VTE: Is There Cancer? From the Publishers of COPYRIGHT © 2016, ALL RIGHTS RESERVED

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The ED referred a 58-year-old man who presented with a 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? 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 *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

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