Superior Vena Cava Syndrome Workup

Updated: May 15, 2017
  • Author: Todd A Nickloes, DO, FACOS; Chief Editor: Vincent Lopez Rowe, MD  more...
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Workup

Imaging Studies

Patients presenting with overt superior vena cava syndrome (SVCS) may be diagnosed by means of physical examination alone. However, subtle presentations necessitate diagnostic imaging.

Chest radiography

Chest radiography may reveal a widened mediastinum or a mass in the right side of the chest. Only 16% of the patients studied by Parish et al in 1981 had normal findings on chest radiography. [14]

Computed tomography

Computed tomography (CT) has the advantage of providing more accurate information on the location of the obstruction and may guide attempts at biopsy by mediastinoscopy, bronchoscopy, or percutaneous fine-needle aspiration. [6] It also provides information on other critical structures, such as the bronchi and the vocal cords.

A CT scan of the chest is the initial test of choice to determine whether an obstruction is due to external compression or due to thrombosis. The additional information is necessary because the involvement of these structures requires prompt action for relief of pressure. (See the images below.)

Superior vena cava syndrome (case 1). Patient was Superior vena cava syndrome (case 1). Patient was 35-year-old man with 3-year history of progressive upper-extremity and fascial swelling. Patient had undergone treatment for histoplasmosis in the past. CT shows narrowed superior vena cava with adjacent calcified lymph nodes and posterior soft-tissue thickening.
Superior vena cava syndrome (case 1, continued). S Superior vena cava syndrome (case 1, continued). Sonogram shows markedly damped venous waveform with complete loss of normal venous pulsatility and minimal respiratory variation.

SPECT

Gallium single-proton emission CT (SPECT) may be of value in select cases.

Magnetic resonance imaging

Magnetic resonance imaging (MRI) has not yet been sufficiently investigated in this setting, but it appears promising. It has several potential advantages over CT, in that it provides images in several planes of view, allows direct visualization of blood flow, and does not require iodinated contrast material (an especially important characteristic when stenting is anticipated). [15]

MRI is an acceptable alternative for patients with renal failure or those with contrast allergies. Potential disadvantages include increased scanning time with attendant problems in patient compliance and increased cost.

Venography

Invasive contrast venography is the most conclusive diagnostic tool (see the image below). It precisely defines the etiology of obstruction. It is especially important if surgical management is being considered for the obstructed vena cava.

Superior vena cava syndrome (case 1, continued). V Superior vena cava syndrome (case 1, continued). Venogram shows almost complete occlusion of superior vena cava with dramatic collateral drainage through left superior intercostal vein.

Radionuclide technetium-99m venography is an alternative minimally invasive method of imaging the venous system. Although images obtained by this method are not as well defined as those achieved with contrast venography, they demonstrate potency and flow patterns. [21]

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Procedures

Most patients with SVCS present before the primary diagnosis is established. Controversy often arises in the treatment of these patients with regard to the need for pathologic confirmation of malignancy before the start of therapy. Treatment without an established diagnosis should be initiated only in patients with rapidly progressive symptoms or those in whom multiple attempts to obtain a tissue diagnosis have been unsuccessful.

Fortunately, relatively noninvasive measures establish the diagnosis in a high percentage of patients with SVCS. Sputum cytologic results are diagnostic in 68% of the cases, whereas biopsy of a palpable supraclavicular node is positive in 87%. [22] Bronchoscopy has a 60% success rate, whereas thoracotomy is 100% successful. [22] Open biopsy is rarely needed for diagnosis. Dosios et al showed that cervical mediastinoscopy and anterior mediastinoscopy are effective in establishing a histologic diagnosis. [23]

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