[Non-infectious respiratory emergencies in patients with cancer]. / Urgences respiratoires (non infectieuses) du patient d'onco-hématologie.

Patients with a solid tumor or hematologic malignancy are often addressed to emergency units for an acute respiratory complication associated with the underlying cancer or secondary to treatments. The current article is part of a thematic series: "Intensive care and emergencies in solid tumours and blood cancer patients" and will develop the following points: (1) malignant proximal airway obstruction and, more specifically, the role of therapeutic bronchoscopy; (2) superior vena cava syndrome by tumor compression and/or secondary to thrombosis (diagnosis, local and systemic treatments); (3) cancer-related pulmonary embolism (incidence, indications for low-molecular weight heparins and direct oral anticoagulants). Other respiratory emergencies will be dealt in the other articles of this series.

Thrombotic superior vena cava syndrome: a national emergency department database study.

Literature regarding etiology and trends of incidence of major thoracic vein thrombosis in the United States is limited. To study the causes, complications, in-hospital mortality rate, and trend in the incidence of major thoracic vein thrombosis which could have led to superior vena cava syndrome (SVCS) between 2010 and 2018. Data from the nationwide emergency department sample (NEDS) that constitutes 20% sample of hospital-owned emergency departments (ED) and in-patient sample in the United States were analyzed using diagnostic codes. A linear p-trend was used to assess the trends. Of the total 1082 million ED visits, 37,807 (3.5/100,000) (mean age 53.81 ± 18.07 years, 55% females) patients were recorded with major thoracic vein thrombosis in the ED encounters. Among these patients, 4070 (10.6%) patients had one or more cancers associated with thrombosis. Pacemaker/defibrillator-related thrombosis was recorded in 2820 (7.5%) patients, while intravascular catheter-induced thrombosis was recorded in 1755 (4.55%) patients. Half of the patients had associated complication of pulmonary embolism. A total of 59 (0.15%) patients died during these hospital encounters. The yearly trend for the thrombosis for every 100,000 ED encounters in the United States increased from 2.17/100,000 in 2010 to 5.98/100,000 in 2018 (liner p-trend < 0.001). Yearly trend for catheter/lead associated thrombosis was also up-trending (p-trend 0.015). SVCS is an uncommon medical emergency related to malignancy and indwelling venous devices. The increasing trend in SVCS incidence, predominantly catheter/lead induced, and the high rate of associated pulmonary embolism should prompt physicians to remain vigilant for appropriate evaluation.

Thromboembolic risk with IVIg: Incidence and risk factors in patients with inflammatory neuropathy.

Our objective was to evaluate whether IV immunoglobulin (IVIg) increases the risk of thromboembolic events in neurology outpatients with inflammatory neuropathies, as there is conflicting evidence supporting this hypothesis, mainly from non-neurologic cohorts. We investigated this question over 30 months in our cohort of patients with inflammatory neuropathies receiving regular IVIg and found a greater incidence of arterial and venous thromboembolic events than population-based rates determined by hospital admissions data. Vascular risk factors were more common in the event group but there were no IVIg administration factors that contributed to the risk. This study suggests that IVIg may have a small but contributory role in determining thromboembolic risk in the inflammatory neuropathy cohort and more evidence is required before it is clear whether the current primary prevention guidelines are appropriate in this group of patients.

Increased frequency of obstructive sleep apnea syndrome in Behçet's syndrome patients with superior vena cava syndrome.

OBJECTIVES: Superior vena cava syndrome (SVCS) is a medical emergency which can also be seen in Behçet's syndrome (BS). Having noted that BS patients with SVCS frequently complained of sleep disturbances, snoring and sleep apnea, suggesting obstructive sleep apnea (OSA), we formally surveyed the risk for OSA among BS patients. METHODS: We studied 28 patients, all male, with SVCS (Group 1), 129 with vascular involvement without a SVCS (Group 2) and 151 with no vascular involvement (Group 3). In addition, 100 apparently healthy individuals (Group 4) were studied. The Berlin questionnaire (BQ), a validated screening tool with a high sensitivity and modest specificity that identifies individuals with high-risk for OSA, was administered to all study participants. RESULTS: The study groups were similar with regard to age (Group 1, mean age: 44.3±9.7; Group 2, mean age: 41.5±8.7, Group 3, mean age: 40.4±9.4 and Group 4, mean age: 42.1±9.4) mean body mass index and the frequency of hypertension and other comorbidities. The frequency of those patients at high-risk for OSA according to the BQ was 57%, 17%, 17% and 11% in Groups 1, 2, 3 and 4, respectively (p<0.05). Age-adjusted ORs of OSA compared to healthy controls (Group 4) was 11.00 (95%CI: 4.01-30.07) for Group 1, 1.78 (95%CI: 0.81-3.94) for Group 2, 1.92 (95%CI: 0.90-4.14) for Group 3. CONCLUSIONS: BS patients with SVCS are at high risk for OSA. This is probably due to the external pressure of the significant presence of venous collaterals that surround the upper airways. Our results should be further confirmed by polysomnography, and future research should be carried out to clarify the causes of this association.

