|Year : 2008 | Volume
| Issue : 6 | Page : 104-107
|Management of lung cancer-related complications
Ahmed Saadeen1, Abdul-Rahman Jazieh2
1 Riyadh Military Hospital, Riyadh, Saudi Arabia
2 King Abdulaziz Medical City for National Guard, Riyadh, Saudi Arabia
Department of Oncology (Mail code 1777), P.O. Box 22490, Riyadh 11426
| Abstract|| |
Lung cancer patients have a plethora of symptoms and complications. This manuscript will review two specific entities, namely, superior vena cava syndrome and the skeletal complications of lung cancer.
Keywords: Lung cancer, complications, treatment
|How to cite this article:|
Saadeen A, Jazieh AR. Management of lung cancer-related complications. Ann Thorac Med 2008;3, Suppl S2:104-7
| Superior Vena Cava Obstruction|| |
Superior vena cava obstruction (SVCO) is usually caused by extrinsic compression of the superior vena cava (SVC) by tumor or lymph nodes; it may be complicated by intracaval thrombus formation. This uncommon manifestation of carcinoma of the bronchus is characterized by swelling of the neck and distention of the veins over the chest.
In recent years, the majority of patients with small-cell lung cancer (SCLC) who had SVCO at diagnosis have tended to receive chemotherapy, whilst the majority of patients presenting with non-small-cell lung cancer (NSCLC) and SVCO have tended to receive radiotherapy. Steroids may also be prescribed. Stenting provides a further treatment option which may be combined with radiotherapy and chemotherapy or used on its own. The optimal timing for stent insertion is currently undecided.
Correct histological diagnosis of the malignancy is important for appropriate management.
Incidence and causes
SVCO is the presenting feature of the underlying disease in up to 50% of cases, and 80-90% of SVCO are due to an underlying malignancy. Lung cancer is the underlying disease in about 70% of cases, lymphoma in 8%, and other malignancies in 10%; about 12% of cases are due to nonmalignant conditions.
It is present at diagnosis in 10% of patients with SCLC and 1.7% of patients with NSCLC. SVCO is also seen in patients with large lung metastases, such as those seen in breast cancer, thyroid cancer, and renal cell carcinoma. ,,,
Patients with central intravenous lines are also at risk of developing SVCO due to clot formation.
Common signs and symptoms of SVCO
SVCO commonly presents as persistent headache and a feeling of fullness in the head which can be mistaken for sinus problems; it is usually associated with edema of the face and both arms, which is usually worse in the morning and may fluctuate over the day. The patient might have a dusky color affecting the skin of the chest wall, arms, or face, along with distended superficial veins.  Dyspnea, dysphagia, and the symptoms of the primary disease are less frequent clinical features. Due to increase in venous pressure on bending forwards or lying down, all symptoms and signs may be exacerbated in these positions. All of the symptoms and signs need not be present in every case and the absence of some of them does not exclude the diagnosis. Clinicians should have a particularly high index of suspicion when caring for patients at risk, e.g., patients with known lung cancer, especially those with right-sided disease.
Investigations for SVCO
The approach to SVCO has changed significantly over the recent decades. In the past, it was considered as an oncological emergency and immediate radiotherapy was commenced, even before attempting to arrive at a histological diagnosis. In addition, invasive diagnostic procedures, such as mediastinoscopy, thoracotomy, etc., were then deemed hazardous.
It is now believed that for the majority of patients SVCO is not an emergency; besides, the outcome of SVCO was found to be unrelated to the duration of symptoms. ,
- Chest x-ray and CT scan of chest may be helpful in identifying the mass causing SVCO.
- When stenting is being considered, venography may help to define the site of the obstruction.
- When the underlying diagnosis is unknown, tissue biopsy (bronchoscopic biopsy or radiologically guided) is essential to provide a definitive histological diagnosis.
- When thrombolytic treatment is being considered, CT head is advised if there is clinical suspicion of cerebral metastasis.
