Use of a Metallic Stent for Relief of Symptoms Caused by Superior Vena Caval Obstruction in a Patient with Advanced Cancer: A Case Report

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1 56 Journal of Pain and Symptom Management Vol. 18 No. 1 July 1999 Clinical Note Use of a Metallic Stent for Relief of Symptoms Caused by Superior Vena Caval Obstruction in a Patient with Advanced Cancer: A Case Report Noel Young, MB BS, FRACR and Paul Glare, MB BS, MA, FRACP Departments of Radiology (N.Y.) and Medical Oncology and Palliative Care (P.G.), Westmead Hospital, Westmead, New South Wales, Australia Abstract This report describes the insertion of a metallic stent in the superior vena cava to relieve the symptoms of malignant superior vena caval obstruction in a 75-year-old woman with far-advanced lung cancer in whom other methods of symptom control had been ineffective. Her symptoms were quickly relieved by insertion of the stent. She died 1 month following the procedure, without recurrence of the symptoms. The technical aspects of the procedure and the issues affecting the clinical decision-making process in this case are discussed. J Pain Symptom Manage 1999;18: U.S. Cancer Pain Relief Committee, Key Words Superior vena cava, obstruction, metal stent, cancer, decision-making Introduction Aggressive medical treatments with purely palliative intent are increasingly being offered to patients with advanced cancer and other diseases. There is much disagreement about the appropriateness of such procedures. On the one hand, they challenge the traditional nontechnological paradigm of palliative care. 1 On the other hand, many of these procedures are now minimally invasive, and can have an immediate and dramatic positive impact on quality of life in appropriately selected patients, particularly when simpler approaches have been ineffective. Address reprint requests to: Paul Glare MB BS, Department of Palliative Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW 2050, Australia. Accepted for publication: September 21, Superior vena cava (SVC) obstruction is a common problem in cancer patients, and may occur in various contexts. The syndrome may be a presenting problem in newly diagnosed patients, a thrombotic complication of central vascular access in patients receiving chemotherapy, or a manifestation of progressive disease in patients with advanced cancer. Management of malignancy-induced SVC obstruction presents a complex clinical challenge. Given time, adequate collateral circulation can develop and the symptoms resolve spontaneously. As a result, no treatment is usually needed when the symptoms are mild. In patients with distressing symptoms, there are various options. Radiotherapy, chemotherapy, and/or corticosteroids maybe effective. If not, insertion of metal stents can be appropriate. We report a case of advanced lung cancer in which clinical judgment indicated that this approach should be taken. U.S. Cancer Pain Relief Committee, /99/$ see front matter Published by Elsevier, New York, New York PII S (99)

