Ij

This material is protected by U.S. copyright law. Unauthorized reproduction is prohibited. To purchase quantity reprints,
please e-mail reprints@ons.org or to request permission to reproduce multiple copies, please e-mail pubpermissions@ons.org.
ONLINE EXCLUSIVE CONTINUING EDUCATION
Superior Vena Cava Syndrome
Jo Ann Flounders, MSN, CRNP, APRN, BC, OCN, CHPN
mediastinum, usually with right-sided perihilar lymphaden-
opathy, also is a cause of SVCS (Haapoja & Blendowski).
Goal for CE Enrollees:
However, Hodgkin's lymphoma rarely causes SVCS, al-
To further enhance nurses' knowledge regarding superior
though it does involve the mediastinum (Yahalom). Medias-
vena cava syndrome (SVCS).
tinal metastases, which are more common in breast carci-
noma, as well as Kaposi's sarcoma, thymoma, fibrous
Objectives for CE Enrollees:
mesothelioma, and germ cell neoplasms commonly are asso-
ciated with SVCS (Chen, Bongard, & Klein, 1990; Haapoja &
On completion of this CE, the participant will be able to
Blendowski; Yahalom) (see Figure 1).
1. Describe the etiology of SVCS.
Nonmalignant causes of SVCS include granulomatous in-
2. Discuss the clinical manifestations and medical manage-
fections secondary to tuberculosis, goiter, aortic aneurysms,
ment of patients with SVCS.
and histoplasmosis-related mediastinal fibrosis (Aurora et al.,
3. Discuss the nursing implications in the care of patients
2000; Haapoja & Blendowski, 1999; Yahalom, 1993). Iatro-
with SVCS.
genic causes of SVCS include venous thrombosis as a conse-
quence of central venous catheters or pacemaker catheters and
fibrosis caused by radiation therapy of the mediastinum (Ya-
uperior vena cava syndrome (SVCS) describes a clini-
halom).
S
cal scenario that occurs when a mechanical obstruction
occludes the superior vena cava. Obstruction may be the
Physiology
result of extraluminal compression by a tumor or enlarged
lymph nodes or intraluminal obstruction by thrombosis or tu-
The superior vena cava is located in the mid-third of the right
mor (Smeltzer & Bare, 1996; Uaje, Kahsen, & Parish, 1996).
anterior superior mediastinum behind the sternum (Haapoja &
The result of the compression or obstruction of the superior
Blendowski, 1999; Smeltzer & Bare, 1996). The venous drain-
vena cava is blocked venous drainage that, in turn, causes
age from the head, neck, upper extremities, and upper thorax
pleural effusions and edema of the face, arm, and trachea.
collects in the superior vena cava en route to the right atrium
With severe superior vena cava obstruction, altered conscious-
(Haapoja & Blendowski). A number of veins drain into the
ness and focal neurologic signs caused by cerebral edema and
superior vena cava (Martini, 1998) (see Figure 2).
impaired cardiac filling can occur (DeMichele & Glick,
1. The cephalic vein joins the axillary vein, exits the arm, and
2001).
forms the subclavian vein at the level of the lateral surface
of the first rib.
Etiology
2. The subclavian vein, which is located superior to the first
rib and along the superior margin of the clavicle, meets the
The most common cause of SVCS is malignant disease
internal and external jugular veins of the same side of the
(Aurora, Milite, & Vander Els, 2000; DeMichele & Glick,
body.
2001; Dietz & Flaherty, 1993; Schafer, 1997; Yahalom,
3. This fusion creates the brachiocephalic or innominate vein,
1993). The risk of developing SVCS for patients with cancer
which receives blood from the vertebral vein of the skull
corresponds to the etiologic factors that cause SVCS. SVCS
and spinal cord and from the internal thoracic vein.
occurs most frequently in men aged 5070 years who have
4. The brachiocephalic veins from each side of the body join
primary or metastatic tumors of the mediastinum (Haapoja &
at the level of the first and second ribs to create the supe-
Blendowski, 1999). Advanced lung cancer, specifically small
rior vena cava, which terminates in the right atrium.
cell carcinoma of the lung and, less frequently, non-small cell
lung cancer (e.g., squamous cell carcinoma, adeno carci-
Jo Ann Flounders, MSN, CRNP, APRN, BC, OCN  , CHPN, is a
noma), causes more than 75% of malignant superior vena
nurse practitioner at Consultants in Medical Oncology and Hema-
cava obstructions. Higher risk of SVCS occurs with right-
tology in Drexel Hill, PA.
