This document discusses Superior vena cava syndrome (SVCS), which is caused by obstruction of the superior vena cava leading to symptoms like facial swelling and difficulty breathing. The document covers the history, anatomy, pathophysiology, clinical features, investigations, grading, and management of SVCS. It notes that while SVCS was once considered a medical emergency, it rarely causes immediate life-threatening issues now. Treatment depends on the underlying cause but may include supportive care, stents, chemotherapy, radiation therapy, or surgery. Radiation often provides symptom relief within 2 weeks for cancers like lung cancer.
Imaging plays an important role in diagnosis and formulating differential diagnosis in case of Solitary pulmonary nodule. It helps in differentiating and predicting benign and malignant nodules.
Imaging plays an important role in diagnosis and formulating differential diagnosis in case of Solitary pulmonary nodule. It helps in differentiating and predicting benign and malignant nodules.
Pulmonary embolism - Notes are made from textbook of Internal medicine to assist medical students and residents to grasp subject in totality. Resources: Harrison's 20thEd, ESC 2019 guidelines on PE
The discovery of malignant cells in pleural fluid
and/or parietal pleura signifies disseminated or
advanced disease and a reduced life expectancy in
patients with cancer.Median survival following
diagnosis ranges from 3 to 12 months and is
dependent on the stage and type of the underlying
malignancy. The shortest survival time is observed
in malignant effusions secondary to lung cancer
and the longest in ovarian cancer, while malignant
effusions due to an unknown primary have an
intermediate survival time.Historically, studies
showed that median survival times in effusions due
to carcinoma of the breast are 5-6 months.
However, more recent studies have suggested
longer survival times of up to 15 months. A
comparison of survival times in breast cancer
effusions in published studies to 1994 calculated
a median survival of 11 months.9
Currently, lung cancer is the most common
metastatic tumour to the pleura in men and breast
cancer in women.Together, both malignancies
account for 50- 65% of all malignant effusions. Lymphomas, tumours of the genitourinary
tract and gastrointestinal tract account for
a further 25% Pleural effusions from an
unknown primary are responsible for 15% of all
malignant pleural effusions.Few studies have
estimated the proportion of pleural effusions due to
mesothelioma: studies from 1975, 1985 and 1987
identified mesothelioma in 1/271, 3/472 and 22/592
patients, respectively, but there are no more recent
data to update this in light of the increasing incidence
of mesothelioma.
Pulmonary embolism - Notes are made from textbook of Internal medicine to assist medical students and residents to grasp subject in totality. Resources: Harrison's 20thEd, ESC 2019 guidelines on PE
The discovery of malignant cells in pleural fluid
and/or parietal pleura signifies disseminated or
advanced disease and a reduced life expectancy in
patients with cancer.Median survival following
diagnosis ranges from 3 to 12 months and is
dependent on the stage and type of the underlying
malignancy. The shortest survival time is observed
in malignant effusions secondary to lung cancer
and the longest in ovarian cancer, while malignant
effusions due to an unknown primary have an
intermediate survival time.Historically, studies
showed that median survival times in effusions due
to carcinoma of the breast are 5-6 months.
However, more recent studies have suggested
longer survival times of up to 15 months. A
comparison of survival times in breast cancer
effusions in published studies to 1994 calculated
a median survival of 11 months.9
Currently, lung cancer is the most common
metastatic tumour to the pleura in men and breast
cancer in women.Together, both malignancies
account for 50- 65% of all malignant effusions. Lymphomas, tumours of the genitourinary
tract and gastrointestinal tract account for
a further 25% Pleural effusions from an
unknown primary are responsible for 15% of all
malignant pleural effusions.Few studies have
estimated the proportion of pleural effusions due to
mesothelioma: studies from 1975, 1985 and 1987
identified mesothelioma in 1/271, 3/472 and 22/592
patients, respectively, but there are no more recent
data to update this in light of the increasing incidence
of mesothelioma.
Superior Vena Cava Syndrome. Etiology and managementRomanusMapunda1
Superior vena cava (SVC) syndrome is a collection of clinical signs and symptoms resulting from either partial or complete obstruction of blood flow through the SVC.
This obstruction is most commonly a result of thrombus formation or tumor infiltration of the vessel wall.
Resection and reconstruction of the SVC is still considered a surgical challenge.
However, with the appropriate indications and surgical technique a clear benefit has been documented in a selected group of patients. This lengthy power point presentation addresses the elective and emergency surgical procedures which can be done on the SVC. The viewer is expected to appreciate the technical challenges of SVC surgery and the ways how to overcome them.....
