Episode 012: Heme/Onc Emergencies, Pt. 1: SVC Syndrome

Emergencies happen in hematology and oncology. This is a fact. But how do we manage these emergencies? Look no further.

In this episode, we talk all about our first oncologic emergencies: superior vena cava (SVC) syndrome.

---

Superior vena cava syndrome:

• Important: although we focus on a possible malignant mass in this discussion about SVC, other things can also cause SVC syndrome.

• How do you know about the chronicity of someone’s possible SVC syndrome? Compare to a recent picture!

• Image of patient with collateralization with SVC syndrome: DOI: 10.1056/NEJMicm1311911

• Workup:

  • Need to determine the etiology; imaging is important:

    • CT of chest (CT venogram)

    • Consider ultrasound to rule out thrombosis

    • Work on getting a biopsy if malignancy is likely

• DDx of mediastinal masses:

  • 5Ts:

    • Thymoma

    • Terrible lymphoma (B or T-cell)

    • Testicular cancer

    • Teratoma

    • Thyroid malignancies

  • Central line (causing occlusion) +/- clot

• So now what?

  • Yes, an answer to what is causing the issue is important, but we need to ensure that patient has a stable airway and temporize the situation

  • Often requires input of specialists, such as Interventional Radiology or Radiation Oncology

• How to treat patients with SVC syndrome?

  • Chemotherapy: Important in chemo-responsive tumors (ex. germ cell tumors, lymphomas, small cell lung cancer)

    • This can take a while to work

  • Placement of stents

    • Provides more immediate relief, but more invasive

  • Radiation treatment:

    • Not always possible

  • Laryngeal edema/cerebral edema: steroids for life-threatening complications

    • Can affect diagnostic yield of sample and affect diagnosis, but may be required in emergent situations

• When is more emergent treatment indicated and consultants definitely need to be called (TELL YOUR CONSULTANT IF ANY OF THESE ARE SEEN!):

  • Hemodynamic instability

  • Worsening respiratory status

  • Worsening neurological status

• Final decision for what to do is often a multi-disciplinary discussion

  • Stents:

    • Provides quick relief

    • Does not prohibit a diagnosis and curative treatment for the underlying malignancy

  • Radiation:

    • Takes several days or weeks; depending on underling histology

    • If they have received prior radiation, they may not be eligible for more radiation

• A HUGE thank you to our special guests:

  • Ryan Miller, MD, MS: PGY5 in Radiation Oncology at Thomas Jefferson University Hospital, Philadelphia, PA

  • Rupal Parikh, MD: PGY6 in Diagnostic/Interventional Radiology at the Hospital of the University of Pennsylvania, Philadelphia, PA

---