sided lung carcinomas because of anatomic proximity to the
superior vena cava. Non-Hodgkin's lymphoma involving the
Digital Object Identifier: 10.1188/03.ONF.E84-E90
ONCOLOGY NURSING FORUM VOL 30, NO 4, 2003
E84
damage to the intima of the superior vena cava from central
1. Patients with small cell lung cancer or, less frequently, non-small cell lung
venous catheters, and venous stasis from extraluminal com-
carcinoma (e.g., squamous cell carcinoma) and those with right lung in-
pression (Haapoja & Blendowski).
volvement
The development of SVCS is dependent on several factors,
2. Patients with non-Hodgkin's lymphoma
including the growth rate of the tumor, extent and location of
3. Male patients aged 5070 years who have primary or metastatic tumors of
the blockage, patency of the azygos vein, and ability to de-
the mediastinum
velop collateral circulation (Schafer, 1997). Collateral circu-
4. Patients with breast carcinoma and mediastinal metastasis, Kaposi's sar-
coma with mediastinal involvement, thymoma, fibrous mesothelioma, and
lation bypasses the site of obstruction and redirects blood flow
germ cell neoplasms
from the upper thoracic venous system and the obstructed
5. Patients with central venous catheters and pacemaker catheters
superior vena cava to the inferior vena cava en route to the
6. Patients who have received previous radiation therapy to the mediastinum
right atrium. Blood flow is redirected to the azygos vein, in-
7. Patients with cancer who have comorbid conditions such as tuberculosis,
ternal mammary veins, thoracic venous system, and vertebral
histoplasmosis, or aortic aneurysm
veins (Haapoja & Blendowski, 1999). Subcutaneous veins
also are important alternative pathways that improve circula-
Figure 1. Patients With Cancer at Increased Risk for
tion when the superior vena cava is fully or partially ob-
Superior Vena Cava Syndrome
structed (Yahalom, 1993).
The most important alternative pathway is the azygos
venous system (Yahalom, 1993). The azygos vein is a major
SVCS is a result of impaired venous drainage when the su-
perior vena cava is compressed extra- or intraluminally, caus-
tributary of the superior vena cava and joins it at the level of
the second thoracic vertebra (Martini, 1998). Impaired venous
ing venous hypertension and congestion of the veins draining
drainage above the level of the azygos vein causes less venous
into the superior vena cava from the head, neck, upper extremi-
pressure and less pronounced SVCS because the venous re-
ties, and upper thorax (Dietz & Flaherty, 1993; Haapoja &
turn from the upper body can be redirected from the subcla-
Blendowski, 1999; Schafer, 1997). Several factors cause the
vian vein to the azygos vein, proximal vena cava, and right
vulnerability of the superior vena cava to compression. The
atrium (Haapoja & Blendowski, 1999; Schafer, 1997). Im-
superior vena cava is located inside the rigid walls of the tho-
paired venous drainage below the azygos vein is a more com-
racic cavity along with the heart, lungs, esophagus, trachea,
plex problem and causes more symptoms because the shunted
aorta, pulmonary artery, and lymph nodes. The superior vena
blood must return to the right atrium by way of the upper ab-
cava is surrounded by inflexible structures, such as the sternum,
dominal veins and the inferior vena cava, which requires
ribs, vertebral bodies, and aorta, with its high intravascular
higher venous pressure. When venous circulation through the
pressure. The right main bronchus is located very close to the
superior vena cava is impaired, venous hypertension, venous
superior vena cava. Because the superior vena cava is a thin-
stasis, and decreased cardiac output result. If untreated, these
walled blood vessel with low intravascular pressure enclosed
will progress to thrombosis, laryngeal and cerebral edema,
in a tight compartment, it can be compressed easily because the
stupor, coma, pulmonary complications, and death (Schafer).
chest has no room for expansion (Dietz & Flaherty).
Extraluminal compression of the superior vena cava by tu-
mors or enlarged lymph nodes can occur acutely or gradually.
Clinical Manifestations
Obstruction can be complete or partial, and collateral venous
drainage may develop. Intraluminal obstruction of the supe-
Symptoms
rior vena cava can be caused by infiltration by tumor, although
thrombosis is the more common cause. Acute and complete
The development of clinical manifestations of SVCS de-
obstruction of the superior vena cava is caused more often by
pends on the amount of venous hypertension, the delay in cir-
thrombosis than by compression or infiltration by tumor
culation time, the development of collateral pathways of circu-
(Baker & Barnes, 1992; Haapoja & Blendowski, 1999). Risk
lation, and the clinical signs and symptoms of the underlying
factors for the formation of thrombus in the superior vena cava
causative pathophysiologic process (Baker & Barnes, 1992;
include a hypercoagulable state in patients with malignancy,
Uaje et al., 1996). Also important is the degree and rapidity of
obstruction of the superior vena cava (Haapoja & Blendowski,
1999; Schafer, 1997; Yahalom, 1993). If onset of SVCS is
gradual, symptoms may be subtle (e.g., facial, neck, or arm
swelling upon arising in the morning because of venous en-
External jugular
gorgement). Patients may have difficulty removing rings from
Left
Internal jugular
innominate
fingers. Patients often notice increased symptoms in the morn-
Right
ing after sleeping in a supine position or with position changes
Subclavian
innominate
such as bending forward or stooping. Rapid onset of SVCS,
Cephalic
in the absence of collateral circulation, will cause a more dra-
Superior
vena cava
matic and life-threatening presentation, often with neurologic
Axillary
and respiratory sequelae resulting from cerebral and laryngeal
edema.
