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Treatment of malignant superior vena cava syndrome by endovascular stent insertion
Lung Cancer (2004) 43, 209—214
Treatment of malignant superior vena cava syndrome by endovascular stent insertion Experience on 52 patients with lung cancer A. Urruticoechea a , R. Mes´ıa a,*, J. Dom´ınguez b , C. Falo a , E. Escalante b , A. Montes a , C. Sancho b , F. Cardenal a , M. Majem a , J.R. Germà a a
Medical Oncology Department, Institut Català d’Oncologia, Hospital Universitari de Bellvitge, L’Hospitalet, Barcelona, Spain b Vascular Radiology Department, Institut Català d’Oncologia, Hospital Universitari de Bellvitge, Av. Gran v´ıa s/n km 2.7, 08907 L’Hospitalet, Barcelona, Spain Received 6 March 2003 ; received in revised form 25 June 2003; accepted 7 July 2003
KEYWORDS Superior vena cava syndrome; Lung cancer; Stent; Mediastinum malignances; Vena cava obstruction; Non-small cell lung cancer; Small cell lung cancer
Summary Background: Superior vena cava syndrome (SVCS) is a frequent presentation of malignancies involving the mediastinum and can seriously compromise treatment options and prognosis. Stenting of superior vena cava is a well-known but not so commonly used technique to alleviate this syndrome. Patients and methods: Between August 1993 and December 2000 we performed 52 stenting procedures in patients affected by non-small cell lung cancer (NSCLC). Results: Phlebographic resolution of the obstruction was achieved in 100% of cases with symptomatic and subjective improvement in more than 80%. One major complication was observed due to bleeding during anticoagulation. Re-obstruction of the stent occurred in only 17% of the cases, the majority due to disease progression. Improvement of the syndrome allowed hydration necessary for full dose platinum treatment when indicated in patients affected by lung cancer. Conclusions: Stenting of the superior vena cava syndrome is a safe and effective procedure achieving a rapid alleviation of symptoms in almost all patients, and allowing for full dose treatment in lung cancer patients. This procedure could change the traditional poorer prognosis attributed to non-small cell lung cancer patients presenting with this syndrome. © 2003 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Superior vena cava syndrome (SVCS) is defined as the signs and symptoms derived from blood impairment through the superior vena cava to right
* Corresponding author. Tel.: +34-9-3260-7744; fax: +34-9-3260-7741. E-mail address: [email protected] (R. Mes´ıa).
atrium. Its clinical presentation includes oedema and vein distension of the head and neck, upper extremities and thorax, dyspnea and, in severe cases, confusion, impaired attention and coma. The main cause of SVCS in adults is lung and mediastinal tumours. Small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) cause the vast majority of cases. Treatment approach to SVCS traditionally includes radiation therapy and chemotherapy, with
0169-5002/$ – see front matter © 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0169-5002(03)00361-1
210
A. Urruticoechea et al.
radiation accomplishing up to 80% success rate in symptomatic relief in SCLC and 46% in NSCLC. Rapid initiation of full dose chemotherapy can result in 80% response rate in SCLC attending to the best series [1]. Delayed response to radiation and chemotherapy, and risk of worsening of the SVCS due to hydration mandatory for chemotherapy including full dose of Cisplatinum, can seriously compromise the results of these treatment approaches. Intravascular placement of metallic stents in the superior vena cava can rapidly achieve relief of vein obstruction [2—4]. It results in symptomatic resolution and makes possible full etiologic treatment. We report our experience with this procedure in a retrospective series of 52 patients focusing on those with NSCLC with no prior treatment.
