Occult Malignancy In Patients Research Articles

The incidence and risk factors of occult malignancy in patients receiving vaginal hysterectomy for pelvic organ prolapse.

The aim of this study was to assess the incidence and risk factors for premalignant and malignant pathology in patients receiving vaginal hysterectomy (VH) and pelvic floor repair (PFR) for pelvic organ prolapse (POP). We performed a retrospective cohort study of pathological results after VH and PFR of 569 women at our institution from January 2011 through December 2020. Age, body mass index (BMI), POP-Q stage, and preoperative ultrasound results were evaluated as risk factors for occult malignancy. Six of the 569 patients (1.1%) had unanticipated premalignant uterine pathology and 2 (0.4%) had unanticipated malignant uterine pathology (endometrial cancer). There was no significant difference in the incidence of premalignant or malignant uterine pathology according to age, BMI, and POP-Q stage. However, if endometrial pathology is confirmed on preoperative ultrasonography, the probability of confirming malignant pathology increases (OR 4.63; 95% CI 1.84-51.4; p=0.016). The incidence of occult malignancy during VH for POP was significantly lower than that found in hysterectomy owing to benign disease. In the case of POP patients, for whom uterine-conserving surgery is not absolutely contraindicated, it can be performed. However, if endometrial pathology is confirmed by preoperative ultrasonography, uterine-conserving surgery is not recommended.

CT imaging for occult malignancy in patients with unprovoked venous thromboembolism (VTE) in a tertiary centre: is it worthwhile?

BackgroundInvestigating patients with unprovoked venous thromboembolism (uVTE) for occult malignancy can prove a diagnostic dilemma and imaging is often used extensively in this patient group.AimsThe primary objective of this study was to determine the incidence of malignancy on CT and other imaging over a 10-year period. A secondary objective was to evaluate the role of laboratory and other non-imaging tests performed.MethodsA retrospective key word search of our hospital’s imaging system was performed to identify patients with unprovoked DVT/PE over the last 10 years. All imaging, histology, endoscopy, laboratory tests, and clinical follow-up over 2 years were analysed. Patients with provoked VTE were excluded.Results150 patients had uVTE. 9 patients were diagnosed with occult malignancy by different investigations on index hospital admission (3 patients) or subsequently on clinical follow-up (6 patients). Mean age of patients was 62 years. 116 patients had CT body imaging. The incidence of malignancy diagnosed by initial CT imaging was 1.7% with a sensitivity of 22%, specificity 87%, and PPV 12.5%. Overall incidence of malignancy identified by imaging alone during the index hospital admission was 2%. Total incidence of malignancy including index admission and follow-up was 6%. Median time to cancer diagnosis was 12 months.ConclusionCT imaging had a low yield for diagnosing malignancy. Extensive imaging strategies increase cost and radiation exposure without improving mortality. Clinical follow-up, history taking, and physical examination guiding appropriate investigations remain the best tool for unmasking occult malignancy in patients with uVTE.

Does Cancer Masquerade as Sarcoidosis?

Sarcoidosis is a granulomatous disorder. Rarely, malignancy is accompanied by a granulomatous reaction. This retrospective study addressed whether cancer can masquerade as sarcoidosis. TriNetX identified 1029 newly diagnosed cases of sarcoidosis between October 2015 and September 2020, of whom 50 had a subsequent diagnosis of malignancy. In 36 cases, the malignancy was unrelated to sarcoidosis. In 7 cases, the diagnosis of sarcoidosis delayed the eventual cancer diagnosis by a range of 1 month to 2 years. In 7 cases, the subsequent diagnosis of cancer might have been related to the therapy for sarcoid. Cancer masquerading as sarcoidosis is very rare occurring in 7 (0.7%) of our 1029 cases. In no case was lung cancer masquerading as sarcoidosis. Searching for occult malignancy in patients with a known diagnosis of sarcoidosis is rarely indicated.

Absence of Susceptibility Vessel Sign in Patients With Malignancy-Related Acute Ischemic Stroke Treated With Mechanical Thrombectomy.