Basilic
In addition to swelling of the face, arms, fingers, or neck,
patients may notice the following early symptoms of SVCS
(Haapoja & Blendowski, 1999; Hunter, 1998; Yahalom, 1993).
Figure 2. Venous Circulation Including the Superior Vena
Dyspnea, which is the most common symptom, and nonpro-
Cava
ductive cough
ONCOLOGY NURSING FORUM VOL 30, NO 4, 2003
E85
Feeling of fullness of the head
scans are noninvasive, accurate in distinguishing between tu-
Difficulty buttoning shirt collars (Stoke's sign); women
mor mass or thrombosis as causes of SVCS, and able to docu-
also may experience breast swelling
ment the extent and the location of involvement. Chest x-ray
Dysphagia and hoarseness
films also may be obtained. Chest x-ray results that are asso-
Chest pain
ciated with SVCS include a lung or mediastinal mass, pleural
Late symptoms of SVCS include
effusion, and superior mediastinal widening (Hunter, 1998;
Life-threatening symptoms of respiratory distress, such as
Yahalom, 1993). In SVCS, lung masses frequently are seen on
orthopnea
the right on chest x-ray films because the superior vena cava
Headache, visual disturbances, dizziness, and syncope
enters from the right (Schafer, 1997).
Lethargy, irritability, and mental status changes.
The least invasive technique should be used to obtain a bi-
opsy or cytology specimen if necessary to confirm histologic
Physical Examination
diagnosis of the underlying malignancy. Collection of sputum
After consideration of risk factors and a review of symp-
for cytology is useful when bronchogenic carcinoma is sus-
toms indicative of SVCS, a physical examination must be
pected. Biopsy of a palpable lymph node is a useful, low-risk
completed. Early physical signs of SVCS include (Haapoja &
diagnostic test (Schafer, 1997). Bronchoscopy with brushings,
Blendowski, 1999; Hunter, 1998; Yahalom, 1993)
mediastinoscopy, or biopsy of a supraclavicular node can pro-
Edema of the face, neck, upper thorax, breasts, and upper
vide specimens for accurate tissue diagnosis (DeMichele &
extremities
Glick, 2001; Haapoja & Blendowski, 1999; Yahalom, 1993).
Prominent venous pattern (i.e., dilated veins of face, neck,
However, a risk of bleeding exists with these invasive proce-
and thorax)
dures because of the increased venous pressure in the head
Jugular vein distention
and neck. A thoracentesis should be performed if increased
Periorbital edema and redness and edema of conjunctivae
pleural fluid is present (Aurora et al., 2000). Bone marrow
Facial plethora (ruddy complexion of face or cheeks)
biopsy may be useful when small cell carcinoma of the lung
Compensatory tachycardia.
or non-Hodgkin's lymphoma is suspected because these ma-
Late signs of SVCS include
lignancies often involve the bone marrow. A bone marrow
Cyanosis of the face or upper torso
biopsy may reduce the need for a pulmonary procedure at a
Engorged conjunctivae
time when bleeding is a possible risk factor (Yahalom).
Mental status changes
Tachypnea, orthopnea, stridor, and respiratory distress
Medical Management
Stupor, coma, seizures, and death.
The four main treatment modalities for SVCS are radiation
Diagnostic Studies
therapy, chemotherapy, pharmacologic therapy, and surgery.
Accurate, definitive histologic diagnosis is necessary to pro-
In patients with cancer, treatment depends on the causative
vide appropriate treatment of SVCS because the modality of
factors of SVCS, severity of the symptoms, underlying malig-
treatment usually is based on the histologic diagnosis of the
nancy, patient's prognosis, and presence of thrombosis (Haa-
underlying malignancy (Yahalom, 1993). However, the
poja & Blendowski, 1999). Treatment is based on the histo-
choice of diagnostic procedures with suspected SVCS de-
logic diagnosis of the primary tumor (Hunter, 1998), the rate
pends on patients' status. On rare occasions, patients will
of onset, and the type of obstruction, either intra- or extra-
present with life-threatening clinical manifestations of SVCS
luminal (Schafer, 1997). Goals of treatment include relief of
that warrant immediate treatment (Baker & Barnes, 1992;
the obstruction and symptoms. The goal of treatment is cure
DeMichele & Glick, 2001; Dietz & Flaherty, 1993). Emer-
when the primary disease is small cell lung cancer, non-
gency treatment without histologic diagnosis is reserved for
Hodgkin's lymphoma, or a germ cell tumor.
