deep vein thrombosis & malignancy department of radiation oncology presented by dr. muhammad...
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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.
THANK YOU
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