2. Patients and methods Between August 1993 and December 2000 stent placement was performed in 52 consecutive patients with malignant SVCS to improve their symptoms. Characteristics of the patients are described in Table 1. Forty-six patients were men, and the population had a median age of 57. In all cases SVCS was caused by lung cancer (37 NSCLC and 15 SCLC), 34 (65%) were in stage III b at the moment of placing the stent, while 18 (35%) were metastatic. In two patients the histology of the tumour was not available prior to the stent placement since the indication of the procedure was urgent. Median Karnofsky index before placement was 60%. We used a semi-quantitative scale to measure four main symptoms and signs (oedema, superficial
collateral vein drainage, neurological impairment and dyspnea) previously and after stent placement. After a clinical indication of SVCS was verified, we explored the venous drainage of both superior limbs using a phlebography. We focused the study on mediastinal veins and the superior vena cava. The obstruction was defined and the collateral drainage identified. When the limits of the obstruction were not enough well defined using peripheral injection of contrast, we repeated the flebography introducing a multiperforated catheter through the stenotic segment. We have recently begun to use calibrated catheters that allow us to obtain more accurate measurements. Once the stent type and the venous access were selected we delivered 5000—10,000 IU sodic heparin bolus, just before stent placement. The stents we have used are mostly stainless steel autoexpandible (Wallstent; Boston Scientific Ireland Ltd.® Gallway, Ireland) (Fig. 1). A total of 65 prosthesis were used in 52 patients. Sixty-one Wallstent prosthesis were placed in 48 patients. In 35 patients one prosthesis was enough. In 13
Table 1 Patients characteristics Total number Male/female Age IK Tumor type
52 46/6 57 (29—77) 60 (40—80) Lung cancer 52
Lung tumors’ stage
Stage III Stage IV
34 18
Previous treatment
None Sur CT RT CT + RT Sur + RT
31 1 14 1 4 1
NSCLC 37 SCLC 15
NSCLC: non-small cell lung cancer; SCLS: small cell lung cancer; Sur: surgery; CT: chemotherapy; RT: radiation.
Fig. 1 The catheter wire is placed in the vena cava stenotic segment. The stent is delivered and the stenosis is solved.
Treatment of malignant superior vena cava syndrome patients two prosthesis were necessary due to the length of the stenotic segment or to shortening of the prosthesis after placement. In four patients we used nitinol autoexpandible stents (Memotherm; Angiomed-Karlsruhe, Germany and Sinus; Optimed-Ettlingen, Germany). The stent diameter ranged between 10 and 16 mm, most of them 12 or 14 mm. The stent length ranks between 30 and 90 mm, average 61 mm. The most frequently selected access was femoral vein, due to the introducer diameter (9F and 10F), but we also used the brachial access without complications. Once the prosthesis is placed on the estenotic segment, it is released under radioscopic control. An angioplasty balloon is used to facilitate the expansion. The entire procedure is performed with the patient under deep sedation and monitored. About 12 h after the procedure, once clotting recovers, the introducer is removed and anticoagulation is reinitiated, with low molecular weight heparin, warfarin or calcic heparin depending on the patient characteristics and the citostatic treatment they were to receive. We maintained anticoagulation for a minimum of 3 months. Maximum duration of anticoagulation was determined by the particular condition of each patient.
3. Results The stent placement was achieved in all 52 cases with 100% success in re-permeabilitation assessed by a second venogram after procedure. As shown in Table 2, symptoms improved in the vast majority of cases. Oedema, present in 100% of patients, improved in 92% of cases (completely in 59%). Dyspnea was present in 40 and decreased in 34 of them (85%) with complete resolution in 24 cases (60%). Collateral thoracic vein distension was present in 45 patients and improved in 33 (73%), up to complete resolution in 17 (38%). Only two patients presented confusion due to SVCS, and in both cases the symptom disappeared completely. Resolution of symptoms was very fast, occurring in the 72 h following stenting in all cases, and in the first 24 h in most
