Lee, WMA

Sze, WM

Wai, HPS

Yau, TK

Yeung, RMW

Yeung, MWR

HKU Scholars Hub

A Review of Superior Vena Cava Obstruction in Hong Kong Chinese Patients

Title A Review of Superior Vena Cava Obstruction in Hong KongChinese PatientsAuthor(s) Wai, HPS; Yeung, RMW; Sze, WM; Yau, TK; Lee, WMACitation Journal of the Hong Kong College of Radiologists, 2001, v. 4, p.143-145Issued Date 2001URL http://hdl.handle.net/10722/220032Rights Journal of the Hong Kong College of Radiologists. Copyright ©Hong Kong Academy of Medicine Press.HPS Wai, RMW Yeung, WM Sze, et al.J HK Coll Radiologists 2001;4:143-145 143J HK Coll Radiologists 2001;4:143-145ORIGINAL ARTICLEINTRODUCTIONSuperior vena cava obstruction (SVCO) was first de-scribed by Hunter in 1757 in a patient with a syphiliticaneurysm of the ascending aorta.1 Nowadays, the ma-jority of cases are due to malignant tumour within themediastinum — namely, lung cancer and lymphoma.2The pathology of SVCO is extrinsic compression of thelarge central veins feeding into the heart, sometimesaccompanied by intravascular tumours or thrombosis.The presenting symptoms are dyspnoea, dilatation ofneck veins, and swelling of soft tissues of the face, neck,and upper limbs. Headache and other cranial symptomsmay occur as a result of cerebral oedema.3,4 SVCO oftenarises acutely and should be treated as an oncologicalemergency.5 It is usually highly responsive to radio-therapy (RT), regardless of tumour type.6 Therefore,active treatment should be considered unless thepatient is extremely ill, or is unable or unwilling toattend for RT.7 High-dose corticosteroid therapy isusually given to reduce oedema associated with medi-astinal tumour.8 Recently, it has been suggested that anCorrespondence: Dr. HPS Wai, Department of Clinical Oncology,Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong.Tel: (852) 2595 4166; Fax: (852) 2515 1266.Submitted: 26 August 2000; Accepted: 28 October 2000.A Review of Superior Vena Cava Obstructionin Hong Kong Chinese PatientsHPS Wai, RMW Yeung, WM Sze, TK Yau, AWM LeeDepartment of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong KongABSTRACTSuperior vena cava obstruction is, in the majority of patients, due to the presence of a malignant tumourwithin the mediastinum, i.e. lung cancer and lymphoma. It is usually highly responsive to radiotherapy,regardless of the underlying tumour type. This article briefly reviews the diagnosis, presentation, and resultsof radiotherapy in a total of 49 patients with superior vena cava obstruction who presented to the depart-ment of clinical oncology at the Pamela Youde Nethersole Eastern Hospital between 1 January 1996 and31 December 1999. Lung cancer accounted for the majority of cases of superior vena cava obstruction. Themost common presenting symptoms were facial and upper limb oedema; all patients presented with a historyof symptoms of less than 3 months duration. The median survival was 6 weeks after diagnosis. Radiotherapywas well tolerated and produced good symptom relief.Key Words: Lung cancer, Mediastinum, Radiotherapy, Superior vena cava obstruction, Symptom reliefaccurate histological diagnosis be obtained in advancein order to establish the correct, effective therapy.5Symptomatic relief following irradiation is reported in50% to 90% of cases; survival of patients with SVCOis determined by their underlying disease rather than bythe syndrome itself.9-11PATIENTS AND METHODSThe present study is a retrospective analysis of pa-tients with SVCO who presented to the department ofclinical oncology, Pamela Youde Nethersole EasternHospital, Hong Kong, between 1 January 1996 and 31December 1999. Medical records of these patientswere retrieved and analysed, specifically for diagnosis,symptom(s), duration of presenting symptom(s), symp-tomatic relief, and RT dosage (dose/fraction, numberof fractions, total dose, and overall treatment time).Statistical AnalysisStatistical analysis was performed using the StatisticalPackage for the Social Sciences (version 8.0). Unlessotherwise stated, all results are expressed as number [no.](%) or mean –  standard deviation (SD) where appropriate.RESULTSA total of 49 patients were analysed in this study. Therewere 34 (69.4%) male and 15 (30.6%) female