Submassive pulmonary thromboembolism as a first sign of occult adenocarcinoma

Objective To analyze the risk factors of venous thromboembolism (VTE) in patients with lung cancer. Methods A total of 2 949 patients with lung cancer admitted to the First Affiliated Hospital of Guangxi Medical University from January 2014 to October 2017 were collected. The cases with VTE were assigned to the VTE group (n=59) , and those without VTE were in the non-VTE group (n=2 890) . First, for VTE and non-VTE groups, gender, age, body mass index (BMI), surgery, chemotherapy, smoking, hypertension, diabetes, coronary heart disease, cerebral infarction and other factors were used to analyze the risk factors for VTE. Next, for VTE group(n=59), patients were sub-classified in pulmonary embolism (PE) group(n=18) and non-PE group(n=41) according to PE history. The two groups were compared to analyze the risk factors for PE in lung cancer patients with deep vein thrombosis (DVT). Results Univariate analysis showed that there were significant differences between the VTE group and the non-VTE group in surgery, chemotherapy, pathological type, lung cancer staging and coronary heart disease (P<0.05). Logistic multivariate regression analysis indicated significant differences between the VTE group and the non-VTE group in chemotherapy, adenocarcinoma and lung cancer stage Ⅳ (P<0.05). The difference of BMI between the PE group and the non-PE group was statistically significant (P<0.05). Conclusion Coronary heart disease, surgery, chemotherapy, pathological type and lung cancer stage are closely related to VTE in patients with lung cancer. Coronary heart disease, chemotherapy, adenocarcinoma and stage IV of lung cancer may be independent risk factors for VTE in patients with lung cancer. BMI≥25 kg/m2 is one of the significant risk factors for PE in lung cancer patients with DVT. Key words: Lung cancer; Venous thromboembolism; Pulmonary embolism; Risk factors

Objective To observe the clinical characteristic and prognosis of primary lung cancer patients with venous thromboembolism(VTE). Methods 589 primary lung cancer patients were selected and divided into VTE group(n= 49)and non VTE group(n= 540).49 cases with VTE were divided into pulmonary thromboembolism(PTE) group(n= 15),including single PTE and PTE combined with deep venous thrombosis(DVT) and DVT group(n= 34).Single factor and multiple logistic regression analysis were performed to determine the factors influencing primary lung cancer patients with VTE.Clinical manifestation,time of onset and prognosis of patients with VTE were analyzed. Results 49 patients with VTE included 10 patients(20. 4%) with single PTE,34 patients(69.4%)with single DVT and 5 PTE patients combined with DVT(10.2%). D-dimer(OR= 1.560,95% CI= 1.018~2.392,χ2= 4.161,P= 0.041),interleukin-1(IL-1,OR= 1.846,95% CI= 1.054-3.234,χ2= 4.594,P= 0.033),tumor necrosis factor(TNF OR= 1.486,95% CI= 1.014-2.178,χ2 = 4.126,P= 0.042),adenocarcinoma(OR= 2.854,95% CI= 1.217-6.695,χ2= 5.812,P= 0.016)and phaseⅢ-Ⅳ(OR= 2.198,95% CI= 1.122-4.305,χ2= 5.272,P= 0.022) were the factors influencing primary lung cancer patients with VTE.Chest tightness,coughing,accelerated heart rate,swelling and pain in lower limb were common clinical manifestations of primary lung cancer patients with VTE.Most patients with VTE occurred within 3 months after a diagnosis of primary lung cancer.There was no significant difference in the time of onset between PTE group and DVT group(P> 0.05).As of July 2014,31 cases(63.2%) died,12 cases(24.5%)survived,and 6 cases(12.2%)lost in 49 patients with VTE.The median survival time of 49 patients with VTE was 9.5 months.The median survival time of PTE group was 5. 8 months,while DVT group was 15.2 months,but no significant difference between them(P> 0.05 ). Conclusion Increased D-dimer,increased IL-1,increased TNF,adenocarcinoma and phaseⅢ-Ⅳcould increase the risk of primary lung cancer patients with VTE.There were little typical clinical symptoms in most patients with VTE,which occurred with in 3 months after a diagnosis of primary lung cancer.They had high mortality and needed to take early diagnosis and treatment through auxiliary examination. Key words: Lung neoplasms; Venous thromboembolism; Prognosis

