Superior vena cava syndrome overview: Difference between revisions
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==Overview== | ==Overview== | ||
'''Superior vena cava syndrome''' (also known as '''SVCS'''), is a group of [[Symptom|symptoms]] caused by obstruction of the [[superior vena cava]]. More than 60% of cases of [[superior vena cava]] [[obstruction]] are caused by [[malignant]] causes, typically a [[tumor]] outside the [[Blood vessel|vessel]] compressing the [[Blood vessel|vessel wall]]. However, in 20% of the cases, the cause is [[benign]]. Characteristic features are [[edema]] (swelling due to excess [[fluid]]) of the face and arms and development of swollen [[Collateral circulation|collateral veins]] on the front of the [[Thoracic wall|chest wall]]. [[Dyspnea|Shortness of breath]] and [[coughing]] are quite common [[Symptom|symptoms]]; [[Dysphagia|difficulty swallowing]] is reported in 11% of cases, [[headache]] in 6%, and [[stridor]] in 4%. The [[prognosis]] is generally poor and the [[survival rate]] of [[Patient|patients]] with [[superior vena cava syndrome]] is approximately 10-20% at 6 months. In less than 5% of cases of [[superior vena cava syndrome]], severe [[Neurological|neurological symptoms]] or [[airway]] compromise are reported. [[Treatment IND|Treatment]] mainly consists of careful [[Medical therapy template|medical therapy]] ([[glucocorticoids]]) and [[surgery]]. | '''Superior vena cava syndrome''' (also known as '''SVCS'''), is a group of [[Symptom|symptoms]] caused by [[obstruction]] of the [[superior vena cava]]. More than 60% of cases of [[superior vena cava]] [[obstruction]] are caused by [[malignant]] causes, typically a [[tumor]] outside the [[Blood vessel|vessel]] compressing the [[Blood vessel|vessel wall]]. However, in 20% of the cases, the cause is [[benign]]. Characteristic features are [[edema]] (swelling due to excess [[fluid]]) of the face and arms and development of swollen [[Collateral circulation|collateral veins]] on the front of the [[Thoracic wall|chest wall]]. [[Dyspnea|Shortness of breath]] and [[coughing]] are quite common [[Symptom|symptoms]]; [[Dysphagia|difficulty swallowing]] is reported in 11% of cases, [[headache]] in 6%, and [[stridor]] in 4%. The [[prognosis]] is generally poor and the [[survival rate]] of [[Patient|patients]] with [[superior vena cava syndrome]] is approximately 10-20% at 6 months. In less than 5% of cases of [[superior vena cava syndrome]], severe [[Neurological|neurological symptoms]] or [[airway]] compromise are reported. [[Treatment IND|Treatment]] mainly consists of careful [[Medical therapy template|medical therapy]] ([[glucocorticoids]]) and [[surgery]]. | ||
==Historical Perspective== | ==Historical Perspective== | ||
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==Pathophysiology== | ==Pathophysiology== | ||
[[Superior vena cava]] syndrome arises from the obstruction of venous blood drainage of the superior vena cava, which is normally involved in the major blood flow return from [[head]], [[neck]], upper extremities, and upper thorax to the [[heart]]. Superior vena cava syndrome is a complication of a partial or complete obstruction due to malignant causes (60%) or benign causes (20%). This syndrome consists on the invasion of the venous wall associated with intravascular thrombosis, enlarged nodes, enlarged [[ascending aorta]], or by extrinsic pressure of a [[tumor]] mass against the thin-walled [[superior vena cava]] which leads to the development of superior vena cava syndrome. Superior vena cava syndrome is associated with a number of conditions that include malignant tumors, tuberculosis, histoplasmosis, and syphilis. | [[Superior vena cava]] syndrome arises from the [[obstruction]] of [[venous blood]] drainage of the [[superior vena cava]], which is normally involved in the major [[blood]] flow return from [[head]], [[neck]], [[upper extremities]], and [[Thorax|upper thorax]] to the [[heart]]. [[Superior vena cava syndrome]] is a complication of a partial or complete [[obstruction]] due to [[malignant]] causes (60%) or benign causes (20%). This [[syndrome]] consists on the [[invasion]] of the [[venous]] wall associated with intravascular [[thrombosis]], enlarged [[Lymph nodes|nodes]], enlarged [[ascending aorta]], or by extrinsic pressure of a [[tumor]] mass against the thin-walled [[superior vena cava]] which leads to the development of [[superior vena cava syndrome]]. [[Superior vena cava syndrome]] is associated with a number of conditions that include [[malignant]] [[Tumor|tumors]], [[tuberculosis]], [[histoplasmosis]], and [[syphilis]]. | ||