211 of them. Karnofsky index, measured in 48 patients prior to and 1 month after the procedure, improved in 31 (69%) and was maintained or deteriorated in 15. All deterioration of performance status was due to disease progression. Complications due to technique placement were: one supraventricular arrhythmia resolved with medical treatment, two septic episodes resolved with antibiotics, and in one case a caudal movement of a Wallstent prosthesis was registered due to a too caudal placement of it which was more obvious after balloon inflation; it was resolved with the collocation of a second stent. During ulterior follow-up six patients showed bleeding due to anticoagulation and, one patient died due to lung bleeding. Re-obstruction of the stent occurred in nine cases (17%) (Fig. 2). Cause of re-obstruction was progression of disease in five cases, in whom poor prognosis of the neoplasm contraindicated further procedures. Fibrosis of the stent caused re-obstruction in one case, which could be solved by angioplastic procedure. This is not a frequent approach to the re-obstruction. Our experience shows, anyway, that due to the uncertain cause in some cases of re-stenosis an ‘‘endovascular’’ approach with angioplasty can achieve success when the re-growth of the tumour is not the causal agent. Three cases of thrombosis due to poor anticoagulation were seen, and they were resolved by increasing anticoagulant dose. One patient, who needed urokinasa for desobstruction intent, had major pelvic bleeding after a venopunction few minutes after. None of the patients experiencing re-obstruction received further antineoplastic therapy. Focusing in patients affected by NSCLC not previously treated, 15 patients out of the global group presented with this condition and adequate performance status to be treated with chemotherapy alone or in combination with radiation therapy if disease was locally advanced. Four of them received Carboplatinum due to their fragile condition, but the remainder could be treated with Cisplatinum and full dose of hydration without any complication. Global response rate was 53% with 6%
Table 2 Clinical improvement rate Symptom or sign
Initial presence
Partial response
Complete response
Global response
Oedema Dyspnea Confusion Vein distension
52 40 2 45
17 pts (33) 10 pts (25)
31 24 2 17
48 pts (92) 34 pts (85)
4 pts (8) 6 pts (15)
33 pts (73)
12 pts (27)
pts pts pts pts
(100) (74) (3) (86)
16 pts (35)
Pts: patients; the values in parenthesis are in percentage.
pts pts pts pts
(59) (60) (100) (38)
Failure
212
A. Urruticoechea et al.
Fig. 2
Angiography performed in a case of stent re-stenosis.
Table 3 Results of treatment after stent placement
in non-small cell lung cancer Number
Tumor stage
Treatment
Best response
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
IV III III IV III III IV III IV III IV III III III III
CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT
Progression Partial response Stable disease Progression Partial response Complete response Partial response Stable disease Partial response Partial response Stable disease Progression Partial response Progression Partial response
b b b b b a b b a a
+ RT + RT + RT + RT + RT + RT + RT
CT: chemotherapy; RT: radiation therapy.
complete response (Table 3). When the stent was placed with palliative intention only due to poor performance status or age, no further treatment was delivered.
4. Discussion Endovascular placement of autoexpandable stents as treatment of SVCS is a safe and effective procedure [5,6]. Classically, SVCS was considered as a medical emergency and radiotherapy was usually elected as the first treatment, sometimes without histological diagnosis. Furthermore, even invasive diagnostic techniques were avoided in order to reduce respiratory and bleeding complications. Nowadays, SVCS is no longer considered as a medical emergency and invasive diagnostic techniques are possible with minimal risk [7]. It is possible even that the prognoses of these patients may depend more on the extent of the disease than on the presence of the syndrome itself [8].
Treatment of malignant superior vena cava syndrome A recent systematic review by Rowell and Gleeson [9] on the results of the different treatment options following lung cancer related SVCS diagnosis reported the higher effectiveness of stent insertion compared with chemotherapy, radiotherapy or steroidal treatment. As presented in our review, complications during the technique, and posterior anticoagulation, are unusual and reversible in the majority of our patients. Complications observed are acceptable in the context of advanced cancer and frail patients. Our rate of complications is consistent with other authors’ reports [10]. A major incidence of complications would be possible in patients with other thoracic organs compromised by tumour extension. Other authors have had complications in patients with previous placed endotracheal prosthesis [11]. Higher intrathoracic pressure due to the presence of stents in two different organs could explain the increased probability of complications. In patients with more than one organ involved, we should establish the priority of treatment and avoid a second prosthesis. An initial accurate histological diagnosis and determination of disease extent, and a treatment schedule not dependent on the presence of SVCS may benefit the outcome of treatment. Etiologic initial treatment with chemotherapy and/or radiotherapy is the first treatment of patients with very sensitive tumours (small cell lung cancer, lymphomas, germ cell tumours, neuroectodermic tumours) since early response (less than 1 week) results in syndrome resolution. In patients with less sensitive tumours such as NSCLC, the early placement of autoexpandable stents, resulting in relief of the