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
3. HISTORY
▪ First recorded description of SVC obstruction (SVCO) - 1757 when
William Hunter described the entity in a patient with a syphilitic
aortic aneurysm.
▪ For nearly two centuries- nonmalignant processes such as aortic
aneurysms, syphilitic aortitis, or chronic mediastinitis due to
tuberculosis were the predominant etiologic factors.
▪ Now Rare
4. ▪ In the preantibiotic era-
▪ syphilitic thoracic aortic aneurysms,
▪ fibrosing mediastinitis,
▪ untreated infection were frequent causes of the SVC syndrome.
▪ Subsequently, malignancy became the most common cause,
accounting for 90 percent of cases by the 1980s.
▪ More recently, the incidence of SVC syndrome due to thrombosis
has risen, largely because of increased use of intravascular
devices such as catheters and pacemakers.
▪ Benign causes now account for 20 to 40 percent of cases of SVC
syndrome.
5. ▪ Once considered a medical emergency.
▪ SVCO rarely experience immediate, life-threatening complications.
9. ▪ Behind the lower border of the first right costal cartilage.
▪ Azygos vein joins it just before it enters the right atrium, at the
upper right front portion of the heart.
▪ Distal 2 cm lying within the pericardial sac
▪ Formed by the joining of the internal jugular and subclavian veins.
▪ No valve divides the superior vena cava from the right atrium.
▪ As a result, the (right) atrial and (right) ventricular contractions are
conducted up into the internal jugular vein and, through the
sternocleidomastoid muscle, can be seen as the jugular venous
pressure.
10.
11. SVC SYNDROME
▪ Constellation of signs and symptoms caused by obstruction of
blood flow in superior vena cava.
▪ External compression
▪ Invasion
▪ Constriction
▪ Thrombosis of SVC
▪ Partial or complete obstruction
14. ▪ Collateral veins may arise from the
azygos, internal mammary, lateral
thoracic, paraspinous, and esophageal
venous systems .
▪ The venous collaterals dilate over several
weeks.
▪ Upper body venous pressure is markedly
elevated initially but decreases over time.
▪ Symptoms and signs from SVC
obstruction depends upon the rate at
which complete obstruction of the SVC
occurs in relation to the recruitment of
venous collaterals.
15. ▪ Malignant disease- symptoms of SVC
syndrome within weeks to months- Rapid
tumor growth does not allow adequate
time to develop collateral flow.
▪ In contrast, fibrosing mediastinitis due to
an infection such as histoplasmosis may
not become symptomatic for years.
▪ Edema- Narrow the lumen of the nasal
passages and larynx, potentially
compromising the function of the larynx
or pharynx- Dyspnea, stridor, cough,
hoarseness, and dysphagia.
▪ Cerebral edema can also occur and lead
to cerebral ischemia, herniation, and
possibly death.
16. ▪ Cardiac output- diminished transiently by
acute SVC obstruction
▪ Within a few hours, blood return is
reestablished by increased venous
pressure and collaterals.
▪ Hemodynamic compromise, if present,
more often results from mass effect on
the heart than from SVC compression.
28. Contrast enhanced chest CT
▪ Defines the level and extent of venous blockage.
▪ Identification of the underlying cause of venous obstruction.
▪ Identify and map collateral pathways of venous drainage
▪ Presence of collateral vessels on CT is a strong indicator of SVC
syndrome, Specificity of 96 percent and sensitivity of 92 percent.
▪ Contrast-enhanced blood from the collateral circulation draining
into the inferior vena cava can simulate the appearance of a liver
"hot spot" on CT
29.
30. Venography
▪ Bilateral upper extremity venography is the gold standard for identification of SVC
obstruction and the extent of associated thrombus formation.
▪ Superior to CT for defining the site and extent of SVC obstruction and for visualizing
collateral pathways.
▪ It does not identify the cause of SVC obstruction unless thrombosis is the sole
etiology.
▪ Radionuclide technetium-99m venography to assess SVC patency and venous flow
patterns does not provide the important diagnostic information that is supplied by
chest CT.
▪ Helical CT with bilateral upper extremity contrast injection (helical CT phlebography)
appears to combine the diagnostic benefit of CT with the same degree of enhanced
vascular detail as digital venography, as long as appropriate techniques for
intravenous injection of contrast material are used to minimize flow artifacts arising
from unopacified blood.
