Occult Cancer in Patients With Acute Pulmonary Embolism

Monreal, Manuel; Casals, A; Boix, Jaume; Olazabal, Ainhoa Alonso; Montserrat, Enric; Mundo, M. Ribas

doi:10.1378/chest.103.3.816

Cited by 54 publications

(38 citation statements)

References 15 publications

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“…Patients with recurrent, idiopathic VTE had an even higher risk of developing cancer [20]. Similar results have been reported in other prospective studies, although the data may not have always been collected and analyzed in a strictly prospective fashion [21, 22, 23, 24]. For example, Schulman and Lindmarker [18]have recently provided important corroboration of these findings in another prospective study, albeit with a very different study design.…”

Section: Occult Malignancy In Patients With Vtesupporting

confidence: 65%

Epidemiology of Thrombosis in Cancer

2001

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We have utilized epidemiological data to address three questions in patients with cancer and venous thromboembolism (VTE): (1) What is the risk for occult cancer in patients with idiopathic versus secondary VTE? (2) What is the risk for thrombosis in patients with cancer (vs. noncancer patients)? (3) What is the risk of recurrent VTE in cancer patients with an initial episode of VTE compared to noncancer patients? The risk for a new cancer diagnosis within 6–12 months of the diagnosis of idiopathic VTE (including pulmonary embolism) is well supported by retrospective analyses of large numbers of unselected patients, population-based retrospective cohort analyses from large registries and prospective studies. The odds ratios for these studies are in the range of 4- to 7-fold increased risk. In surgical patients with known cancer the odds ratio for an episode of postoperative VTE is approximately 2, when compared to a control group of noncancer patients subjected to the same procedures. A similar odds ratio of approximately 2 exists for the relative risk for recurrence of VTE in the first 3 months after an initial episode in cancer patients treated with heparin and warfarin (Coumadin^®) compared to noncancer patients. Therefore, patients with idiopathic VTE are at increased risk for occult cancer and cancer patients are at increased risk for VTE. Appropriate studies are underway to determine the best strategies for anticoagulant management of these patients.

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Section: Occult Malignancy In Patients With Vtesupporting

confidence: 65%

Epidemiology of Thrombosis in Cancer

2001

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“…The reported association between PE and occult malignancy refers mainly to those with no risk factors and/or recurrent thromboembolism [26][27][28] .…”

Section: Predisposing Factorsmentioning

confidence: 99%

A practical approach to the diagnosis of venothromboembolism

Corris

2001

Clinical Medicine

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A negative D-dimer result in a patient presenting with signs and symptoms in keeping with venous thromboembolism but with a low clinical probability is sufficient to exclude the diagnosis Ventilation perfusion isotope scanning, although widely available, should only be used in patients with suspected pulmonary embolism who have a normal chest radiograph or no previous chronic cardiopulmonary disease Studies suggest good sensitivity and specificity of spiral computerised tomography (CT) in the diagnosis of central or segmental pulmonary emboli All hospitals receiving acute medical emergencies should devise their own algorithm for diagnosis of venothromboembolism that reflects local expertise and availability of investigations Key Pointsare no absolute contraindications, although particular care should be exercised in patients with known sensitivity to contrast media and in those with severe pulmonary hypertension, renal impairment or following acute MI. The femoral vein approach is commonly used, but some prefer the internal jugular or subclavian approach because of the reduced risk of disturbing thrombi and the ability to maintain venous access for pressure monitoring and the administration of thrombolytic drugs where indicated. Good liaison between the radiologist and intensive care unit is recommended. Pigtail catheters of sufficient size (7F) to enable high-flow injections of non-ionic contrast media should be used. Volume and flow will depend on facilities available. Superselective injections may be necessary. A main PA injection may be sufficient when prior echocardiography suggests the possibility of a large centrally placed clot. Where prior V/Q scan is non-diagnostic, angiography can be confined to the more abnormal side 65 .Minor complications have been reported in 2% and major or fatal complications in 0.5-1.3% of investigations 66 using these techniques, mainly in patients already severely ill. The introduction of low osmolar non-ionic contrast media has led to a reduction in complications, a recent report finding only one major (non-fatal) complication in every 300 patients 67 .There may be difficulties in interpretation of PA results, even by experienced radiologists. The PIOPED study found 19% interobserver disagreement, varying from 2% for central to 34% for subsegmental abnormalities 68 , and 11% within-observer discrepancy. A recent study with consensus review in patients with non-diagnostic lung scans led to a change in initial diagnosis in 20%. There was better agreement when digital subtraction was used, but this is not widely available. RecommendationsThe algorithm shown in Fig 1 outlines one approach to the investigation of a patient presenting with suspected VTE. ConclusionsThe investigation of suspected VTE will continue to be refined by further evidence from prospective studies using D-dimers and spiral CT. Moreover, newer modalities such as magnetic resonance imaging (MRI) are beginning to demonstrate diagnostic value, particularly in North America. However, at present, routine use of M...

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“…Sometimes pericardial effusion may be the initial presentation well before the diagnosis of primary cancer. 6 The diagnosis of pulmonary thromboembolism may only be suspected when there is persistent symptoms of cardiorespiratory distress with new echocardiographic findings of dilated RA & RV with PAH (RA,RV being initially compressed by cardiac tamponade) following a successful pericardiocentesis.…”

Section: Introductionmentioning

confidence: 99%