syndrome and rapid improvement of performance status, allows us to use full chemotherapy doses or radiation in the conventional way, and might not condition the optimal sequence of the best tumour treatment. In locally advanced and metastatic NSCLC, the introduction of chemotherapy with Cisplatin as standard treatment [12] might be a problem in patients with SVCS due to the high hydration volume required for Cisplatin administration. Our work stresses the role of stents in the treatment of the NSCLC who present SVCS as initial manifestation and not only as palliative treatment of advanced disease. In patients with poor performance status or concomitant illnesses that make impossible etiologic treatment, and in tumour recurrences without any other oncological treatment to be offered, stent placement produces good palliation of symptoms [13]. Since the first series published [14] in 1992, various series have reported the stenting as a palliative procedure [3,11,15—22]. Nevertheless, there are no controlled studies comparing with ra-
213 diotherapy. There is only a comparative work based on historical series, where the resolution rate was clearly superior in the stent group (100% versus 56% in the radiotherapy group) and much faster (in less than 72 h versus 2—3 weeks). The probability of syndrome recurrence was higher in the radiotherapy group (88% versus 9%). Furthermore, radiotherapy may produce an increase of symptoms due to inflammation in the first days of treatment. A broad range of anticoagulation schemes associated with stenting can be used. Some authors have used fibrinolytic drugs before the placement, in an attempt to avoid emboli release and reduce the obstruction length [11,15]. Optimal duration of anticoagulation is another controversy, and periods of 1—9 months have been used [11,16]. The stent is highly thrombogenic in the first month, until neoendothelium covers the endovascular superficies, and we agree that anticoagulation is mandatory in this period. Currently, we maintain anticoagulation for 3 months or longer if hypercoagulability is suspected. In conclusion, an endovascular stent placement for a malignant SVCS achieves a rapid and persistent obstruction symptom resolution in the majority of the patients, with a low rate of complications. This placement permits patients with advanced disease a good palliation of this syndrome and, in selected patients, such as those with NSCLC, where SVCS is the main symptom in the initial presentation, allows an early initiation of the treatment indicated by the disease extent and should be considered as the first treatment option. Election of the adequate technique for each SVCS situation will permit a better outcome of our patients.
References [1] Urban T, Lebeu B, Chastang C, et al. Superior vena cava syndrome in small-cell lung cancer. Arch Int Med 1993;153(3):384—7. [2] Tanigawa N, Sawada S, Mishima K, et al. Clinical outcome of stenting in superior vena cava syndrome associated with malignant tumors. Comparison with conventional treatment. Acta Radiol 1998;39(6):669—74. [3] Nicholson AA, Ettles DF, Arnold A. Treatment of malignant superior vena cava obstruction: metal stents or radiation therapy. J Vasc Intervent Radiol 1997;8(5):781—8. [4] Dyet JF, Nicholson AA, Cook AM. The use of the Wallstent endovascular prosthesis in the treatment of malignant obstruction of the superior vena cava. Clin Radiol 1993;48(6):381—5. [5] Thony F, Moro D, Witmeyer P, et al. Endovascular treatment of superior vena cava obstruction in patient with malignancies. Eur Radiol 1999;9(5):965—71. [6] Lanciego C, Chacon JL, Julian A, et al. Stenting as first option for endovascular treatment of malignant superior vena cava s´ındrome. Am J Roentgenol 2001;177(3):585— 93.
214 [7] Laguna Del Estal P, Gazapo Navarro T. Murillas Angoitti J, et al. Superior vena cava syndrome: a study based on 81 cases. An Med Int 1998;15(9):470—5. [8] Würschmidt J, Bünemann H, Heilmann H-P. Small cell lung cancer with and without superior vena cava syndrome: a multivariate analysis of prognostic factors in 408 cases. Int J Radiat Oncol Biol Phys 1995;33(1):77—82. [9] Rowell NP, Gleeson FV. Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus: a systematic review. Clin Oncol (R Coll Radiol) 2002;14(5):338—51. [10] Smayra T, Otal P, Chabbert V, et al. Long-term results of endovascular stent placement in the superior caval venous system. Cardiovasc Intervent Radiol 2001;24(6):388— 94. [11] Stock KW, Jacob AL, Proske M, et al. Treatment of malignant obstruction of the superior vena cava with selfexpanding Wallstent. Thorax 1995;50:1151—6. [12] Marcy P-Y, Margné N, Bentolila F, et al. Superior vena cava obstruction: is stenting necessary. Support Care Cancer 2001;9(2):103—7. [13] Pignon JP, Stewart LA, Souhami RL, et al. Non-small cell lung cancer collaborative group: a meta-analysis using updated data on individual patients from 52 randomized clinical trials. Br Med J 1995;311:899—909. [14] Rocchini AP, Meliones JN, Beekman RH, et al. Use of balloon expandable stents to treat experimental peripheral
