VTE: Is There Cancer? From the Publishers of
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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
Transcript of VTE: Is There Cancer? From the Publishers of
VTE: Is There Cancer?
COPYRIGHT © 2016, ALL RIGHTS RESERVED
From the Publishers of
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
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
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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
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 PLUSSerum 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% 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
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.
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.
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)
Copyright © 2016
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