Superior Vena Cava Obstruction
An approach to symptom management to guide decision-making in the management of patients with life-threatening illness
Appropriate assessment to identify cause and severity of symptoms
Explanation to patient and family
Referral to appropriate service: Acute oncology service
Institute non-pharmacological interventions
Prescribe appropriate first-line treatment
Consider second-line treatment
Involvement of interdisciplinary team
Review assessment and management
Introduction
Superior Vena Cava Obstruction (SVCO) is due to compression, invasion and /or thrombosis of the Superior Vena Cava by mediastinal lymph nodes or tumour in the region of the right main bronchus. It is caused by:
- Carcinoma of the bronchus 75% (most common)
- Lymphoma 15%
- Breast 10%
- Colon 10%
- Oesophagus 10%
- Testis 10%
Appropriate assessment to identify cause and severity of symptoms
- Symptoms – are those of venous hypertension and include breathlessness (due to laryngeal oedema, tracheal or bronchial obstruction), headache (due to cerebral oedema), visual changes, dizziness and swelling of the face, neck and arms.
- Signs – include engorged conjunctivae, peri-orbital oedema, non-pulsatile dilated neck veins and dilated collateral veins (chest and arms). Papilloedema is a late feature.
SVCO can present acutely, causing very distressing symptoms. In the Palliative Care setting the diagnosis e.g. Ca Bronchus is usually already known and so a high index of suspicion is required.
Explanation to patient and family
Without treatment SVCO can progress over several days resulting in death. In patients presenting with advanced SVCO, the prognosis is poor even with treatment, unless the primary cancer is responsive to either radiotherapy or chemotherapy. The prognosis depends on the prognosis of the cancer. Hospice staff will need to inform the patient and family of the seriousness of the situation and the urgency of seeking treatment while also providing the ongoing support and security they will need at this time.
Management: Emergency treatment (needed for advanced, acute SVCO)
Referral to appropriate service: Acute oncology service
Contact specialist oncology centre as a priority. If possible the patient should be transferred to an oncology centre for management.
Institute non-pharmacological interventions
Sit patient upright and give 60% oxygen.
Prescribe appropriate first-line treatment
- Dexamethasone – 8-16 mg p.o. or i/v or SC.
- Furosemide – 40 mg p.o. or i/v (maximum rate 4 mg/min)
- Consider prophylactic anti-convulsant.
Disease-specific palliative therapy
Emergency radiotherapy or chemotherapy (Small Cell Carcinoma of Bronchus, Lymphoma or Testicular Cancer) is given with steroid cover, e.g. dexamethasone
16 mg daily. Survival may be prolonged for several months but a recurrence may be more difficult to control.
Consider second-line treatment
Intra-luminal stents can be inserted via the femoral vein into the SVC in patients whose SVCO has recurred after standard treatment. It may also be used as a first line treatment to control symptoms.
Thrombosis in the SVC may be an added problem and should be managed accordingly using the appropriate thrombolytic agent.
Involvement of interdisciplinary team
Due to the prognostic implications of SVCO, the interdisciplinary team should be involved in support and counselling for the patients and/or family and carers.
Review assessment and management
Regular follow-up is required which may involve close communication with the oncologist involved if the patient has been transferred to an oncology centre. Patients may be on a high dose of steroids and will require close monitoring. Many patients will need In Patient Unit admission for daily assessments by a Palliative Care doctor and monitoring by the interdisciplinary team.