Emergencias oncológicas torácicas del paciente con cáncer de pulmón / Oncologic thoracic emergencies of patients with lung cancer

El paciente con cáncer de pulmón es el paciente oncológico que más frecuentemente acude a urgencias por complicaciones relacionadas con su enfermedad. Se define como emergencia oncológica cualquier evento agudo en un paciente oncológico que se desarrolla de manera directa o indirecta debido al tumor y que pone en riesgo la vida del paciente. Las emergencias oncológicas se dividen en metabólicas, hematológicas y estructurales; en este artículo abordaremos las principales complicaciones estructurales torácicas de los pacientes con cáncer de pulmón, en las que las pruebas de imagen tienen un papel fundamental en su diagnóstico. Las principales emergencias oncológicas torácicas del cáncer de pulmón son: obstrucción de la vía aérea, síndrome de vena cava superior, tromboembolismo pulmonar agudo, taponamiento pericárdico, hemoptisis masiva, compresión medular y derrame pleural. Las emergencias oncológicas son causa importante de morbimortalidad en pacientes con cáncer de pulmón. Los médicos de urgencias juegan un papel fundamental en su detección precoz, por lo que el conocimiento y la correcta identificación de las principales emergencias oncológicas torácicas del paciente con cáncer de pulmón permiten un manejo diagnóstico y terapéutico óptimo

Patients with lung cancer are the type of cancer patient who are most often admitted to emergency departments due to disease-related complications. An oncologic emergency is defined as any acute event in a patient with cancer that develops directly or indirectly from the tumour and that threatens the patient's life. Oncologic emergencies are divided into metabolic, haematologic and structural emergencies. In this article, we address the main structural thoracic complications of patients with lung cancer, in which imaging tests play an essential role in their diagnosis. The main oncologic thoracic emergencies of lung cancer are airway obstruction, superior vena cava syndrome, acute pulmonary thromboembolism, pericardial tamponade, massive haemoptysis, spinal cord compression and pleural effusion. Oncologic emergencies are a significant cause of morbidity and mortality in patients with lung cancer. Emergency department physicians play a fundamental role in the early detection of these emergencies. The knowledge and correct identification of the main oncologic thoracic emergencies of patients with lung cancer therefore enable optimal diagnostic and therapeutic management

Endovascular Therapy for Central Venous Thrombosis.

Central vein thrombosis is defined as thrombosis of the major vessels draining either the upper or lower extremities. It presents most commonly in the upper limb, where it affects the subclavian veins and the superior vena cava; in the lower limb, it affects the common iliac veins and the inferior vena cava. These different anatomical segments pose unique challenges in both acute and chronic settings, and this article will summarize the current best practice treatment options.

The Extended Dwell Peripheral Intravenous Catheter Is an Alternative Method of NICU Intravenous Access.

