Incidental Findings of Tumors in a Routine Venous Duplex

Abstract

Introduction Deep venous thrombosis (DVT) is a condition routinely evaluated for in a vascular laboratory on a daily basis. Patients usually present with symptoms of peripheral pain, swelling, shortness of breath, or chest pain. Pain and swelling are not symptoms unique to DVT, however, and an ultrasound test could potentially serve as a basis for incidental findings that would serve as an underlying reason for the patient's symptoms. It is important to recognize the role in evaluating flow characteristics and using appropriate methods for identifying deep veins to exclude, or include, DVT as a cause for symptoms. Case Reports Two case studies are presented here in light of excluding DVT and identifying tumors. The first patient presented to the emergency department with left upper extremity swelling and pain. A left upper-extremity venous ultrasound was performed to discover all veins were fully compressible. No intraluminal thrombus was noted, yet all veins demonstrated abnormal, continuous flow. A significant proximal venous obstruction was indicated at the level of the left clavicle by ultrasound based on the observed abnormal flow. A chest X-ray and computed tomography was ordered, and the presence of a large Pancoast tumor was discovered. It extended superiorly from the left lung towards the clavicle, extrinsically compressing the proximal left subclavian vein. The patient subsequently had concurrent chemotherapy and radiation therapy treatment and rehabilitation. The second patient presented with a mild fever and tachycardia and was status postcervical tumor surgery. The ultrasound revealed multiple segments of homogenously echogenic, Doppler-silent, incompressible structures visualized adjacent to the deep vasculature system throughout bilateral lower extremities. These structures could easily be mistaken for DVT as they appeared similar in B-mode character. Clear identification of venous flow demonstrated around these structures differentiated the veins, and the contiguous visualization of the vein lumen, from these structures. These structures were diagnosed as Schwannoma, tumors consisting only of Schwann cells, that run along the nerves, which in turn run along the deep vasculature.