2 Vol. 18 No. 1 July 1999 Metallic Stents for SVC Obstruction 57 Case Report A 75-year-old woman who had been a lifelong heavy smoker had a history of cancer of the right breast in 1974, was treated by mastectomy and axillary dissection followed by extensive radiotherapy. She remained well until April 1996, when she had an episode of hemoptysis. A chest radiograph showed a large mass in the upper lobe of the right lung. Thoracic computerized tomography (CT) scan demonstrated tumor infiltration into the adjacent anterior chest wall and superior mediastinum. Biopsy of the mass confirmed adenocarcinoma, but it was uncertain whether this was a second primary lung cancer or a late metastasis from her previous breast cancer. No further radiotherapy could be offered because of her prior management. She was treated with tamoxifen and then medroxyprogesterone in the hope it was metastatic breast cancer. The patient remained asymptomatic until May 1997, when she presented with a short history of the symptoms and signs of SVC obstruction, including shortness of breath at rest, stridor, and distention of the neck veins. Chest radiography showed the right lung mass to be larger. She was referred to a palliative care physician and treated with dexamethasone, with a good symptom response within 48 hours. Six weeks later, in mid-june 1997, the patient represented with increasing stridor; swelling in the face, neck and arms; and shortness of breath. The chest radiograph showed the mass in the right upper lobe to be much larger, now occupying much of the right lung (Fig. 1). She was very distressed by these symptoms and her scores on a quality-of-life (QOL) questionnaire completed on two occasions in the weeks prior to stenting, as part of a separate research project, indicated her QOL had fallen from 90% of ideal to 70% of ideal as the SVC obstruction became symptomatic. Oncologic review was obtained. No further radiotherapy was considered possible and chemotherapy was not offered because of the low probability that the available agents would effectively palliate her symptoms without causing substantial toxicity. Because hormone therapy and corticosteroids were no longer effective, symptom relief by SVC stenting was considered the best management option, and the patient was agreeable to this. Right arm venography and SVC venography showed a high-grade stenosis of the SVC from tumor encasement and infiltration (Fig. 2). A Memotherm (Angiomed, Karlsruhe, Germany) metal self-expanding stent was placed successfully across the stricture, with assistance by intraluminal balloon angioplasty (Fig. 3). Her symptoms improved dramatically within 24 hours, with resolution of her stridor and improved shortness of breath. There was also objective reduction in head, neck, and arm swelling in the following days. The procedure had entailed no complications. She returned home 6 days later. Over the next few weeks, the patient began to lose weight and became increasingly weak. She had to be admitted to an inpatient hospice unit where she died a short time later, exactly 1 month after stent insertion. There was no recurrence of SVC obstruction clinically. Discussion Malignancy is the most common cause of SVC obstruction. Treatment options include radiotherapy, chemotherapy, and surgery. 2 4 Each has limitations, and insertion of metallic stents into the SVC lumen is an alternative to conventional management. The role of this modality in the palliative care setting is not yet well understood. Reestablishment of the SVC lumen with metal stents was first reported in Several small series have appeared since. 6 9 Rapid resolution of the obstruction and the patient s symptoms is usually achieved. In one series, the mean SVC diameter improved from 3 mm to 14 mm with stenting, and the mean pressure gradient across the stenosis fell from 21 mm Hg to 3 mm Hg. 7 Complications of this approach are infrequent, with thrombosis, stent misplacement and migration being the most common. Blockage of the stent by tumor occurs rarely. 7 Survival time post-stenting is short in patients with cancer, usually being less 6 months. 8,9 Stent technology and delivery application is constantly changing. We chose to use a Memotherm metal stent because of its highly accurate and simple delivery placement system. In our patient, balloon angioplasty was needed to enable expansion of the stent. Clinical decision-making regarding the use of modern medical technology in patients with

3 58 Young and Glare Vol. 18 No. 1 July 1999 Fig. 1. Chest radiograph in June 1997 showing the right lung mass causing SVC obstruction. advanced disease is a complex process. Many factors need to be taken into account, including: (i) the clinical status of the patient; (ii) the risks, harms, and benefits to the patient of the intervention; (iii) the patient s goals, priorities, and expectations at this stage of illness; (iv) anticipation of problems to be encountered if the intervention is, or is not, performed; and (v) ethical and legal issues. This calculation is necessary in any clinical setting, but is more complicated in patients with advanced disease. Benefit must clearly outweigh risks and burdens to justify an intervention, yet these are all difficult to measure with any certainty when outcomes are mainly subjective and the clinical status of the patient is deteriorating rapidly.10 Patient preferences may also change rapidly as the goal of treatment changes. Was the decision to undertake the stenting procedure in this patient the correct one? She had locally advanced nonsmall cell lung cancer that had been following a relatively indolent course. She was maintaining a good performance status with few symptoms prior to the development of the SVC obstruction. We estimated her prognosis was approximately 3 months, with little chance of surviving more than 1 year. There were no further antineoplastic treatments to offer her. Although we had not previously stented the SVC in a patient with advanced cancer, our experience in patients with benign SVC obstruction indicated that the

