Deep VeinThrombosis

&Malignancy

Department of Radiation Oncology

Presented byDr. Muhammad Zubaer Hussain

IncidenceAbout 600,000 hospitalizations per year

occur for DVT in the United States. 100,000 to 300,000 VTE-related deaths

occur annually in the United States.Approximately 1 person in 20 develops a

DVT in the course of his or her lifetime.

In-hospital VTE

In hospitalized patients, the incidence of venous thrombosis is considerably higher and varies from 20-70%.

The in-hospital case- fatality rate for VTE is 12% rising to 21% in elderly persons.

Venous thrombosis is second leading cause of death in cancer patients.

Lower Limb DVT Although most DVT is occult and resolves

spontaneously without complication, It is the underlying source of 90% of acute

PEs PE occurs in approximately 10% of patients

with acute DVT and can cause up to 10% of in hospital deaths.

Cause 25,000 deaths per year in the United States.

Upper Limb DVT

Asymmetry in the supraclavicular fossa or in the circumference of the upper arms.

A prominent superficial venous pattern may be evident on the anterior chest wall.

Lower Limb DVT

Upper Limb DVT

Risk FactorsAge (In elderly persons, the incidence is increased 4-fold) Immobilization longer than 3 daysPregnancy and the postpartum period Major surgery in previous 4 weeksPlane/car trips (> 4 hours) in previous 4 wks Cancer (30%)Previous DVT

Risk Factors…ContdStroke (DVT is found in 53% of paralyzed limbs, compared with only 7% on

the nonaffected side.)

Acute myocardial infarction (AMI)Congestive heart failure (CHF) Sepsis Nephrotic syndrome Ulcerative colitis Multiple trauma CNS/spinal cord injuryBurns

Risk FactorsHomocystinuria Polycythemia rubra vera Thrombocytosis Inherited disorders of coagulationDrug abuse Oral contraceptives

Malignancy & DVT Malignancy is noted in as many as 30% of

patients with venous thrombosis. 90% of cancer patients having some

abnormal coagulation factors. Chemotherapy may increase the risk of

venous thrombosis by affecting the vascular endothelium, coagulation cascades, and tumor cell lysis.

The incidence has been shown to increase in those patients undergoing longer courses of therapy.

AETIOLOGY of DVT inCANCER PATIENTS

Hypercoagulable State Increased plasma levels of Clotting factors Cancer procoagulantTissue factorCytokines Inrceased plasminogen activator

Surgical Intervertion Chemotherapy Prolonged Immobilization

TYPE of CANCERS with DVT Pancreas Lung Breast GI tumor Prostate Multiple Myeloma Lymphoma Leaukaemia

Postoperative venous thrombosis

Varies depending on a multitude of patient factors, including the type of surgery undertaken.

Without prophylaxis, general surgery operations typically have an incidence of DVT around 20% in benign disease, whereas 36% in cancer patients.

DIAGNOSIS

Symptoms and SignsLower limb DVT characteristically starts with Pain (50%) Swelling An increase in temperature and Dilatation of the superficial veins. Often, however, there are only minimal S/S Typically unilateral but may be bilateral

(when clot extends proximally into the inferior vena cava. )( Bilateral DVT is more commonly seen in patients with

underlying malignancy )

Symptoms and Signs

Most specific symptom Leg pain - Occurs in 50% of patients but is nonspecific

Tenderness - Occurs in 75% of patients

Warmth or Erythema of the skin over the area of thrombosis

Symptoms and Signs …contd

Clinical symptoms of pulmonary embolism (PE) as the primary manifestation

Calf pain on dorsiflexion of the foot (Homans sign)

Variable discoloration of the lower extremity

Well’s Score

Clinical characteristic Score

Active cancer (patient receiving treatment for cancer within the previous 6 months or currently receiving palliative treatment)

1

Paralysis, paresis or recent plaster immobilisation of the lower extremities

1

Recently bedridden for 3 days or more, or major surgery within the previous 4 weeks

1

Localised tenderness along the distribution of the deep venous system

1

Entire leg swollen 1

Calf swelling at least 3 cm larger than that on the asymptomatic side (measured 10 cm below the tibial tuberosity)

1

Pitting oedema confined to the symptomatic leg 1

Collateral superficial veins (non-varicose) 1

Alternative diagnosis at least as likely as DVT -2

Well’s Score…contd

Clinical probabilityTotal score

DVT low probability < 1

DVT moderate probability 1-2

DVT high probability > 2

DIFFERENTIAL DIAGNOSES

Table 262-2 Differential Diagnosis

    Ruptured Baker's cyst

    Cellulitis

    Postphlebitic syndrome/venous insufficiency

Symptoms and Signs …contd Baker's cysts usually occur in patients with

rheumatoid arthritis. Cellulitis is usually distinguished by

Marked skin erythema and temperature which is localised within a well-demarcated area of the leg and may be associated with an obvious source of entry of infection

Fever and chills Postphlebitic syndrome.

Leg is diffusely edematousskin ulceration, especially in the medial

malleolus of the leg

INVESTIGATIONS

D-dimerCompression USG (sensitivity is ~99.5%)

Venogram

Investigations of Suspected DVT

D-dimer

D-dimer is a useful "rule out" test.Sensitivity >80% for DVT and >95% for PE.Levels increase in patients with MIPneumoniaSepsis

USG of Rt. Popliteal Vein

COMPLICATIONS

VTE can cause death from PE

or, among survivorsCh. thromboembolic Pulmonary HTN Postphlebitic/Post thrombotic/Chronic

venous insufficiency± Ulceration

Management

Prophylactic management:Non Pharmacological: Early mobilization of all patients Intermittent pneumatic compression Mechanical foot pumps Graduated compression stockings.

Prophylactic management (Contd)Pharmacological: (Moderate to High risk of

DVT) Low molecular weight heparins (eg. Enoxaparin)

Unfractionated heparin Fondaparinux Apixaban Dabigatran Rivaroxaban Warfarin Aspirin

Prophylactic management (Contd)Pharmacological: Enoxaparin 40mg sc once daily Fondaparinux 2.5 mg sc once daily Apixaban PO ( Showing promising result in clinical trial) Warfarin 10 mg on the first and second days, with 5 mg on

the third day; subsequent doses are titrated against the INR.

Moderate risk of DVT: Major surgeryOr,

Major medical illness, e.g. Heart failure Myocardial infarction with complications Sepsis Active malignancy Stroke and other conditions leading to lower

limb paralysis

High risk of DVT: Major abdominal or pelvic surgery

for malignancy

or

with history of DVT

or

known thrombophilia

  Major hip or knee surgery Neurosurgery

Management of Established DVT

General management: Elevation of limb AnalgesiaAnticoagulant: (mainstay of treatment)

Inferior Vena Caval (IVC) Filters CI to anticoagulation and Recurrent venous thrombosis despite intensive

anticoagulation.

Management of Established DVT

Anticoagulant:Low molecular weight heparin(LMWH):

1mg/kg sc 12 hrly

or,

Unfractionated heparin

5000 U iv loading continuous inf 20U/kg/hr

Parenteral anticoagulation should be continued for a minimum of 5 days

Warfarin: 10 mg on the first and second days, with 5 mg on the third day; subsequent doses are titrated against the INR.

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