Therapeutic Handbook - GGC Prescribing

Initial Management of Superior Vena CavaObstructionIntroductionSuperior Vena Cava Obstruction (SVCO) is an oncological emergency and any patients should bediscussed with a Registrar or above immediately, and with the local Respiratory team or on-callOncology team at the Beatson, as soon as possible to guide investigation and management.SVCO results from the compression of the superior vena cava by either a tumour arising in the rightmain or upper lobe bronchus or mediastinal lymphadenopathy. Initially it is diagnosed clinically in thepresence of neck and facial swelling and distended veins over the anterior chest wall. There mayalso be swelling of one or both arms and symptoms of dyspnoea and headache. Malignancy is thecommonest cause (> 90%), most typically lung cancer, lymphoma, metastatic disease, mesotheliomaand thymoma.Assessment / monitoringThe initial assessment includes:• Obtain full history including:- Details of known malignancies and their treatment- The development of new or worsening respiratory symptoms, arm swelling and headaches,and rapidity of onset- Co-morbidities- Medication including use of and contraindications to corticosteroids and anticoagulation.Examine for distended external and internal jugular veins, collateral veins on the anterior chest wall,facial, arm and neck swelling, and conjunctival redness.• The investigation of choice is a contrast enhanced spiral or multi-slice chest CT (CTPA). Thisdefines tumour extent, and often the site of occlusion or stenosis and the extent of any thrombusformation. Impending SVCO can be an incidental finding on CT.• Confirmation of diagnosis by histology may involve fine needle aspirate of palpable nodes,bronchoscopy, or CT guided biopsy. Seek advice from Respiratory or Oncology as soon aspossible to guide investigation and management.In addition to above, questions that may influence whether the patient should be considered for SVCstent or chemotherapy / radiotherapy are:• Is there a relative contraindication for radiotherapy? E.g. Previous chest / mediastinalradiotherapy? Is the patient able to lie reasonably flat?• Performance status (0 = normal activity, 1 = restricted daily activity, 2 = ambulatory and selfcaring, out of bed > 50% of the day, 3 = capable of limited self care, in bed > 50% time, 4 =unable to self care, chair / bed-bound)• Availability of stenting (performed by interventional radiology)Respiratory SystemPage 155