BACKGROUND: Establishing vascular access is a common neonatal intensive care unit procedure. The extended dwell peripheral intravenous (EPIV) catheter is a 6-cm and 8-cm silicone catheter for peripheral vein insertion, which is a newer vascular access device than peripherally inserted central catheters (PICCs) and peripheral intravenous (PIV) catheter. Extended dwell peripheral intravenous catheters have been widely used in adults but evidence in neonates is lacking. PURPOSE: To explore indwell time, success rate, catheter-associated complications, and cost among EPIV catheters, PICCs, and PIV catheters in neonates. METHODS: We retrospectively compare patient demographics, indwell time, success rate, and catheter-associated complications, and analyze the rate of hyaluronidase-treated intravenous (IV) fluid extravasation on neonates who had an EPIV catheter, a PICC, or a PIV catheter in a level III neonatal intensive care unit. We also estimate the insertion cost of these 3 vascular access devices on the basis of our hospital charges. RESULTS: Extended dwell peripheral intravenous catheters were inserted in 432 neonates with an indwell time of 4.0 ± 2.3 (mean ± SD) days. Peripherally inserted central catheters were inserted in 202 neonates with an average indwell time of 7.3 ± 4.4 (mean ± SD) days, which was longer than EPIV catheters (P < .001). Peripherally inserted central catheters had a higher success rate of 83.6% than 71.7% of EPIV catheters, meaning succeeded in lasting through the completion of therapy (P = .001). Peripherally inserted central catheters were associated with 4 cases of life-threatening complications; none was seen in the EPIV catheter group. The incidence of hyaluronidase-treated IV fluid extravasation was less in EPIV catheter recipients (1.2%) than in the PIV catheter recipients (3.9%) (P = .004); none was in the PICC group. Cost savings were noted with using an EPIV catheter. IMPLICATIONS FOR PRACTICE: Extended dwell peripheral intravenous catheter is a feasible option for neonatal vascular access. IMPLICATIONS FOR RESEARCH: These data provide a baseline for future studies to explore the efficacy and effectiveness of EPIV catheter in the neonates.

Pediatric superior vena cava syndrome: An evidence-based systematic review of the literature.

Superior vena cava syndrome (SVCS) results in vascular, respiratory, and neurologic compromise. A systematic search was conducted to determine the prevalence of pediatric SVCS subtypes and identify clinical characteristics/treatment strategies that may influence overall outcomes. Data from 101 case reports/case series (142 patients) were analyzed. Morbidity (30%), mortality (18%), and acute complications (55%) were assessed as outcomes. Thrombosis was present in 36%, with multi-modal anticoagulation showing improved outcome by >50% (P = 0.004). Infant age (P = 0.04), lack of collaterals (P = 0.007), acute complications (P = 0.005), and clinical presentation may have prognostic utility that could influence clinical decisions and surveillance practices in pediatric SVCS.

Endovascular stent-based revascularization of malignant superior vena cava syndrome with concomitant implantation of a port device using a dual venous approach.

PURPOSE: The aim of this paper is to evaluate the safety and efficacy of endovascular revascularization of malignant superior vena cava syndrome (SVCS) and simultaneous implantation of a totally implantable venous access port (TIVAP) using a dual venous approach. MATERIALS AND METHODS: Retrospectively, 31 patients (mean age 67 ± 8 years) with malignant CVO who had undergone revascularization by implantation of a self-expanding stent into the superior vena cava (SVC) (Sinus XL®, OptiMed, Germany; n = 11 [Group1] and Protégé ™ EverFlex, Covidien, Ireland; n = 20 [Group 2]) via a transfemoral access were identified. Simultaneously, percutaneous access via a subclavian vein was used to (a) probe the lesion from above, (b) facilitate a through-and-through maneuver, and (c) implant a TIVAP. Primary endpoints with regard to the SVC syndrome were technical (residual stenosis < 30%) and clinical (relief of symptoms) success; with regard to TIVAP implantation technical success was defined as positioning of the functional catheter within the SVC. Secondary endpoints were complications as well as stent and TIVAP patency. RESULTS: Technical and clinical success rate were 100% for revascularization of the SVS and 100% for implantation of the TIVAP. One access site hematoma (minor complication, day 2) and one port-catheter-associated sepsis (major complication, day 18) were identified. Mean catheter days were 313 ± 370 days. Mean imaging follow-up was 184 ± 172 days. Estimated patency rates at 3, 6, and 12 months were 100% in Group 1 and 84, 84, and 56% in Group 2 (p = 0.338). CONCLUSION: Stent-based revascularization of malignant SVCS with concomitant implantation of a port device using a dual venous approach appears to be safe and effective.

A Review of Open and Endovascular Treatment of Superior Vena Cava Syndrome of Benign Aetiology.

