Obstruction of the superior vena cava.

A 10 year experience in 66 patients with obstruction of the superior vena cava (SVC) was reviewed. Pathogenesis was malignancy in all except two patients with granulomatous mediastinitis (3%). Venography was especially helpful in determining extent of SVC obstruction and collateral circulation. Only nine patients are still alive; 57 are dead (mean survival, 3.9 months). Patients with upper airway obstruction and/or cerebral edema only survived 1.4 months (P less than 0.001). The two patients with benign obstruction had a new operation to bypass the SVC using a spiral graft of saphlenous vein with complete relief of SVC syndrome up to 26 months. Lymphomas responded to radiation (63% improved), but response in the bronchogenic carcinoma group was variable (42% improved) and was not related to palliative radiation, chemotherapy, or both. Patients receiving full-course mediastinal radiation (more than 5,000 rads) had improved survival (9.9 months). Three patients with bronchogenic carcinoma and severe SVC syndrome (cerebral edema and upper airway obstruction) had excellent palliation using spiral vein bypass graft and postoperative radiation. This experience suggests that treatment of patients with obstruction of SVC based on evaluation of signs, symptoms, and venography may provide extended palliation. If the syndrome is mild, full-course mediastinal radiation is given. If there is cerebral edema or upper airway obstruction, operation to bypass the SVC will relieve SVC syndrome immediately and will allow orderly radiation therapy.