Should endovascular stenting be used routinely as first-line treatment for malignant superior vena cava syndrome?—a critical review in the context of recent advances in oncological treatments

Abstract

Malignant superior vena cava syndrome (SVCS) is no longer considered a medical emergency in most cases because it rarely leads to life-threatening complications. However, it results in disturbing symptoms that can significantly affect patients' quality of life. Treating this condition effectively while minimising treatment-related morbidity is of increasing importance as cancer patients are living longer from advances in oncological treatments. This clinical practice review discusses the implications of these advances on the decision to consider stenting as the initial treatment for SVCS. Stenting is increasingly popular as it provides quick symptomatic relief with low rates of complications. Systemic treatments have evolved in the past two decades with the development of immunotherapy and targeted therapies that have different response patterns compared to conventional chemotherapy. Furthermore, major changes have also been seen in radiotherapy techniques that allow treatments to better conform to targets while sparing normal tissues.These advances have changed practice patterns for stent placement in SVCS patients in both the localised and metastatic settings. Prospective studies using standardised patient-reported outcome tools are needed to determine the optimal treatment sequence for SVCS patients, as current recommendations are mainly based on retrospective single-arm studies. An individualized approach with multidisciplinary input is therefore important to optimize patient outcomes before more robust evidence is available.

Surgical resection of an intraluminal tumor in the azygos vein with an unknown primary site causing superior vena cava syndrome

“…2 SVC syndrome management often includes chemotherapy, radiotherapy, and/or endovascular stenting. 2,10 Chemotherapy is recommended as a definitive treatment because SVC syndrome can be caused by chemosensitive malignancies; approximately 80% of patients with such malignancies achieved complete symptomatic relief, although this is lower for patients with less chemo-sensitive malignancies such as non-small cell lung cancer, at less than 60%. 11 Recently, palliative radiotherapy has been reported to be an effective management with a high clinical success rate of approximately 90%.…”

“…12,13 Endovascular stenting has a similarly high clinical success rate of over 90%, and is often considered the first-line treatment because it provides more rapid symptom resolution than radiation therapy or chemotherapy. 2,13 However, these methods were previously unsuccessful in treating patients with malignant SVC syndrome, who reported medial survival times of less than 6 months and who mostly died of cancer-specific causes. 12,13 SVC resection and reconstruction are considered the treatment of choice for SVC invasion by lung malignancies, especially for those without lymph node involvement, with reported median survival times of up to 12 months and 5-year survival rates of 30%-50%, compared with 5% for radiotherapy.…”

“…Randomized studies involving patients with SVC syndrome are challenging, so data are limited 2 . SVC syndrome management often includes chemotherapy, radiotherapy, and/or endovascular stenting 2,10 .…”

“…Randomized studies involving patients with SVC syndrome are challenging, so data are limited 2 . SVC syndrome management often includes chemotherapy, radiotherapy, and/or endovascular stenting 2,10 . Chemotherapy is recommended as a definitive treatment because SVC syndrome can be caused by chemosensitive malignancies; approximately 80% of patients with such malignancies achieved complete symptomatic relief, although this is lower for patients with less chemo‐sensitive malignancies such as non‐small cell lung cancer, at less than 60% 11 …”

“…Radiotherapy, endovascular stenting, and/or chemotherapy have often been used to manage malignant SVC syndrome, with surgical resection being rarely performed. 2 Here, we report a 69-year-old man with SVC syndrome caused by an intraluminal mass in the azygos vein who underwent surgical resection.…”