patients who demonstrate brain edema with mental status
Radiation therapy is the primary treatment modality for
changes, decreased cardiac output with hemodynamic com-
patients with SVCS caused by non-small cell lung cancer and
promise, or laryngeal edema with respiratory compromise and
has been advocated for most patients with SVCS caused by
impending loss of airway (DeMichele & Glick). Therefore, if
any malignancy (Haapoja & Blendowski, 1999; Hunter, 1998;
the development of SVCS is rapid with acute respiratory and
Knopp, 1997; Schafer, 1997; Yahalom, 1993). Emergency ra-
diotherapy treatment is started immediately without histologic
neurologic symptoms, treatment (e.g., radiation therapy) may
be started immediately before a definitive tissue diagnosis is
diagnosis only when patients present with acute, life-threaten-
obtained. Tissue diagnosis and a complete workup for me-
ing symptoms (Schafer). In most situations, however, a tissue
tastasis then can proceed during treatment (Schafer, 1997).
or cytologic diagnosis should be made before radiation treat-
ment is started (Knopp). The treatment field should include
However, if the development of SVCS is gradual, as occurs
more commonly, the diagnostic workup should be completed
the tumor with appropriate margins and the mediastinal and
first to confirm a definitive diagnosis before treatment is ini-
hilar lymph nodes (DeMichele & Glick, 2001; Knopp; Yaha-
tiated. Appropriate workup for epidural extension of malig-
lom). Patients with non-small cell lung cancer with mediasti-
nant disease (magnetic resonance imaging [MRI] of the spine)
nal adenopathy and without distant metastases usually have
or pericardial involvement (echocardiogram) should be com-
the supraclavicular nodes included in the radiation treatment
pleted as necessary.
field.
Daily radiotherapy doses for patients with SVCS are usu-
The preferred diagnostic tools to confirm the diagnosis of
SVCS are chest computed tomography (CT) scan with IV
ally 300400 cGy for the first two to four days in hopes of
contrast and chest MRI scan (Chen et al., 1990; DeMichele &
obtaining expedient symptom relief, followed by daily dose
fractions of 180200 cGy (Knopp, 1997; Schafer, 1997;
Glick, 2001; Haapoja & Blendowski, 1999). CT and MRI
ONCOLOGY NURSING FORUM VOL 30, NO 4, 2003
E86
should be initiated within five to seven days of the onset of
Yahalom, 1993). The total dose of radiation is determined by
symptoms for maximum effectiveness (Aurora et al., 2000;
the histologic diagnosis and the extent of disease (Knopp).
Stewart, 1996). Catheter removal may be necessary.
Many patients demonstrate clinical improvement before ob-
Anticoagulants may be used to help relieve venous obstruc-
jective signs of tumor reduction are noted on chest x-rays
tion by preventing thrombus formation when SVCS is caused
(DeMichele & Glick, 2001). Symptom relief occurs within
by a tumor. However, pharmacologic management of SVCS
three weeks in 85%90% of patients (Knopp), and many no-
with anticoagulant therapy is controversial (DeMichele &
tice improvement in symptoms within three to four days of
Glick, 2001; Nomori, Nara, Morinaga, & Soejima, 1998). The
initiating radiotherapy (Haapoja & Blendowski, 1999). Symp-
risk of hemorrhage with anticoagulant therapy must be
tomatic improvement is a result of the improved flow of blood
weighed against the possible benefits. One potential preven-
through the superior vena cava, as well as the development of
tive measure for catheter-induced thrombosis is prophylactic
collateral pathways of venous blood flow after the increased
administration of 1 mg per day of warfarin (Bern et al., 1990;
pressure in the mediastinum is relieved (Ahmann, 1984; Ya-
Haapoja & Blendowski, 1999).
halom).
