Managing malignancy-related superior vena cava obstruction in palliative care

Superior vena cava obstruction does not independently predict a poor prognosis; prognosis is directly related to the underlying tumour type and stage. Openly and honestly discuss active treatment and supportive care options, while considering the potential benefits and burdens of management options, and the patient’s prognosis, preferences and goals of care—see Principles of symptom management in palliative care. For principles of managing emergency presentations, see Emergencies in palliative care.

General management options include relieving symptoms (eg breathlessness, headache). Elevating the head of the patient’s bed can reduce central venous pressure and may relieve headache.

Corticosteroids can be trialled as a temporising option in life-threatening situations while specialist advice is being sought or while discussions about prognosis with family or carers occur—see Corticosteroids for life-threatening malignancy-related superior vena cava obstruction in palliative care.

Despite historical use, diuretics are no longer recommended for the emergency management of malignancy-related superior vena cava obstruction because of a lack of evidence of benefit to support their use, and the potential for harmful reduction in venous returnShenoy, 2017Todd KH, 2016.

Active management of malignancy-related superior vena cava obstruction requires multidisciplinary specialist input. Management is guided by tissue biopsy and staging scans, and has 2 key aspects: relief of the obstruction and management of the underlying cancer. A combination of therapies may be required, depending on symptom severity, and the stage and type of tumour. Treatment options include thrombolysis, intravascular stenting, chemotherapy, radiotherapy and surgery.

If active management is inappropriate, continue to focus on management of distressing symptoms—see Breathlessness in palliative care and Severe acute breathlessness in palliative care.

For management of symptoms in the last days of life, see Principles of care in the last days of life.

If death appears imminent, see Catastrophic terminal events in palliative care for management.