patients.Superior Vena Cava Obstruction in Chinese144 J HK Coll Radiologists 2001;4:143-145The median age at presentation was 69 years (range, 15to 86 years). The mean follow-up time was 10.6 –11.9 weeks (range, 0.1 to 50.0 weeks). Symptoms atpresentation were as follows: facial and upper limboedema in 36 patients (73.5%), dyspnoea in 30 (61.2%),distension of neck veins in 30 (61.2%), chest pain in 3(6.1%), and cough in 12 (24.5%). None of the patientspresented with symptoms of increased intracranialpressure. The mean duration of presenting symptomswas 26.8 days (range, 1 to 90 days). All patients pre-sented with a history of symptoms of less than 3 monthsduration. Among the 49 patients, 38 (77.6%) had ahistological diagnosis while 11 (22.4%) had a clinicaldiagnosis only. The patients’ diagnoses are summarisedin Table 1.Forty eight patients (98.0%) received RT. The remain-ing patient was too sick to receive active treatment.Forty one patients completed the course of RT and themedian total dose was 28 Gy in seven daily fractionsover 10 days. The results of treatment in different groupsof patients are summarised in Table 2. Overall, symp-tomatic relief was reported for 38 patients (79.2%).The percentage and duration of symptomatic relief aresummarised in Table 3. Of the 40 patients who starteddexamethasone before RT, 30 (75.0%) had decreaseddexamethasone requirement after RT and 13 (32.5%)eventually stopped the corticosteroid altogether. Themedian survival of the whole group was 6 weeks (range,1 to 56 weeks) after diagnosis.DISCUSSIONThe majority of patients in this study presented withfacial and upper limb oedema — a prominent featurecausing them to seek medical treatment. The othercommon presenting symptoms were cough, distensionof neck veins, and dyspnoea. None of the patients pre-sented with cranial symptoms due to cerebral oedema.Thus, these findings are in accordance with previouslypublished data showing dyspnoea and facial and upperlimb oedema to be the most common symptoms inSVCO,6,11,12 while cranial symptoms are rare.9Bronchogenic carcinoma accounted for the majority ofthe cases of SVCO in this series (79.6%), followed bylymphoma. These findings are again consistent withthose in the literature.8,13 However, only patients withmalignant disease causing SVCO were included in ourreview; non-malignant causes such as mediastinalfibrosis and thrombosis of the superior vena cava (whichaccount for a proportion of cases in general hospitals)were not seen here.14,15 The reason for this may be due to adifferent referral pattern to a clinical oncology department.A lower rate of symptom relief was observed in patientsreceiving both corticosteroid therapy and RT comparedwith those receiving RT alone (Table 2). The reasonfor this may be the fact that those who received bothcorticosteroid therapy and RT had poorer performancestatus and worse symptoms at the outset; as a result,they responded less well to treatment. On the otherhand, patients with milder symptoms and better per-formance status at presentation did not require cortico-steroid therapy and responded well to RT.In our study, treatment of SVCO was mostly palliative,with a total radiation dose of 28 Gy. According to theliterature, a total dose of 20 Gy in five fractions or 30Gy in 10 fractions is usually adequate for palliation.The choice of total dose and fractionation schedulesdepends on the histology of the tumour.16 RT wasusually well tolerated and resulted in significant symp-tomatic improvement. Treatment could be completedin most of the patients (>80%), and the symptomsTable 1. The diagnoses of patients with superior vena cavaobstructionDiagnoses No. (%)NSCLC 33 (67.3)SCLC 6 (12.2)Lymphoma 2 (4.1)Carcinoma of thyroid 1 (2.0)Thymoma 1 (2.0)Metastatic carcinoma 6 (12.2)Abbreviations: NSCLC = non-small cell lung cancer; SCLC = small cell lungcancer.Table 2  Results of treatment in different groups of patients withsuperior vena cava obstructionPatient group No. (%) Symptom reliefafter RT (%)NSCLC 33 (67.3) 78.8Other diagnosis 16 (32.7) 81.3Corticosteroid therapy and RT 39 (79.6) 76.9RT only 9 (18.4) 100Table 3. Improvement of patients’ symptoms after radiotherapy(RT)Symptom Symptom relief Median durationafter RT (%) of symptom