By Dr Deepu
Images
Definition
History
Pathophysiology
Presentation and Findings
Causes
Diagnostic Workup
Management
Images
Definition
History
Pathophysiology
Presentation and Findings
Causes
Diagnostic Workup
Management
Management
In the management of superior vena cava syndrome (SVCS),
the goals are to relieve symptoms and to attempt cure of the primary malignant
process.
Only a small percentage of patients with rapid-onset
obstruction of the superior vena cava (SVC) are at risk for life-threatening
complications.
Patients with clinical SVCS often gain significant
symptomatic improvement from conservative treatment measures, including
elevation of the head of the bed and supplemental oxygen.
Emergency treatment is indicated when brain edema,
decreased cardiac output, or upper airway edema is present.
Corticosteroids and diuretics are often used to relieve
laryngeal or cerebral edema, although documentation of their efficacy is
questionable.
Radiotherapy has been advocated as a standard treatment
for most patients with SVCS. It is used as the initial treatment if a
histologic diagnosis cannot be established and the clinical status of the
patient is deteriorating; however, reviews suggest that SVC obstruction alone
rarely represents an absolute emergency that necessitates treatment without a
specific diagnosis.
The fractionation schedule for radiotherapy usually
includes two to four large initial fractions of 3-4 Gy, followed by daily
delivery of conventional fractions of 1.5-2 Gy, up to a total dose of 30-50 Gy.
The radiation dose depends on tumor size and radioresponsiveness. The radiation
portal should include a 2-cm margin around the tumor.
During irradiation, patients improve clinically before
objective signs of tumor shrinkage are evident on chest radiography. Radiation
therapy palliates SVC obstruction in 70% of patients with lung carcinoma and in
more than 95% of those with lymphoma.
In patients with SVCS secondary to non–small-cell
carcinoma of the lung, radiotherapy is the primary treatment. The likelihood of
patients benefiting from such therapy is high, but the overall prognosis of
these patients is poor.
When SVCS is due to thrombus around a central venous
catheter, patients may be treated with thrombolytics (eg, streptokinase,
urokinase, or recombinant tissue-type plasminogen activator) or anticoagulants
(eg, heparin or oral anticoagulants).
Removal of the catheter, if possible, is another option,
and it should be combined with anticoagulation to prevent embolization. These
agents are most effective when patients are treated within 5 days after the
onset of symptoms.
Dexamethasone
Important therapeutic agent in a number
of malignant diseases. Exerts biologic action predominately by binding to
glucocorticoid receptor. For symptomatic management in tumor-associated edema.
Thrombolytics
The potential benefits of thrombolytics
for the treatment of pulmonary embolism include fast dissolution of
physiologically compromising pulmonary emboli, quickened recovery, prevention
of recurrent thrombus formation, and rapid restoration of hemodynamic
disturbances. For deep vein thrombosis, lysis of the thrombus can prevent
pulmonary embolism and permanent pathologic changes, such as venous valvular
dysfunction and postphlebitic syndrome.eg Urokinase
Anticoagulants
In superior vena cava syndrome (SVCS),
these agents are used mainly to prevent pulmonary embolism from superior vena
cava (SVC) thrombus.
Eg: Heparin and Warfarin
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