Acute SVCO presents a serious diagnostic and therapeutic dilemma to the thoracic surgeon. It is highly desirable to obtain a definitive tissue diagnosis but this requirement must be balanced against the risks inherent in invasive diagnostic procedures in these oft-times critically ill patients. In the past 5 years we have developed an algorithm that has been used successfully in 18 patients presenting with acute SVCO. The decision tree consists of scalene node biopsy, bronchoscopy and mediastinoscopy with categorization into low and high risk groups in the latter. The gender distribution of the 18 patients was 12 male and 6 female with the ages being 58.3 +/- 16.3 and 64.2 +/- 11.2 years respectively. The duration of symptoms range from 1.5 to 12 weeks and averaged 4.5 +/- 3.2 weeks. Two patients had palpable scalene nodes which were positive at biopsy. Bronchoscopy was positive in 5 out of 11 examinations. In 5 instances it was not done. Twelve patients underwent various forms of mediastinal biopsy and one underwent sternotomy. Seven patients requiring mediastinoscopy were judged to be high risk as defined by severe airway and vascular obstruction. Perioperative difficulties occurred in two patients due to cardiorespiratory factors associated with the obstruction. Both patients were undergoing cervical mediastinoscopy under general anesthesia and no difficulties were encountered in high risk patients when local anesthesia was used to perform anterior mediastinotomy. Five patients that were considered low risk all underwent uncomplicated procedures under general anesthesia. Thirteen patients proved to have bronchogenic carcinoma and a specific tissue diagnosis was obtained in 12. The undetermined diagnosis was in a patient who had prior radiotherapy.

1. Dr Rab Nawaz Maken
Dr. Abdul Mateen
MINAR, MULTAN

2. The clinical manifestation of superior
vena cava (SVC) obstruction, with severe
reduction in venous return from the
head, neck and upper extremities

5. Benign causes of SVCO
• Retrosternal goiter
• Mediastinal fibrosis
• Tuberculosis
• Sarcoidosis
• SVC thrombosis
• IV catheters
• Post Radiation fibrosis
• Aortic aneurysm

6.  Symptoms:
 Dyspnea 63%
 Facial and neck swelling 50%
 Fullness in head 50%
 Cough 24%
 Arm swelling 18%
 Chest pain 15%
 Dysphagia 9%

7.  Signs:
 Venous distention of neck 66%
 Venous distention of chest wall 54%
 Facial edema 46%
 Cyanosis 20%
 Edema of the arms 14%
 Plethora of the face 10%
 Chemosis
 Vocal cord paralysis 3%
 Horner’s syndrome 3%

8. Historically was considered a potentially life-
threatening emergency
Standard of care was immediate radiotherapy
The emergent approach is not appropriate for
most patients

9. Confirm obstruction Define the cause
CT Chest and/or MRI Chest
Contrast venography
Radionuclide venography
X-ray chest
Sputum cytology
Bronchoscopy and biopsies
Image guided biopsy
Thoracocentasis
Lymph node biopsy
Mediastinoscopy
Thoracotomy

10. Chest radiographic findings
Superior mediastinum widening 64%
Pleural effusion 22%
Right hilar mass 10%
Bilateral diffuse infiltrates 7%
Cardiomegaly 6%
Calcified paratracheal nodes 5%
Mediastinal (anterior) mass 3%
Normal 16%

12. Management outline
Histological
diagnosis
Staging
of the
disease
Treatment
Curative
Vs
Palliative

13. General Measures
1. Bed Rest
2. Elevate head of the bed
3. Oxygen
4. Diuretics
5. Steroids
6. Bronchodilators
7. Treatment of the cause

14.  Symptomatic obstruction is usually a prolonged process
 Most patients are not in immediate danger at presentation
 Most have time for a full diagnostic work up
 Prebiopsy radiation can obscure the diagnosis

15. Current strategies aim at accurate
diagnosis of underlying etiology before
therapy

16.  Controversial role with limited symptomatic relief
 Used for short period only and continued only if
response is seen or in raised ICP
 Decrease the inflammatory response to tumor
invasion and edema surrounding the tumor mass.
 Anti-inflammatory properties

17.  Induces symptomatic improvement
 Decrease venous return to the heart by
decreasing preload, relieving the increased
pressure in the SVC
 May result in dehydration that may result in
thrombosis and worsening of SVCO

18.  Effective for most malignant causes
 RT palliates in 70% of patients with CA lung and in more than 95%
with lymphoma
 Improvement is often apparent within 72 hours
 Treatment of choice in NSCLC
 Initially high dose /fraction for 3-4 days and then switch to
conventional fractionation. Total dose depend upon the cause
 Pt may be treated in sitting position with AP portal only initially

20.  NHLs, germ cells, and small cell lung cancers usually respond to
chemotherapy and/or radiation
 Can achieve long term remission with tumor specific directed therapy
 Symptomatic improvement usually takes 1-2 weeks after start of
therapy
 May be used as single modality or combined with Radiotherapy
 Evaluation after every cycle upto 3 cycles and then decide for further
therapy

21.  Role is controversial
 May be helpful if primary cause is thrombus
formation
 In most cancer Pts, LMWH and Aspirin is
usually treatment of choice

22.  Endovascular placement under fluoroscopy
 Patients who have benign or recurrent disease in
previously irradiated fields
 Tumors refractory chemotherapy
 Patient too ill to tolerate radiation or chemotherapy

23.  Treatment of choice in benign causes or
where expected survival is prolonged
 Thrombectomy and bypass surgery are
options available