BACKGROUND: The widespread use of central venous catheters, ports, pacemakers, and defibrillators has increased the incidence of benign superior vena cava syndrome (SVCS). This study aimed at reviewing the results of open and endovascular treatment of SVCS. METHOD: Medical literature databases were searched for relevant studies. Studies with more than five adult patients, reporting separate results for the SVC were included. Nine studies reported the results of endovascular treatment of SVCS including 136 patients followed up for a mean of 11-48 months. Causes of SVCS were central venous catheters and pacemakers (80.6%), mediastinal fibrosis (13.7%), and other (5.6%). Percutaneous transluminal angioplasty (PTA) and stenting was performed in 73.6%, PTA only in 17.3%, and thrombolysis, PTA, and stenting in 9%. Four studies reported the results of open repair of SVCS including 87 patients followed up between 30 months and 10.9 years. The causes were mediastinal fibrosis (58.4%), catheters and pacemakers (28.5%), and other (13%). Operations performed included a spiral saphenous interposition graft, other vein graft, PTFE graft, and human allograft. Thirteen patients required re-operations (15%) before discharge mainly for graft thrombosis. RESULTS: In the endovascular group technical success was 95.6%. Thirty day mortality was 0%. Regression of symptoms was reported in 97.3%. Thirty-two patients (26.9%) underwent 58 secondary procedures. In the open group the 30 day mortality was 0%. Symptom regression was reported in 93.5%. Twenty-four patients (28.4%) underwent a total of 33 secondary procedures. CONCLUSIONS: Endovascular is the first line treatment for SVCS caused by intravenous devices, whereas surgery is most often performed for mediastinal fibrosis. Both treatments show good results regarding regression of the symptoms and mid-term primary patency, with a significant incidence of secondary interventions.

Home parenteral nutrition-associated thromboembolic and bleeding events: results of a cohort study of 236 individuals.

UNLABELLED: Essentials Sparse or outdated studies focus on thrombotic and bleeding risk in home parenteral nutrition (HPN). 236 HPN patients followed at a single center for a total of 684 patient-years were evaluated. Rates of venous thrombosis and major bleeding, and prevalence of vena cava syndrome are provided. Anticoagulants might reduce thrombosis risk, but population-specific safety concerns remain. SUMMARY: Background Home parenteral nutrition (HPN) is necessary for patients with intestinal failure. Recurrent catheter-related thrombosis (CRT) is common, leading to infectious complications, pulmonary embolism, vascular access loss and intestinal transplantation. The efficacy and safety of anticoagulants are unknown in this setting and based on sparse and low-quality observational data. Objectives Our aim was to estimate the incidence of thromboembolic, bleeding and anticoagulant-related complications in HPN patients, and evaluate risk factors for first venous thrombosis (VT). Methods This retrospective cohort study included all adult patients followed for long-term HPN at our center between 1986 and 2014. Primary outcomes were symptomatic objectively diagnosed VT, encompassing CRT and venous thromboembolism, and major bleeding. Secondary outcomes were vena cava syndrome and heparin-induced thrombocytopenia or hypersensitivity. Results A total of 236 patients were included (median HPN duration, 17 months) and 136 received anticoagulants at HPN onset (57.6%). Overall, the annual incidence of first VT was 11.4% (95% confidence interval [95% CI], 8.6-14.7%); VT was associated with a personal history of thrombosis (adjusted hazard ratio, 2.22; 95% CI, 1.06-4.64), whereas anticoagulation seemed to account only for a mild protection (adjusted hazard ratio, 0.72; 95% CI, 0.36-1.44). The annual incidence of major bleeding was 4.3% for patients on anticoagulants vs. 1.8% for those off anticoagulants. Vena cava syndrome developed in 20.7% of patients with VT. One patient had isolated heparin-induced thrombocytopenia (0.6%) and four had heparin hypersensitivity (2.5%). Conclusions Patients on HPN have a significant risk of venous thrombosis, major bleeding and vena cava syndrome. Anticoagulants might reduce thrombosis risk, but population-specific safety concerns remain.

Prevalence and etiology of focal liver opacification in patients with superior vena cava obstruction.

OBJECTIVE: This study aimed to assess the prevalence and etiologies of focal liver opacification (FLO) in the setting of superior vena cava (SVC) obstruction. METHODS: An archival search using key words to identify patients with SVC obstruction or severe narrowing and who had computed tomographic scans with intravenous contrast was performed at our institution. RESULTS: Thirty-one patients were included. Focal liver opacification was identified in 9 (29%). The most common direct causes of FLO and SVC obstruction were benign. CONCLUSIONS: Focal liver opacification caused by SVC obstruction is relatively common. Focal liver opacification is more commonly associated with benign causes of obstruction such as end-stage renal disease. Identifying FLO is important not only as an indirect sign of SVC obstruction but also must be distinguished from avidly enhancing liver masses. This study also reflects the overall recent increase in benign causes of SVC obstruction.

