The clinical diagnosis of SVCO is usually obvious and investigation should be aimed at establishing the cause, especially if there is no preexisting diagnosis of malignancy. Unless the patient has very severe and life-threatening symptoms (e.g. associated stridor) treatment should not start until a clear diagnosis (including pathology if possible) has been made.

Chest x-ray usually shows a right paratracheal mass or other indications of lung cancer or mediastinal lymphadenopathy. It is rarely normal.

CT thorax is required only if CXR findings are equivocal or if indicated for the normal investigation of the underlying tumour. Venogram is needed if there is no obvious mass causing external compression, or if thrombolysis or stent insertion are planned. FNA cytology samples should be taken from, for example, cervical lymphadenopathy.

Bronchoscopy is essential if the clinical picture and CXR suggest lung cancer and a histopathological diagnosis is not yet obtained. Mediastinal biopsy (mediastinoscopy, mediastinotomy, mini-thoracotomy, or directed-needle biopsy) is essential if a pathological diagnosis has not been established any other way. There is an increased risk of haemorrhage from these procedures in patients with SVCO, but this is small in experienced hands.

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