1. VTE: Is There Cancer? From the Publishers of
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3. 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?
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4. 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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5. 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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6. 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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7. 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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8. Wedding Dress

9. Trousseau Sign
Venous thrombosis in the setting of malignancy

10. *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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11. 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 Mar 6;3:CD doi: / CD pub2.

12. *Carrier M. et al. Screening for Occult Cancer in Unprovoked Venous Thromboembolism.
N Engl J Med Aug 20;373(8): doi: /NEJMoa Epub 2015 Jun 22.

13. SOME Study Group Cancer Percentage 95% CI Limited screening 14/431
3.2%
Limited plus CT
19/423
4.5%
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 Aug 20;373(8): doi: /NEJMoa Epub 2015 Jun 22

14. 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:

15. 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:

16. 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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