▪ Neither approach is warranted unless an intervention (placement of an endovascular
stent, surgery) is planned.
31.
32. MR venography
▪ Magnetic resonance venography (MRI) is an alternative approach
that may be useful for patients with contrast dye allergy or those
for whom venous access cannot be obtained for contrast
enhanced studies
34. Histologic diagnosis
▪ The clinical history combined with CT imaging will generally
differentiate between benign causes of SVC obstruction
(particularly caval thrombosis) and extrinsic compression related
to malignancy.
▪ Histologic diagnosis is a prerequisite for choosing appropriate
therapy for the patient with SVC syndrome associated with
malignancy.
37. ▪ SVC syndrome associated with malignancy
▪ Alleviate symptoms and treat the underlying disease.
▪ The average life expectancy among patients who present with malignancy-associated SVC syndrome is
approximately six months.
▪ But there is wide variability depending on the underlying malignancy.
▪ Treatment of SVC syndrome and its underlying cause results in long-term relapse-free survival and cure.
▪ Most likely to be achieved in chemotherapy-sensitive malignancies using a combined modality treatment
approach.
▪ Evidence-based guidelines for management of SVC syndrome are not available.
▪ A general recommendation supporting radiotherapy or stent placement for symptomatic SVC syndrome
from lung cancer has been made by both the National Comprehensive Cancer Network (NCCN) and the
American College of Chest Physicians .
▪ Initial management should be guided by the severity of symptoms and the underlying malignant condition
as well as the anticipated response to treatment.
38. Need for emergent RT ??????
▪ Emergency RT is no longer considered necessary for most patients for several reasons:
▪ Symptomatic obstruction is often a prolonged process developing over a period of weeks or
longer prior to clinical presentation.
▪ Deferring therapy until a full diagnostic work-up has been completed does not pose a hazard
for most patients, provided the evaluation is efficient and the patient is clinically stable.
▪ illustrated in a review of 107 cases of SVC syndrome, in which no serious complication
resulted from the SVC obstruction itself or investigative procedures leading to the diagnosis
despite a prolonged period between the onset of symptoms and the initiation of therapy in
some cases.
▪ RT prior to biopsy may obscure the histologic diagnosis.
▪ One study of 19 patients with symptomatic mediastinal masses who received emergency RT,
a histologic diagnosis could not be established in eight (42 percent) from a biopsy obtained
after such treatment.
▪ Current management guidelines-accurate histologic diagnosis prior to starting therapy and
the upfront use of endovascular stents in severely symptomatic patients to provide more rapid
relief than can be achieved using RT.
39. Exception
▪ Patients who present with stridor due to
▪ central airway obstruction
▪ severe laryngeal edema, and
▪ those with coma from cerebral edema.
▪ These situations represent a true medical emergency, and these
patients require immediate treatment (stent placement and RT) to
decrease the risk of sudden respiratory failure and death.
40. Supportive care and medical management
▪ No data documenting the effectiveness of this maneuver, the head
should be raised to decrease hydrostatic pressure and head and
neck edema.
▪ Obstruction of blood flow through the SVC slows venous return.
This can result in local irritation or thrombosis of veins in the upper
extremities, or delayed absorption of drugs from the surrounding
tissues. Thus, the use of intramuscular injections in the arms
should be avoided.
▪ For patients who have obstruction of the SVC resulting from
intravascular thrombus associated with an indwelling catheter,
removal of the catheter is indicated, in conjunction with systemic
anticoagulation.
41. Glucocorticoids
▪ Two settings in which systemic administration of glucocorticoids
may be helpful.
▪ Symptomatology due to SVC syndrome caused by steroid-
responsive malignancies such as lymphoma or thymoma.
▪ In patients undergoing RT, particularly if laryngeal edema is
present, glucocorticoids are commonly prescribed to reduce
swelling.
▪ Only case reports to suggest benefit.
42. Diuretics
▪ Diuretics are also commonly recommended, although it is unclear
whether venous pressures distal to the obstruction are affected by
small changes in right atrial pressure.
▪ In a retrospective series of 107 patients with SVC syndrome from a
variety of causes, the rate of clinical improvement was similar
among patients receiving glucocorticoids, diuretics, or both
43. Chemotherapy for small cell lung cancer, NHL, and
germ cell tumors
▪ Initial chemotherapy is the treatment of choice for patients with symptomatic
SVC syndrome.