==Causes== | ==Causes== | ||
Superior vena cava syndrome may be caused by obstruction of the [[superior vena cava]] by neoplastic invasion of the venous wall, intravascular thrombosis, enlarged lymph nodes, enlarged [[ascending aorta]], or by extrinsic pressure of a [[tumor]] against the thin-walled [[superior vena cava]].<ref name="wiki1">Superior vena cava syndrome. https://en.wikipedia.org/wiki/Superior_vena_cava_syndrome Accessed on January, 11 2016</ref> | [[Superior vena cava syndrome]] may be caused by [[obstruction]] of the [[superior vena cava]] by [[neoplastic]] [[Invasive (medical)|invasion]] of the [[Venous|venous wall]], [[intravascular]] [[thrombosis]], enlarged [[Lymph node|lymph nodes]], enlarged [[ascending aorta]], or by extrinsic [[pressure]] of a [[tumor]] against the thin-walled [[superior vena cava]].<ref name="wiki1">Superior vena cava syndrome. https://en.wikipedia.org/wiki/Superior_vena_cava_syndrome Accessed on January, 11 2016</ref> | ||
==Differentiating Superior Vena Cava Syndrome from other Diseases== | ==Differentiating Superior Vena Cava Syndrome from other Diseases== | ||
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==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
Superior vena cava syndrome is a common oncologic emergency. The [[incidence]] rate in the United States is approximately 15,000 individuals each year. The incidence of superior vena cava syndrome increases with age; the median age of diagnosis is between 40-60 years. Males are more commonly affected with superior vena cava syndrome than females.<ref name="pmid17168344">{{cite journal |vauthors=Higdon ML, Higdon JA |title=Treatment of oncologic emergencies |journal=Am Fam Physician |volume=74 |issue=11 |pages=1873–80 |year=2006 |pmid=17168344 |doi= |url=}}</ref> | [[Superior vena cava syndrome]] is a common [[Oncologic emergencies|oncologic emergency]]. The [[incidence]] rate in the United States is approximately 15,000 individuals each year. The incidence of [[superior vena cava syndrome]] increases with age; the median age of diagnosis is between 40-60 years. [[Male|Males]] are more commonly affected with [[superior vena cava syndrome]] than [[Female|females]].<ref name="pmid17168344">{{cite journal |vauthors=Higdon ML, Higdon JA |title=Treatment of oncologic emergencies |journal=Am Fam Physician |volume=74 |issue=11 |pages=1873–80 |year=2006 |pmid=17168344 |doi= |url=}}</ref> | ||
==Risk Factors== | ==Risk Factors== | ||
The most potent risk factor in the development of superior vena cava syndrome is intrathoracic malignancies. Other common risk factors include [[thrombosis]] (due to intravascular devices), postradiation fibrosis, and [[mediastinitis]].<ref name="pmid1307879">{{cite journal |vauthors=Baker GL, Barnes HJ |title=Superior vena cava syndrome: etiology, diagnosis, and treatment |journal=Am. J. Crit. Care |volume=1 |issue=1 |pages=54–64 |year=1992 |pmid=1307879 |doi= |url=}}</ref> | The most potent risk factor in the development of [[superior vena cava syndrome]] is [[intrathoracic]] [[malignancies]]. Other common risk factors include [[thrombosis]] (due to intravascular devices), [[Fibrosis|postradiation fibrosis]], and [[mediastinitis]].<ref name="pmid1307879">{{cite journal |vauthors=Baker GL, Barnes HJ |title=Superior vena cava syndrome: etiology, diagnosis, and treatment |journal=Am. J. Crit. Care |volume=1 |issue=1 |pages=54–64 |year=1992 |pmid=1307879 |doi= |url=}}</ref> | ||
==Screening== | ==Screening== | ||
