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 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
Get biopsy (eventually) if this is malignancy

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 (https://www.jefferson.edu/university/jmc/departments/radiation_oncology/education/residency/residents/miller.html)

Rupal Parikh, MD: PGY6 in Diagnostic/Interventional Radiology at the Hospital of the University of Pennsylvania, Philadelphia, PA (https://www.pennmedicine.org/departments-and-centers/department-of-radiology/education-and-training/residency-programs/current-residents/ir-integrated-residents/ir-dr-fifth-year/rupal-parikh-md)

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