Radiotherapy for SVC syndrome Somvilai Chakrabandhu, MD. Division of Therapeutic Radiology and Oncology, Faculty of Medicine, Chiang Mai University

SVC syndrome Definition The clinical manifestation of obstruction of the superior vena cava, with severe reduction in venous return from the head, neck, and upper extremities

SVC syndrome Superior vena cava carries venous blood from the head, arms, and upper trunk to the heart carries approximately one third of the venous return to the heart.

SVC syndrome Obstruction of Superior vena cava Reduction in venous return of face, neck, upper extremities Collateral development of venous system - azygos, internal thoracic, paraspinous, esophageal

SVC syndrome Types of SVC obstruction Extrinsic compression Mediastinal structure or lymph nodes Intrinsic obstruction Thrombosis Neoplastic infiltration

SVC syndrome Causes of SVC obstruction Malignant about 80% Lung cancer Lymphoma Metastasis malignancy to mediastinal LNs Non-malignancy Infection (stphilis, TB) Fibrosis Thrombus (central venous catheter)

SVC syndrome Symptoms Dyspnea (most common) Orthopnea Facial / Neck swelling Cough hoarseness Headache Nasal congestion Hemoptysis Dysphagia Dizziness Syncope

SVC syndrome The severity of the symptoms depends on the degree of narrowing of the superior vena cava Symptom onset depends on speed of SVC obstruction onset Malignant disease can arise in weeks to months Not enough time to develop collaterals As the obstruction develops venous collaterals are formed

SVC syndrome Physical finding Edema of face, arms Dilated neck veins Increased collateral veins over anterior chest wall Cyanosis Severe cases include proptosis, glossal and laryngeal edema

Wilson L et al.N Engl J Med 2007;356:1862-9

Radiographic Studies Chest x-ray Most common findings Mediastinal widening Pleural effusion

Radiographic Studies CT Chest with contrast Preferred choice defines the level of obstruction Maps out collateral pathways Can differentiate between vena caval thrombosis and extrinsic compression

Radiographic Studies CT scan : Diagnosis level of obstruction

Radiographic Studies MRI useful in patients with IV contrast allergies Positronemission tomography (PET) sometime useful

SVC syndrome Management Superior vena cava syndrome associated with malignant conditions involves both treatment of the cancer and relief of the symptoms of obstruction

Immediate action is needed SVC syndrome Emergency condition Stridor from laryngeal edema and impending airway obstruction Confusion related to associated cerebral edema Immediate action is needed Attention to the ABCs assessment Stabilize the airway

SVC syndrome Non- Emergency condition Most patients are not in immediate danger at presentation Sit upright : relief of the usual dyspnea Oxygen support, if indicated Consider steroids Controversial issue with regards to treatment benefit at presentation

SVC syndrome Treatments & interventions Medical management : Corticosteroid and diuretic for laryngeal and cerebral edema (controversy) Thrombolytic drug : thrombotic cause

SVC syndrome Treatments & interventions Surgical treatment : bypass Endovascular stent increasingly used immediate relief symptom Refractory to RT/ chemotherapy

SVC syndrome Treatments & interventions RT and chemotherapy Relief symptom and Treatment malignancy

Radiation Therapy Excellent symptom relief: dyspnea edema of face and distention of neck and thoracic vein Symptomatic improvement usually takes 1-2 weeks after radiotherapy

Radiation Therapy Radiation dose for palliation Radiation field 20 - 30 Gy in 5 – 10 fractions Depend on patient condition Radiation field Encompass mediastinal lymph nodes / hilar region

Radiation Therapy Supine position

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