Prolonged survival following the superior vena cava syndrome

Review of evolving etiologies, implications and treatment strategies for the superior vena cava syndrome

Superior vena cava syndrome (SVCS) is a relatively common sequela of mediastinal malignancies and may cause significant patient distress. SVCS is a medical emergency if associated with laryngeal or cerebral edema. The etiologies and management of SVCS have evolved over time. Non-malignant SVCS is typically caused by infectious etiologies or by thrombus in the superior vena cava and can be managed with antibiotics or anti-coagulation therapy, respectively. Radiation therapy (RT) has long been a mainstay of treatment of malignant SVCS. Chemotherapy has also been used to manage SVCS. In the past 20 years, percutaneous stenting of the superior vena cava has emerged as a viable option for SVCS symptom palliation. RT and chemotherapy are still the only modalities that can provide curative treatment for underlying malignant etiologies of SVCS. The first experiences with treating SVCS with RT were reported in the 1970’s, and several advances in RT delivery have subsequently occurred. Hypo-fractionated RT has the potential to be a more convenient therapy for patients and may provide equal or superior control of underlying malignancies. RT may be combined with stenting and/or chemotherapy to provide both immediate symptom palliation and long-term disease control. Clinicians should tailor therapy on a case-by-case basis. Multi-disciplinary care will maximize treatment expediency and efficacy.

Superior vena cava obstruction in small cell bronchogenic carcinoma. Clinical parameters and survival

A clinical pathologic review with analysis of prognostic factors was conducted in 56 patients who were seen at the University of Texas M. D. Anderson Hospital and Tumor Institute between 1969 and 1980 with the syndrome of superior vena cava (SVC) obstruction secondary to small cell bronchogenic carcinoma. Most patients were men (60%), nonambulatory (61%), and had demonstrable extrathoracic disease (70%). The most common symptoms and signs of SVC obstruction were jugular venous distention (100%), swollen face (88%), and dyspnea (50%). Swollen arms (34%) and engorgement of thoracic veins (32%) were also common. Initial treatment consisted of irradiation alone, 17 patients (30%); chemotherapy alone, 32 patients (57%); or both, 7 patients (13%). Patients receiving chemotherapy initially had poor prognoses, as evidenced by the greater proportion of nonambulatory patients (72%) in this group. All but two patients received chemotherapy at some point during their clinical courses. There were 12 (21%) early deaths; 2 (12%) in the radiation arm; 9 (28%) in the chemotherapy arm; and 1 (14%) in the combined modality group. All treatment modalities were rapidly effective in controlling the symptoms associated with SVC obstruction. Within 1 week from onset of treatment, 9 of 14 (64%) evaluable patients responded to irradiation, 23 of 23 (100%) to chemotherapy, and 5 of 6 (83%) to combined modality treatment. The type of initial treatment did not influence survival significantly, although patients who achieved complete clinical remissions survived longer (median, 62 weeks). Death was usually due to disease progression in distant sites. Multivariate analysis indicated that the most important prognosticators of patients' survival were pretreatment performance status, disease-extent score, and age.

Mediastinoscopy in advanced superior vena cava obstruction

Superior vena cava syndrome can be a rapidly progressive, lethal process that is caused by a malignancy in 92 to 94% of cases. Since all effective therapy is inherently harmful, it would be reassuring to have a definitive tissue diagnosis before initiating treatment. Because easily accessible tissue is not always available, mediastinoscopy must be relied on to confirm the diagnosis in some patients. Twenty-nine patients with advanced superior vena cava syndrome were reviewed. Fifteen of them required mediastinoscopy to confirm the diagnosis, since lesser procedures, i.e., bronchoscopy, needle biopsy, and sputum cytology, were negative for malignant tissue. Contrary to reports in the literature, mediastinoscopy can be performed safely in patients with advanced superior vena cava syndrome and can yield a definitive diagnosis in each.