In the majority of cases the treatment is that of the underlying cause and it is important to establish a clear diagnosis (including pathology) before starting. It is unusual for the symptoms to be so severe as to require emergency treatment (unless there is coincident tracheal compression) and the gradual development of collateral circulation means that symptoms often stabilize.

♦ Treatment choices for commonest underlying tumours include: —Small cell lung cancer: chemotherapy (unless physical state very poor); radiotherapy (at relapse following chemotherapy). —Non-small cell lung cancer: surgery is very rarely possible because SVCO is usually associated with locally advanced tumour; radical radiotherapy may be possible if the tumour is central but localized; for most, palliative radiotherapy is appropriate. —Non-Hodgkin's lymphoma: usually chemotherapy.

♦ Corticosteroids are frequently prescribed (e.g. Dexamethasone 4 mg qds) but there is no good evidence for their efficacy; anti-tumour effect in lymphoma and Hodgkin's disease; helpful if the patient has associated stridor.

♦ Thrombolysis is increasingly used as a prelude to stenting. Extensive thrombus in the SVC and tributary veins may lead to persistent or increasing symptoms and signs despite successful tumour treatment. Thrombolysis should only be considered after venography and if other measures are unlikely to be successful. Where thrombus has formed around a Hickman line (often in association with continuous infusion chemotherapy) removal of the line will usually lead to resolution of SVCO.

♦ Stenting: an expanding metal stent can be manoeuvred into the SVC at the point of stricture. If an interventional cardiologist with experience can provide a rapid service, this is now treatment of choice for patients with severe symptoms.

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