A. Urruticoechea et al.
[15]
[16] [17] [18] [19] [20] [21]
[22]
pulmonary artery and superior vena cava stenoses: preliminary experience. Pediatr Cardiol 1992;13:92—6. Kee ST, Kinoshita L, Razavi MK, et al. Superior vena cava syndrome: treatment with catheter-directed trombolysis and endovascular stent placement. Radiology 1998;206:187—93. Hennequin LM, Fade O, Fays JG, et al. Superior vena cava stent placement: results with the Wallstent endoprothesis. Radiology 1995;196:353—61. Oudkerk M, Heystraten FMJ, Stoter G. Stenting in malignant vena caval obstruction. Cancer 1993;71:142—6. Kishi K, Sonomura T, Mitsuzane K, et al. Self-expandable metallic stent therapy for superior vena cava syndrome: clinical observations. Radiology 1993;189:531—5. Rösch J, Uchida BT, Hall LD et al. Gianturco-Rösch expandable Z-stents in the treatment of superior vena cava syndrome. Cardiovasc Intervent Radiol 1992;15:319−27. Irving D, Dondelinger RF, Reidy JF, et al. Gianturco selfexpanding stents: clinical experience in the vena cava and large veins. Cardiovasc Intervent Radiol 1992;15:328—33. Furui S, Sawada S, Karamoto K, et al. Gianturco stent placement in malignant caval obstruction: analysis of factors for predicting the outcome. Radiology 1995; 195(1):147—52. Gross CM, Krämer J, Waigand J, et al. Stent implantation in patients with superior vena cava syndrome. AJR 1997;169:429—32.
Treatment of malignant superior vena cava syndrome by endovascular stent insertion Experience on 52 patients with lung cancer A. Urruticoechea a , R. Mes´ıa a,*, J. Dom´ınguez b , C. Falo a , E. Escalante b , A. Montes a , C. Sancho b , F. Cardenal a , M. Majem a , J.R. Germà a a
Medical Oncology Department, Institut Català d’Oncologia, Hospital Universitari de Bellvitge, L’Hospitalet, Barcelona, Spain b Vascular Radiology Department, Institut Català d’Oncologia, Hospital Universitari de Bellvitge, Av. Gran v´ıa s/n km 2.7, 08907 L’Hospitalet, Barcelona, Spain Received 6 March 2003 ; received in revised form 25 June 2003; accepted 7 July 2003
KEYWORDS Superior vena cava syndrome; Lung cancer; Stent; Mediastinum malignances; Vena cava obstruction; Non-small cell lung cancer; Small cell lung cancer
Summary Background: Superior vena cava syndrome (SVCS) is a frequent presentation of malignancies involving the mediastinum and can seriously compromise treatment options and prognosis. Stenting of superior vena cava is a well-known but not so commonly used technique to alleviate this syndrome. Patients and methods: Between August 1993 and December 2000 we performed 52 stenting procedures in patients affected by non-small cell lung cancer (NSCLC). Results: Phlebographic resolution of the obstruction was achieved in 100% of cases with symptomatic and subjective improvement in more than 80%. One major complication was observed due to bleeding during anticoagulation. Re-obstruction of the stent occurred in only 17% of the cases, the majority due to disease progression. Improvement of the syndrome allowed hydration necessary for full dose platinum treatment when indicated in patients affected by lung cancer. Conclusions: Stenting of the superior vena cava syndrome is a safe and effective procedure achieving a rapid alleviation of symptoms in almost all patients, and allowing for full dose treatment in lung cancer patients. This procedure could change the traditional poorer prognosis attributed to non-small cell lung cancer patients presenting with this syndrome. © 2003 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Superior vena cava syndrome (SVCS) is defined as the signs and symptoms derived from blood impairment through the superior vena cava to right
* Corresponding author. Tel.: +34-9-3260-7744; fax: +34-9-3260-7741. E-mail address: [email protected] (R. Mes´ıa).