Surgical intervention for SVCS includes stent placement or
The side effects of radiation therapy are related to the tis-
superior vena cava bypass and is used occasionally when
sues included in the radiation field, the length and dose of
SVCS is chronic or recurrent (Ingle, 1997; Schafer, 1997).
radiotherapy, and the status of the patient (Sitton, 1998). Po-
Surgical intervention in patients with malignancy-induced
tential side effects include skin changes, fatigue, dyspnea,
SVCS should be reserved for patients who have failed other
cough, pneumonitis, anorexia, pharyngitis, esophagitis, leuko-
therapeutic treatments such as radiation therapy and chemo-
penia, and anemia (Haapoja & Blendowski, 1999; Knopp,
therapy. Surgery to relieve the obstruction may be beneficial
1997; Sitton).
in patients with retrosternal goiter or aortic aneurysm (Yaha-
Chemotherapy provides local and systemic treatment of
lom, 1993).
neoplastic disease and is used to treat highly chemosensitive
malignancies such as small cell lung cancer and lymphoma
Nursing Care
(Haapoja & Blendowski, 1999; Schafer, 1997; Yahalom,
1993). Chemotherapy is the treatment of choice for patients
who previously have received the maximum dose of medias-
Recognition of early signs of SVCS can allow treatment be-
tinal radiation therapy (Dietz & Flaherty, 1993; Hunter, 1998).
fore life-threatening symptoms of respiratory and neurologic
Treatment for small cell lung cancer includes platinum-
distress occur. Early detection of SVCS will allow time for ac-
based chemotherapy regimens such as cisplatin or carboplatin
curate histologic diagnosis in patients with an undiagnosed
with etoposide. Cyclophosphamide-based regimens, such as
malignancy or an unknown etiology of SVCS. Accurate diag-
cyclophosphamide, doxorubicin, and vincristine, also may be
nosis is necessary so that prompt and successful treatment of
used (Haapoja & Blendowski, 1999; Thomas, Williams, Co-
the underlying causative malignancy may be initiated. Nurses
bos, & Turrisi, 2001). Chemotherapeutic treatment for non-
frequently are able to perceive subtle changes in the status of
Hodgkin's lymphoma is based on the stage and histologic type
patients and should complete accurate and thorough ongoing
of lymphoma. Possible chemotherapies include single-agent
assessment of cardiopulmonary status to identify early abnor-
drugs, such as cyclophosphamide or fludarabine, as well as
mal changes. For example, the inability to button shirts or
combinations of drugs such as cyclophosphamide, doxorubi-
complete activities of daily living because of dyspnea can be
cin, vincristine, and prednisone (Cheson, 2001). Relief of
important early changes in patient status. In fact, nurses
symptoms of SVCS often occurs within 714 days in most pa-
should assume a proactive role and ask patients who are at risk
tients with malignancy-induced SVCS treated with chemo-
for SVCS if they are experiencing any of these symptoms.
therapy (Haapoja & Blendowski; Yahalom, 1993). Multi-
Nursing assessment includes strict monitoring of vital signs,
modality therapy with chemotherapy in combination with
level of consciousness, edema, tissue perfusion, respiratory
radiation therapy may be used.
status, functional status, and level of endurance of physical
Pharmacologic treatment of SVCS includes steroids, di-
activity. Fluid and electrolyte balance should be monitored
uretics, and thrombolytic therapy (Hunter, 1998). Medical
because overhydration may exacerbate the symptoms of
management of SVCS with corticosteroids and diuretics alone
SVCS (Haapoja & Blendowski, 1999; Uaje et al., 1996). In
may be used when patients demonstrate minimal symptoms
addition, diuretics may be used to decrease edema, necessitat-
and have adequate collateral venous blood flow (Aurora et al.,
ing attention to fluid and electrolyte balance.
2000; Haapoja & Blendowski, 1999). The goal of treatment
Nursing interventions in patients with SVCS include mea-
with diuretics and corticosteroids is reduction in edema and
sures to relieve dyspnea, such as elevating the head of the bed
inflammation; however, the benefit of the use of corticoster-
and providing oxygen (Haapoja & Blendowski, 1999; Hunter,
oids and diuretics is controversial (Escalante, 1993; Haapoja
1998). Maintenance of IV access is challenging because
& Blendowski; Yahalom, 1993). A potential side effect of
venipunctures and IV fluid administration should be avoided
diuretic therapy is hypovolemic shock caused by decreased
in the upper extremities. Therefore, central venous access de-
vascular volume with diuresis and the resultant low venous
vices are necessary and require expert nursing management.
return to the heart (Schafer, 1997).
Nurses should ensure that blood pressure measurement is
Thrombolytic therapy may be used when SVCS is caused
avoided in the upper extremities. Assessment of patients for
by catheter-induced intraluminal thrombosis. Thrombolytic
side effects of SVCS treatment is a primary nursing respon-
therapy or tissue plasminogen activators are used to treat cath-
sibility so that prompt intervention can be initiated. Potential
eter-induced thrombosis and can effectively lyse clots
side effects of radiation therapy include skin changes (e.g.,
(Greenberg, Kosinski, & Daniels, 1991; Haapoja & Blen-
erythema, dry or moist desquamation), fatigue, dyspnea,
dowski, 1999; Ingle, 1997). Treatment with thrombolytics
pneumonitis, dysphagia, pharyngitis, esophagitis, leukopenia,
ONCOLOGY NURSING FORUM VOL 30, NO 4, 2003
E87
and anemia. Potential side effects of chemotherapy include
ment and interventions to prevent complications are necessary
stomatitis, nausea, vomiting, fatigue, leukopenia, anemia, and
for patients who have been treated with surgical intervention.
