From the Publishers of
VTE: Is There Cancer?
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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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Question
• So what do I do now?
• Search for hypercoagulable
state?
• Search for cancer?
• Change anticoagulation?
• Help me on this one
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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%
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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.
*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)
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