Background: Venous thromboembolism is the formation of clot in a deep vein, which causes complete or partial obstruction of the vein. This can be shown as a deep vein thrombosis or a pulmonary embolism. Deep vein thrombosis or pulmonary embolism, consequently, are a common complication after surgical procedures. Therefore, the need for appropriate guidelinebased preventive therapy of venous thromboembolism is crucial. The aim of our study was to determine the adequacy of preventive therapy for deep vein thrombosis or pulmonary embolism in surgical patients who were diagnosed with deep vein thrombosis or pulmonary embolism from 1.1.2007 to 31.12.2011 at the Murska Sobota General Hospital as a complication of surgical treatment and to compare the test group with the control group, in which there was no not either deep vein thrombosis or pulmonary embolism after surgical treatment. Methods: We reviewed the guidelines for the prevention of venous thromboembolism and determined the appropriate selection of drugs, the adequacy of dose and dosing interval, and the appropriate duration of therapy based on the risk assessment score provided by the guidelines. In the test group, we included 144 patients who were treated in the surgical department at the Murska Sobota General Hospital between 2007 and 2011 and had deep venous thrombosis or pulmonary embolism as main or associated diagnosis as a complication during surgical treatment. In the control group, we included 142 patients who were treated in the surgical department at the Murska Sobota General Hospital and did not had venous thromboembolism as the principal or accompanying diagnosis. Both groups were compared. Results : In the control group, 77% of patients received thromboprophylaxis according to the guidelines, while the proportion in the test group was 56%. Significant differences receiving adequate thromboprophylaxis (p <0.05) between the two groups were demonstrated with the chi-square test. Conclusion: According to the findings of our study we can conclude that the proportion of patients with adequate thromboprophylaxis in surgical patients is still not optimal. The key to appropriate thromboprophylaxis is a good risks assessment of the patient and appropriate selection of thromboprophylaxis therapie. We believe, that it would be reasonable to introduce a formal and active strategies for the prevention of venous thromboembolism to provide the most appropriate protection of patients at increased risk.

Background Venous thromboembolism (VTE) with its two presentations: deep vein thrombosis(DVT) and pulmonary embolism (PE) is the third leading cause of cardiovascularmorbidity and mortality. To obtain national data on this pathology, the Council ofCardiovascular Emergencies and the Research Area of the Argentine Society of Cardiologyconducted a prospective registry of patients with confirmed VTE in 54 centersduring one year. Methods Patients with confirmed VTE were included in a prospective, consecutive and continuousregistry during 2009-2010 in 54 participating centers of the Autonomous Cityof Buenos Aires and the rest of the country (n = 26 and 28, respectively). Individualpatient data were registered in an electronic form.ResultsOne hundred and eighty one patients with median age of 66 years (53-79), 59% ofwhich were women, were included in the study. Pulmonary embolism was diagnosedin 34%, DVT in 33% and PE + DVT in 33%. The most prevalent risk factors wereprolonged rest in 42% of cases, cancer in 20%, history of VTE in 10% and none in9%. All DVT were diagnosed by venous Doppler. Pulmonary embolism was diagnosedby spiral CT scan (86%), ventilation/perfusion scintigraphy (16%) and arteriography(0.8%). Seventy percent of patients received low molecular weight heparin, 40%unfractionated heparin, 11% thrombolytic agents and 10% had no treatment. Venacava filter was used in 12% of cases and mechanical ventilation in 9%. Recurrent PEwas observed in 4% of patients, shock in 14% and in-hospital mortality was 7%.ConclusionsProlonged rest was the most prevalent risk factor. Only 9% of patients showed noknown risk factors. Helical CT scan was the preferred method for PE diagnosis.Low molecular weight heparin was the treatment of choice for VTE. Thrombolyticswere used in 11% of PE patients and vena cava filter in 12% of VTE patients. VTEin-hospital mortality was 7%.

