Unraveling the superior vena cava syndrome conundrum in lung cancer patients, a retrospective multivariate analysis – A tertiary care center venture

R Arjuhn; S Jeeva; TN Vijayasree; Giridhran Ramaswamy; B Antoinette Mary Nithiya

doi:10.4103/aort.aort_27_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 3 | Issue : 1 | Page : 32-34

Unraveling the superior vena cava syndrome conundrum in lung cancer patients, a retrospective multivariate analysis – A tertiary care center venture

R Arjuhn, S Jeeva, TN Vijayasree, Giridhran Ramaswamy, B Antoinette Mary Nithiya
Department of Radiation Oncology, Madras Medical College, Chennai, Tamil Nadu, India

Date of Submission	04-Oct-2022
Date of Decision	13-Nov-2022
Date of Acceptance	15-Nov-2022
Date of Web Publication	16-May-2023

Correspondence Address:
Dr. R Arjuhn
Department of Radiation Oncology, Madras Medical College, Chennai, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aort.aort_27_22

Abstract

BACKGROUND: Need to address superior vena cava syndrome (SVCS) is essential since SVCS has the potential to be fatal if not treated as an emergency.
MATERIALS AND METHODS: Forty histologically confirmed patients with SVCS due to lung cancer treated from January 2015 to December 2020 were taken up for the study. Two groups of patients received two different radiation regimens for SVCS: Treatment 1:300 cGy per fraction for 10 fractions (40%, n = 18) and Treatment 2:400 cGy per fraction for 5 fractions (52.5%, n = 22). These two groups were analyzed in terms of clinical outcomes based on tumor and treatment characteristics and their association with symptom reduction and treatment response in SVCS in lung cancer patients.
RESULTS: The mean survival for Treatment 1 is 6.6 months and Treatment 2 is 8 months but is not a statistically significant difference (P = 0.587; confidence interval [CI] 95%). The mean symptom reduction for Treatment 1 is within 10.1 days and for Treatment 2 is within 5.6 days, which is statistically significant (P = 0.001; CI 95%). Overall survival for patients whose symptoms reduced after treatment is 9.85 months while for patients where no symptom reduction is 1.2 months, which is statistically significant (P = 0.0005; CI 95%).
CONCLUSION: Radiotherapy (RT) regimen of 400 cGy per fraction for 5 fractions is superior to 300 cGy per fraction for 10 fractions regimen in terms of rate of SVCS symptom reduction. patients whose SVCS symptoms improved after planned RT has better overall survival. Whereas progression/nil improvement/incompletion of planned RT have poorer prognosis in terms of overall survival.

Keywords: Clinical outcomes, lung, prognosis, superior vena cava, superior vena cava obstruction

How to cite this article:
Arjuhn R, Jeeva S, Vijayasree T N, Ramaswamy G, Mary Nithiya B A. Unraveling the superior vena cava syndrome conundrum in lung cancer patients, a retrospective multivariate analysis – A tertiary care center venture. Ann Oncol Res Ther 2023;3:32-4

How to cite this URL:
Arjuhn R, Jeeva S, Vijayasree T N, Ramaswamy G, Mary Nithiya B A. Unraveling the superior vena cava syndrome conundrum in lung cancer patients, a retrospective multivariate analysis – A tertiary care center venture. Ann Oncol Res Ther [serial online] 2023 [cited 2023 May 31];3:32-4. Available from: http://www.aort.info/text.asp?2023/3/1/32/376893

Introduction

Superior vena cava syndrome (SVCS) is a cluster of signs and symptoms brought about by superior vena caval vessel lumen obstruction, which is caused by three main mechanisms: (1) tumor compression, (2) tumor invasion, and (3) thrombosis.

Some of the symptoms/signs that can be seen with SVCS are facial/cervical edema, swelling of the thoracic/cervical veins, cough, dysphagia, and dyspnea.^{[1],[2],[3],[4],[5],[6],[7],[8]} Before the arrival of effective antibiotics, tuberculosis causing bulky mediastinal adenopathy and syphilis causing syphilitic thoracic aortic aneurysms resulting in superior vena cava compression were the primary etiologies of SVCS.^{[9],[10],[11],[12]}

With the advent of effective antibiotics and newer medical technology, it was found that around 80% of SVCS is caused by malignant etiologies,^[2] especially lung cancer contributing up to 75%.^{[2],[3],[4],[5],[6]} In this study, SVCS due to lung cancers were discussed.

The need to address SVCS is essential since SVCS has a potential to be fatal if not treated as an emergency.

SVCS due to tumor mass is considered in this study as it is an radiation oncologic emergency and optimal management for relief of symptoms and its impact on survival outcomes remains to be an area of active research and this study hopes to aid the ever-growing scientific knowledge on this fatal disease condition.

