This document discusses Superior Vena Cava Syndrome (SVCS), which is caused by obstruction of the Superior Vena Cava (SVC). Malignancies are the most common cause, especially lung cancers like non-small cell lung cancer and small cell lung cancer. Symptoms range from mild edema to life-threatening signs. Diagnosis involves imaging like CT or MRI venography. Treatment depends on the severity and cause of SVCS, but may include steroids, endovascular stenting, chemotherapy, and/or radiotherapy. The goal is prompt symptom relief while determining the best long-term management based on the underlying condition.
LUNG CANCER remains the leading cause of cancer-related mortality in men and women in the United States, accounting for over 157,000 deaths annually.Despite advances in imaging, lung cancer is often detected when the disease has spread from the primary tumour to regional lymph nodes or distant sites. Appropriate therapy is dependent on accurate staging to identify those patients who are surgical candidates and those patients for whom chemotherapy and radiation therapy is indicated.
In this review, the current staging system for lung cancer is discussed, along with practical imaging approaches.
New technology called Electromagnetic Navigation Bronchoscopy® (ENB) that uses virtual bronchoscopy and real time 3-dimensional CT images that enable me to localize these peripheral lung nodules for diagnosis and treatment. This outpatient procedure is minimally invasive and therefore has a small risk of pneumothorax (2-3%) and its published diagnostic yield rates range from 67% - 86%
LUNG CANCER remains the leading cause of cancer-related mortality in men and women in the United States, accounting for over 157,000 deaths annually.Despite advances in imaging, lung cancer is often detected when the disease has spread from the primary tumour to regional lymph nodes or distant sites. Appropriate therapy is dependent on accurate staging to identify those patients who are surgical candidates and those patients for whom chemotherapy and radiation therapy is indicated.
In this review, the current staging system for lung cancer is discussed, along with practical imaging approaches.
New technology called Electromagnetic Navigation Bronchoscopy® (ENB) that uses virtual bronchoscopy and real time 3-dimensional CT images that enable me to localize these peripheral lung nodules for diagnosis and treatment. This outpatient procedure is minimally invasive and therefore has a small risk of pneumothorax (2-3%) and its published diagnostic yield rates range from 67% - 86%
Discrete,well marginated opacity that is less than or equal to 3cm in diameter is described as Solitary Pulmonary Nodule.Definitions,incidence,prevalence,etiology,evaluation and management has been described in this powerpoint presentation.
Discrete,well marginated opacity that is less than or equal to 3cm in diameter is described as Solitary Pulmonary Nodule.Definitions,incidence,prevalence,etiology,evaluation and management has been described in this powerpoint presentation.
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.
Ischemic colitis is the most common form of intestinal ischemia. It manifests as a spectrum of injury from transient self-limited ischemia involving the mucosa and submucosa to acute fulminant ischemia with transmural infarction that may progress to necrosis and death. Although there are a variety of causes, the most common mechanism is an acute, self-limited compromise in intestinal blood flow.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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
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.
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.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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!
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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
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
2. Introduction
• Emergencies in patients with cancer may be classified into three
groups: Pressure or obstruction caused by a space-occupying lesion,
metabolic or hormonal problems (paraneoplastic syndromes) and
treatment-related complications.
• Superior vena cava syndrome (SVCS) is the clinical manifestation of
superior vena cava (SVC) obstruction, with severe reduction in venous
return from the head, neck, and upper extremities.
• Characteristic symptoms and signs may develop quickly or gradually
when this thin-walled vessel is compressed, invaded, or thrombosed
by processes in the superior mediastinum.
3. Malignant causes
1.Primary : Older age groups : NSCLC (most common)
SCLC (highest risk)
Younger age groups : Lymphoma (PMBL,T-
LBL,DLBCL)
Mediastinal Germ cell tumour.
2.Secondaries (Nodal metastasis) : Breast carcinoma
Benign Causes : Catheter induced, Behcet’s, TB,
Mediastinal fibrosis etc
4.
5. Malignancy is the most common cause of SVCS by and far .This can be
due to any of the following mechanisms :
1. Extrinsic compression of the vein in the superior mediastinum by the
tumour or mediastinal lymph nodes.
2. Direct intravenous infiltration by the tumour mass.
3. Procoagulant status in malignancy can enhance catheter related venous
thrombosis.
