Deep VeinThrombosis&MalignancyDepartment of Radiation OncologyPresented byDr. Muhammad Zubaer Hussain
Incidence • About 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 supraclavicularfossa 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 Factors • Age(In elderly persons, the incidence is increased 4-fold) • Immobilization longer than 3 days • Pregnancy and the postpartum period • Major surgery in previous 4 weeks • Plane/car trips (> 4 hours) in previous 4 wks • Cancer (30%) • Previous DVT
Risk Factors…Contd • Stroke (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 injury • Burns
Risk Factors • Homocystinuria • Polycythemiarubravera • Thrombocytosis • Inherited disorders of coagulation • Drug 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 procoagulant • Tissue factor • Cytokines • Inrceasedplasminogen 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.
Symptoms and Signs Lower 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
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 localisedwithin 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 edematous • skin ulceration, especially in the medial malleolus of the leg
D-dimer • Compression USG (sensitivity is ~99.5%) • Venogram
D-dimer • D-dimer is a useful "rule out" test. • Sensitivity >80% for DVT and >95% for PE. • Levels increase in patients with • MI • Pneumonia • Sepsis
COMPLICATIONS VTE can cause • death from PE or, among survivors • Ch. 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) • Warfarin10 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 surgery Or, • 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 • Analgesia • Anticoagulant: (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 inf20U/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.