thrombocytopenia. Therefore, nursing care of patients with
Nurses should assess patients and caregivers for ineffective
SVCS undergoing radiation therapy and chemotherapy in-
coping, depression, and anxiety and provide interventions to
cludes monitoring blood counts to detect bone marrow sup-
improve coping abilities. Assessment of pain and interven-
pression (Haapoja & Blendowski). Nurses should provide in-
tions to relieve pain should be ongoing. Discharge planning
structions to the patient and family regarding self-care
should include consideration of referral for homecare or hos-
measures to prevent complications, such as notifying a phy-
pice services as needed.
sician when the patient's temperature is greater than 100.5F
The author would like to thank John Sprandio, MD, of Consultants in Medi-
or providing saline mouth rinses several times a day. If pa-
cal Oncology and Hematology in Drexel Hill, PA, for reviewing this manu-
tients are treated with anticoagulant therapy, bleeding precau-
script.
tions should be emphasized with patients and caregivers.
Nurses should assess for side effects of corticosteroids, such
Author Contact: Jo Ann Flounders, MSN, CRNP, APRN, BC,
as weakness of involuntary muscles, mood swings, dyspepsia,
OCN, CHPN, can be reached at joann@theflounders.com, with
insomnia, or hyperglycemia (Hunter). Postoperative assess-
copy to editor at rose_mary@earthlink.net.
References
Martini, F. (1998). Fundamentals of anatomy and physiology (4th ed.). Up-
Ahmann, F. (1984). A reassessment of the clinical applications of the supe-
per Saddle River, NJ: Prentice Hall.
rior vena cava syndrome. Journal of Clinical Oncology, 2, 961969.
Nomori, H., Nara, S., Morinaga, S., & Soejima, K. (1998). Primary malignant
Aurora, R., Milite, F., & Vander Els, N. (2000). Respiratory emergencies.
lymphoma of superior vena cava. Annals of Thoracic Surgery, 66, 1423
Seminars in Oncology, 27, 256269.
1424.
Baker, G. & Barnes, H. (1992). Superior vena cava syndrome: Etiology, di-
Schafer, S. (1997). Oncologic complications. In S. Otto (Ed.), Oncology nurs-
agnosis, and treatment. American Journal of Critical Care, 1, 5464.
ing (3rd ed., pp. 406474). St. Louis, MO: Mosby Yearbook.
Bern, M., Lokich, J., Wallach, S., Bothe, A., Benotti, P., Arkin, C., et al.
Sitton, E. (1998). Nursing implications of radiation therapy. In J. Itano & K.
(1990). Very low dose of warfarin can prevent thrombosis in central
Taoka (Eds.), Core curriculum for oncology nursing (3rd ed., pp. 616
venous catheters. Annals of Internal Medicine, 112, 423428.
629). Philadelphia: Saunders.
Chen, J., Bongard, F., & Klein, S. (1990). A contemporary perspective on
Smeltzer, S., & Bare, B. (1996). Oncology: Nursing the patient with cancer. In
superior vena cava syndrome. American Journal of Surgery, 160, 207211.
S. Smeltzer & B. Bare (Eds.), Brunner and Suddarth's textbook of medical-
Cheson, B. (2001). Hodgkin's disease and the non-Hodgkin's lymphomas. In
surgical nursing (8th ed., pp. 309316). Philadelphia: Lippincott-Raven.
R. Lenhard, R. Osteen, & T. Gansler (Eds.), Clinical oncology (pp. 497
Stewart, I. (1996). Superior vena cava syndrome: An oncologic complication.
516). Atlanta, GA: American Cancer Society.
Seminars in Oncology Nursing, 12, 312317.
DeMichele, A., & Glick, J. (2001). Cancer-related emergencies. In R. Len-
Thomas, C., Williams, T., Cobos, E., & Turrisi, A. (2001). Lung cancer. In
hard, R. Osteen, & T. Gansler (Eds.), Clinical oncology (pp. 733764).
R. Lenhard, R. Osteen, & T. Gansler (Eds.), Clinical oncology (pp. 269
Atlanta, GA: American Cancer Society.
295). Atlanta, GA: American Cancer Society.