Background and PurposeClots rich in platelets and fibrin retrieved from patients with acute ischemic stroke (AIS) have been shown to be independently associated with the absence of the susceptibility vessel sign (SVS) on MRI and active malignancy. This study analyzed the association of SVS and the presence of active malignancy in patients with AIS who underwent mechanical thrombectomy (MT).MethodsThis single-center, retrospective, and cross-sectional study included consecutive patients with AIS with admission MRI treated with MT between January 2010 and December 2018. SVS status was evaluated on susceptibility-weighted imaging. Adjusted odds ratios (aORs) were calculated to determine the association between absent SVS and the presence of active or occult malignancy. The performance of predictive models incorporating and excluding SVS status was compared using areas under the receiver operating characteristics curve (auROC).ResultsOf 577 patients with AIS with assessable SVS status, 40 (6.9%) had a documented active malignancy and 72 (12.5%) showed no SVS. The absence of SVS was associated with active malignancy (aOR 4.85, 95% CI 1.94–12.11) or occult malignancy (aOR 11.42, 95% CI 2.36–55.20). The auROC of predictive models, including demographics and common malignancy biomarkers, was higher but not significant (0.85 vs. 0.81, p = 0.07) when SVS status was included.ConclusionAbsence of SVS on admission MRI of patients with AIS undergoing MT is associated with malignancy, regardless of whether known or occult. Therefore, the SVS might be helpful in detecting paraneoplastic coagulation disorders and occult malignancy in patients with AIS.

MO1018: Nephrotic Syndrome as a Paraneoplastic Entity

Abstract BACKGROUND AND AIMS Association between nephrotic syndrome (NS) and cancer is well known. However, it has been barely studied and sustained. Membranous nephropathy (MN) has often been identified as a glomerular paraneoplastic disease. Reported incidence of cancer at the time of biopsy or one year follow-up of MN is 10–20%. Incidence rates in other glomerulopathies are limited. Concomitant malignancy is associated with poor renal outcome in NS since therapy for cancer is a priority and immunosuppressive therapies for NS should be restricted. There is no consensus for cancer screening in patients with NS, with or without known risk factors for cancer. Our aim is to establish the incidence of neoplasia in a cohort of patients of two tertiary hospitals in Spain who develop NS. We analyze clinical characteristics, glomerular disease, types of malignancies and risk factors for cancer in this population. METHOD All patients > 18 years old with NS at one tertiary hospital in Madrid between January 2013 and December 2019 and at one tertiary hospital in Barcelona between January 2018 and June 2020 were included. Demographical and clinical data, laboratory results, and tests performed for cancer screening were recorded. Patients who presented cancer the year before or 24 months after the diagnosis of NS were identified. We performed a logistic regression model to identify independent risk factors for cancer in this population. RESULTS A total of 114 patients presented with NS during the study periods. A total of 57% were men, and the mean age was 57.28 ± 17.3 years. A total of 60% patients presented high blood pressure and 36% type 2 DM2; 7% patients presented HIV infection and 6% hepatitis C infection. A total of 44.7% reported smoking and 13.1% of alcohol consumption. More frequent histologic diagnosis were: diabetic nephropathy (17.5%), MN (14.9%), minimal change disease (7.9%) and membranoproliferative glomerulonephritis (7.9%). Eight patients presented positivity for anti-phospholipase A2 receptor antibodies. A total of 20 patients presented cancer (17.5%): 12 patients had a malignancy diagnosed the year before the NS onset (10 patients with solid organ malignancy and 2 patients with haematological cancer) and 8 patients 24 months after NS onset (3 patients with solid organ malignancy and 5 patients with haematological cancer). In the univariate analysis, patients with cancer were older (72.35 ± 10.28 versus 53.20 ± 17.13 years old; P < .0001). There were no differences in terms of smoking, viral infections, renal function, proteinuria or type of glomerulopathy. In a multivariate analysis, age was the only risk factor for cancer in patients with NS {OR = 1.122, [95% confidence interval (95% CI) 1.050–1.1980]; P = .0007}. Patients who were diagnosed with cancer were submitted more frequently to gastroscopy (50% versus 25.5%; P = .0323), colonoscopy (60% versus 26.6%; P = .038) and mammography (30% versus 11.7%; P = .370) as screening procedures for malignancy than those without cancer diagnosis. There were no differences in other screening procedures such as chest X-ray, fecal occult blood test, CT scan or abdominal ultrasound. CONCLUSION In our cohort, 17.5% patients with NS presented also concomitant cancer. Age was the only risk factor for neoplasia in this cohort. No association between cancer and gender, type of glomerulopathy, or known risk factors for neoplasia such as alcohol, tobacco or viral infection was found. Patients who were diagnosed with cancer were more frequently submitted to specific cancer screening procedures. It is important to develop screening strategies to find occult malignancy in patients with NS since this condition compromises renal outcome and life expectancy.

