Incidental Pulmonary Emboli Research Articles

Cancer-Associated Thrombosis: Management of a Patient With an Isolated Calf Deep Vein Thrombosis.

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.Venous thromboembolism occurs frequently in patients with cancer and is the second leading cause of death, after the cancer itself. There is a well-established consensus of the need for anticoagulation in patients with a proximal deep vein thrombosis or pulmonary embolism. But with improved imaging technology and widescale use of contrast imaging for cancer staging, many incidental pulmonary emboli are detected in patients with cancer. Furthermore, many isolated distal deep vein thromboses and subsegmental pulmonary emboli are identified. There have been questions if these small or asymptomatic thromboses require anticoagulation management similar to more proximal or symptomatic thromboses. In this Oncology Grand Rounds, we will review the existing evidence for these situations. We will also review management strategies for cancer-associated thrombosis, reflecting the evolving drugs and evidence over the past 20 years.

Incidental central pulmonary emboli in outpatients with deep vein thrombosis.

While it has been demonstrated that large asymptomatic pulmonary embolism (PE) can occur, many studies have assessed inpatients or patients with known risk factors for venous thromboembolism (such as malignancy). There are few data regarding incidental PE in outpatients with deep vein thrombosis (DVT) or assessing whether these emboli occur centrally or peripherally in the pulmonary arteries. To determine the rates of incidental central and peripheral PE in outpatients with proximal and distal DVT. This was a retrospective cross-sectional study of 120 patients attending our community imaging clinic between January 2015 and March 2020, with ultrasound-confirmed lower limb DVT, and subsequent computed tomography pulmonary angiogram (CTPA) within 24 h. Exclusion criteria were symptoms indicative of PE. Imaging reports were retrospectively reviewed to record the proximity of DVT and the location of any PE as either central (pulmonary trunk or main pulmonary arteries) or peripheral (lobar, segmental or subsegmental pulmonary arteries). Incidental PE occurred in 71 patients (59.2%), with a rate of 77.5% in proximal and 50.0% in distal DVT. Sixteen patients had central PE (13.3% of all patients with DVT; 22.5% of all patients with PE). Two patients (both with proximal DVT) had PE in the pulmonary trunk. Incidental PE occur frequently in outpatients with lower limb DVT, including the possibility of asymptomatic central emboli. Further studies with larger patient cohorts would be useful to assess the utility of baseline chest imaging in outpatients with DVT.

Incidental pulmonary emboli are associated with a very high probability of progressive malignant disease on staging CT scans.

The link between malignancy and venous thromboembolism (VTE) is well established; the risk has been shown to be higher in certain tumour types and in patients receiving platinum-based chemotherapy regimens. 'Active' cancer is often quoted as being a particular risk factor for VTE, but the definition varies widely and the supporting evidence is weak. This study was conceived to establish whether incidental pulmonary emboli are associated with an increased likelihood of progressive disease on a staging computed tomography (CT) scan. All CT scans containing incidental PEs over the course of a year in a large specialist cancer hospital were examined (n = 306). An age-matched control group was assembled. Multivariate logistic regression analysis was performed to establish the relationship of several independent variables, including progressive disease, with the dependent variable of the presence or absence of incidental pulmonary emboli. Progressive disease was present in 144 of 306 (47.1%) of the patients in the PE group but only 63 of 306 (20.6%) of the control group patients. Progressive disease on the staging CT scan was found to have an odds ratio for incidental PE of 3.46, with a 95% CI of 2.38-5.01. Receiving platinum-based chemotherapy resulted in an odds ratio of 3.89 (2.41-6.28) for PE. Receiving non-platinum-based systemic anti-cancer therapy (SACT) resulted in an odds ratio for PE of 1.71 (1.16-2.50). The detection of an incidental PE on a staging CT scan is associated with a very high risk of progressive malignant disease.

Optimising CT-chest protocols and the added value of venous-phase contrast timing; Observational case-control.

To optimize CT chest protocol by comparing venous contrast timing with arterial timing for contrast opacification in vessels, qualitative image quality and radiologists' satisfaction and diagnostic confidence in assessing for potential nodal, pleural and pulmonary disease in general oncology outpatients. Matched case-control study performed following CT protocol update. 92 patients with a range of primary malignancies with 2 CT chests in a 2-year period, one with an arterial phase protocol and the second in the 60 second venous phase, were included. Contrast attenuation in aorta, pulmonary artery and liver were measured. Subjective measurements assessed perivenous artefact, confidence in nodal pleural and pulmonary assessment and presence of pulmonary emboli. Statistical analysis was performed using paired and unpaired t-tests. Venous-phase CT demonstrated more consistent enhancement of the vessels, with higher attenuation of the nodes, pulmonary and pleural lesions. There was a significant reduction in perivenous beam hardening artefact on venous-phase CT (P < 0.001). Diagnostic confidence was significantly higher for nodal assessment and pleural abnormality visibility (P < 0.001) and pleural assessment (P < 0.05). There was no significant difference in pulmonary mass visibility. There was adequate enhancement to diagnose significant pulmonary emboli (PE) with 4 incidental PEs detected on the venous phase, extending to segmental vessels. Venous-phase CT chest performs better than arterial-phase on all fronts, without compromising assessment of incidental pulmonary emboli. When intravenous contrast is indicated in a routine chest CT (excluding a CT-angiogram), the default timing should be a venous or 60s phase.

Patient Experience of Living With Cancer‐Associated Thrombosis in Canada (PELICANADA)

IntroductionPrevious research from the United Kingdom and Spain has identified several areas of unmet clinical and support need for cancer patients diagnosed with venous thromboembolism. It is not known whether such experiences are restricted to those countries health care systems and culture. We therefore evaluated patients’ experience of cancer‐associated thrombosis (CAT) within a Canadian setting. MethodsPurposive sampling of patients with CAT attending a regional thrombosis clinic in Vancouver was undertaken. Semistructured interviews were audio recorded, transcribed, and coded using NVivo software. A deductive approach was taken by applying the framework matrix from the original study to these data on a case‐by‐case basis. ResultsTwenty patients (10 male, 10 female) aged 39 to 74 (mean, 63) representing a breadth of different cancers participated. Commonalities between the UK and Canadian patients included the traumatic nature of experiencing CAT, the need for information, and adaptive behaviors through ritualization. Two new themes were identified: (1) Patients with incidental pulmonary emboli (iPE) were usually telephoned about their thrombus with little support and suboptimal communication; and (2) cost implications of accessing low‐molecular‐weight heparin varied according to insurance cover. Patients were sometimes converted to warfarin for financial reasons. ConclusionThe distress associated with CAT is a common experience across different populations but may be ameliorated by early access to specialist services, information, and support. The current process for managing iPE could be improved with better communication and a dedicated clinical pathway. Funding issues may influence choice of anticoagulant.

ACUTE PULMONARY EMBOLISM ASSOCIATED WITH A MOBILE RIGHT ATRIAL THROMBUS MANAGED BY SUCTION THROMBECTOMY

SESSION TITLE: Pulmonary Vascular Disease SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/22/2019 3:45 PM - 4:45 PM INTRODUCTION: Pulmonary embolism (PE) associated with a free-floating right heart thrombus (RHT) carries a much higher mortality risk. Optimal management of RHT is controversial. Suction thrombectomy can be a viable treatment option. CASE PRESENTATION: A 66-year-old female was admitted for Rasmussen’s encephalitis. After 2 weeks in the hospital she developed sudden decreased motor skills, facial droop and lethargy. Computed tomography (CT) of the head and neck was unremarkable except for incidental large pulmonary emboli. CT angiogram of the chest confirmed PE extending from the distal main arteries into the lobar branches bilaterally (Fig. 1). An echocardiogram showed a 4x2.6 cm mobile mass within the right atrium that crossed the tricuspid valve (Fig. 2). She had been on deep vein thrombosis (DVT) prophylaxis throughout her hospital stay with subcutaneous heparin and over the 24-hour period preceding these events, her platelet count had decreased from 345,000 to 83,000. Argatroban infusion was started for suspected heparin induced thrombocytopenia. Venous doppler ultrasound showed a DVT in the left leg. She was hemodynamically stable with oxygen saturation in the upper 90’s on room air. However, the patient was considered to have a high mortality risk given her clot burden and the size of the mobile RHT. She was not a candidate for surgery or thrombolytics but considered a candidate for suction thrombectomy. During the procedure, intracardiac echocardiography identified a large thrombus completely filling the right atrium (Fig 3). The Penumbra® suction system was introduced via a 8.5 French sheath to perform the aspiration. Given the size of the thrombus, a snare was used to break up the clot while applying continuous suction with the penumbra device. Aspiration of the clot was successful with minimal residual clot present on the eustachian valve (Fig 4). Video images of the procedure were recorded. The patient did well after the procedure and was discharged on oral anticoagulation. DISCUSSION: There are several suction thrombectomy systems available. The smaller cannulas of the Penumbra® system provide the advantage of flexibility. To our knowledge, this is the first reported case using this system for the management of a RHT. The use of this device in intermediate-risk PE is currently being evaluated in a clinical trial. CONCLUSIONS: Given the lack of clear guidelines for management of RHT, suction thrombectomy with the Penumbra® system can be considered especially when thrombolytics are contraindicated. Further studies are however needed to assess its use for this indication. Reference #1: Barrios D, Rosa-Salazar V, Morillo R, Nieto R, Fernandez S, Zamorano JL, et al. Prognostic Significance of Right Heart Thrombi in Patients With Acute Symptomatic Pulmonary Embolism: Systematic Review and Meta-analysis. Chest. 2017;151(2):409-16. Reference #2: Nosher JL, Patel A, Jagpal S, Gribbin C, Gendel V. Endovascular treatment of pulmonary embolism: Selective review of available techniques. World journal of radiology. 2017;9(12):426-37. Reference #3: Evaluating the Safety and Efficacy of the Indigo Aspiration System in Acute Pulmonary Embolism (EXTRACT-PE) [Available from: https://clinicaltrials.gov/ct2/show/NCT03218566 DISCLOSURES: No relevant relationships by Yasir Akhtar, source=Web Response No relevant relationships by Isaac Biney, source=Web Response No relevant relationships by Peter McKeown, source=Admin input No relevant relationships by Francisco Soto, source=Web Response No relevant relationships by J Turner, source=Web Response

The pathological challenge of establishing a precise diagnosis for pulmonary tumour thrombotic microangiopathy: identification of new diagnostic criteria.

Pulmonary tumour thrombotic microangiopathy (PTTM) is a fatal disease of patients with cancer that causes progressive pulmonary hypertension (PH). Its pathology is characterised by fibrocellular intimal proliferation and thrombosis caused by tumour emboli in microscopic pulmonary arteries. However, such PTTM-like lesions often appear incidentally. We sought to identify features that distinguished PTTM from incidental pulmonary tumour emboli, and to gain an overall picture of PTTM morphology in terms of its pathogenesis. Twenty-five PTTM cases were classified into two groups: (i) a definite group (n=14), clinically diagnosed with PH; and (ii) a suspicious group (n=11) with respiratory symptoms but without a clinical evidence of PH. As a control group, autopsy cases with PTTM-like lesions lacking progressive respiratory symptoms were selected (n=7). PTTM-like lesions in these groups were studied and a diagnostic guide for PTTM formulated as follows: PTTM-like lesions with >17 affected vessels observed in a 1-cm2 area of lung specimen, and the absence of pulmonary metastatic nodules. PTTM due to gastric cancers was shown to have a significantly shorter course and larger arterial involvement than cases with non-gastric cancers. Serial sections revealed a PTTM lesion to be a longitudinal obstruction that accumulated in microscopic pulmonary arteries and that showed a proximal extension via supernumerary arteries. We suggest novel pathological diagnostic characteristics for PTTM deduced from a study of 25 autopsy cases. This includes PTTM-like lesions with >17 affected vessels in a 1-cm2 area of lung specimen and the absence of pulmonary metastatic nodules.

Cardiovascular findings on cross-sectional imaging: spectrum of incidental and critical findings and clinical relevance for the abdominal radiologist.

Although not the primary focus of the exams, cardiovascular structures are included to some extent on all abdominal or whole-body cross-sectional studies. Cardiovascular findings often present incidentally and may range from chronic to acute and emergent pathologies. Among the most common cardiovascular findings are the presence of cardiac calcifications, most commonly coronary, which correlate with the presence of coronary artery and valvular disease. Signs of myocardial ischemia, both acute and chronic, and its complications may also be visualized. Cardiac filling defects most commonly represent thrombus and are associated with systemic arterial embolic complications. Pericardial findings often manifest as effusion or thickening, which may lead to hemodynamic consequences visible at imaging. Incidental pulmonary emboli and systemic venous thrombi may be incidentally detected, particularly in hospitalized and oncologic patients, and warrant immediate attention. This review will highlight the appearance of common and important incidental cardiovascular findings and related pitfalls and discuss reporting and follow-up recommendations relevant to the abdominal radiologist.

Incidental pulmonary emboli in stage IV melanoma patients: Prevalence in CT staging examinations and improved detection with vessel reconstructions based on dual energy CT.

ObjectivesMalignancy is the strongest predictor for venous thromboembolism. Dual energy CT (DECT) can support assessment of pulmonary emboli (PE) by providing vessel reconstructions (DECT-VR) and highlighting thrombi. Purpose was to determine prevalence and risk factors of PE in staging examinations of stage IV-melanoma patients and to evaluate the potential of DECT-VR to improve PE diagnosis.Material and methodsThis retrospective study was approved by IRB. Contrast-enhanced, conventional grey scale CT (cCT) and DECT-VR of 200 stage IV-melanoma patients were reviewed by three radiologists in consensus. Overall prevalence was determined. One-sided Wilcoxon-test was performed to compare the number of detected emboli between cCT and cCT with supplementary DECT-VR. Frequencies of risk factors were compared with χ2 test.ResultsOn cCT, 9 PE were detected (6 patients, correlating to 3% of the study population with 0.05 emboli per patient). With the supplementary DECT-VR, number of diagnosed emboli increased from 9 to 17 (p < 0.05) (in total 9 patients, correlating to 0.09 emboli per patient). Emboli on DECT-VR were mainly subsegmentally (7 of 8). There was no significant difference in the frequency of risk factors.ConclusionsThe prevalence of pulmonary emboli in our cohort of 200 stage IV melanoma patients was 5%. DECT-VR improved significantly diagnosis of PE, especially when located subsegmentally.

Radiographer screening for incidental pulmonary emboli on routine contrast-enhanced computerised tomography scans at a cancer centre

To introduce and assess effectiveness of a radiographer-led screening programme for the detection of unsuspected pulmonary emboli on routine contrast-enhanced computed tomography (CT), and to evaluate radiographer response to this extended role. A training programme was devised for all radiographic staff working in CT. The screening service was introduced and monthly quality assurance performed with cumulative analysis of the first 2 years. Clinical effectiveness before and after screening was evaluated by comparing the time interval between the scan and the start of a clinical consultation for anticoagulant prescription. A satisfaction survey was sent to all participating staff. Thirty-two radiographers completed the training. During the training period, the radiographer detection rate of incidental pulmonary emboli was 89%. Main, lobar, segmental, and subsegmental emboli were detected. The overall detection rate after full introduction of the programme was 92% for the first 2 years. The time interval between the scan and clinical consultation for anticoagulant prescription dropped from a mean of 1.5 days to a mean of 26 minutes and ensured that treatment was commenced at the same patient attendance. Eighty-four percent of staff completed the satisfaction survey and all were satisfied with the extended role. Radiographer screening for incidental pulmonary emboli was effective and accurate. It resulted in immediate communication with the responsible physician and commencement of anticoagulation therapy at the same hospital attendance, creating a "one-stop" service. Radiographer satisfaction with the extended role was high.

139 Admit or Discharge: Management of Incidental Pulmonary Embolism in an Emergency Center

It is common for incidental pulmonary emboli (IPE) to be detected by computed tomography (CT) scans performed during a cancer evaluation. Our purpose was to describe outcomes in cancer patients presenting to an emergency department (ED) with a diagnosis of IPE. Retrospective chart review of patients presenting to the ED of a major cancer hospital from Jan 1, 2013 to Dec 31, 2014. Eligibility criteria included all age >18 y cancer patients undergoing an out-patient lung CT scan for cancer staging. Exclusion criteria were patients with known pulmonary embolism (PE) within 1 year prior, on anticoagulation therapy for Venous Thromboembolism (VTE), CT scan obtained for suspected PE, against medical advice discharge, or being a non-malignant cancer patient. Medical records were reviewed and data extracted for demographics, cancer type and stage, comorbidities, performance status, vitals, location of the emboli, anticoagulation, ED disposition, and cause of death. Of 1411 newly diagnosed PE patients during the study period, 208 (15%) presented to the ED met the entry criteria of IPE found during routine cancer staging. Of IPE patients, 15 were excluded (12 recurrent PE, 1 benign tumor, and 2 left against medical advice). Of the study cohort consisting of 193 patients, 111 (58%) were male, mean age was 63.37 years (SD=12.09), 139 (72%) were white, 27 (14%) black, 17 (9%) Hispanic, and 10 (5%) of other race/ethnicity. The majority of IPE patients had solid tumors (n=174, 90%) and 69% of patients (n=133) were discharged home on low molecular weight heparin. Cox regression analysis showed that sex, race, Charlson Comorbidity Index (age unadjusted), cancer stage, performance status, tachycardia, hypoxia and location of the emboli were associated with hospital admission. Admitted patients were more likely to die within 30 days, 16 of 60 (27%), than discharged patients, 0 (0%, Fisher exact test; p<0.001). Half of the admitted patients died within 180 days compared with 25 of 133 (19%) of the discharged patients (p<0.001). The risk of death within 30 days was higher if the emboli was located in the saddle or main pulmonary artery (PA) (40%) than those with lobar, segmental or sub-segmental PA (10%, 6% and 5 %, respectively). Multivariate analyses suggest that tachypnea and location of the emboli are associated with 30 day survival (p<0.05), and that performance status and location of the emboli are associated with 180 day survival and overall survival (p<0.05 for all). A cohort of selected ED cancer patients diagnosed with IPE may be identified for outpatient anticoagulation treatment and may be safely discharged.

ASCIA‐P75: ELEVATED VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) PLAYS AN IMPORTANT ROLE IN THE DIAGNOSIS OF POEMS SYNDROME

POEMS syndrome is a rare paraneoplastic syndrome that is caused by an underlying plasma cell disorder. It is characterised by polyradiculoneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes. The diagnosis is challenging due to the multifaceted nature of its manifestations. VEGF is one of the major diagnostic criteria of the syndrome. A 40 year-old man developed severe fatigue, footdrop and ascending weakness. IVIG was initiated for the presumptive diagnosis of CIDP with little effect. Corticosteroids, plasmapheresis, mycophenolate and rituximab did not halt the progression of his symptoms. Within one year, there was a significant deterioration in his fine motor skills and ability to walk. Significant findings on investigations included an IgA lambda paraprotein on serum IFE, a trace of paraprotein in 24-hour urine collection, sclerotic bone lesions, decreased DLCO on lung function test, incidental pulmonary emboli on CTPA, mild splenomegaly, prolactinaemia and low testosterone with raised FSH and LH indicative of primary hypogonadism. A VEGF level was obtained from a research laboratory showing significant elevation at 3292 pg/ml (normal control 778 pg/ml). The VEGF level was instrumental in reaching a unifying diagnosis of POEMS syndrome in this patient who was then able to undertake definitive treatment of chemotherapy with autologous stem cell transplant for curative intent. This case illustrates the utility of VEGF in diagnosing a rare yet devastating syndrome that often presents as a diagnostic dilemma with multisystem manifestations. VEGF levels correlate with disease activity rendering it a useful assay for monitoring the patient's response to therapy. VEGF is only available in research settings at present. Increased awareness of its utility will not only optimise the investigation and management of POEMS but also assist in the advocacy of adding the test to the MBS schedule for its use in clinical practice.

P167 Outcomesand Predictors Of Mortality In Cancer Patients With Incidental Pulmonary Embolism

Objectives Incidental pulmonary emboli (iPE) are detected in a significant minority of contrast CT scans performed during the management of patients with cancer. These patients are reported to have an increased mortality compared to matched controls. This study investigates outcomes and predictors of mortality following iPE. Methods Reports of all contrast-enhanced CT scans including the chest, excluding dedicated CT pulmonary angiography, performed between 1st May 2012 and 30th September 2013, were searched for prospectively identified iPE. Clinical data was collected from multiple sources, including clinic letters, discharge summaries, and the hospital patient database. Patients presenting with acute symptoms consistent with PE or those already receiving therapeutic anticoagulation were excluded. Potential clinical and radiological predictors of mortality were defined pre-hoc and tested using Student’s t-test and Cox proportional-hazard regression. Results There were 160 cancer patients with iPE. Anticoagulation treatment was given in 97% of cases. Overall 30-day and 6-month mortality following iPE was 20.6% (95% confidence interval 15.0–27.6%) and 52.5% (44.8–60.1%), respectively. Increased 30-day and 6-month mortality was observed in scans performed on inpatients compared to outpatients (38.2% vs 11.4%, p = 0.0004 and 78.2% vs 40.0%, p There were 86 (53.8%) central (main or lobar pulmonary arteries), 60 (37.5%) segmental, and 14 (8.8%) subsegmental pulmonary emboli. No significant mortality difference was observed between these radiological features. Conclusion This study has assessed potential poor prognostic features in patients with cancer and iPE. Despite the vast majority receiving therapeutic anticoagulation, there is a high 30-day and 6-month mortality. The benefits of conventional treatment in this clinical situation are as yet unclear.

Incidental Versus Symptomatic Pulmonary Embolism in Cancer Patients: A Multivariate Analysis of Recurrent VTE and Mortality.

AbstractAbstract 2257Venous thromboembolism (VTE) is a major cause of morbidity and mortality in cancer. In the context of frequent high-resolution imaging, pulmonary emboli (PE) are frequently identified incidental to other indications for imaging. Several key questions need answers. In cancer, are incidentally identified and symptomatic PEs of comparable clinical importance regarding risk of recurrent VTE and death? Can we identify a subgroup of patients with incidentally identified PEs for whom the risk of recurrent VTE is sufficiently low that long-term anticoagulation may not be necessary? Several recent studies suggest that incidental PE may result in comparable rates of recurrent VTE and death as symptomatic PE. However, those studies did not control for cancer type and anatomic distribution of the initial PE. We now report a comprehensive data set on PE in cancer, derived from MSKCC. All PE in a 2-year period (2008–9) were reviewed, with 2-year follow-up. We evaluated the cases for all cause mortality with time, as well as all recurrent VTE.There were 755 initial symptomatic PE with 122 recurrent VTE events and 574 initial incidental PEs with 124 recurrent VTE. 43.2% of all PEs were identified incidentally. The percent of total PEs that were identified incidentally varied markedly with different cancer types, pancreas (70.7%), colorectal (61.4%), hematologic (33.3%), gastro-esophageal (37.7%), lung (32.8%), breast (15.1%), gynecological (30.0%), brain (5.0%). Brain tumor patients less frequently undergo comprehensive body imaging for cancer staging, and therefore, asymptomatic PEs may be less likely identified incidentally. Because of the well-recognized differences in rates of recurrent VTE and mortality in different cancer types, differences in the percent of incidental PEs supports the necessity of considering cancer type in outcome analysis.The overall hazard ratios of death and recurrent VTE were highest in the first month after the initial PE, gradually declining with time. The cumulative rates of all cause mortality was higher for symptomatic PE in the initial 2 months, but equalized by 12 months. (All cause mortality, symptomatic PE: 1 month: 15%, 2 month: 24%, 6 month: 40%, 12 month: 53%. Incidental PE: 1 month: 6%, 2 month: 12%, 6 month: 30%, 12 month: 47%). Cumulative rates of recurrent VTE were similar in both cohorts. (Symptomatic PE: 3 month: 11.0%, 6 month: 13.6%, 12 month: 16.0%. Incidental PE: 3 month: 11.7%, 6 month: 17.1%, 12 month: 21.4%). For most major cancer types, early (1-month) mortality and 12-month recurrent VTE rates were similar regardless of the incidental versus symptomatic nature of the initial PE. However, for colorectal cancer, the 1-month mortality for symptomatic PE was 14.3% (8 of 56), but only 3.4% (3 of 89) for incidental PE, and the 12-month recurrent VTE rate was 17.9% for symptomatic PE and 5.6% for incidental PE.The anatomic location of the initial PE also evaluated. Segmental arteries were the most common initial location of symptomatic (45%) and incidental (47%) PE. Importantly, after an initial incidental PE, the risk of recurrent VTE was consistent, regardless of the initial anatomic location. For each category; main plus saddle, lobar, segmental, and subsegmental, the recurrent VTE rates were between 20 – 25%. The fact that a cancer patient exhibits a PE predicts recurrent VTE, with less relevance to the anatomic location of the initial event. Conclusions:In our institution, 43.2% of PEs in cancer patients were identified incidentally, by imaging studies performed for cancer staging, or evaluation of complaints not typically associated with PE. All cause mortality was twice as high in the first two months after a symptomatic PE as an incidental PE, but by the third month, the monthly rates became equivalent. The hazard ratio of recurrent VTE was similar between the symptomatic PE and incidental PE cohorts, including subgroups. A possible exception is in colorectal cancer, in which the 1- month mortality and 12-month recurrent VTE rates were higher for symptomatic PE. However, due to the retrospective nature of this study, and the multiple parameters considered, that observation needs confirmation. As even “small” subsegmental PEs are associated with recurrent VTE rates comparable to large proximal PEs, our data do not suggest that there are any subgroups for which anticoagulation is not justified. Disclosures:No relevant conflicts of interest to declare.

P-0006 Inferior Survival in Patients Diagnosed with Venous Thromboembolism Whilst Receiving Neoadjuvant Chemotherapy for Upper GI Malignancy.

ABSTRACT Introduction A high risk of venous thromboembolism (VTE) is associated with both active malignancy and chemotherapy. Previous studies in patients undergoing neoadjuvant chemotherapy for upper gastrointestinal (UGI) malignancies have estimated this risk to be around 10-15%. However, to our knowledge, this high rate of VTE has not yet been shown to be adversely associated with patient outcome in this group. Methods We undertook a single-centre descriptive study of all patients undergoing neoadjuvant chemotherapy for UGI malignancies (oesophageal and gastric) between 2007 and 2011, using our prospectively collected database. Frequency of symptomatic and incidental VTE occurring from commencement of chemotherapy and up to three months post-operatively, as well as survival data, was established. These were examined for association with a number of demographic, disease and treatment-related factors. Statistical analysis was performed using SPSS. Download : Download full-size image Results 115 patients were identified, with a mean follow-up period of 626 days. All patients were treated with a platinum-based chemotherapy regimen. The incidence of VTE was 14/115 (12.2%): 50% were deep vein thromboses, and 50% pulmonary emboli. 64% of VTEs were symptomatic and 36% were incidental pulmonary emboli diagnosed from pre-operative imaging. The mean time from commencing chemotherapy to diagnosis of VTE was 42 days (range 6-195 days). 91% were diagnosed pre-operatively, and 9% post-operatively. 45/115 (39%) of patients died during the study period. Neither incidence of VTE nor death was found to be associated with any of the following factors on multivariate analysis: age, gender, disease site, histology, tumour size, and nodal involvement. However, there was a significant difference in survival between those who were and were not diagnosed with VTE (Cox regression analysis, hazard ratio=2.71, 95% CI 1.28-5.75, p=0.009), and this effect was independent of all other variables analysed. Conclusion We have reported a 12% incidence of VTE in patients undergoing neoadjuvant chemotherapy for UGI malignancies, which is consistent with previous studies. However, our data suggest that the majority of VTEs in this patient group are occurring pre-operatively, and that those suffering a VTE have inferior outcomes in terms of survival, at least in the early stages of treatment. Use of prophylactic anticoagulation is not currently recommended in this setting, at least in part because the majority of patients receive neoadjuvant chemotherapy as outpatients. We propose a prospective randomized-controlled study of the use of prophylactic anticoagulation in outpatients receiving neoadjuvant chemotherapy for UGI malignancies. In the era of novel oral anticoagulant therapy, this would represent a welcome opportunity to improve outcomes in this patient group.

Symptoms Adversely Impact Survival Among Patients With Cancer and Unsuspected Pulmonary Embolism

TO THE EDITOR: In their retrospective cohort study, den Exter et al found no significant differences in recurrent pulmonary emboli (PE), bleeding, or death when comparing patients with cancer who had incidental PE identified on routine staging computed tomography scans and patients with cancer who were diagnosed with PE on the basis of the presence of symptoms. The authors are the first, to our knowledge, to use as a comparator symptomatic patients with dedicated scans demonstrating PE to assess the clinical significance of incidental PE. However, we previously demonstrated that 75% of patients with incidental PE, which we referred to as unsuspected PE (UPE), were actually symptomatic. Variability in the treating oncologists’ index of suspicion for PE may significantly influence whether patients with cancer are referred for radiologic studies to rule out PE, even in the presence of symptoms. Thus, patients who were included in the incidental PE group in the study by den Exter et al may have, at a different institution or with a different physician, been referred for a dedicated study to rule out PE. In a follow-up study that included 70 patients with UPE and 137 ageand stage-matched patients with similar cancers but without PE, we found that UPE adversely affected survival. Notably, patients with symptomatic UPE had significantly shorter survival than patients with asymptomatic clots (unpublished analysis, Fig 1). In fact, respiratory symptoms and fatigue have been independently associated with shorter survival in patients with cancer. Symptoms should thus be considered a critical variable in any survival analysis of patients with cancer and suspected or unsuspected PE. As research and treatment recommendations arise from these and related data, we caution against the use of the words incidental and asymptomatic as interchangeable terms. We recommend that symptoms be clearly reported when possible and that the term unsuspected rather than asymptomatic or incidental be used because of the assumptions and potential bias that are associated with the latter terms.

The clinician's response to a report of an incidental pulmonary embolism detected on multidetector CT

BackgroundThe prevalence of incidental pulmonary emboli (PE) detected on contrast enhanced CT performed for other reasons is approximately 2.5%. The treatment decisions based upon the discovery of incidental PE have...

PO-05 Incidental pulmonary emboli in cancer patients – a single centre experience

PO-05 Incidental pulmonary emboli in cancer patients – a single centre experience

Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT

To review cases discussed at a radiology departmental errors and discrepancies meeting, classify these to determine common patterns of error, and, focussing on CT, present a small number of specific errors that occur commonly. All cases discussed at our departmental discrepancies and complications meeting over a 30 month period were reviewed. Those where a genuine error was agreed to have arisen were classified by error type: poor image interpretation (false positive, false negative, misclassification); technical error (poor technique or procedural complication); and communications error. The imaging method from which the error arose was also recorded. Specific recurring errors were identified and collated. Two hundred and fifty-six errors were identified in 222 patients. Two hundred and twenty-five errors (88%) were due to poor image interpretation (14 false positive, 155 false negative, 56 misclassification). Seven errors (3%) were technical and 24 errors (9%) were due to poor communication. One hundred and fifty-nine (62%) of the 256 errors arose in relation to CT, 31 (12%) to ultrasound, 29 (11%) to magnetic resonance imaging (MRI), 24 (9%) to radiography, and 13 (5%) to fluoroscopy examinations, three (1.2%) of which involved vascular intervention. Several repeating errors arising during CT reporting were identified. Error is commonly identified in relation to radiological examinations. Most errors involve image interpretation, but a significant proportion result from departmental miscommunication. The majority of errors are false-negative interpretations and occur during interpretation of CT examinations. Recurring false-negative CT errors include failure to appreciate unexpected bowel or pancreatic malignancy, incidental pulmonary emboli, abnormality of vascular structures, bone lesions, omental disease, incidental abnormality present on targeted examinations or lesions on the periphery of the field of view.

Incidental Pulmonary Emboli in Oncology Patients: Prevalence, CT Evaluation, and Natural History

Incidental Pulmonary Emboli in Oncology Patients: Prevalence, CT Evaluation, and Natural History