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) Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCall Instagram: @TheFellowOnCall Listen in on: Apple Podcast, Spotify, and Google Podcast