Real-world experience with limited screening for occult malignancy in patients presenting with spontaneous venous thromboembolism: a single-centre, retrospective cohort study.

Spontaneous venous thromboembolism (VTE) may represent the first manifestation of previously undiagnosed malignancy; however, contemporary international guidelines call for a limited approach to screening for malignancy in such patients. This retrospective cohort study of 328 patients presenting to the Auckland City Hospital Thrombosis Unit identified 17 patients who were subsequently diagnosed with some form of malignancy within 12 months of their presentation. Review of their history, physical examination and limited age and gender-appropriate cancer screening investigations as described by the National Institute for Clinical Excellence and International Society of Thrombosis and Haemostasis guidelines revealed that all 17 would have been safely diagnosed by the 'limited' screening approach endorsed by these guidelines, thus presenting a 'real-world' basis for clinicians to pursue 'limited' screening for malignancy in their everyday practice in patients with spontaneous VTE.

A Descriptive Analysis of Occult Gynecologic Malignancy in a Large Series of Supracervical Hysterectomy with Sacrocolpopexy

<h3>Study Objective</h3> The incidence of occult malignancy in patients with pelvic organ prolapse (POP) undergoing a supracervical hysterectomy (SCH) at the time of robotic-assisted laparoscopic sacrocolpopexy (RA-SCP) is not well documented in the medical literature. This has clinical implications as discovery would entail further operative management to perform staging, remove oncologic burden, and possibly revise the approach to pelvic reconstructive surgery. This study aims to detect the prevalence of oncologic pathology and ability of diagnostic preoperative work-up to detect such disease. <h3>Design</h3> Retrospective descriptive analysis. <h3>Setting</h3> University-affiliated community hospital. <h3>Patients or Participants</h3> All women undergoing a RA-SCP with SCH by one surgeon between March 2017 and March 2020 without symptoms of abnormal or postmenopausal bleeding. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> A total of 425 women were included in this study. Of these, 19 (4.2%) patients were found to have uterine pathology of either pre-malignancy (n=14, 3.5%) or malignancy (n=5, 1.2%). Transvaginal ultrasonography (TVUS) had lower cases of missing pathology compared to EMB in the case of endometrial cancer (EC) (0% vs. 1.2%), endometrial hyperplasia +/- atypia (EH) (2.4% vs. 3%), or in combination EC and EH (2.4% vs 4.2%). EC and EH collectively were undiagnosed by either TVUS or EMB until final pathology in 4.2% of cases. <h3>Conclusion</h3> A small subset of asymptomatic postmenopausal women who undergo a SCH at the time of RA-SCP for POP will have underlying gynecologic malignancy or premalignant conditions. EMB or TVUS in these patients have inadequate sensitivity to rule out endometrial pathology and patients should be counseled appropriately regarding the small but possible necessity to remove the cervix in its entirety. Patients may be offered an intraoperative pathology assessment of the SCH prior to attachment of SCP mesh material to the cervix when appropriate.

Clinical Characteristics and Risk Factors of Cerebral Hemorrhage in Patients with Occult Malignant Tumors.

ProposeTo investigate the clinical characteristics and potential risk factors of the first onset of cerebral hemorrhage in patients with occult malignant tumors.Patients and methodsIn this retrospective study, 23 patients with occult malignant tumors with the first onset of cerebral hemorrhage were enrolled in the tumor group, and 92 patients without occult tumors in the same period were enrolled in the control group. There were no statistical differences in age and sex between both groups by propensity score matching. Collected clinical data included age, sex, smoking history, drinking history, hypertension history, diabetes history, past medical history, routine blood tests, neutrophil-to-lymphocyte ratio (NLR), liver and kidney function, fasting blood glucose level, coagulation function, tumor markers, imaging examinations, National Institute of Health stroke scale (NIHSS) score on admission, modified Rankin Scale (mRS) score 90 days after intracerebral hemorrhage and final mRS score.ResultsCompared with the control group, the tumor group had fewer patients with hypertension (52.2% vs 81.5%, P<0.05), and the NLR was significantly decreased in the tumor group (2.74 vs 5.46, P<0.05). The tumor group had a greater number of patients with the bleeding sites located in the lobar regions (43.5% vs.19.6%, P<0.05) and a higher coagulation dysfunction (52.2% vs 29.3%, P<0.05) than the control group. Multivariate logistic regression analysis revealed that no history of hypertension (OR: 3.141, 95% CI: 1.107–8.916), lobar cerebral hemorrhage (OR: 3.465 95% CI:1.172–10.243), and coagulation dysfunction (OR: 3.176, 95% CI: 1.131–8.913) were independent predictors of occult tumors, and the receiver operating characteristic (ROC) curve showed that the area under the curve of the three-index combined diagnosis was 0.748, C-statistic analysis also showed the same result.ConclusionNo history of hypertension, lobar cerebral hemorrhage, and coagulation dysfunction may be predictors of the risk of occult malignancies in patients with cerebral hemorrhage.