Aim

The purpose of this study is to analyze clinical outcomes based on demographic variables, tumor characteristics, treatment characteristics (radiation dose, duration and completion of radiotherapy [RT]), and its association with symptom reduction and treatment response in SVCS in lung cancer patients.

Materials and Methods

This retrospective study was approved by Institutional Review Board. This is a retrospective study involving 40 consecutive histologically confirmed patients with SVCS due to lung cancer treated at the Radiation Oncology Department at Madras Medical College from January 2015 to December 2020 were taken up for the study.

The demographic variables of the patient, clinical features, radiological findings, location of tumor, RT dose, follow-up period, and outcomes are analyzed.

Male gender with SVCS is around 87% (n = 35), whereas female gender with SVCS accounts for about 13% (n = 5).

The mean age of the entire cohort is 54.5 years but SVCS occurs in females at a slightly younger age (41.6 years) when compared to male (n = 35) which is 56.4 years.

Ninety percent found to have SVCS signs/symptoms at presentation, whereas only 20% reported superior vena cava obstruction symptoms as the first or chief symptom. Among which 30% (n = 12) had metastasis at presentation with most common metastatic form being pleural effusion (12.5%) followed by liver metastasis (10%).

The most common histology present in this study is nonsmall cell lung carcinoma (NSCLC) accounting for 80% (n = 32) and small cell lung carcinoma accounts for 20% (n = 8). 72.5% (n = 29) underwent palliative RT while 27.5% (n = 11) had emergency RT.

Two groups of patients received two different radiation regimens:

Treatment 1: 300 cGy per fraction for 10 fractions (40%, n = 18)
Treatment 2: 400 cGy per fraction for 5 fractions (52.5%, n = 22).

Results

Signs/symptoms improved within a week on RT in 40% (n = 16) of patients, within 10 days after RT in 12.5% (n = 5) of the patients, and within 14 days in 17.5% (n = 7) patients. Unfortunately, 17.5% (n = 7) had nil improvement by RT.

The mean overall survival of the entire cohort is 7.06 months. Only 23.6% (n = 9) survived up to 1 year and it reduces to 7% (n = 3) at 2-year mark.

The mean survival for Treatment 1 is 6.6 months and that of Treatment 2 is 8 months. However, there is no statistically significant difference in the survival outcome between the treatments (P = 0.587; confidence interval [CI] 95%).

The mean symptom reduction for Treatment 1 is within 10.1 days and the that of Treatment 2 is within 5.6 days, which is statistically significant (P = 0.001; CI 95%).

The mean overall survival of patients who have metastasis at presentation is 6.6 months which rises to 8.9 months if the patients complete the planned RT. This rise is particularly marked with 400 cGy per fraction in 5 fractions regimen.

Overall survival of the patients who progresses while on RT or defaulted for RT is 0.85 months and 0.9 months, respectively. This observation also shows 12.5% (n = 5) of patients who progressed while on RT.

Overall survival for patients whose symptoms reduced after treatment is 9.85 months and for patients where no symptom reduction is 1.2 months, which is statistically significant (P = 0.0005; CI 95%).

Discussion

Considering the literature, the average incidence of SVCS is 1.2–8.6 patients/year,^[13],[14] therefore, the sample size of 40 patients for 5 years in this study is significant. Strikingly higher preponderance of SVCS is seen with male gender (87%, n = 35) and positive smoking history (72.5%, n = 29) which is in accordance with the literature.

Mean overall survival of 23.6% at 1-year mark is independent of histology and falls in line with the current knowledge of SVCS.^{[1],[3],[8],[15]}

The most common histology in this study is NSCLC. However, effect on the type of histology on symptom reduction and overall survival is not pronounced in this study.

It is clearly seen that the effect of severity, metastasis, and histology is insignificant on the overall survival provided that the patient responds by improvement of symptoms upon RT treatment.

There is no statically significant differentiation between the nonresponders (12.5%, n = 5) in both the regimes – those receiving (n = 3) 300 cGy per fraction for 10 fractions when compared to those receiving (n = 2) 400 cGy per fraction for 5 fractions.

RT regimen of 400 cGy per fraction for 5 fractions gives faster symptom relief than 300 cGy per fraction for 10 fractions regimen, but overall survival after completion of both the regimen is not statistically significant.

Conclusion

RT regimen of 400 cGy per fraction for 5 fractions is superior to 300 cGy per fraction for 10 fractions regimen in terms of rate of reduction of SVCS symptoms. Patients whose SVCS symptoms improved after planned RT has better overall survival. Whereas progression on RT, nil improvement after planned RT, incompletion of planned RT have poorer prognosis in terms of overall survival.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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