▪ Clinical response to chemotherapy alone is usually rapid.
▪ When chemotherapy is the initial intervention of choice and the SVC obstruction
is unrelieved, chemotherapy should be administered through a dorsal foot vein .
▪ Symptomatic improvement usually occurs within one to two weeks of treatment
initiation. In a review of treatment for SVC obstruction in patients with lung
cancer, chemotherapy alone relieved symptoms of SVC obstruction in 77
percent of those with SCLC, although 17 percent had a later recurrence.
▪ For these malignancies, use of RT alone usually yields poorer long-term results
and may compromise the subsequent results of chemotherapy .
▪ Certain situations (eg, limited stage SCLC, some subtypes of NHL), the addition
of RT to systemic chemotherapy may decrease local recurrence rates and
improve overall survival.
44. ▪ Among patients with SVC syndrome and NHL, symptoms
suggesting involvement of other mediastinal structures (eg,
dysphagia, hoarseness or stridor) and shorter symptom duration
appear to be adverse prognostic factors
45. Non-small cell lung cancer
▪ As compared with more therapy-sensitive malignancies, the degree and
rapidity of response to chemotherapy is less in NSCLC.
▪ Symptom relief in this setting is more rapidly achieved by the use of an
endovascular stent.
▪ SVC obstruction is a strong predictor of poor prognosis in patients with
NSCLC, with a median survival of only five months in one series.
▪ Long-term relapse-free survival has been rarely reported in patients with
locally advanced disease and SVC syndrome treated with chemotherapy
alone or a combined modality approach that includes both RT and
chemotherapy, therapy of SVC syndrome in patients with NSCLC is most
often directed toward palliation of symptoms rather than long-term
remission. For previously unirradiated patients, palliation is most often
achieved with external beam irradiation.
46. Radiation therapy
▪ Radiation therapy (RT) is widely advocated for SVC syndrome caused by radiosensitive tumors in patients who have not
been previously irradiated.
▪ Most of the malignancies causing SVC syndrome are radiation-sensitive, and at least in lung cancer, symptomatic
improvement is usually apparent within 72 hours.
▪ In a systematic review, RT was associated with complete relief of symptoms of SVC obstruction within two weeks in 78 and
63 percent of patients with SCLC and NSCLC, respectively.The rates of relapse post-treatment were 17 and 19 percent for
SCLC and NSCLC, respectively.
▪ Objective measurement of the change in vena caval obstruction may not parallel measures of symptomatic improvement.
▪ In an autopsy series,complete and partial SVC patency was found in only 14 and 10 percent of patients after RT for SVC
syndrome, despite reported relief of symptoms in 85 percent. These data have led some to suggest that the development of
collateralization may have contributed more to symptomatic improvement than the effect of RT, and to question the value
of urgent RT in patients with SVC syndrome from chemotherapy sensitive malignancies.
▪ Relief of symptoms may not be achieved for up to four weeks, and approximately 20 percent of patients do not obtain
symptomatic relief from RT. F
▪ urthermore, the benefits of RT are often temporary, with many patients developing recurrent symptoms before dying of the
underlying disease.
▪ Particularly if symptoms are severe, more rapid palliation can be achieved through the use of an intraluminal stent, followed
by RT for disease control. Stent placement is also effective in relieving symptoms in patients who fail to respond to RT.
47. Endovascular Stents
▪ Indications:
▪ Stent can be placed before a tissue diagnosis is available
▪ Useful procedure for patients with severe symptoms who require
urgent intervention.
▪ An endovascular stent is particularly appropriate for rapid
symptom palliation in patients with NSCLC and mesothelioma and
for those with recurrent disease who have previously received
systemic therapy or RT.
▪ The role of endovascular stenting in patients presenting with
chemotherapy sensitive tumors (ie, SCLC, NHL, germ cell tumors)
and SVC obstruction is uncertain.
48. ▪ Self-expanding endovascular stent restores venous return and provides
rapid and sustained symptom palliation in patients with SVC syndrome.
▪ The technical success rate is in the range of 95 to 100 percent, and over
90 percent of patients report relief of symptoms.
▪ The stent is placed percutaneously via the internal jugular, subclavian, or
femoral vein, under local anesthetic. A guide wire is manipulated through
the stenosis or obstruction in order to deploy the metal stent across the
lesion. One stent may not be sufficient to bridge the entire extent of the
stenotic area, particularly with involvement of the brachiocephalic veins.
Sometimes two or even three stents in series ("kissing stents").