In some cases, both external compression and thrombosis coexist
6. Lung Cancers
• Because of their common presentation with bulky centrally located masses
involving the hila and mediastinum, small cell lung cancer (SCLC) and squamous
cell carcinoma are the most common histologic lung cancer subtypes responsible
for SVCS.
• In lung cancer patients, SVCS was present in up to 8.6% of the patients.
• In patients with stage III non–small-cell lung cancer (NSCLC), the presence of SVCS
has been reported to be a significant factor indicative of shorter survival.
• Risk of SVCS is highest with small cell lung ca ,but due to higher prevalence NSCLC
are the most common cause of svc.
7. Lymphomas
• Lymphoma involving the mediastinum is the cause of SVCS in 2% to 21% of
patients
• Most patients with SVCS have either diffuse large cell B lymphoma or
lymphoblastic lymphoma.
• Although Hodgkin lymphoma commonly involves the mediastinum, it rarely
causes SVCS.
• SVC syndrome is even more common in patients with primary mediastinal large
B-cell lymphoma with sclerosis, an unusual and aggressive NHL subtype that
represents 3 to 7 percent of all diffuse large cell lymphoma .
8. Although most NHLs cause SVC
syndrome by extrinsic
compression due to enlarged
lymph nodes , patients with
intravascular (angiotropic)
lymphoma have intravascular
occlusion as the primary
pathogenic mechanism
9. Other malignancies
• Breast cancer is the most common metastatic disease causing SVCS in up to 11%
of the cases.
• Other rare primary or metastatic mediastinal malignancies such as thymic
malignancies, pleural mesothelioma, sarcomas, and primary mediastinal germ
cell tumors may cause SVCS.
• The prognosis of patients with SVCS strongly correlates with the prognosis of the
underlying disease.
10. Non malignant aetiologies
• As many as 40% of patients have been reported to present with nonmalignant
SVCS, most commonly due to thrombosis due to the presence of central vein
catheters .
• Other rare nonmalignant causes of SVCS include inflammatory vascular
conditions that may be associated with an increased risk of thrombosis, such
as Behçet’s disease, vascular anomalies or aneurysms exerting pressure on
the SVC, and inflammatory mediastinal processes such as fibrosing
mediastinitis (a prior infection with Histoplasma capsulatum) or Castleman
disease.
• Other infections that have been associated with fibrosing mediastinitis include
tuberculosis, nocardiosis, actinomycosis, aspergillosis, blastomycosis, and
Bancroftian filariasis
11.
12. SUPERIOR VENACAVA ANATOMY
• The SVC is the major low-pressure vessel for drainage of venous blood from the head, neck, upper
extremities, and upper thorax
• It is located in the right superior mediastinum and is surrounded by the sternum, trachea, right
mainstem bronchus, aorta, pulmonary artery, and perihilar and paratracheal lymph nodes.
• The SVC extends from the junction of the right and left innominate veins to the right atrium, over
a distance of 6 cm to 8 cm. The distal 2 cm of the SVC are within the pericardial sac.
• The left and right brachiocephalic veins merge at the level of the aortic arch to form the SVC. The
brachiocephalic veins themselves receive contributions from the internal and external jugular
veins, subclavian veins, internal mammary veins, pericardiophrenic veins, superior intercostal
veins, and inferior thyroid vein.
• The azygos vein—the main auxiliary vessel—enters the SVC posteriorly, just above the pericardial
reflection. The physiologic width of the SVC is 1.5 cm to 2 cm.
13.
14. Anatomic
classification
of SVC
obstruction
includes 3
levels of
obstruction:
An obstruction proximal to the azygous vein causes the
blood to return to right atrium through the azygous
system and intercostal veins into the SVC
In SVC obstruction at the level of azygos, blood cannot
re-enter the SVC through the azygos system and is
forced to utilize other collateral veins, leading into the
inferior vena cava (IVC) and from there into the right
atrium- and symptoms are usually more severe
In SVC obstruction below the level of azygos vein, blood
will be redirected via azygos and hemiazygos system in
a retrograde manner ultimately to the IVC, hence
causing less severe symptoms
18. Clinical Presentation :
The presentation of SVC obstruction depends upon the
• Time course of SVC invasion or compression,
• The degree of luminal compromise, and
• Whether recruitment of venous collaterals has compensated for the narrowing.
