Utility of additional abdominopelvic CT in detecting occult cancer in patients with unprovoked venous thromboembolism

Vaidyanathan, S.; Walsh, John J.; Cliffe, Helen; Saleem, Nayyar; Weston, Michael; Lowe, Andy; Chowdhury, Fahmid U.

doi:10.1016/j.crad.2016.02.016

Cited by 7 publications

(6 citation statements)

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“…Total incidence of occult cancer in uVTE ranges from 4 to 10% in the literature [ 1 – 4 , 9 , 10 ]; however, a recently published systematic review [ 1 ] and 2 recently published randomised trials (SOME [ 2 ] MVTEP [ 4 ]) showed a lower incidence of occult malignancy in approximately 4–6% of patients with uVTE; however, the reason why remains unclear. The total incidence of malignancy was 6% (index admission and follow-up) in our patient cohort, which is in line with the current literature [ 1 , 2 , 4 , 13 , 14 ]. Median time to cancer diagnosis was 12 months with 6 malignancies (4%) diagnosed at 1 year, and 3 malignancies (2%) identified at 24 months signifying the importance of continued clinical follow-up of these patients.…”

Section: Discussionsupporting

confidence: 92%

CT imaging for occult malignancy in patients with unprovoked venous thromboembolism (VTE) in a tertiary centre: is it worthwhile?

et al. 2023

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Background Investigating patients with unprovoked venous thromboembolism (uVTE) for occult malignancy can prove a diagnostic dilemma and imaging is often used extensively in this patient group. Aims The primary objective of this study was to determine the incidence of malignancy on CT and other imaging over a 10-year period. A secondary objective was to evaluate the role of laboratory and other non-imaging tests performed. Methods A retrospective key word search of our hospital’s imaging system was performed to identify patients with unprovoked DVT/PE over the last 10 years. All imaging, histology, endoscopy, laboratory tests, and clinical follow-up over 2 years were analysed. Patients with provoked VTE were excluded. Results 150 patients had uVTE. 9 patients were diagnosed with occult malignancy by different investigations on index hospital admission (3 patients) or subsequently on clinical follow-up (6 patients). Mean age of patients was 62 years. 116 patients had CT body imaging. The incidence of malignancy diagnosed by initial CT imaging was 1.7% with a sensitivity of 22%, specificity 87%, and PPV 12.5%. Overall incidence of malignancy identified by imaging alone during the index hospital admission was 2%. Total incidence of malignancy including index admission and follow-up was 6%. Median time to cancer diagnosis was 12 months. Conclusion CT imaging had a low yield for diagnosing malignancy. Extensive imaging strategies increase cost and radiation exposure without improving mortality. Clinical follow-up, history taking, and physical examination guiding appropriate investigations remain the best tool for unmasking occult malignancy in patients with uVTE.

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Section: Discussionsupporting

confidence: 92%

CT imaging for occult malignancy in patients with unprovoked venous thromboembolism (VTE) in a tertiary centre: is it worthwhile?

et al. 2023

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“…In these populations with a cancer risk of 5% or less, it has been clearly demonstrated that an extended cancer screening strategy is not associated with any clinical benefits. 5,[10][11][12][13] In our different analyses, recurrent VTE less than 1 year after the first event was constantly found as a good predictor for cancer diagnosis. This can be explained by the addition of the heightened risk of cancer diagnosis in the year following a first unprovoked VTE event to the increased risk of recurrence of cancer-associated VTE.…”

Section: Discussionmentioning

confidence: 66%

Incidence of Cancer after a Second Unprovoked Venous Thromboembolic Event

et al. 2019

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Patients with two unprovoked venous thromboembolism (VTE) events could be at high risk for cancer diagnosis and may therefore benefit from extended cancer screening strategies. However, accurate data on the incidence of cancer in this population is lacking. In a prospective cohort study, we followed-up with all patients who experienced two unprovoked symptomatic VTE events that occurred in less than 2 years apart. We estimated the 1-year incidence rate of cancer following the second unprovoked VTE event using the Kaplan–Meier method. Potential predictors for cancer diagnosis were assessed using a Cox proportional hazard regression model. Between May 2000 and December 2013, we included 197 patients with two episodes of symptomatic unprovoked VTE that occurred in less than 2 years apart. Their mean age was 66.2 ± 16.3 years, and 122 (51.8%) were male. Seventeen patients were diagnosed with cancer during the year following the second episode of unprovoked VTE, corresponding to a cumulative incidence rate of 9.19% (95% confidence interval [CI]: 5.81–14.37). The 1-year cumulative incidence rate of cancer was 35.88% (95% CI: 19.75–59.25) in patients with VTE recurrence on anticoagulation, 5.51% (95% CI: 2.9–10.32) among patients with a second episode of unprovoked VTE occurring after stopping anticoagulation and 1.15% (95% CI: 0.16–7.88) when time elapsed between the first and recurrent VTE was > 1 year. Our study suggests that the incidence of cancer in patients with a second episode of unprovoked VTE that occurs off anticoagulation, or > 1 year after the first event, is similar to that of patients with a first unprovoked VTE event.

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“…8 A UK cohort study reported that none of the CT abdomen/pelvis done as per the 2012 NICE recommendations for occult cancer screening in patient with unprovoked VTE revealed any occult cancer over a median followup period of 22 months. 9 Clinicians should keep a low threshold for suspicion for cancer in patients presenting with unprovoked VTEs, and all patients should undergo a thorough medical history, examination, baseline laboratory blood tests and a chest X-ray if they did not undergo any chest imaging. There are further tools being developed to identify subsets of patients who would benefit from extensive screening, although they are not yet validated.…”

Section: Letters To the Editormentioning

confidence: 99%

Pulmonary embolism

Thompson

2019

Clinical Medicine

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Editor-I read with interest 'Lesson of the month 1: A rare adverse reaction between flucloxacillin and paracetamol', published in March's Clinical Medicine , and write with a similar case seen recently in our institution, to further highlight this issue. In addition, although the diagnostic test of choice (urinary organic acids) was unavailable locally we were able to confirm the diagnosis by liaising with another hospital laboratory within our region. An 80-year-old patient with left leg cellulitis and a nondrainable calf abscess, requiring a 3-week course of intravenous flucloxacillin, developed marked hypokalaemia and was found to have a severe, high anion-gap metabolic acidosis (pH 7.16, bicarbonate 7.4 mmol/L, base excess-22.4 mmol/L, serum anion gap 30 mmol/L), without acute kidney injury. Pyroglutamic acidosis was suspected and flucloxacillin and paracetamol were discontinued, and N-acetylcysteine was administered. The acidosis resolved over the course of several days. Urinary organic acid testing was performed at another hospital in the region, showing grossly increased levels of pyroglutamic acid, which had resolved when a repeat specimen was sent 9 days later. ■

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Utility of additional abdominopelvic CT in detecting occult cancer in patients with unprovoked venous thromboembolism

Cited by 7 publications

References 10 publications

CT imaging for occult malignancy in patients with unprovoked venous thromboembolism (VTE) in a tertiary centre: is it worthwhile?

CT imaging for occult malignancy in patients with unprovoked venous thromboembolism (VTE) in a tertiary centre: is it worthwhile?

Incidence of Cancer after a Second Unprovoked Venous Thromboembolic Event

Pulmonary embolism

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