Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchus: a systematic review

Objective: To conduct a systematic review to determine the relative effectiveness of treatments currently employed in the management of superior vena caval obstruction (SVCO). Search strategy: Electronic searching of the Cochrane Clinical Trials Register, Medline and Embase with identification of further studies from references cited in trials identified by electronic searching. Selection criteria: Both randomized and non-randomized controlled trials in which patients with carcinoma of the bronchus and SVCO had been treated with any combination of steroids, chemotherapy, radiotherapy or insertion of an expandable metal stent. Data collection and analysis: There were three randomized and 98 non-randomized studies of which two and 44 respectively met the inclusion criteria. Main results: Superior vena caval obstruction was present at diagnosis in 10.0% of patients with small cell lung cancer (SCLC) and 1.7% of patients with non-small cell lung cancer (NSCLC). In one small randomized trial in SCLC, the rate of SVCO relapse was not significantly reduced by giving radiotherapy on completion of chemotherapy. In another, in NSCLC, the addition of induction chemotherapy to a course of synchronous chemo-radiotherapy did not provide greater relief of SVCO. In SCLC chemotherapy and/or radiotherapy relieved SVCO in 77%; 17% of those treated had a recurrence of SVCO. In NSCLC, 60% had relief of SVCO following chemotherapy and/or radiotherapy; 19% of those treated had a recurrence of SVCO. Insertion of an SVC stent relieved SVCO in 95%; 11% of those treated bad further SVCO but recanalization was possible in the majority resulting in a long-term patency rate of 92%. Morbidity following stent insertion was greater if thrombolytics were administered. Reviewers' conclusions: Chemotherapy and radiotherapy are effective in relieving SVCO in a proportion of patients whilst stent insertion may provide relief in a higher proportion and more rapidly. The effectiveness of steroids and the optimal timing of stent insertion (whether at diagnosis or following failure of other modalities) remain uncertain.