While this often occurs over a protracted period, acute thrombosis of a prior stable
partial obstruction can also occur, leading to abrupt symptoms
19. Clinical features :
#Symptoms and signs may be aggravated by bending forward, stooping, or lying down.
Mild to Moderate symptoms
• Non pulsatile dilated veins
• Diffuse edema of upper limbs
and face
• Heaviness of head
Dyspnea
Severe symptoms
• Reduced C.O resulting in Heart
failure
• Massive pleural effusions (rt>lt)
• Seizures with significant cerebral
edema
• Visual disturbances
• Stridor
20. •Respiratory symptoms can be related to edema from
SVC syndrome, which can narrow the lumen of the
nasopharynx and larynx, causing dyspnea, stridor,
cough, hoarseness, and dysphagia.
• Respiratory distress can also be related to pleural
effusion or from pulmonary restriction from severe
chest or breast swelling .
•Severe manifestations of venous outflow obstruction
can reduce perfusion pressure, potentially leading to
ischemia and venous gangrene, limb loss, and even
death .
25. Management
• Older broad principle : Initiate radiotherapy immediately after diagnosis.
• The paradigm shift in management:
• Acute mortality owing to SVC syndrome is uncommon (0.3%)
• The clinical course of SVCS rarely represents an absolute emergency.
• Radiotherapy without confirming the tissue diagnosis in chemo-sensitive,
tumours is not useful.
• Biopsy after radiotherapy gives inaccurate tissue diagnosis and hampers
further management.
26. Investigations
• Initial imaging :
1. X Ray chest : The most common radiographic abnormalities seen
are superior mediastinal widening and pleural effusion.
2. Conventional venography:The limitation of invasive venography
is the inability, to evaluate the specific cause of extrinsic SVC
compression
3. Imaging of choice : CECT thorax
4. Venous doppler used as adjunct in minor cases.
27. • Tissue Diagnosis :
1. Ct guided core needle biopsy .If not possible, invasive procedures are used
(risk of tracheal collapse).
2. Endobronchial fine-needle aspiration, Mediastinoscopy, Thoracocentesis.
3. Thoracoscopic biopsy: It is diagnostic if all other procedures have failed
• Disease Staging :FDG PET CT
28. Ultrasound
• Ultrasound — The central vasculature offers several challenges to
ultrasonography. As compared with the peripheral vasculature, evaluation of the
central veins using ultrasonography is more indirect.
• Doppler is used to assess respiratory variations and waveforms while color
Doppler is used to assess flow and direction.
• Findings that suggest central venous occlusion include dampening of the
waveforms with loss of venous pulsatility and loss of respiratory variation.
• Typical manoeuvres used during peripheral ultrasonography such as venous
compression and other supportive manoeuvres are limited because of anatomic
constraints
29. CT –MRV
• Computed tomography — Both non-contrast and contrast-enhanced CT can
demonstrate overall size, position, and calcifications of the thoracic central
vasculature .
• CT or MR venography can define the level and extent of venous blockage, identify
and map collateral pathways of venous drainage, and often permit identification
of the underlying cause of venous obstruction.
• The presence of collateral vessels on CT is a strong indicator of SVC obstruction,
with a specificity of 96 percent and sensitivity of 92 percent
30. Conventional venography
• Conventional, catheter-based venography remains the gold standard
for vascular imaging though is rarely necessary for initial diagnosis .
• While CT or MR provides a broad picture, in addition to providing
visualization of stenosis, thrombus, and collateral pathways, catheter-
based venography provides real-time clinical information regarding
flow patterns and rates and better "resolution" of smaller vessels,
often with less contrast than less invasive modalities.
• Furthermore, catheter-based venography offers an opportunity to
treat any hemodynamically significant lesions.
• However, catheter-based venography does not image the surrounding
structures, and thus will not identify the specific cause of
31. Recommendations
• For patients who present with mild to moderate symptoms (edema, pain),
including suspected superior vena cava (SVC) syndrome (grade 0,1,2 with
or without a known malignancy, either a venous duplex study or cross-
sectional imaging (computed tomographic [CT] venography, magnetic
resonance [MR] venography) may be used as the initial study .