atrium. Its clinical presentation includes oedema and vein distension of the head and neck, upper extremities and thorax, dyspnea and, in severe cases, confusion, impaired attention and coma. The main cause of SVCS in adults is lung and mediastinal tumours. Small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) cause the vast majority of cases. Treatment approach to SVCS traditionally includes radiation therapy and chemotherapy, with
0169-5002/$ – see front matter © 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0169-5002(03)00361-1
210
A. Urruticoechea et al.
radiation accomplishing up to 80% success rate in symptomatic relief in SCLC and 46% in NSCLC. Rapid initiation of full dose chemotherapy can result in 80% response rate in SCLC attending to the best series [1]. Delayed response to radiation and chemotherapy, and risk of worsening of the SVCS due to hydration mandatory for chemotherapy including full dose of Cisplatinum, can seriously compromise the results of these treatment approaches. Intravascular placement of metallic stents in the superior vena cava can rapidly achieve relief of vein obstruction [2—4]. It results in symptomatic resolution and makes possible full etiologic treatment. We report our experience with this procedure in a retrospective series of 52 patients focusing on those with NSCLC with no prior treatment.
2. Patients and methods Between August 1993 and December 2000 stent placement was performed in 52 consecutive patients with malignant SVCS to improve their symptoms. Characteristics of the patients are described in Table 1. Forty-six patients were men, and the population had a median age of 57. In all cases SVCS was caused by lung cancer (37 NSCLC and 15 SCLC), 34 (65%) were in stage III b at the moment of placing the stent, while 18 (35%) were metastatic. In two patients the histology of the tumour was not available prior to the stent placement since the indication of the procedure was urgent. Median Karnofsky index before placement was 60%. We used a semi-quantitative scale to measure four main symptoms and signs (oedema, superficial
collateral vein drainage, neurological impairment and dyspnea) previously and after stent placement. After a clinical indication of SVCS was verified, we explored the venous drainage of both superior limbs using a phlebography. We focused the study on mediastinal veins and the superior vena cava. The obstruction was defined and the collateral drainage identified. When the limits of the obstruction were not enough well defined using peripheral injection of contrast, we repeated the flebography introducing a multiperforated catheter through the stenotic segment. We have recently begun to use calibrated catheters that allow us to obtain more accurate measurements. Once the stent type and the venous access were selected we delivered 5000—10,000 IU sodic heparin bolus, just before stent placement. The stents we have used are mostly stainless steel autoexpandible (Wallstent; Boston Scientific Ireland Ltd.® Gallway, Ireland) (Fig. 1). A total of 65 prosthesis were used in 52 patients. Sixty-one Wallstent prosthesis were placed in 48 patients. In 35 patients one prosthesis was enough. In 13
Table 1 Patients characteristics Total number Male/female Age IK Tumor type
52 46/6 57 (29—77) 60 (40—80) Lung cancer 52
Lung tumors’ stage
Stage III Stage IV
34 18
Previous treatment
None Sur CT RT CT + RT Sur + RT
31 1 14 1 4 1
NSCLC 37 SCLC 15
NSCLC: non-small cell lung cancer; SCLS: small cell lung cancer; Sur: surgery; CT: chemotherapy; RT: radiation.
Fig. 1 The catheter wire is placed in the vena cava stenotic segment. The stent is delivered and the stenosis is solved.
Treatment of malignant superior vena cava syndrome patients two prosthesis were necessary due to the length of the stenotic segment or to shortening of the prosthesis after placement. In four patients we used nitinol autoexpandible stents (Memotherm; Angiomed-Karlsruhe, Germany and Sinus; Optimed-Ettlingen, Germany). The stent diameter ranged between 10 and 16 mm, most of them 12 or 14 mm. The stent length ranks between 30 and 90 mm, average 61 mm. The most frequently selected access was femoral vein, due to the introducer diameter (9F and 10F), but we also used the brachial access without complications. Once the prosthesis is placed on the estenotic segment, it is released under radioscopic control. An angioplasty balloon is used to facilitate the expansion. The entire procedure is performed with the patient under deep sedation and monitored. About 12 h after the procedure, once clotting recovers, the introducer is removed and anticoagulation is reinitiated, with low molecular weight heparin, warfarin or calcic heparin depending on the patient characteristics and the citostatic treatment they were to receive. We maintained anticoagulation for a minimum of 3 months. Maximum duration of anticoagulation was determined by the particular condition of each patient.
