Lung Cancer 2004;43:209–14. Urruticoechea A, Mesia R, Domingguez J, et al.
Study Summary: In this study, the authors report their experience of placing endovascular stents in 52 patients with malignant superior vena cava syndrome. The underlying cause of SVCS was nonsmall-cell lung cancer (NSCLC) in 37 patients and small-cell lung cancer in 15 patients. All patients had either stage III (n = 34) or stage IV (n = 18) disease. Thirty-one patients had received no prior radiation or chemotherapy. A total of 62 stents were placed in 52 patients. Wall stents were used in the majority of patients. Most stents were placed through femoral venous access under fluoroscopic guidance. The procedure was technically successful in all cases. There were no immediate major complications. All patients received anticoagulation for at least 3 months. One patient died as a result of pulmonary hemorrhage during follow up.
Symptoms resulting from superior vena obstruction improved within 24 hours in some cases and within 72 hours in all cases. Edema improved in 92% of cases, dyspnea improved in 85% of cases, and venous distention improved in 73% of cases. Karnofsky score improved in 69% of patients. Obstruction of the stent occurred in 9 (17%) patients during follow up. The causes of obstruction were progression of disease in 5 cases, thrombosis in 3 cases, and fibrosis of the stent in 1 case. According to the authors, relief of edema after stent placement allowed intravenous fluid administration necessary for cisplatin-based chemotherapy in several patients.
Comments: Most patients with SVCS resulting from lung cancer have advanced malignancy and relief of symptoms is an important treatment goal (Chest 2003;123:284S–311S). Generally, these patients are treated with chemotherapy, radiotherapy, or a combination of both (Chest 1993;103:394S–7S). A recent review reported a 77% response rate in SVCS as a result of small-cell lung cancer and 60% response rate in SVCS resulting from nonsmall-cell lung cancer (Clin Oncol 2002;14:338–51). There are 2 main limitations of these therapies in SVCS: 1) the response to radiation and chemotherapy is slow and it could take several days to weeks before patients experience improvement in symptoms; and 2) aggressive radiation or chemotherapy is not possible in many patients as a result of advanced disease, poor performance status, or comorbid conditions.
A number of studies have shown that superior vena cava stent is a useful treatment option in patients with SVCS (Eur Radiol 2003;13:853–62, AJR Am J Roentgenol 2001;177:585–93). The initial response rate is more than 90% and the patients experience relief in symptoms within 24 to 72 hours (Radiology 1995;196:353–61, Eur JCardiothorac Surg 2003;24:208–11). The majority of SVC stents in the past, however, were placed after failure of chemotherapy or radiation therapy (Acta Radiol 1998;39:669–74). The results from the current and other recent studies support stent placement as the frontline treatment of malignant SVCS (AJR Am J Roentgenol 2001;177:585–93, Eur JRadiol 2003;47:247–50). This option should be a serious consideration in initial treatment of SVCS resulting from nonsmall-cell lung cancer, which is less chemosensitive than small-cell lung cancer or lymphoma (Respiration 2004;71:178–83). Rapid resolution of edema after a SVC stent in the current study allowed administration of intravenous fluid and more aggressive chemotherapy. This is an important argument in favor of early stent placement.
An unresolved question is the need for anticoagulation therapy after placing SVC stents (Clin Oncol 2002;14:338–51). Anticoagulants are used because there is some risk of SCV thrombosis resulting from endovascular prosthesis (Eur Radiol 2003:13:853–62). However, their use increases the risk of bleeding, including fatal pulmonary hemorrhage resulting from lung cancer. Future studies should address this important issue.