• Duplex ultrasound is useful for excluding thrombus in the subclavian,
axillary, and brachiocephalic veins and is the initial imaging study for
patients with mild-to-moderate symptoms who present with extremity
swelling and who have an indwelling device, or those with a known
malignancy at low risk to cause venous obstruction. Additional imaging
studies may be needed depending upon the suspected etiology.
32. •Severe symptoms — For patients with severe or life-
threatening symptoms (e.g., severe acute primary
venous thrombosis, grade 3,4 SVC syndrome (table 1),
cross-sectional imaging with either CT or MR
venography is typically recommended as the initial
imaging modality to establish the diagnosis and for
surgical planning, depending upon the clinical
scenario and availability of institutional resources.
33. During the Diagnostic process :
• Supplemental oxygen
• Head end elevation (as high as tolerated)
• Diuretics (carefully assessing the hemodynamic status )
• Salt restricted diet (SRD)
*The use of upper extremities to deliver injectables should be avoided
34. Role of Steroids
• Steroids:They should only be considered after pathologic
confirmation of the cause of SVCS in symptomatic patients who
require urgent palliation, as steroid initiation prior to pathologic
confirmation can significantly hamper efforts for an accurate
diagnosis, especially with lymphomas.
• For patients receiving RT on an emergency basis -a short course of
high-dose corticosteroids is suggested to minimize the risk of central
airway obstruction secondary to edema .
35. • The goal of SVCS treatment depends on the cause, and in
malignancies, it depends on the stage of the disease.
• Malignant tumors are potentially curable if they present at
a non-metastatic stage, even in the presence of SVCS.
• The treatment of SVCS should be selected according to the
underlying histology and stage of the primary process.
36. SUPERIOR VENACAVA SYNDROME
Immediate
endovascular
procedure to
relieve obstruction
Grade 3 and lower
symptoms with no life
threatening signs.
Oxygen
Low salt diet
Head end elevation
Diuretics
Malignant(Metast
atic vs local)
Benign
,treat
underlying
cause.
Curative intent
(Multimodality
CT /RT)
Palliative
intent –RT
/Stent
Life threatening
symptoms
Cardiac failure, Stridor,
significant cerebral
edema
Diagnostic evaluation,
FDG PET, Tissue
Diagnosis.
38. “When the therapeutic goal is only palliation of SVCS or
when urgent treatment of the venous obstruction is required,
direct opening of the occlusion should be considered.
Endovascular stenting and angioplasty with possible
thrombolysis may provide prompt relief of symptoms before
more cancer-specific therapy”
39. Managing a thrombus :
• Thrombolysis : Mechanical > Pharmacological.
Anti coagulation based on Khorana score after thrombolysis and anti
platelets after stenting for 2 to 3 months to prevent stent thrombosis.
• Thrombolysis is often an integral part of the endovascular
management of SVCS, because thrombosis is frequently a critical
component of the obstruction and lysis is necessary to allow the
passage of the wire. Most reports have emphasized the use of
combination endovascular therapy: thrombolysis, angioplasty, and
stent insertion.
40.
41.
42. SMALL-CELL LUNG CANCER
• Platinum-based chemotherapy alone or in combination with thoracic
RT is the standard treatment for SCLC and is effective in rapidly
improving the symptoms of SVCS.
• No significant difference in response rates to chemotherapy or RT has
been detected in most studies.
• However, upfront RT in combination with chemotherapy may be
associated with better overall survival, suggesting that optimal local
control matters. Relief of SVCS typically occurs within 7 to 10 days
after initiation of therapy.
43. NON–SMALL-CELL LUNG CANCER
• A review of SVCS in lung cancer indicated that chemotherapy relieved
SVCS in 59% of patients with NSCLC; RT relieved the obstruction in
63% of patients with NSCLC.
• Nevertheless, in almost 20% of the patients, the obstruction recurred.
Response to RT was higher in patients who had received prior therapy
(94% vs 70%), suggesting that RT is an effective salvage option even in
recurrent SVCS.
44. NON-HODGKIN LYMPHOMA
• The primary treatment for non-Hodgkin lymphoma is chemotherapy,
as it has both local and systemic activity.
• Local consolidation with RT is beneficial in patients with early-stage,
diffuse, large-cell lymphoma, particularly if the mass is bulky.
