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VTE: Is There Cancer?
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Sages of the East,
I was wondering if you could shed some light on a
dilemma on a patient evaluation and management
question.
The ED referred a 58-year-old man who presented with a
1 week history of unprovoked left leg pain. He was
found to have left popliteal, posterior tibial and peroneal
vein thrombi. He was started on rivaroxaban 15 mg, BID
for 21 days and referred to me for follow up.
What do I do now?
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Past Medical History
• High blood pressure• No history of cancer• Past surgical history: none• Non-smoker, non-drinker• No family history of VTE• Review of systems: negative, not sedentary, no
recent trauma or travel
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Physical Examination
• BP 120/70, P 70, R 12, Weight 72Kg, BMI 27• Age 58, well nourished, white, male• Lungs clear without crackles• Heart regular rhythm, S1 and S2 normal, no murmurs• Abdomen soft, active bowel sounds, no organomegaly• Left leg swelling, erythema, pain• Pulses plus 2 bilaterally• No lymphadenopathy• Stool negative for occult blood, prostate normal size
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Case
• Labs: Normal CBC, plts, Electrolytes, BUN, SCr, UA, LFTs • CxR: NAD• U/S: Left popliteal, posterior tibial, peroneal vein thrombus
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• So what do I do now?• Search for hypercoagulable state?• Search for cancer?• Change anticoagulation?• Help me on this one
Question
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Wedding Dress
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Trousseau Sign
Venous thrombosis in the setting of malignancy
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*36 studies: unprovoked venous thrombosis
Limited Cancer Screening:History, physical examination, basic blood work, chest radiography Extensive Cancer Screening:Same as limited PLUSSerum tumor markers or abdominal ultrasonography or computed tomography
Baseline combined prevalence cancer: 6.1%
12 month after baseline cancer prevalence : 10%
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*Robertson L1, Yeoh SE, Stansby G, Agarwal R. Effect of testing for cancer on cancer- and venous thromboembolism (VTE)-related mortality and morbidity in patients with unprovoked VTE. Cochrane Database Syst Rev. 2015 Mar 6;3:CD010837. doi: 10.1002/14651858.CD010837.pub2.
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*Carrier M. et al. Screening for Occult Cancer in Unprovoked Venous Thromboembolism. N Engl J Med. 2015 Aug 20;373(8):697-704. doi: 10.1056/NEJMoa1506623. Epub 2015 Jun 22.
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SOME Study
Group Cancer Percentage 95% CILimited screening 14/431 3.2% 1.9-5.4Limited plus CT 19/423 4.5% 2.9-6.9
Limited Screening : 29% of occult cancers missedLimited Plus: 26% of occult cancers missed
NO Difference between the two groups re: mean time to cancer diagnosis
*Carrier M. et al. Screening for Occult Cancer in Unprovoked Venous Thromboembolism. N Engl J Med. 2015 Aug 20;373(8):697-704. doi: 10.1056/NEJMoa1506623. Epub 2015 Jun 22
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Mean time to cancer diagnosisLimited screening: 4.2 monthsLimited screening PLUS: 4.0 months
Reproduced with Permission from Massachusetts Medical SocietyCarrier M et al. Screening for Occult Cancer in Unprovoked Venous Thromboembolism.N Engl J Med 2015;373:697-704.
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Reproduced with Permission from Massachusetts Medical SocietyCarrier M et al. Screening for Occult Cancer in Unprovoked Venous Thromboembolism. N Engl J Med 2015;373:697-704.
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Summary
58-year-old man with unprovoked VTESearch for occult cancer
H&P, Rectal, Hemoccult, CBC, Electrolytes, BUN, Scr, LFTs, PSA, CxR ,
No imaging merely to search for cancer
Treatment of unprovoked DVT Standard: LMWH Warfarin Consider: Direct Acting Oral Anticoagulants
as effective (all) with less major bleeding (rivaroxiban, apixaban)
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