Superior vena cava syndrome radiation therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]

Overview

Rapid radiotherapy is recommended for all patients who develop superior vena cava syndrome secondary to malignant tumor. The feasibility of radiation therapy depends on the stage of cancer at diagnosis. Radiation dosage will depend on clinical features.

Radiation Therapy

Most of the thoracic tumors causing superior vena cava syndrome are sensitive to radiotherapy. The majority of cases of superior vena cava syndrome are symptomatic and require radiation therapy for symptom relief.

Indications

The feasibility of radiation therapy depends on the stage of cancer at diagnosis. If the obstruction caused by the SVCS is caused by a tumor that is not sensitive to chemotherapy, radiation therapy is indicated.

Emergent RT

• RT prior to biopsy can obscure histologic diagnosis
• Endovascular stents in severely symptomatic patients provide more rapid relief
• Consider emergency RT (and endovascular stent) if:
  • Stridor from severe laryngeal edema
  • Coma from cerebral edema

RT Dose/Schedule

• Initially use high-dose fractions (3-4 Gy) for 2 or 3 days for curative treatment, followed by standard 1.8-2 Gy/fx
• It is not unusual to palliate with 3Gy x 10, or 4Gy x 5, or 2.5Gy x 15
• Symptomatic relief can be apparent in 72 hours, complete relief can be observed by 2 weeks (78% SCLC, 63% NSCLC)
• Superior vena cava syndrome patency improvement only in 31% of the cases, so some symptomatic relief is probably due to the development of collateral circulation over time
• Many patients will recur symptomatically prior to death
• Consider chemotherapy before or with RT if:
  • SCLC, NHL, and germ cell tumors
  • In the absence of distant metastasis, aggressive management is indicated
  • Symptomatic relief within the first 30 days might be a good prognostic factor
  • Treatment with larger fractions of radiation is thought to be beneficial in developing a rapid response.