Purpose of the Study: Clinical prediction models have been developed to assess the pre-test probability for pulmonary embolism (PE). The Wells model and the revised Geneva score are the two most well studied. Our purpose was to compare the two prediction models, and indentify the frequent clinical findings of PE in patients admitted to the University Clinic of Pulmonary and Allergic Diseases Golnik. Methods: In 100 random emergency department patients and hospital inpatients with suspected PE and performed pulmonary CT angiography (CTPA) as the gold standard, a retrospective assessment of the clinical probability of PE by the Wells rule and the revised Geneva score was made. ECG, D-dimer, NT-proBNP, arterial blood gas analysis, chest X-ray, CTPA and 13 other clinical findings were analysed as well. Results: Average age was 65 years (SD 14.5), 39 % were male. The overall prevalence of PE was 33 %. The rates of PE in low, moderate, and high PE risk groups as determined according to the Wells model and the revised Geneva score were 3.7, 53,1, 100, and 14.3, 32.1, 83.3 %, respectively. ROC analysis showed that the Wells model was statistically more accurate than the Geneva score with the area under the curve (AUC) in Wells model 0.85 (95 % CI 0.762–0.936) and in Geneva score 0.73 (95 % CI 0.612–0.838). Sudden dyspnea, active malignancy, venous thromboembolism (VTE) history, estrogen therapy, deep vein thrombosis (DVT) signs, ECG changes and lower PaCO2 were significantly more frequent in PE group. All patients with PE had an increased concentration of D-dimer, and no PE were diagnosed in the group of patients with normal D-dimer. CTPA was ordered in 17 % of patients with low pre-test probability of PE according to Wells criteria and normal D-dimer. Conclusions: The Wells model is more accurate than the Geneva scoring system for the diagnosis of PE in patients admitted to a pulmonary clinic. Additional findings, such as sudden dyspnea, estrogen therapy, ECG changes and lower PaCO2, should always be incorporated in clinical assessment of PE. Adding the Wells algorithm to the clinical pathway for PE management might slightly decrease the number of CTPA.

Focus in this discussion of pulmonary embolism is on the following: risk factors (age heredity and blood type obesity estrogen and oral contraceptive use/pregnancy cardiovascular disease cancer and other risk factors); pathophysiology and presenting symptoms; laboratory procedures and findings (radiography electrocardiography lung scanning and evaluation of lower extremity veins); treatment modalities (heparin therapy thrombolysis and surgery); and prevention. Pulmonary embolism may be the primary cause or a major contributory cause in as many as 200000 deaths per year in the US. Most of these deaths occur in patients in whom the diagnosis is not suspected and thus not treated. The mortality rate for untreated pulmonary embolism is approximately 30%. 90% of patients survive the initial embolic event but the correct diagnosis is made in no more than 2/3 of cases. Risk factors for the development of deep venous thrombosis are based upon the Virchow-Aschoff postulates which include: trauma or disruption of the vein wall; stasis of blood flow in the veins; and increased coagulability of the blood. More than 85-90% of all pulmonary emboli originate from deep venous thromboses in the popliteal and femoral deep veins. Other important although less frequent sites of origin of venous thromboembolism include the pelvic veins the renal and hepatic veins the axillary veins in the upper extremities and the right atrium. Accurate diagnosis and effective prevention and treatment depend on the clinicians awareness of risk factors for development of deep vein thrombosis. Estrogen may accelerate intimal proliferation in arteries and veins and it may also increase permeability of venous vascular endothelium. The risk of thromboembolism increases as the dose of estrogen increases. Both pregnancy and oral contraceptive use significantly decrease venous tone and the velocity of blood flow in the calf of the leg. Appropriate treatment includes thrombolytic therapy for patients with massive pulmonary embolism which results in hypotension or shock. Anticoagulant therapy with herapin followed by an oral anticoagulant is the primary treatment for most patients with submassive emboli in which there is less cardiovascular compromise. When thrombolytic therapy is used it should always be followed by anticoagulant therapy. Prevention of primary or recurrent deep vein thrombosis is directed toward improving venous blood flow and reducing hypercoagulability.