3. Results The stent placement was achieved in all 52 cases with 100% success in re-permeabilitation assessed by a second venogram after procedure. As shown in Table 2, symptoms improved in the vast majority of cases. Oedema, present in 100% of patients, improved in 92% of cases (completely in 59%). Dyspnea was present in 40 and decreased in 34 of them (85%) with complete resolution in 24 cases (60%). Collateral thoracic vein distension was present in 45 patients and improved in 33 (73%), up to complete resolution in 17 (38%). Only two patients presented confusion due to SVCS, and in both cases the symptom disappeared completely. Resolution of symptoms was very fast, occurring in the 72 h following stenting in all cases, and in the first 24 h in most
211 of them. Karnofsky index, measured in 48 patients prior to and 1 month after the procedure, improved in 31 (69%) and was maintained or deteriorated in 15. All deterioration of performance status was due to disease progression. Complications due to technique placement were: one supraventricular arrhythmia resolved with medical treatment, two septic episodes resolved with antibiotics, and in one case a caudal movement of a Wallstent prosthesis was registered due to a too caudal placement of it which was more obvious after balloon inflation; it was resolved with the collocation of a second stent. During ulterior follow-up six patients showed bleeding due to anticoagulation and, one patient died due to lung bleeding. Re-obstruction of the stent occurred in nine cases (17%) (Fig. 2). Cause of re-obstruction was progression of disease in five cases, in whom poor prognosis of the neoplasm contraindicated further procedures. Fibrosis of the stent caused re-obstruction in one case, which could be solved by angioplastic procedure. This is not a frequent approach to the re-obstruction. Our experience shows, anyway, that due to the uncertain cause in some cases of re-stenosis an ‘‘endovascular’’ approach with angioplasty can achieve success when the re-growth of the tumour is not the causal agent. Three cases of thrombosis due to poor anticoagulation were seen, and they were resolved by increasing anticoagulant dose. One patient, who needed urokinasa for desobstruction intent, had major pelvic bleeding after a venopunction few minutes after. None of the patients experiencing re-obstruction received further antineoplastic therapy. Focusing in patients affected by NSCLC not previously treated, 15 patients out of the global group presented with this condition and adequate performance status to be treated with chemotherapy alone or in combination with radiation therapy if disease was locally advanced. Four of them received Carboplatinum due to their fragile condition, but the remainder could be treated with Cisplatinum and full dose of hydration without any complication. Global response rate was 53% with 6%
Table 2 Clinical improvement rate Symptom or sign
Initial presence
Partial response
Complete response
Global response
Oedema Dyspnea Confusion Vein distension
52 40 2 45
17 pts (33) 10 pts (25)
31 24 2 17
48 pts (92) 34 pts (85)
4 pts (8) 6 pts (15)
33 pts (73)
12 pts (27)
pts pts pts pts
(100) (74) (3) (86)
16 pts (35)
Pts: patients; the values in parenthesis are in percentage.
pts pts pts pts
(59) (60) (100) (38)
Failure
212
A. Urruticoechea et al.
Fig. 2
Angiography performed in a case of stent re-stenosis.
Table 3 Results of treatment after stent placement
in non-small cell lung cancer Number
Tumor stage
Treatment
Best response
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
IV III III IV III III IV III IV III IV III III III III
CT CT CT CT CT CT CT CT CT CT CT CT CT CT CT
Progression Partial response Stable disease Progression Partial response Complete response Partial response Stable disease Partial response Partial response Stable disease Progression Partial response Progression Partial response
b b b b b a b b a a
+ RT + RT + RT + RT + RT + RT + RT
CT: chemotherapy; RT: radiation therapy.
complete response (Table 3). When the stent was placed with palliative intention only due to poor performance status or age, no further treatment was delivered.