Dietz, K., & Flaherty, A. (1993). Oncologic emergencies. In S. Groenwald,
Uaje, C., Kahsen, K., & Parish, L. (1996). Oncology emergencies. Critical
M. Frogge, M. Goodman, & C. Yarbro (Eds.), Cancer nursing principles
Care Nursing Quarterly, 18(4), 2634.
and practice (3rd ed., pp. 800839). Boston: Jones and Bartlett.
Yahalom, J. (1993). Oncologic emergencies. In V. DeVita, S. Hellman, & S.
Escalante, C. (1993). Causes and management of superior vena cava syn-
Rosenberg (Eds.), Cancer: Principles and practice of oncology (4th ed.,
drome. Oncology, 7(6), 6168.
pp. 23702385). Philadelphia: Lippincott-Raven.
Greenberg, S., Kosinski, R., & Daniels, J. (1991). Treatment of superior vena
cava thrombosis with recombinant tissue type plasminogen activator.
Chest, 99, 12981301.
Haapoja, I., & Blendowski, C. (1999). Superior vena cava syndrome. Semi-
For more information . . .
nars in Oncology Nursing, 15, 183189.
Hunter, J. (1998). Structural emergencies. In J. Itano & K. Taoka (Eds.), Core
eMedicine: Superior Vena Cava Syndrome
curriculum for oncology nursing (3rd ed., pp. 340354). Philadelphia:
Saunders.
www.emedicine.com/EMERG/topic561.htm
Ingle, R. (1997). Lung cancers. In S. Groenwald, M. Frogge, M. Goodman,
National Cancer Institute: Superior Vena Cava Syndrome
& C. Yarbro (Eds.), Cancer nursing principles and practice (4th ed., pp.
www.nci.nih.gov/cancerinfo/pdq/supportivecare/superior-
1260 1290). Boston: Jones and Bartlett.
vena-cava/healthprofessional
Knopp, J. (1997). Lung cancer. In K. Dow, J. Bucholtz, R. Iwamoto, V.
Links can be found using ONS Online at www.ons.org.
Fieler, & L. Hilderley (Eds.), Nursing care in radiation oncology (2nd ed.,
pp. 293315). Philadelphia: Saunders.
ONCOLOGY NURSING FORUM VOL 30, NO 4, 2003
E88
ONF Continuing Education Examination
Superior Vena Cava Syndrome
Credit Hours: 1.4
a. Computed tomography (CT) scan and magnetic reso-
Passing Score: 80%
nance imaging (MRI) scan.
CE Test ID #03-30/4-10
b. Positron emission tomography scan and CT scan.
Test Processing Fee: $15
c. Chest x-ray and MRI scan.
d. Bronchoscopy and chest x-ray.
The Oncology Nursing Society is accredited as a provider
07.
A patient is to begin radiation therapy for superior vena
of continuing education (CE) in nursing by the
cava syndrome. The nurse should teach the patient that
American Nurses Credentialing Center's Commission on
the
Accreditation.
a. Symptom relief will occur within three weeks after the
California Board of Nursing, Provider #2850.
start of treatment.
b. Radiation therapy will target the area from the esopha-
CE Test Questions
gus to the pelvis.
c. Radiotherapy doses will remain at 300400 cGy for a
01. Which system should the nurse plan to address first for a
total of six weeks.
patient with superior vena cava syndrome?
d. Side effects of radiation are local reactions unlike the
a. Respiratory
systemic reactions of chemotherapy.
b. Neurologic
08.
What physical examination findings would be consistent
c. Gastrointestinal
with a late sign of superior vena cava syndrome?
d. Musculoskeletal
a. Jugular vein distention
02. A patient comes to the clinic and describes being unable
b. Bradycardia and orthopenia
to button his shirt collars. In his history, which diagnosis
c. Periorbital edema and redness
would be most significant?
d. Cyanosis of the face or upper torso
a. Non-small cell carcinoma of the left lung
09.
The first major goal of superior vena cava syndrome treat-
b. Small cell carcinoma of the right lung
ment is to
c. Hodgkin's lymphoma with a central line
a. Increase the patient's life expectancy.
d. Liver carcinoma with metastatic disease
b. Prevent the spread of the primary tumor.
03. A patient is seen in the emergency department with a di-
c. Cure the primary disease with the treatment.
agnosis of superior vena cava syndrome. The nurse could
d. Provide relief of the obstruction and symptoms.
expect the patient to describe
10.
A patient with small cell lung cancer who has received
a. Decreased symptoms in the evening after lying down.
previous radiation develops superior vena cava syn-
b. Increased swelling of neck upon arising in the morn-
drome. Which treatment option would be most appropri-
ing.
ate?
c. Difficulty buttoning his shirt because of numbness in
a. Chemotherapy
his fingers.
b. Radiation therapy
d. Increased symptoms when his position is changed
c. Thrombolytic agents
from sitting to standing.
d. Surgical stent placement
04. Which are likely to be the first presenting signs or symp-
11.
