Treatment of malignant superior vena cava syndrome by endovascular stent insertion: Experience on 52 patients with lung cancer
Introduction
Superior vena cava syndrome (SVCS) is defined as the signs and symptoms derived from blood impairment through the superior vena cava to right atrium. Its clinical presentation includes oedema and vein distension of the head and neck, upper extremities and thorax, dyspnea and, in severe cases, confusion, impaired attention and coma. The main cause of SVCS in adults is lung and mediastinal tumours. Small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) cause the vast majority of cases.
Treatment approach to SVCS traditionally includes radiation therapy and chemotherapy, with radiation accomplishing up to 80% success rate in symptomatic relief in SCLC and 46% in NSCLC. Rapid initiation of full dose chemotherapy can result in 80% response rate in SCLC attending to the best series [1]. Delayed response to radiation and chemotherapy, and risk of worsening of the SVCS due to hydration mandatory for chemotherapy including full dose of Cisplatinum, can seriously compromise the results of these treatment approaches.
Intravascular placement of metallic stents in the superior vena cava can rapidly achieve relief of vein obstruction [2], [3], [4]. It results in symptomatic resolution and makes possible full etiologic treatment. We report our experience with this procedure in a retrospective series of 52 patients focusing on those with NSCLC with no prior treatment.
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Patients and methods
Between August 1993 and December 2000 stent placement was performed in 52 consecutive patients with malignant SVCS to improve their symptoms. Characteristics of the patients are described in Table 1. Forty-six patients were men, and the population had a median age of 57. In all cases SVCS was caused by lung cancer (37 NSCLC and 15 SCLC), 34 (65%) were in stage III b at the moment of placing the stent, while 18 (35%) were metastatic. In two patients the histology of the tumour was not available
Results
The stent placement was achieved in all 52 cases with 100% success in re-permeabilitation assessed by a second venogram after procedure. As shown in Table 2, symptoms improved in the vast majority of cases. Oedema, present in 100% of patients, improved in 92% of cases (completely in 59%). Dyspnea was present in 40 and decreased in 34 of them (85%) with complete resolution in 24 cases (60%). Collateral thoracic vein distension was present in 45 patients and improved in 33 (73%), up to complete
Discussion
Endovascular placement of autoexpandable stents as treatment of SVCS is a safe and effective procedure [5], [6]. Classically, SVCS was considered as a medical emergency and radiotherapy was usually elected as the first treatment, sometimes without histological diagnosis. Furthermore, even invasive diagnostic techniques were avoided in order to reduce respiratory and bleeding complications. Nowadays, SVCS is no longer considered as a medical emergency and invasive diagnostic techniques are
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