According to the the National Cancer Institute, there is insufficient evidence to recommend routine screening for superior vena cava syndrome.<ref name="screening">National Cancer Institute. Cardiopulmonary Syndromes. http://www.cancer.gov/about-cancer/treatment/side-effects/cardiopulmonary-pdq#section/_AboutThis_1 Accessed on January 13, 2016</ref> | According to the the National Cancer Institute, there is insufficient evidence to recommend routine screening for [[superior vena cava syndrome]].<ref name="screening">National Cancer Institute. Cardiopulmonary Syndromes. http://www.cancer.gov/about-cancer/treatment/side-effects/cardiopulmonary-pdq#section/_AboutThis_1 Accessed on January 13, 2016</ref> | ||
==Natural History, Complications and Prognosis== | ==Natural History, Complications and Prognosis== | ||
If left untreated, patients with superior vena cava syndrome may progress to develop a complete blood flow obstruction and a decreased cardiac output with [[hypotension]], leading to [[heart failure]] and death. Common complications of superior vena cava syndrome include airway obstruction, increased [[ICP]], laryngeal edema, and [[cerebral edema]]. The prognosis will vary depending on the cause of the syndrome, and the amount of blockage that has already occurred. Prognosis is generally poor and the survival rate of patients with superior vena cava syndrome is approximately 10-20% at 6 months.<ref name="pmid17476012">{{cite journal |vauthors=Wilson LD, Detterbeck FC, Yahalom J |title=Clinical practice. Superior vena cava syndrome with malignant causes |journal=N. Engl. J. Med. |volume=356 |issue=18 |pages=1862–9 |year=2007 |pmid=17476012 |doi=10.1056/NEJMcp067190 |url=}}</ref> | If left untreated, [[Patient|patients]] with [[superior vena cava syndrome]] may progress to develop a complete [[blood]] flow obstruction and a decreased [[cardiac output]] with [[hypotension]], leading to [[heart failure]] and death. Common [[complications]] of superior vena cava syndrome include [[airway obstruction]], increased [[ICP]], [[laryngeal edema]], and [[cerebral edema]]. The [[prognosis]] will vary depending on the cause of the [[syndrome]], and the amount of blockage that has already occurred. [[Prognosis]] is generally poor and the [[survival rate]] of patients with [[superior vena cava syndrome]] is approximately 10-20% at 6 months.<ref name="pmid17476012">{{cite journal |vauthors=Wilson LD, Detterbeck FC, Yahalom J |title=Clinical practice. Superior vena cava syndrome with malignant causes |journal=N. Engl. J. Med. |volume=356 |issue=18 |pages=1862–9 |year=2007 |pmid=17476012 |doi=10.1056/NEJMcp067190 |url=}}</ref> | ||
==Diagnosis== | ==Diagnosis== | ||
===Staging=== | ===Staging=== | ||
According to the Journal of Thoracic Oncology, there are 5 stages of superior vena cava syndrome based on the severity and incidence. Each stage is assigned a grade and a description that designate disease severity.<ref name="pmid17476012">{{cite journal |vauthors=Wilson LD, Detterbeck FC, Yahalom J |title=Clinical practice. Superior vena cava syndrome with malignant causes |journal=N. Engl. J. Med. |volume=356 |issue=18 |pages=1862–9 |year=2007 |pmid=17476012 |doi=10.1056/NEJMcp067190 |url=}}</ref><ref name="pmid18670297">{{cite journal |vauthors=Yu JB, Wilson LD, Detterbeck FC |title=Superior vena cava syndrome--a proposed classification system and algorithm for management |journal=J Thorac Oncol |volume=3 |issue=8 |pages=811–4 |year=2008 |pmid=18670297 |doi=10.1097/JTO.0b013e3181804791 |url=}}</ref> | According to the Journal of Thoracic Oncology, there are 5 stages of [[superior vena cava syndrome]] based on the severity and [[incidence]]. Each stage is assigned a grade and a description that designate disease severity.<ref name="pmid17476012">{{cite journal |vauthors=Wilson LD, Detterbeck FC, Yahalom J |title=Clinical practice. Superior vena cava syndrome with malignant causes |journal=N. Engl. J. Med. |volume=356 |issue=18 |pages=1862–9 |year=2007 |pmid=17476012 |doi=10.1056/NEJMcp067190 |url=}}</ref><ref name="pmid18670297">{{cite journal |vauthors=Yu JB, Wilson LD, Detterbeck FC |title=Superior vena cava syndrome--a proposed classification system and algorithm for management |journal=J Thorac Oncol |volume=3 |issue=8 |pages=811–4 |year=2008 |pmid=18670297 |doi=10.1097/JTO.0b013e3181804791 |url=}}</ref> | ||