4 Vol. 18 No. 1 July 1999 Metallic Stents for SVC Obstruction Fig. 2. A superior vena cavagram performed via a right femoral vein approach shows significant tumor constriction (open arrow). The right jugular vein is distended above the SVC stricture (closed arrow). benefits of the procedure ought to outweigh the burdens in her case. Relief of the SVC obstruction was the patient s main priority and she expected us to be able to do something about it. We could not envisage problems arising later on as a result of stenting (other than the known but uncommon complications of the procedure), whereas to do nothing and hope for a collateral circulation to develop would cause avoidable prolongation of her current suffering. Thus, we could see no ethical problems with the intervention. The patient understood what stent insertion involved, our uncertainty about its usefulness in her case, and our belief that serious side effects were unlikely. She had absolutely no hesitation in submitting herself for the procedure. Although health care resources are limited, and there is much concern about the high costs of care in the last year of life, we believe the cost of the intervention [venography ($A 700), the device ($A 1800), and the radiologist s fee ($A 1300)] was justified. 59 Fig. 3. A superior vena cavagram performed after the insertion of the metal stent shows significant, although subtotal, alleviation of the stenosis. As a result of this analysis, we remain convinced that the decision to go ahead with stenting was the correct one, and the outcome achieved supports this view. The patient was very satisfied, both in terms of the rapidity of symptom control and the minimal burden involved. The fact that she lived only 1 month after the procedure may have been disappointing from a cost-effectiveness point of view, but in our opinion only served to vindicate the decision to intervene when we did. Those who administer health funds might think otherwise. In conclusion, insertion of metal stents appears to be a safe, effective way of providing symptomatic relief in malignant SVC obstruction in the palliative care setting. Interventional radiology is widely used in other clinical contexts11 and there is no inherent reason why it should be denied to patients with far advanced cancer, especially if they have symptoms that can not be relieved more simply. There is now a vast range of readily performed

5 60 Young and Glare Vol. 18 No. 1 July 1999 procedures that are safe, well-tolerated, and rapidly effective. 12 Correct identification of appropriate patients for such aggressive interventions is the major challenge facing palliative care clinicians. An analysis of the relevant clinical and ethical factors can inform the decisionmaking process. References 1. Tuch H, Woodrow A. Technology in terminal illness (abst). J Pall Care 1995;11: Davenport D, Feree C, Blake D, Raben M. Radiation therapy in the treatment of superior vena caval obstruction. Cancer 1978;42: Perez CA, Presant CA, Van Amburg AL. Management of superior vena cava syndrome. Semin Oncol 1978;5: Chen JC, Bongard F, Klein SP. A contemporary perspective on superior vena cava syndrome. Am J Surg 1990;160: Charnsangavej C, Carrasco CH, Wallace S, Wright KC, Ogawa K, Richli W, Gianturco C. Stenosis of the vena cava: preliminary assessment of treatment with expandable metal stents. Radiology 1986; 161: Kazushi K, Sonomura T, Mitsuzane K, Nishida N, Yang R, Sato M, Yamada R, Shirai S, Kobayashi H. Self-expandable metallic stent therapy for superior vena cava syndrome: clinical observations. Radiology 1993;189: Gaines PA, Belli AM, Anderson P, McBride K, Hemingway AP. Superior vena caval obstruction managed by the Gianturco 2 Stent. Clin Rad 1994; 49: Matthijs O, Kuijpers TJA, Schmitz PIM, Loosveld O, de Wit R. Self-expanding metal stents for palliative treatment of superior vena caval syndrome. Cardiovasc Intervent Radiol 1996;19: Shah R, Sabaratnam S, Lowe RA, Mearns AJ. Stenting in malignant obstruction of superior vena cava. J Thorac Cardiovasc Surg 1996;112: Randall F, Downie RS. Palliative care ethics: a good companion. Oxford: Oxford University Press, Thomson KR. Interventional radiology. Lancet 1997;350: Adam A, Hemingway AP. Interventional radiology. In: Doyle D, Hanks GWC, Mac Donald N, eds. Oxford textbook of palliative medicine, 2nd ed. Oxford: Oxford University Press, 1998: