Radiotherapy for SVC syndrome Somvilai Chakrabandhu MD Division

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

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

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

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 – 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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