Treatment of SVCO
Treatment includes general measures for symptomatic relief of SVCO and definitive treatment targeted at the underlying cause. It may include the following:
- The sitting-up posture alleviates the pressure sensation inside the head.
- Oxygen supplementation relieves shortness of breath.
- Systemic steroid is generally used in conjunction with radiotherapy because of concerns about radiation-induced edema.
- Diuretic has been used with anecdotal reports of benefit.
- Benzodiazepine and morphine are also effective means for symptomatic control.
Radiotherapy is the definitive treatment of choice for SVCO in NSCLC. Three patterns of radiotherapy are commonly practiced ,, :
- Conventional daily fractionation throughout (1.8-2 Gy daily fraction)
- Large initial fractions of 4 Gy for the first few days followed by conventional daily fractionation till the desired total dose is reached
- Hypofractionation throughout
It is unclear which regimen is the best. Some investigators believe that large-dose fractions may produce faster relief of symptoms.
Chemotherapy is the initial definitive treatment of choice for patients with SCLC. Sculier et al . demonstrated that symptomatic relief of SVCO was achieved in 73% of patients initially treated with chemotherapy and in only 43% of patients initially treated with radiation therapy.
For lymphoma also the standard of care is chemotherapy because it provides both local and systemic therapeutic activity. The choice of regimen depends on the grade, stage, and histological subtype. Steroids should not be used where a diagnosis of lymphoma is probable as this could obscure the histological diagnosis and induce the tumorlysis syndrome.
Stenting , using metallic expandable stents, is recommended for persistent or recurrent SVCO in patients who have failed chemotherapy or radiotherapy. Recently, a few authors have reported response rates of 85-100% in SVCO treated with stenting. Relief of SVCO was frequently complete and obtained with a delay of only 24-72 h. It was suggested that stenting should be used as the first-choice treatment in SVCO and not just after failure of other treatments or symptom recurrence after classical treatment. Nicholson et al . conducted a study in which they compared 76 SCLC and NSCLC patients who had SVCO treated with stent to 25 historic controls treated with thoracic radiotherapy. They concluded that stent insertion fulfills the requirements of a palliative procedure significantly better than radiotherapy and should be the procedure of first choice.  This issue is still undecided and there is no prospective data for definite recommendations on the best timing of this intervention. ,,,,,
Prognosis and treatment outcome
SVCO may recur as the disease progresses. Rowell and Gleeson conducted a systemic review on the management of SVCO in lung cancers. In SCLC, chemotherapy with or without radiotherapy relieved SVCO in 77%, with 17% of those treated suffering a relapse of SVCO. In NSCLC patients, 60% had relief of SVCO by chemotherapy with or without radiotherapy and recurrent SVCO occurred in 19% cases.
There may be a role for long-term anticoagulation in preventing recurrence in patients with a reasonable life expectancy.
| Skeletal Complications of Lung Cancer|| |
Lung cancer has the propensity to spread to the bones and, therefore, skeletal complications of lung cancer are common; such complications have a deterimental impact on the quality of life and survival of the patient. ,
It is estimated that 30-65% of lung cancers will develop bone metastases that may lead to bone pain, fractures, spinal cord compression, and hypercalcemia. These complications, in addition to the performance of radiotherapy or surgical intervention, are considered skeletal-related events (SRE). 
The following are the approaches to the prevention and treatment of SRE.
I. Prevention of SRE
It is prudent to attempt to prevent SREs prior to their occurrence in order to decrease morbidity and improve quality of life and survival; in addition, it may help decrease the cost of health care and health resource utilization. 
In a study of 773 patients with various solid tumors, 50% of the patients had NSCLC.  In this study, patients were randomized to receive placebo or zoledronic acid at doses of either 4 mg or 8 mg. (The 8-mg dose arm was dropped later due to concerns about renal toxicity.) This study revealed that zoledronic acid significantly reduced all SREs as compared to placebo (38% vs. 47%; P = 0.03). The hazard ratio for SRE in lung cancer patients receiving zoledronic acid was 0.70 ( P = 0.036). Therefore, the authors recommended that patients with lung cancer and bone metastasis should receive bisphosphonates.