===History and Symptoms=== | ===History and Symptoms=== | ||
The hallmark of superior vena cava syndrome is elevated jugular venous pressure. A positive history of cancer and intra-vascular devices are suggestive of superior vena cava syndrome. The most common symptoms of superior vena cava syndrome include upper body [[swelling]], [[dyspnea]], and cough.<ref name="pmid16502166">{{cite journal |vauthors=Uberoi R |title=Quality assurance guidelines for superior vena cava stenting in malignant disease |journal=Cardiovasc Intervent Radiol |volume=29 |issue=3 |pages=319–22 |year=2006 |pmid=16502166 |doi=10.1007/s00270-005-0284-9 |url=}}</ref> | The hallmark of [[superior vena cava syndrome]] is elevated [[jugular venous pressure]]. A positive history of [[cancer]] and intra-vascular devices are suggestive of [[superior vena cava syndrome]]. The most common [[Symptom|symptoms]] of [[superior vena cava syndrome]] include upper body [[swelling]], [[dyspnea]], and [[cough]].<ref name="pmid16502166">{{cite journal |vauthors=Uberoi R |title=Quality assurance guidelines for superior vena cava stenting in malignant disease |journal=Cardiovasc Intervent Radiol |volume=29 |issue=3 |pages=319–22 |year=2006 |pmid=16502166 |doi=10.1007/s00270-005-0284-9 |url=}}</ref> | ||
===Physical Examination=== | ===Physical Examination=== | ||
Common physical examination findings of superior vena cava syndrome include the pemberton's sign, facial [[swelling]], and [[jugular venous distension]].<ref name="pmid16502166">{{cite journal |vauthors=Uberoi R |title=Quality assurance guidelines for superior vena cava stenting in malignant disease |journal=Cardiovasc Intervent Radiol |volume=29 |issue=3 |pages=319–22 |year=2006 |pmid=16502166 |doi=10.1007/s00270-005-0284-9 |url=}}</ref><ref name="caca">Superior Vena Cava Syndrome. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/managing-side-effects/superior-vena-cava-syndrome/?region=bc Accessed on January 13, 2016</ref> | Common [[physical examination]] findings of [[superior vena cava syndrome]] include the [[pemberton's sign]], facial [[swelling]], and [[jugular venous distension]].<ref name="pmid16502166">{{cite journal |vauthors=Uberoi R |title=Quality assurance guidelines for superior vena cava stenting in malignant disease |journal=Cardiovasc Intervent Radiol |volume=29 |issue=3 |pages=319–22 |year=2006 |pmid=16502166 |doi=10.1007/s00270-005-0284-9 |url=}}</ref><ref name="caca">Superior Vena Cava Syndrome. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/managing-side-effects/superior-vena-cava-syndrome/?region=bc Accessed on January 13, 2016</ref> | ||
===Laboratory findings=== | ===Laboratory findings=== | ||
There are no diagnostic laboratory findings associated with superior vena cava syndrome. | There are no [[Diagnosis|diagnostic]] [[Laboratory findings template|laboratory findings]] associated with [[superior vena cava syndrome]]. | ||
===Chest X Ray=== | ===Chest X Ray=== | ||
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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
Superior vena cava syndrome (also known as SVCS), is a group of symptoms caused by obstruction of the superior vena cava. More than 60% of cases of superior vena cava obstruction are caused by malignant causes, typically a tumor outside the vessel compressing the vessel wall. However, in 20% of the cases, the cause is benign. Characteristic features are edema (swelling due to excess fluid) of the face and arms and development of swollen collateral veins on the front of the chest wall. Shortness of breath and coughing are quite common symptoms; difficulty swallowing is reported in 11% of cases, headache in 6%, and stridor in 4%. The prognosis is generally poor and the survival rate of patients with superior vena cava syndrome is approximately 10-20% at 6 months. In less than 5% of cases of superior vena cava syndrome, severe neurological symptoms or airway compromise are reported. Treatment mainly consists of careful medical therapy (glucocorticoids) and surgery.