A patient develops an acute and complete obstruction
toms of early superior vena cava syndrome?
of the superior vena cava. What is the mostly likely
a. Dysphagia and hoarseness
cause?
b. Headaches and orthopnea
a. Intraluminal compression by a tumor
c. Visual disturbances and syncope
b. Extraluminal compression by a tumor
d. Dyspnea and nonproductive cough
c. Intraluminal compression by a thrombosis
05. A patient is diagnosed with acute superior vena cava syn-
d. Extraluminal compression by an enlarged lymph
drome. The medical intervention that would be used first
node
is
12.
The most important pathway for collateral circulation is
a. Chemotherapy to treat the primary cancer.
the
b. Radiation therapy to reduce the tumor size.
a. Inferior vena cava.
c. Diuretics to decrease the accumulating fluid.
b. Azygos vein.
d. Tissue biopsy to diagnose the cause of occlusion.
c. Upper abdominal veins.
06. The diagnostic procedures with the highest sensitivity of
d. Thoracic venous system.
detecting superior vena cava syndrome are the
ONCOLOGY NURSING FORUM VOL 30, NO 4, 2003
E89
13. Which information should the nurse communicate with
14. A patient with superior vena cava syndrome is exhibiting
staff regarding the patient with superior vena cava syn-
neurologic and respiratory sequela. What is most likely
drome?
the cause?
a. Blood pressures should be taken only in the left arm.
a. Pleural effusion of the left lung
b. Vital signs need to be taken only at the end of each shift.
b. Cerebral and laryngeal edema
c. Blood draws should be performed only through the
c. Cardiac tamponade from the edema
central venous access device.
d. Syndrome of inappropriate antidiuretic hormone
d. Input and output should be calculated at the end of
each day.
Oncology Nursing Forum Answer/Enrollment Form
Superior Vena Cava Syndrome (Test ID #03-30/4-10)
To receive continuing education (CE) credit for this issue, simply
form along with a check or money order for $15 per test pay-
1. Read the article.
able to the Oncology Nursing Society. Payment must be in-
2. Oncology Nursing Society members may take the test and
cluded for your examination to be processed.
get results immediately on ONS Online. Simply log on to
4. The deadline for submitting the answer/enrollment form is
www.ons.org and click on ONF (Oncology Nursing Forum)
two years from the date of this issue.
under the Publications heading. Use your ONS membership
5. Contact hours will be awarded to RNs who successfully com-
number to access the site, select the issue you wish to use,
plete the program. Successful completion is defined as an
scroll down to find the CE test, and follow the instructions.
80% correct score on the examination and a completed evalu-
After successfully completing the test, pay with a credit card.
ation program. Verification of your CE credit will be sent to
3. To enroll via the mail, record your answers on the form be-
you. Certificates will be mailed within six weeks following
low and complete the program evaluation (you may make
receipt of your answer/enrollment form. For more informa-
copies of the form.) Mail the completed answer/enrollment
tion, call 866-257-4667, ext. 6296.
8.
9.
1.
5.
2.
6.
7.
4.
3.
I n s t r u c t i o n s : Mark
a  10.
a
a
a
a
a
a
a
a
a
your answers clearly by
b
b
b
b
b
b
b
b
b
b
placing an "x" in the
c
c
c
c
c
c
c
c
c
c
box next to the correct
d
d
d
d
d
d
d
d
d
d
answer. This is a stan-
11.
a  20.
a
dard form; use only the
a 18.
a 19.
a 12.
a 15.
a 16.
a 13.
a 17.
a 14.
b
number of spaces re-
b
b
b
b
b
b
b
b
b
c
quired for the test you
c
c
c
c
c
c
c
c
c
d
d
d
are taking.
d
d
d
d
d
d
d
Name
Telephone #
Address
Social Security #
City
State
Zip
State(s) of licensure/license no(s).
Program Evaluation
Not at all
Low
Medium
High
1. How relevant were the objectives to the CE activity's goal?
2. How well did you meet the CE activity's objectives (see page E84)?
Objective #1
Objective #2
Objective #3
3. To what degree were the teaching/learning resources helpful?
Too basic
Appropriate Too complex
4. Based on your previous knowledge and experience, do you think
that the level of the information presented in the CE activity was
minutes
5. How long did it take you to complete the CE activity?
My check or money order payable to the Oncology Nursing Society is enclosed. U.S. currency only. (Do not send cash.)
After completing this form, mail it to: Oncology Nursing Society, P.O. Box 3510, Pittsburgh, PA 15230-3510.
For more information or information on the status of CE certificates, call 866-257-4667, ext. 6296.
ONCOLOGY NURSING FORUM VOL 30, NO 4, 2003
E90