Frequency of superior vena cava obstruction in pediatric heart transplant recipients and its relation to previous superior cavopulmonary anastomosis.

The risk factors for superior vena cava (SVC) obstruction after pediatric orthotopic heart transplantation (OHT) have not been identified. This study tested the hypothesis that pretransplant superior cavopulmonary anastomosis (CPA) predisposes patients to SVC obstruction. A retrospective review of the Pediatric Cardiac Care Consortium registry from 1982 through 2007 was performed. Previous CPA, other cardiac surgeries, gender, age at transplantation, and weight at transplantation were assessed for the risk of developing SVC obstruction. Death, subsequent OHT, or reoperation involving the SVC were treated as competing risks. Of the 894 pediatric OHT patients identified, 3.1% (n = 28) developed SVC obstruction during median follow-up of 1.0 year (range: 0 to 19.5 years). Among patients who developed SVC obstruction, 32% (n = 9) had pretransplant CPA. SVC surgery before OHT was associated with posttransplant development of SVC obstruction (p <0.001) after adjustment for gender, age, and weight at OHT and year of OHT. Patients with previous CPA had increased risk for SVC obstruction compared with patients with no history of previous cardiac surgery (hazard ratio 10.6, 95% confidence interval: 3.5 to 31.7) and to patients with history of non-CPA cardiac surgery (hazard ratio 4.7, 95% confidence interval: 1.8 to 12.5). In conclusion, previous CPA is a significant risk factor for the development of post-heart transplant SVC obstruction.

Blood loss during flexible bronchoscopy: a prospective observational study.

BACKGROUND: Haemorrhage remains a complication of flexible bronchoscopy. OBJECTIVES: We aimed to measure the actual blood loss in patients at low risk of bleeding and to assess its association with the underlying pulmonary pathology, superior vena cava (SVC) syndrome, procedure(s) performed and laboratory values. METHODS: We screened all patients scheduled for flexible bronchoscopy and enrolled 234 subjects over 18 months. Subjects with a history of haemorrhagic tendency, platelets <20 × 10(3)/µl, a history of anti-coagulation or anti-platelet therapy and a history or clinical evidence of liver failure were excluded. Blood loss during the procedure was measured from aspirated secretions with a haemoglobin detector and categorised into minimal (<5 ml), mild (5-20 ml), moderate (20-100 ml) and severe bleeding (>100 ml). RESULTS: Overall, 210 subjects had minimal, 19 had mild and 5 had moderate bleeding. No subject experienced severe blood loss. Patients with SVC syndrome had the highest mean blood loss (6.0 ml) when compared to bronchogenic carcinoma without SVC syndrome (p = 0.033) and other diagnosis (p = 0.026). The blood loss with trans-bronchial needle aspiration (TBNA, mean 3.4 ml) was significantly less than with TBNA combined with endobronchial or transbronchial biopsy (mean 5.0 ml, p < 0.001). Anaemia, a platelet count of 25-155 × 10(3)/µl and an international normalized ratio of >1.3 were not associated with an increased risk of bleeding. CONCLUSIONS: We found no severe bleeding in this cohort preselected to have a low clinical risk of bleeding. Moreover, our data suggest that clinical screening and a platelet count ≥20 × 10(3)/µl alone may be sufficient to identify low-risk patients.

Coronary fistulas can develop collateral vessels: angiographic follow-up of an embolized giant right coronary artery-superior vena cava fistula in a patient with variant angina.

A 54-year-old man was transferred to our emergency department because of acute inferior myocardial infarction. However, ST-segment elevation resolved after intravenous nitrate administration on admission and coronary angiography revealed a nonobstructive atherosclerotic plaque at the mid-portion of the circumflex artery and a giant tortuous fistula from the right sinus of Valsalva to the superior vena cava. The patient was diagnosed with variant angina and coronary arteriovenous fistula after vasodilator treatment and maximal treadmill stress test. After effective medical treatment of variant angina and successful percutaneous coil embolization of the fistula, the patient had not experienced any angina episodes for 1 year. However, control coronary angiography revealed partial persistence of fistula flow because of new collateral vessels, bridging distal and proximal parts of the occluded segment. We present the first coexistence of coronary to superior vena cava fistula and variant angina in the literature. This report also shows the ability of coronary fistulas to develop collateral vessels, like coronary arteries.