II. Treatment of SREs
If an SRE occurs, the patient should be prescribed bisphosphonate if it is not already being given. The patient should continue bisphosphonate treatment if it has already been started as the occurrence of the SRE does not indicate a failure of the drug. There are studies showing that bisphosphonates can delay a second SRE. Furthermore, bisphosphonate therapy alleviates bone pain and controls hypercalcemia. 
Radiotherapy could be used for control of pain and to decrease the risk of fracture. Even patients with surgical fixation of bone lesions require radiotherapy. Radiotherapy is also a mainstay treatment modality for cord compression.
Surgical intervention is indicated in impending fracture or actual fractures and spinal cord compression.
D. Palliative care measures
Symptom control in cases with bone metastasis can be attempted using various pharmacological methods (medication) or interventions such as nerve block.
In summary, SREs are common in lung cancer due to its propensity to spread to the bones. Management of these complications will improve the overall condition of the patient and enhance quality of life.
| References|| |
|1.||Bell DR, Woods RL, Levi JA. Superior vena cava obstruction: A 10-year experience. Med J Aust 1986;145:566-8. [PUBMED] |
|2.||Schraufnagel DE, Hill R, Leech JA, Pare JA. Superior vena cava obstruction: Is it an emergency? Am J Med 1981;70:1169-74. [PUBMED] |
|3.||Parish JM, Marschke RF, Dines DE, Lee RE. Etiologic considerations in superior vena cava syndrome. Mayo Clin Proc 1981;56:407-13. |
|4.||Yellin A, Rosen A, Reichert N, Lieberman Y. Superior vena cava syndrome: The myth - the facts. Am Rev Respir. |
|5.||Rowell NP, Gleeson FV. Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus. Cochrane Database Syst Rev 2001:4:CD001316. |
|6.||Perez-Soler R, McLaughlin P, Velasquez WS, Hagemeister FB, Zornoza J, Manning JT, et al . Clinical features and results of management of superior vena cava syndrome secondary to lymphoma. J Clin Oncol 1984;2:260-6. [PUBMED] [FULLTEXT]|
|7.||Ahmann FR. A reassessment of the clinical implications of the superior vena cava syndrome. J Clin Oncol 1984;2:961-9. [PUBMED] [FULLTEXT]|
|8.||Gauden SJ. Superior vena cava syndrome induced by bronchogenic carcinoma: Is this an oncologic emergency? Austral Radiol 1993;37:363-6. |
|9.||Nicholson AA, Ettles DF, Arnold A, Greenstone M, Dyet JF. Treatment of malignant superior vena cavaobstruction: Metal stents or radiation therapy. J Vasc Interv Radiol 1997;8:781-8. [PUBMED] |
|10.||Loeffler JS, Leopold KA, Recht A, Weinstein HJ, Tarbell NJ. Emergency prebiopsy radiation for mediastinal masses: Impact on subsequent pathologic diagnosis and outcome. J Clin Oncol 1986;4:716-21. [PUBMED] [FULLTEXT]|
|11.||Armstrong BA, Perez CA, Simpson JR, Hederman MA. Role of irradiation in the management of superior vena cava syndrome. Int J Radiat Oncol Biol Phys 1987;13:531-9. [PUBMED] |
|12.||Crowe MT, Davies CH, Gaines PA. Percutaneous management of superior vena cava occlusions. Cardiovasc Intervent Radiol 1995;18:367-72. [PUBMED] |
|13.||Doty DB. Bypass of superior vena cava: Six years' experience with spiral vein graft for obstruction of superior vena cava due to benign and malignant disease. J Thorac Cardiovasc Surg 1982;83:326-38. [PUBMED] |
