Download superior vena cava syndrome (svcs)

SUPERIOR VENA CAVA
SYNDROME
(SVCS)
DEFINITION
 clinical expression of obstruction of blood
flow through the SVC
 developing quickly or gradually
 in case of pathological process in the
superior mediastinum causing
compression, invasion or thrombosis
ANATOMY AND
PATHOPHYSIOLOGY
 Thin – walled
 Compliant
 Easily compressible
 Vulnerable to any space occupying process in its
vicinity
 Extensive collateral system (azygos venous
system, internal mammary veins, lateral thoracic
veins, paraspinous veins, esophageal venous
network, subcutaneous veins)
 Maintains blood at a low pressure
ETIOLOGY
 Malignant conditions – 85%
 Lung cancer – underlying process in 70%
 Small cell lung cancer – the most common
histologic subtype
 Lymphoma involving the mediastinum (8%)
 Other primary mediastinal malignancies:
thymoma, germ cell tumors
 Metastatic mediastinal tumors (breast cancer,
testis cancer)
ETIOLOGY
 Nonmalignant conditions
 Thrombosis ( central vein catheters,
pacemakers)
 Mediastinal fibrosis (e.g. due to
radiotherapy or histoplasmosis)
ETIOLOGY IN CHILDREN
 Mainly iatrogenic (70%) – secondary to
cardiovascular surgery for congenital
heart diseases, ventriculoatrial shunt for
hydrocephalus, SVC catheterization for
parenteral nutrition
 Congenital anomalies of the
cardiovascular system
 Mediastinal tumors (lymphomas in 75%)
SYMPTOMS
 Dyspnea
 Facial swelling or
63%
50%
 Head fullness
 Cough
 Arm swelling
 Chest pain
 Dysphagia
 Hoarseness
24%
18%
15%
9%
PHYSICAL FINDINGS
 Venous distention of neck
 Venous distention of chest wall
 Facial edema
 Cyanosis
 Edema of arms
 Exophtalmus
66%
54%
46%
20%
14%
DIAGNOSTIC PROCEDURES
 Chest film (superior mediastinal widening,
pleural effusion, right hilar mass, bilateral
diffuse infiltrates, cardiomegaly, calcified
paratracheal nodes, mediastinal (anterior) mass)
 CT (more detailed information about the SVC, its
tributaries and other critical structures such as
bronchi and the cord)
 MRI
 Contrast venography (valuable if surgical bypass
is considered for the obstructed vena cava); an
alternative – radionuclide technetium-99m
venography
DIAGNOSTIC PROCEDURES
Procedures that help to establish the histologic
diagnosis are the priority!
 Sputum cytology
 Thoracocentesis (if there is pleural effusion)
 Supraclavicular lymph node biopsy
 Bronchoscopy (brushing, washing, biopsy samples)
 Percutaneous transthoracic fine-needle biopsy under CT
or fluoroscopic guidance
 Mediastinoscopy
 Bone marrow biopsy
 Thoracotomy
MANAGEMENT
 The treatment should be selected
according to the histologic disorder and
stage of the primary process!
 Goals:
 relieve symptoms
 attempt cure of the primary malignant
process
METHODS
 Radiotherapy
 Chemotherapy
 Thrombolytic therapy
 Anticoagulants
 Transluminal angioplasty and endoprosthesis
insertion
 Surgery
 General measures
RADIATION THERAPY
 Radiosensitive cancers (non-small cell
lung cancer)
 Contraindications to chemotherapy
 Combination therapy: chemo- and
radiotherapy (lymphomas, small cell lung
cancer)
 Unknown histologic diagnosis in case of
the deteriorating patient clinical status
CHEMOTHERAPY
 Provides both local and systemic
therapeutic activity
 Chemosensitive carcinomas
Lymphomas
Small cell lung cancer
* Alone or in conjunction with radiotherapy
INVASIVE METHODS
 Percutaneus transluminal angioplasty
using baloon technique
 Insertion of expandable wire stents
 With or without thrombolytic therapy
 Successful in opening catheter induced
SVC obstructions
SURGERY
 Bypass grafts
 In oncologic patients - considered only
after other therapeutic methods have been
exhausted
TROMBOLYTIC THERAPY
 Streptokinase
 Urokinase
 Recombinant tissue-type plasminogen
activator
*May cause lysis of the thrombus early in its
formation
Anticoagulants
 Heparin
 Oral anticoagulants
* May reduce the extent of the thrombus and
prevent progression
GENERAL MEASURES
 Bed rest with the head elevated
 Oxygen
 Steroids
PROGNOSIS
 Strongly correlates with the prognosis
for the underlying disease
 Average survival for cancer patients: 7-8
months
 5 months for lung cancer patients
 Average survival in case of primary benign
process: 9 years