was concluded that SVCO in patients with SCLC should be treated initially with systemic chemotherapy, as for other presentations of this disease. The current data do not support the commonly held view that SVCO in SCLC should be approached as an oncologic emergency.

Superior vena cava obstruction syndrome: recommendations for management

The main cause of superior vena cava syndrome (SVCS) is malignant disease. However, multiple other diseases must be considered in the differential diagnosis and a new entity, SVCS due to central venous catheters, represents an etiology of increasing importance. SVCS due to malignancy should not be considered as a radiotherapeutic emergency. Careful management including invasive procedures such as mediastinoscopy to make a definite diagnosis should be performed when necessary by skilled practitioners, as specific therapy depends on a histologic diagnosis. Irradiation remains the standard treatment for many solid tumours, particularly non-small cell lung cancer. For chemosensitive tumours such as small cell bronchogenic carcinoma or lymphoma, chemotherapy can be recommended as initial treatment, and it is associated with high regression rates of the SVCS. In the case of a recent thrombosis of the superior vena cava, fibrinolytics may be applied as suggested by the experience obtained with central venous catheters.

[Thrombosis of the superior vena cava in Behcet's disease. Apropos of a case associated with chylothorax]

The authors report a case of superior vena cava thrombosis associated to a chylothorax during Behcet's disease. This thrombosis was revealed during an evolutive phase by dyspnea and a superior vena cava syndrome. Its course was favourable under a medical treatment associating: pleural drainage, parenteral feeding, corticotherapy and heparin therapy. Then the authors review the bibliography and recall the frequency, pathogenesis, clinic and treatment of this unusual complication of the Touraine's aphthosis. Such a complication appears paradoxically to present a favourable course.