Superior vena cava syndrome in thoracic malignancies.

The superior vena cava syndrome (SVCS) comprises various symptoms due to occlusion of the SVC, which can be easily obstructed by pathological conditions (eg, lung cancer, due to the low internal venous pressure within rigid structures of the thorax [trachea, right bronchus, aorta]). The resulting increased venous pressure in the upper body may cause edema of the head, neck, and upper extremities, often associated with cyanosis, plethora, and distended subcutaneous vessels. Despite the often striking clinical presentation, SVCS itself is usually not a life-threatening condition. Currently, randomized controlled trials on many clinically important aspects of SVCS are lacking. This review gives an interdisciplinary overview of the pathophysiology, etiology, clinical manifestations, diagnosis, and treatment of malignant SVCS.

Managing superior vena cava syndrome as a complication of pacemaker implantation: a pooled analysis of clinical practice.

BACKGROUND: Superior vena cava syndrome (SVCS) is a rare complication of pacemaker implantation. Numerous methods have been employed to treat this condition, ranging from anticoagulation and thrombolysis to surgical interventions and stenting. However, thus far only small case series have been reported and there is no currently accepted standard of care. METHODS: Our group preformed a PubMed literature search to identify cases of symptomatic SVCS that developed following implantation of permanent pacemakers or implanatable cardioverter defibrillators and were treated with one of five different modalities: anticoagulation, thrombolysis, venoplasty, stenting, and surgical reconstuction. Duration of follow-up and incidence of recurrence of symptoms were the main end-points. RESULTS: One hundred and four eligible cases from 74 different publications were identified, in which SVCS presented at a median of 48 (range 0-396) months after device implantation. We found that over the last 40 years, conservative treatments have been replaced by surgical reconstruction, and most recently by stenting, as the most common therapeutic modality employed. Anticoagulation, thrombolysis, and venoplasty alone were all associated with high recurrence rates. Surgery and stenting were more successful: recurrence rates were 12% and 5% over a median follow-up of 16 (range: 2-179) and 9.5 (range: 2-60) months, respectively. CONCLUSIONS: Currently, transvenous stenting is the most common treatment used for pacemaker-related SVCS, usually with conservation of the implanted leads. Both surgery and stenting appear to be effective treatments, with low incidences of recurrent SVCS over the first 12 months, but there is unfortunately a paucity of data on long-term outcomes. (PACE 2010; 420-425).

Malignant superior vena cava syndrome: is this a medical emergency?

BACKGROUND: Superior vena cava syndrome (SVCS) is an association with a variety of benign and malignant etiologies. The aim of this study was to evaluate if malignant SVCS is a real medical emergency or if we are able to obtain a definite histological diagnosis before chemoradiotherapy. MATERIALS AND METHODS: In this prospective case series study, we have evaluated epidemiological characteristics and the ability to obtain a definitive histological diagnosis before chemoradiotherapy and the role of chemoradiotherapy prior to obtaining tissue specimens on the results of diagnostic interventions in patients with malignant SVCS who came to thoracic surgery wards of Imam Khomeini (Tehran) and Ghaem and Imam Reza (Mashhad) hospitals in Iran from 2001 to 2006. RESULTS: Among 50 patients with SVCS, the M/F ratio was 32/18. Mean age was 61.7 years, and the most common symptom was dyspnea (86%). We performed successful tissue sampling before chemoradiotherapy in 44 cases (88%), and histological diagnoses in 100% of these cases were established, but among the other 6 patients (12%) who received chemoradiotherapy first because of unstable general conditions, histological diagnoses were obtained in only one patient (16.7%) after chemoradiotherapy (P<0.01). No in-hospital deaths were reported among our cases. CONCLUSION: Because we are able to establish tissue specimens by minimally invasive methods in most SVCS cases and because chemoradiation may preclude obtaining an exact pathological diagnosis, we suggest performing diagnostic interventions prior to chemoradiation in patients with SVC syndrome and without emergent clinical conditions.