4. Discussion Endovascular placement of autoexpandable stents as treatment of SVCS is a safe and effective procedure [5,6]. Classically, SVCS was considered as a medical emergency and radiotherapy was usually elected as the first treatment, sometimes without histological diagnosis. Furthermore, even invasive diagnostic techniques were avoided in order to reduce respiratory and bleeding complications. Nowadays, SVCS is no longer considered as a medical emergency and invasive diagnostic techniques are possible with minimal risk [7]. It is possible even that the prognoses of these patients may depend more on the extent of the disease than on the presence of the syndrome itself [8].
Treatment of malignant superior vena cava syndrome A recent systematic review by Rowell and Gleeson [9] on the results of the different treatment options following lung cancer related SVCS diagnosis reported the higher effectiveness of stent insertion compared with chemotherapy, radiotherapy or steroidal treatment. As presented in our review, complications during the technique, and posterior anticoagulation, are unusual and reversible in the majority of our patients. Complications observed are acceptable in the context of advanced cancer and frail patients. Our rate of complications is consistent with other authors’ reports [10]. A major incidence of complications would be possible in patients with other thoracic organs compromised by tumour extension. Other authors have had complications in patients with previous placed endotracheal prosthesis [11]. Higher intrathoracic pressure due to the presence of stents in two different organs could explain the increased probability of complications. In patients with more than one organ involved, we should establish the priority of treatment and avoid a second prosthesis. An initial accurate histological diagnosis and determination of disease extent, and a treatment schedule not dependent on the presence of SVCS may benefit the outcome of treatment. Etiologic initial treatment with chemotherapy and/or radiotherapy is the first treatment of patients with very sensitive tumours (small cell lung cancer, lymphomas, germ cell tumours, neuroectodermic tumours) since early response (less than 1 week) results in syndrome resolution. In patients with less sensitive tumours such as NSCLC, the early placement of autoexpandable stents, resulting in relief of the syndrome and rapid improvement of performance status, allows us to use full chemotherapy doses or radiation in the conventional way, and might not condition the optimal sequence of the best tumour treatment. In locally advanced and metastatic NSCLC, the introduction of chemotherapy with Cisplatin as standard treatment [12] might be a problem in patients with SVCS due to the high hydration volume required for Cisplatin administration. Our work stresses the role of stents in the treatment of the NSCLC who present SVCS as initial manifestation and not only as palliative treatment of advanced disease. In patients with poor performance status or concomitant illnesses that make impossible etiologic treatment, and in tumour recurrences without any other oncological treatment to be offered, stent placement produces good palliation of symptoms [13]. Since the first series published [14] in 1992, various series have reported the stenting as a palliative procedure [3,11,15—22]. Nevertheless, there are no controlled studies comparing with ra-
213 diotherapy. There is only a comparative work based on historical series, where the resolution rate was clearly superior in the stent group (100% versus 56% in the radiotherapy group) and much faster (in less than 72 h versus 2—3 weeks). The probability of syndrome recurrence was higher in the radiotherapy group (88% versus 9%). Furthermore, radiotherapy may produce an increase of symptoms due to inflammation in the first days of treatment. A broad range of anticoagulation schemes associated with stenting can be used. Some authors have used fibrinolytic drugs before the placement, in an attempt to avoid emboli release and reduce the obstruction length [11,15]. Optimal duration of anticoagulation is another controversy, and periods of 1—9 months have been used [11,16]. The stent is highly thrombogenic in the first month, until neoendothelium covers the endovascular superficies, and we agree that anticoagulation is mandatory in this period. Currently, we maintain anticoagulation for 3 months or longer if hypercoagulability is suspected. In conclusion, an endovascular stent placement for a malignant SVCS achieves a rapid and persistent obstruction symptom resolution in the majority of the patients, with a low rate of complications. This placement permits patients with advanced disease a good palliation of this syndrome and, in selected patients, such as those with NSCLC, where SVCS is the main symptom in the initial presentation, allows an early initiation of the treatment indicated by the disease extent and should be considered as the first treatment option. Election of the adequate technique for each SVCS situation will permit a better outcome of our patients.
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