To explore the clinical characteristics and outcomes of lung cancer patients with venous thromboembolism (VTE). The clinical data of 80 lung cancer patients with VTE hospitalized from January 2003 to April 2013 at our hospital were reviewed. The clinical factors of age, gender, clinical manifestations, pathological type, clinical stage, performance status and therapeutic regimen were recorded and analyzed. And the pulmonary thromboembolism (PTE) patients with deep venous thrombosis (DVT) were enrolled into PTE group. The occurrences, clinical manifestations and prognosis of VTE were evaluated. A total of 80 patients were enrolled. There were 40 males and 40 females with a mean age of (65.8 ± 11.3) years. Adenocarcimoma was identified in 58 (72.5%) patients and advanced lung cancer in 71 (88.8%) patients. Among 37 (46.3%) patients with histodifferentiation results, 89.2% (33/37) of them were moderately and/or poorly differentiated. In 32 (40.0%) patients on chemotherapy, 71.9% (23/32) of them received a platinum-based regimen. There were 35 (43.8%) pulmonary thromboembolism embolism (PTE) and 45 (56.2%) DVT patients. Among PTE patents, 14 (40.0%) were identified incidentally. Dyspnea and swollen of limb were the most common symptoms. Only 20.0% (16/80) patients received VTE prophylaxis. After a definite diagnosis of cancer, 73.8%, 77.5%, 82.5% and 85.0% of patients experienced an event within 3, 6, 9 and 12 months respectively. Up to April 2014, among 53 deceased patients, 77.4% (41/53) died from lung cancer, 9.3% (5/53) PTE while 13.2% (7/53) due to other causes. The cumulative mortality rates within 3, 6, 9 and 12 months after VTE event were 49.1%, 67.9%, 77.4% and 79.2% respectively. Adenocarcimoma, advanced lung cancer, poor histodifferentiation and platinum-based chemotherapy regimen are the risk factors of VTE in lung cancer patients. Most events of VTE occur within 3-6 months after a diagnosis of lung cancer while most mortality cases within 1 year after VTE events.

Individualised strategy of warfarin treatment for deep vein thromboembolism – case reports

Introduction: Pulmonary embolism (PE) is a complication of deep vein thrombosis, presenting with various clinical features. While the majority of cases remain unexpressed, some patients manifest with symptoms from dyspnea and tachypnea to acute cor pulmonale. Accurate diagnosis in the intensive care unit (ICU) or emergency department (ED) is crucial and requires various examinations, including bedside echocardiography. Materials and Methods: This research included 34 systematic reviews and clinical cases acquired from PubMed and Science Direct, using the keywords PE, echocardiography, and McConnell`s sign. Results: Pulmonary embolism is a condition that could remain unexpressed or result in a sudden death, depending on the size of the embolus entering the pulmonary vasculature. Up to 60% of cases of PE are asymptomatic and resolve on their own; however in cases with major vessel occlusion the patient faces life-threatening conditions such as severe hypoxemia or acute cor pulmonale. These cases are linked to high mortality rates, requiring early detection and specific management. The diagnostic process includes routine tests, such as chest radiography. However, bedside echocardiography allows fast and accurate diagnosis based on a distinct set of criteria. Echocardiographic features of PE include severely dilated right ventricle (RV) with decreased systolic function, septal flattening, with normal movement and size of the left ventricle. McConnell`s sign is pathognomonic for PE. It is a type of an RV dysfunction consisting of akinesia of the mid-free wall but normal motion of the apex. The aim of this review is to analyze the clinical significance of McConnell`s sign in diagnosing acute pulmonary embolism. Conclusions: Acute PE is a life-threatening condition, requiring urgent and accurate diagnosis for proper patient management. McConnell`s sign is the most distinct echocardiographic finding described in patients with acute PE. It may be useful in cases of massive pulmonary embolism in which a rapid presumptive diagnosis is required in ICU/ED settings.

It is well-known that malignancies, particularly pancreatic and brain cancers, often present as venous thromboembolism. However, stroke and angina attributable to arterial occlusion are relatively common presentations as well. We are reporting a patient, with treatment-naïve hepatitis C and multiple liver nodules, was admitted for deep vein thrombosis (DVT) and pulmonary embolism (PE). Subsequently, she developed an ascending paralysis due to spinal cord infarct (SCI) despite adequate anticoagulation. She also had an enlargement of left supraclavicular lymph node, which was confirmed histologically metastatic cholangiocarcinoma. To our best knowledge, this is the first literature report showing the association linking SCI to metastatic cholangiocarcinoma as a consequence of hypercoagulable state of malignancy.

Background: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE), is one of the major complications of cancer, and is associated with poor prognosis.Case Description: Here we present a 71-year-old man with stage IV duodenal adenocarcinoma who developed intermittent hemoptysis and had increased serum D-dimer at the time of disease progression. Chest computed tomography showed prominent filling defects within bilateral main and branch pulmonary arteries. After treatment with low-molecular weight heparin and salvage chemotherapy with gemcitabine and oxaliplatin, the patient had disease stabilization and improved PTE for the following two months.Conclusions: Although the occurrence of PTE in duodenal adenocarcinoma patients is extremely rare, a high clinical suspicion plus prompt diagnostic procedures are indicated to facilitate proper treatment of this rare condition.

Background: Venous thromboembolism (VTE), comprising the conditions of deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common acute cardiovascular event associated with increased long-term morbidity, functional disability, all-cause mortality, and high rates of recurrence. Major advances in identification, prophylaxis, and treatment over the past 3-decades have likely changed its clinical epidemiology. However, there are little published data describing contemporary, population-based, trends in VTE prevention and management. Objectives: To examine recent trends in the epidemiology of clinically recognized VTE and assess the risk of recurrence after a first acute episode of VTE. Methods: We used population-based surveillance to monitor trends in acute VTE among residents of the Worcester, Massachusetts, metropolitan statistical area (WMSA) from 1985 through 2009, including in-hospital and ambulatory settings. Results: Among 5,025 WMSA residents diagnosed with acute PE and/or lowerextremity DVT between 1985 and 2009 (mean age = 65 years), 46% were men and 95% were white. Ageand sex-adjusted annual event rates (per 100, 000) of clinically recognized acute first-time and recurrent VTE was 142 overall, increasing from 112 in 1985/86 to 168 in 2009, due primarily to increases in PE occurrence. During this period, non-invasive diagnostic VTE testing increased,

Objective To analyze the risk factors of pulmonary embolism in patients with negative D- dimer in serum in order to determine the need of pulmonary computed tomography angiograph (CTA) to confirm the final diagnosis in those patients for avoidance of misdiagnosis. Methods A retrospective analysis of 106 patients suspected to suffer from pulmonary embolism (PE) with serum negative D-dimer checked with pulmonary CTA was carried out. According to the results of CTA, the patients were divided into two groups, namely PE group (n=41) and non-PE group (n=65). The difference in clinic presentation, the time elapsed from onset to visit, N-terminal pro-brain natriuretic peptide (NT-proBNP) , high risk factors (such as immobilization for 3 weeks, leg swelling and pain to palpation, history of deep vein thrombosis, malignancy) and Wells score (≥4 points indicates probability of PE). And logistic regression analysis was made to investigate the risk factors in PE with negative D-dimer. Results The analysis study showed that 38.6% of total patients suspected to suffer from PE with serum negative D-dimer were checked by CTA to confirm the presence of PE. One important characteristics of the D-dimer negative PE patients was the longer time consumed from onset to visit [(9.51±2.01) d vs. (4.01±1.92) d, P <0.05] , and majority of the CTA positive patients suspected to suffer from PE with negative D-dimer had high risks of PE (P <0.01). Compared with the non-PE group, the Wells score ≥4 points and the level of serum NT-proBNP significantly increased in the PE group (P <0.01). Logistic regression analysis revealed that dyspnea, high NT-proBNP level and Wells sore ≥4 points were risk factors for D-dimer negative PE. Conclusion Delayed treatment was the main cause of misdiagnosis of D-dimer negative PE. Dyspnea, high NT-proBNP level and Wells sore ≥4 points were risk factors for suspected PE patients with negative D-dimer, and these patients should be confirmed by pulmonary CTA. On the contrary, PE could be excluded if patients with D-dimer negative had no these risk factors. Key words: D-dimer; Negative; Risk factor; N-terminal pro-brain natriuretic peptide; Pulmonary embolism

Largely on the basis of postmortem studies, pulmonary emboli have been implicated as an etiologic factor in the acute and chronic respiratory failure of chronic obstructive pulmonary disease (COPD). The diagnosis of pulmonary embolism clinically or by tests directed at the lungs (except pulmonary angiography) is likely to be inaccurate in the presence of COPD because of the underlying abnormalities. We reasoned that by directing tests at the lower extremities to determine the presence or absence of deep venous thrombosis (DVT), we might obtain an accurate reflection of the presence of pulmonary emboli (PE), since virtually all PE are believed to arise in those deep veins. Accordingly, in a group of 45 patients with decompensated COPD, we performed ascending contrast venography (12 patients), 125I-labeled fibrinogen scanning (6 patients), or both (27 patients). Only 2 patients had proximal DVT, which was probably present on admission (4.4%). Two other patients developed DVT (limited to the calf) while hospitalized, (overall incidence of 8.9%). Another patient developed superficial thrombophlebitis during the study but before venography. Noninvasive tests for DVT (Doppler ultrasound and impedance plethysmography) were performed in 40 subjects. A negative result had a high predictive value (94% for each), but contrary to findings in other settings, a positive test had a poor predictive value (Doppler = 33%, IPG = 25%).

Venous thromboembolism is a common complication among hospital inpatients and contributes to longer hospital stays, morbidity, and mortality. Some venous thromboembolisms may be subclinical, whereas others present as sudden pulmonary embolus or symptomatic deep vein thrombosis. Ultrasonic Doppler and venographic techniques have shown deep vein thrombosis of the lower limb to occur in half of all major lower limb orthopaedic operations performed without antithrombotic prophylaxis. Deep vein thrombosis of the lower limb is also seen in a quarter of patients with acute myocardial infarction, and more than half of patients with acute ischaemic stroke. Deep vein thrombosis of the lower limb normally starts in the calf veins. About 10-20% of thromboses extend proximally, and a further 1-5% go on to develop fatal pulmonary embolism. Appropriate antithrombotic measures can reduce this complication. Until recently, some clinicians were reluctant to provide such prophylaxis routinely. As unfounded fears of major bleeding complications from anticoagulant regimens wane, preventive treatments are used more often with medical and surgical patients. However, the risk of bleeding can be serious and this has particular bearing in postoperative patients. Venous thromboembolism can also arise spontaneously in ambulant individuals particularly if they have associated risk factors such as thrombophilia, previous thrombosis, or cancer. However, in over half of these patients, no specific predisposing factors can be identified at presentation. Venous thromboembolism often manifests clinically as deep vein thrombosis or pulmonary embolism, and is possibly one of the preventable complications that occur in hospitalised patients