From the Publishers of VTE: Is There Cancer? COPYRIGHT © 2016, ALL RIGHTS RESERVED Terms of Use The Consult Guys® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the Consult Guys® slide sets constitutes copyright infringement. Copyright © 2016 Copyright © 2016 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 Copyright © 2016 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 Copyright © 2016 Case • Labs: Normal CBC, plts, Electrolytes, BUN, SCr, UA, LFTs • CxR: NAD • U/S: Left popliteal, posterior tibial, peroneal vein thrombus Copyright © 2016 Question • So what do I do now? • Search for hypercoagulable state? • Search for cancer? • Change anticoagulation? • Help me on this one Copyright © 2016 Wedding Dress Trousseau Sign Venous thrombosis in the setting of malignancy *36 studies: unprovoked venous thrombosis Limited Cancer Screening: History, physical examination, basic blood work, chest radiography Extensive Cancer Screening: Same as limited PLUS Serum tumor markers or abdominal ultrasonography or computed tomography Baseline combined prevalence cancer: 6.1% 12 month after baseline cancer prevalence : 10% Copyright © 2016 *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. *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. SOME Study Group Cancer Percentage 95% CI Limited screening 14/431 3.2% 1.9-5.4 Limited plus CT 19/423 4.5% 2.9-6.9 Limited Screening : 29% of occult cancers missed Limited 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 Mean time to cancer diagnosis Limited screening: 4.2 months Limited screening PLUS: 4.0 months Reproduced with Permission from Massachusetts Medical Society Carrier M et al. Screening for Occult Cancer in Unprovoked Venous Thromboembolism. N Engl J Med 2015;373:697-704. Reproduced with Permission from Massachusetts Medical Society Carrier M et al. Screening for Occult Cancer in Unprovoked Venous Thromboembolism. N Engl J Med 2015;373:697-704. Summary 58-year-old man with unprovoked VTE Search 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) Copyright © 2016 Produced by and Copyright © 2016 COPYRIGHT © 2016, ALL RIGHTS RESERVED