▪ Total occlusion of the SVC is not necessarily a contraindication to
intraluminal stent placement nor is the presence of thrombus within a
stenotic area. In such cases, balloon angioplasty or catheter-directed
thrombolysis or mechanical thrombectomy could be considered prior to
stent placement.
49. ▪ There appears to be no significant difference in the published
outcomes of the three most commonly used stainless steel stents
(Gianturco Z stent, the Palmaz stent, or the Wallstent) .There are
newer self-expanding stents (Luminex, Smart, Protege) made from
nitinol (a nickel-titanium alloy) that exhibit shape memory effect
and superelasticity. They have some advantages over the first-
generation stents including a greater precision in placement within
a stenotic area, lower thrombogenicity, and a higher radial force
that allows them to withstand extrinsic compression and better
maintain long-term patency. Covered stents may have higher long-
term patency rates as compared to uncovered stents, but
additional experience is needed.
50. ▪ Systematic review of the literature of patients with SVC obstruction due
to lung cancer (either SCLC or NSCLC) .
▪ 159 patients who underwent stent placement, 95 percent had relief of
symptoms, and the incidence of reocclusion (usually due to thrombosis
or tumor ingrowth into the stent) was only 11 percent.
▪ In contrast, of the over 600 patients with SCLC, chemotherapy alone,
chemoradiotherapy, and RT resulted in complete or partial relief of
symptoms in 84, 94, and 78 percent of cases, respectively.
▪ Among 150 patients with NSCLC, approximately 60 percent had relief
with chemotherapy or RT. Overall, relapse rates were lower with SVC
stenting (11 versus 17 to 19 percent with RT and/or chemotherapy) in
both SCLC and NSCLC.
51. Thrombolytic therapy
▪ When extensive thrombosis occurs as a complication of SVC stenosis,
local catheter-directed thrombolytic therapy may be of value to reduce
the length of the obstruction and the number and length of stents
required, and also reduce the risk of embolization.
▪ The thrombus may also be removed by mechanical thrombectomy,
although this is used less often than thrombolysis.
▪ Thrombolytic therapy has also been administered following placement of
an endovascular stent in an attempt to decrease secondary reocclusion.
▪ Benefit of thrombolytics- unclear, and increase the risk of hematoma,
gastrointestinal hemorrhage, hemoptysis and epistaxis.
▪ In a systematic review, the morbidity of stent insertion was greatest
when thrombolytics were also administered, and there was no evidence
that reocclusion rates were lower . Thus, this approach is not generally
recommended.
52. Need for long-term anticoagulation ???????
▪ Short-term anticoagulation is often recommended after stent
placement but whether long-term anticoagulation is necessary is
an area of uncertainty.
▪ To prevent stent reocclusion, some advocate anticoagulation for
periods of one to nine months while others suggest antiplatelet
therapy alone.
▪ There are no data upon which to form an evidence-based
recommendation: warfarin 1 mg daily with the goal of maintaining
an INR of less than 1.6 is a reasonable approach.
▪ An alternative approach is dual antiplatelet therapy (eg,
clopidogrel 75 mg daily plus aspirin) for three months after stent
placement.
53. Complications of stent placement
▪ 3 to 7 percent of patients.
▪ Early complications include infection, pulmonary embolus, stent
migration, hematoma at the insertion site, bleeding, and rarely,
perforation or rupture of the SVC.
▪ Late complications include bleeding (1 to 14 percent) and death (1 to 2
percent) from anticoagulation and stent failure with reocclusion.
▪ Stent failure is most often caused by thrombus or tumor ingrowth.
▪ Most patients with malignancy-related SVC syndrome have a short life
expectancy, the stent usually remains patent until death.
▪ If reocclusion does occur, it can be treated with a second stent or
thrombolytic therapy, with good secondary patency rates.
54. Surgical intervention
▪ Surgical bypass is rarely performed in patients with malignant
cause of SVC syndrome because of the success of endovascular
stenting.
▪ Surgical management is more often undertaken in patients with
benign causes of SVC syndrome.
▪ One possible exception is malignant thymoma and thymic
carcinoma, which are relatively resistant to chemotherapy and
radiation.
57. Summary
▪ SVC syndrome results from extrinsic and intrinsic compression of
SVC
▪ Clinical presentation depends on acuity of obstruction and
adequate collateral development.
▪ Majority of svc due to malignancy
▪ Histologic diagnosis to guide treatment and determine prognosis.