|14.||Dyet JF, Nicholson AA, Cook AM. The use of the Wallstent endovascular prosthesis in the treatment of malignant obstruction of the superior vena cava. Clin Radiol 1993;48:381-5. [PUBMED] |
|15.||Marcy PY, Magne N, Bentolila F, Drouillard J, Bruneton JN, Descamps B. Superior vena cava obstruction: Is stenting necessary? Support Care Cancer 2001;9:103-7. |
|16.||Nackaerts K, Axelson O, Brambilla E, Bromen K, Hirsch FR, Nemery B, et al . Epidemiology of lung cancer: A general update. Eur Respir Rev 2002;12:84:112-21. |
|17.||Nicholson AA, Ettles DF, Arnold A, Greenstone M, Dyet JF. Treatment of malignant superior vena cava obstruction: Metal stents or radiation therapy. J Vasc Interv Radiol 1997;8:781-8. [PUBMED] |
|18.||Ostler PJ, Clarke DP, Watkinson AF, Gaze MN. Superior vena cava obstruction: A modern management strategy. Clin Oncol 1997;9:83-9. |
|19.||Rosch J, Uchida BT, Hall LD, Antonovic R, Petersen BD, Ivancev K, et al . Gianturco-Rosch expandable Z-stents in the treatment of superior vena cava syndrome. Cardiovasc Intervent Radiol 1992;15:319-27. |
|20.||Rowell NP, Gleeson FV. Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus: A systematic review. Clin Oncol 2002;14:338-51. |
|21.||Sasano S, Onuki T, Mae M, Oyama K, Sakuraba M, Nitta S. Wallstent endovascular prosthesis for the treatment of superior vena cava syndrome. Jpn J Thorac Cardiovasc Surg 2001;49:165-70. [PUBMED] |
|22.||Smayra T, Otal P, Chabbert V, Chemla P, Romero M, Joffre F, et al . Long-term results of endovascular stent placement in the superior caval venous system. Cardiovasc Intervent Radiol 2001;24:388-94. [PUBMED] [FULLTEXT]|
|23.||Stanford W, Jolles H, Ell S, Chiu LC. Superior vena cava obstruction: A venographic classification. AJR Am J Roentgenol 1987;148:259-62. [PUBMED] [FULLTEXT]|
|24.||Coleman RE. Skeletal complications of malignancy. Cancer 1997;80:1588-94. [PUBMED] [FULLTEXT]|
|25.||Delea T, Langer C, McKiernan J, Liss M, Edelsberg J, Brandman J, et al . The cost of treatment of skeletal-related events in patients with bone metastases from lung cancer. Oncology 2004;67:390-6. [PUBMED] [FULLTEXT]|
|26.||Tsuya A, Kurata T, Tamura K. Skeletal Metastases in non-small cell lung cancer: A retrospective study. Lung Cancer 2007;57:229-32. |
|27.||Aapro M, Abrahamsson PA, Body JJ. Guidance on the use of biphosphonates in solid tumours: Recommendations of an international expert panel. Ann Oncol 2008;19:420-32. |
|28.||Facchini G, Caraglia M, Santini D, Nasti G, Ottaiano A, Striano S, et al . The clinical response on bone metastasis from breast and lung cancer during treatment with zoledronic acid is inversely correlated to skeletal related events (SRE). J Exp Clin Cancer Res 2007;26:307-12. [PUBMED] [FULLTEXT]|
|29.||Rosen LS, Gordon D, Tchekmedyian S, Yanagihara R, Hirsh V, Krzakowski M, et al . Zoledronic acid versus placebo in the treatment of skeletal metastases in patients with lung cancer and other solid tumors: A phase III, double-blind, randomized trial - the zoledronic acid lung cancer and other solid tumors study group. J Clin Oncol 2003;21:3150-7. |
| Article Access Statistics|
| Viewed||3750 |
| Printed||199 |
| Emailed||3 |
| PDF Downloaded||527 |
| Comments ||[Add] |