Historical Perspective
Superior vena cava syndrome was first discovered by William Hunter (1718-1783), a Scottish obstetrician, in 1757.[1]
Pathophysiology
Superior vena cava syndrome arises from the obstruction of venous blood drainage of the superior vena cava, which is normally involved in the major blood flow return from head, neck, upper extremities, and upper thorax to the heart. Superior vena cava syndrome is a complication of a partial or complete obstruction due to malignant causes (60%) or benign causes (20%). This syndrome consists on the invasion of the venous wall associated with intravascular thrombosis, enlarged nodes, enlarged ascending aorta, or by extrinsic pressure of a tumor mass against the thin-walled superior vena cava which leads to the development of superior vena cava syndrome. Superior vena cava syndrome is associated with a number of conditions that include malignant tumors, tuberculosis, histoplasmosis, and syphilis.
Causes
Superior vena cava syndrome may be caused by obstruction of the superior vena cava by neoplastic invasion of the venous wall, intravascular thrombosis, enlarged lymph nodes, enlarged ascending aorta, or by extrinsic pressure of a tumor against the thin-walled superior vena cava.[2]
Differentiating Superior Vena Cava Syndrome from other Diseases
Superior vena cava syndrome should be differentiated from other causes of dyspnea and jugular venous distention, such as, cardiac tamponade, chronic obstructive pulmonary disease, mediastinitis, pneumonia, acute respiratory distress syndrome, and syphilis.[3]
Epidemiology and Demographics
Superior vena cava syndrome is a common oncologic emergency. The incidence rate in the United States is approximately 15,000 individuals each year. The incidence of superior vena cava syndrome increases with age; the median age of diagnosis is between 40-60 years. Males are more commonly affected with superior vena cava syndrome than females.[4]
Risk Factors
The most potent risk factor in the development of superior vena cava syndrome is intrathoracic malignancies. Other common risk factors include thrombosis (due to intravascular devices), postradiation fibrosis, and mediastinitis.[5]
Screening
According to the the National Cancer Institute, there is insufficient evidence to recommend routine screening for superior vena cava syndrome.[6]
Natural History, Complications and Prognosis
If left untreated, patients with superior vena cava syndrome may progress to develop a complete blood flow obstruction and a decreased cardiac output with hypotension, leading to heart failure and death. Common complications of superior vena cava syndrome include airway obstruction, increased ICP, laryngeal edema, and cerebral edema. The prognosis will vary depending on the cause of the syndrome, and the amount of blockage that has already occurred. Prognosis is generally poor and the survival rate of patients with superior vena cava syndrome is approximately 10-20% at 6 months.[7]
Diagnosis
Staging
According to the Journal of Thoracic Oncology, there are 5 stages of superior vena cava syndrome based on the severity and incidence. Each stage is assigned a grade and a description that designate disease severity.[7][8]
History and Symptoms
The hallmark of superior vena cava syndrome is elevated jugular venous pressure. A positive history of cancer and intra-vascular devices are suggestive of superior vena cava syndrome. The most common symptoms of superior vena cava syndrome include upper body swelling, dyspnea, and cough.[9]
Physical Examination
Common physical examination findings of superior vena cava syndrome include the pemberton's sign, facial swelling, and jugular venous distension.[9][10]
Laboratory findings
There are no diagnostic laboratory findings associated with superior vena cava syndrome.
Chest X Ray
On chest x-ray, indirect signs such as superior mediastinal widening and right hilar prominence may indicate the presence of a mediastinal mass.[11]
CT
On enhanced CT scan, findings include location and severity of the superior vena cava obstruction, superimposed thrombosis, a mediastinal mass or lymphadenopathy, collateral vessels, and associated lung masses. CT scan is the imaging modality of choice.[11]
MRI
MRI may be helful to provide images without the use of contrast (useful in patients with renal failure).[12]
Ultrasound
Doppler ultrasound may be valuable in assessing the site and nature of the obstruction in superior vena cava syndrome. Venous patency and the presence of thrombi can also be assessed by using contrast and rapid scanning techniques.[13]
Other Imaging Findings
Other imaging finding is the radionuclide technetium-99m venography.[14]
Other Diagnostic Studies
Other diagnostic studies in the evaluation of superior vena cava syndrome include sputum tests, bronchoscopy, and biopsy. In addition, invasive contrast venography is also a diagnostic tool in the diagnosis of superior vena cava syndrome. It may be useful on the etiology of obstruction and exact location of the obstruction, also helpful in the surgical management of the obstructed vena cava.[15]
Treatment
Medical Therapy
Superior vena cava syndrome is a medical emergency and requires prompt treatment. The treatment of superior vena cava syndrome depends on the etiology of the obstruction, the severity of the symptoms, the prognosis of the patient, patient preferences, and goals for therapy.[7]
Surgery
Elective stent placement and surgical bypass is recommended for all patients who develop superior vena cava syndrome.[7]
Radiation Therapy
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.[7]
Primary Prevention
There are no primary preventive measures available for superior vena cava syndrome.
References
- ↑ William Hunter. https://en.wikipedia.org/wiki/William_Hunter_%28anatomist%29 Accessed on December 11, 2016
- ↑ Superior vena cava syndrome. https://en.wikipedia.org/wiki/Superior_vena_cava_syndrome Accessed on January, 11 2016
- ↑ Menon A, Gupta A (2015). "Superior vena cava syndrome". Indian J. Med. Res. 142 (3): 350. doi:10.4103/0971-5916.166606. PMC 4669875. PMID 26458355.
- ↑ Higdon ML, Higdon JA (2006). "Treatment of oncologic emergencies". Am Fam Physician. 74 (11): 1873–80. PMID 17168344.
- ↑ Baker GL, Barnes HJ (1992). "Superior vena cava syndrome: etiology, diagnosis, and treatment". Am. J. Crit. Care. 1 (1): 54–64. PMID 1307879.
- ↑ National Cancer Institute. Cardiopulmonary Syndromes. http://www.cancer.gov/about-cancer/treatment/side-effects/cardiopulmonary-pdq#section/_AboutThis_1 Accessed on January 13, 2016
- ↑ 7.0 7.1 7.2 7.3 7.4 Wilson LD, Detterbeck FC, Yahalom J (2007). "Clinical practice. Superior vena cava syndrome with malignant causes". N. Engl. J. Med. 356 (18): 1862–9. doi:10.1056/NEJMcp067190. PMID 17476012.
- ↑ Yu JB, Wilson LD, Detterbeck FC (2008). "Superior vena cava syndrome--a proposed classification system and algorithm for management". J Thorac Oncol. 3 (8): 811–4. doi:10.1097/JTO.0b013e3181804791. PMID 18670297.
- ↑ 9.0 9.1 Uberoi R (2006). "Quality assurance guidelines for superior vena cava stenting in malignant disease". Cardiovasc Intervent Radiol. 29 (3): 319–22. doi:10.1007/s00270-005-0284-9. PMID 16502166.
- ↑ Superior Vena Cava Syndrome. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/managing-side-effects/superior-vena-cava-syndrome/?region=bc Accessed on January 13, 2016
- ↑ 11.0 11.1 Superior Vena Cava Syndrome. Dr Amir Rezaee and Radswiki et al. Radiopedia http://radiopaedia.org/articles/superior-vena-cava-obstruction Accessed on January 13, 2016
- ↑ Marcy PY, Magné N, Bentolila F, Drouillard J, Bruneton JN, Descamps B (2001). "Superior vena cava obstruction: is stenting necessary?". Support Care Cancer. 9 (2): 103–7. PMID 11305067.
- ↑ Birch A, Um D, Laselle B (2014). "Ultrasound detection of superior vena cava thrombus". West J Emerg Med. 15 (6): 715–8. doi:10.5811/westjem.2014.6.14006. PMC 4162737. PMID 25247051.
- ↑ Muramatsu T, Miyamae T, Mashimo M, Suzuki K, Kinoshita S, Dohi Y (1994). "Hot spots on liver scans associated with superior or inferior vena caval obstruction". Clin Nucl Med. 19 (7): 622–9. PMID 7924107.
- ↑ Mahmud AM, Isawa T, Teshima T, Hirano T, Anazawa Y, Miki M, Nukiwa T (1996). "Radionuclide venography and its functional analysis in superior vena cava syndrome". J. Nucl. Med. 37 (9): 1460–4. PMID 8790193.