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Part 4

Interventions

Correct interventions
Chest CT
Urgent referral to radiation oncology
Start Decadron 8 mg every 6 hours

Incorrect interventions
Increase Morphine Sulfate to 45 mg q 12 hours Clinically , the patient has an SVCO. At this time, the increase dose of morphine per se is unlikely to be helpful if the underlying SVCO is not managed. A blanket increase of Morphine should not be done at this point.

Superior Vena Cava Obstruction (SVCO)

Malignant mediastinal lymphadenopathy can result in SVCO. The most common cause is lung cancers (causing 60-70% of malignant SVCOs) especially small cell lung cancer. Other causes of malignant SVCO include breast cancer, lymphoma and germ cell tumor.

Patients present with facial and neck swelling, dyspnea, headaches, chest wall distension and occasionally syncope. SVCO is a palliative care urgency and requires prompt attention.

Treatment depends on anticipated life expectancy:

  1. Hours to days: These patients may be too ill to tolerate most interventions. Consider oral steroids to decrease lymphadenopathy, symptomatic management of dyspnea, headaches etc.
  2. Days to weeks or more: Patients with lymphoma or small cell lung cancer are often treated with palliative chemotherapy. Patients with non-small cell lung cancer are palliated with radiation therapy (RT) with or without stent placement during or after RT. Patients with lymphoma and germ cell tumor may be candidates for curative RT.

Mr. Silver was treated with an accelerated course of radiation therapy and continued on the Decadron with significant improvement in his breathlessness.

 
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