New Fellow Bootcamp Series: SVC Syndrome

An exciting new academic year is about to begin. We know this can be daunting, especially for our newest hematology/oncology fellows. Over the next two weeks, we re-boot some of our high yield episodes you need to know to prepare for your first days as a new fellow and your nights on call. 

Next up: Superior vena cava (SVC) syndrome ! [Originally episode 012]

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Be sure to check out our Rotation Guides to get you in tip-top shape for fellowship!

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Check out our recent tweetorial on this topic prepared by TFOC member, Dr. Karam Elsolh

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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: Dr. Miller is now an attending Radiation Oncologist at Kaiser Permanente in Southern California

  • Rupal Parikh, MD: Dr. Parikh is now an attending Interventional Radiologist at UCSD in San Diego, California!

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