relief(weeks)Dyspnoea 73.3 6.6 –  2.0Facial and upper limb oedema 80.6 13.9 –  3.4Distension of neck veins 76.7 14.8 –  4.0Chest pain 66.7 10.9 –  6.6Cough 85.7 7.7 –  3.7HPS Wai, RMW Yeung, WM Sze, et al.J HK Coll Radiologists 2001;4:143-145 145that were best controlled included cough and facialand upper limb oedema. Among all the symptoms,relief of the distension of neck veins and facial andupper limb oedema were the most durable.The treatment results of this study were comparablewith most of the reported overseas series.9-11 For patientswith SVCO secondary to non-small cell lung cancer,RT is the primary treatment. The likelihood of reliev-ing signs and symptoms of SVCO is high, but the over-all prognosis for these patients is poor.8,10,11,15 RT hasbeen advocated as standard treatment for most patientswith SVCO.9,17,18 It is used as the initial treatment if ahistological diagnosis cannot be established while, atthe same time, the clinical status of the patient isdeteriorating.13 Armstrong et al observed improvementof symptoms within 2 weeks or less in 70% of irradi-ated patients.11 Serial venography and autopsy findingssuggest that the symptomatic improvement achievedafter RT is not always due to improvement of flowthrough the superior vena cava, but is probably alsoa result of the development of collaterals after thepressure in the mediastinum is eased.5CONCLUSIONRT with a dose of 28 Gy in seven daily fractions in 10days is usually well tolerated and produces good symp-tom relief in patients with SVCO. Our retrospectiveanalysis described the outcome of patients treated mainlyby RT; the results were in accordance with the existingpublished literature.REFERENCES1. Hunter W. The history of an aneurysm of the aorta, with someremarks on aneurysms in general. Med Obser Inq 1757;1:323.2. Jones LA. Superior vena cava syndrome: an oncologic compli-cation. Semin Oncol Nurs 1987;3:211-215.3. Mclntire FT, Sykes EM. Obstruction of the superior vena cava.A review of the literature and a report of two personal cases. AnnIntern Med 1949;30:925-960.4. Schechter MM. The superior vena cava syndrome. Am J MedSci 1954;227:46-56.5. Ahmann FR. A reassessment of the clinical implications of thesuperior vena cava syndrome. J Clin Oncol 1984;2:961-969.6. Bell DR, Woods RL, Levi JA. Superior vena cava obstruction:a 10-year experience. Med J Aust 1986;145:566-568.7. Schraufnagel DE, Hill R, Leech JA, Pare JAP. Superior vena cavaobstruction: is it an emergency? Am J Med 1981;70:1169-1174.8. Goodman R. Superior vena cava syndrome. Clinical manage-ment. J Am Med Assoc 1975;231:58-61.9. Perez CA, Presant CA, Van Amburg AL 3rd. Management ofsuperior vena cava syndrome. Semin Oncol 1978;5:123-134.10. Davenport D, Ferree C, Blake D, Raben M. Radiation therapyin the treatment of superior vena cava obstruction. Cancer 1978;42:2600-2603.11. Armstrong BA, Perez CA, Simpson JR, Hederman MA. Roleof irradiation in the management of superior vena cavaobstruction. Int J Radiat Oncol Biol Phys 1987;13:531-539.12. Parish JM, Marschke RF, Dines DE, Lee RE. Etiologic consid-erations in superior vena cava obstruction. Mayo Clinic Proc1981;56:407-413.13. Yellin A, Rosen A, Reichert N, Lieberman Y. Superior vena cavaobstruction: myth — the facts. Am Rev Respir Dis 1990;141:1114-1118.14. Sculier JP, Feld R. Superior system: recommendation formanagement. Cancer Treat Rev 1985;12:209-218.15. Bertrand M, Presant CA, Klein L, Scott E. Iatrogenic superiorvena cava obstruction: a new entity. Cancer 1984;54:376-378.16. Dobbs J, Barrett A, Ash D. Palliative Irradiation. In: Dobbs J,Barrett A, Ash D, eds. Practical Radiotherapy Planning. 2nded. London: Edward Arnold; 1994:291-295.17. Loeffler JS, Leopold KA, Recht A, et al. Emergency prebiopsyradiation for mediastinal masses: impact on subsequent pathologicdiagnosis and outcome. J Clin Oncol 1986;4:716-721.18. Scarantino C, Salazar OM, Rubin R, et al. The optimum radia-tion schedule in the treatment of superior vena cava obstruction:importance of 99mTc scintinangiograms. Int J Radiat Oncol BiolPhys 1979;5:1987-1995.

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A Review of Superior Vena Cava Obstruction in Hong Kong Chinese Patients

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