• In a report of 36 patients with SVCS secondary to non-Hodgkin
lymphoma, all patients achieved complete relief of SVCS symptoms
within 2 weeks of the onset of any type of treatment, whether
treated with chemotherapy alone, chemoradiation, or RT alone.
45. Radiotherapy :
• The primary effect of palliative RT is achieved by shrinking the
underlying compressive/invasive malignant masses, thus decreasing
the extrinsic pressure on the SVC.
• For lymphomas, daily fractions of 1.8 to 2 Gy are recommended. For
lung cancers, standard palliative fractions of 3 to 4 Gy per fraction are
commonly used.
• In the absence of distant metastatic disease, the RT course may be
extended to a definitive treatment course, in combination with
sequential or concurrent chemotherapy when feasible.
46. • In the definitive treatment setting, the radiation field should encompass
all gross disease with appropriate margins for clinical and planning
target volumes.
• The total prescription dose of definitive RT is determined by the
underlying histology and matching standard of care.
• In the palliative setting, the RT field should encompass all gross disease
responsible for the SVCS, which may include the hilar, mediastinal, and
supraclavicular lymph nodes.
• Elective nodal irradiation is generally not recommended when treating
patients with lymphoma or lung cancer.
47. • Percutaneous transluminal angioplasty using balloon dilatation,
insertion of expandable metal stents, or both has been used successfully
to open and maintain the patency of SVC obstruction resulting from
malignant and benign causes.
• It is an effective and safe initial treatment for obtaining immediate relief
of the obstruction if the clinical status of the patient is rapidly
deteriorating.
48. Surgery
• In malignancy-induced SVCS, the tumor involvement causing SVCS is typically so
extensive that it is not considered technically resectable.
• There may be exceptions in which definitive surgical resection may be considered if
feasible (e.g., in a young, fit patient with a non-lymphomatous, nonmetastatic diagnosis
of malignancy & Residual mass after treatment for germ cell tumor) .
• In most cases, however, palliative surgical intervention should be considered only after
other therapeutic maneuvers such as RT, chemotherapy, and stenting have been
exhausted.
• The most common surgical approach is via a sternotomy or thoracotomy with extensive
resection of the tumor and reconstruction of the SVC.
49. SVC RECONSTRUCTION
• SVC reconstruction using grafts such as expanded polytetrafluoroethylene has become
possible with modern surgical techniques.
• There is also growing experience with direct bypass grafts for SVC obstruction.
• The preferred bypass route is between an innominate or jugular vein on the left side and
the right atrial appendage, using an end-to-end anastomosis.
50. SUMMARY OF TREATMENT:
• In patients with suspected underlying malignancy as the cause of SVCS who present with non–life-
threatening symptoms, an efficient diagnostic effort should be attempted before any oncologic treatment
is given.
• After the cause of SVCS has been established, treatment of the primary process should promptly follow.
• Combination of systemic therapy and RT is the treatment of choice for most NSCLC, SCLC, and
lymphomas.
• RT of the lesion and adjacent nodal areas results in optimal local control.
• Updated CT scanning and [18F]-fluorodeoxyglucose positron emission tomography imaging should be
incorporated into any carefully designed definitive RT treatment plan.
• Percutaneous endovascular intervention should be considered in severe cases because it relieves
symptoms rapidly without masking the diagnosis.
• Significant progress has been made in endovascular stent placement, with high rates of technical success
and low restenosis and complication rates.
• These endovascular techniques are optimally combined with histology-specific oncologic treatments for
durable local control.
51. • It emphasizes that in most patients (>85%) with SVCS, the symptoms are
not severe (grades 0, 1, and 2) and cancer-specific treatment could follow
appropriate diagnosis and staging.
• . Grade 3 (severe) patients who present with mild or moderate cerebral
edema, mild or moderate laryngeal edema, or diminished cardiac reserve
may be considered for immediate stent intervention or early RT;
otherwise, they should receive disease-specific treatment.
• Only the rare (<5%) grade 4 (life-threatening) patients who develop
significant cerebral edema or laryngeal edema with stridor or have
significant hemodynamic compromise should undergo stent insertion
immediately.
• Most experts recommend anticoagulation after thrombolysis (to prevent
disease progression and recurrence) and aspirin after stent placement in
the absence of thrombosis, but data are limited.