Paraneoplastic neurologic syndromes with multiple neural autoantibodies: A report of two cases

We present two patients who presented with classical paraneoplastic syndromes with multiple central nervous system (CNS) autoantibodies in each case. The presence of multiple antibodies made the detection of a malignancy more likely and both patients were subsequently diagnosed with small cell lung carcinoma (SCLC). We highlight that the presence of multiple CNS autoantibodies increases the likelihood of detecting a malignancy but that the clinical presentation and response to treatment can vary despite similar antibody profiles. Clinicians should be alert to the need to search for occult malignancy in patients with multiple CNS autoantibodies.

Arthritis as an initial presentation of malignancy: two case reports

BackgroundArthritis is rarely reported as a paraneoplastic manifestation of occult malignancy. We report herein two cases of paraneoplastic arthritis due to occult malignancy.Case 1The patient was a 65-year-old woman of asian descent who was a former smoker with a history of spine surgery performed for L4/L5 degenerative disc disease. She presented with a 1-month history of oligoarthritis affecting both ankle joints and early morning stiffness of about 3 hours. Laboratory tests were positive for antinuclear antibody at a titer of 1:320 (speckled) but negative for rheumatoid factor. She was treated for seronegative spondyloarthritis and started on prednisolone without much improvement. A routine chest radiograph incidentally revealed a right lung mass which was found to be adenocarcinoma of the lung. She was treated with gefitinib and her arthritis resolved.Case 2The patient was a 64-year-old woman of asian descent, nonsmoker, who presented with a chief complaint of asymmetrical polyarthritis involving her right wrist, second and third metacarpophalangeal joints, and first to fifth proximal interphalangeal joints. She was treated for seronegative rheumatoid arthritis (RA) and started on sulfasalazine, with poor clinical response. Six months later, she developed abdominal pain which was diagnosed as ovarian carcinoma by laparotomy. Her arthritis resolved following treatment of her malignancy with chemotherapy.ConclusionIn summary, paraneoplastic arthritis usually presents in an atypical manner and responds poorly to disease-modifying antirheumatic drugs. Accordingly, we recommend screening for occult malignancy in patients presenting with atypical arthritis.

Risk scores for occult cancer in patients with unprovoked venous thromboembolism: Results from an individual patient data meta‐analysis

BackgroundThe Registro Informatizado de Pacientes con Enfermedad TromboEmbólica (RIETE) score and the Screening for Occult Malignancy in Patients with Idiopathic Venous Thromboembolism (SOME) risk scores aim to identify patients with acute unprovoked venous thromboembolism (VTE) at high risk of occult cancer, but their predictive performance is unclear. MethodsThe scores were evaluated in an individual patient data meta‐analysis. Studies were eligible if enrolling consecutive adults with unprovoked VTE who underwent protocol‐mandated screening for cancer. The primary outcome was a cancer diagnosis between 30 days and 2 years of follow‐up. The discriminatory performance was evaluated by computing the area under the receiver (ROC) curve in random‐effects meta‐analyses. ResultsThe RIETE score could be calculated in 1753 patients, of whom 63 (3.6%) were diagnosed with cancer. The pooled area under the ROC curve was 0.59 (95% confidence interval [CI], 0.52‐0.66; I2 = 0%). Of the 427 patients (24%) classified as high risk, 25 (5.9%) were diagnosed with cancer compared with 38 of 1326 (2.9%) low‐risk patients (hazard ratio [HR], 2.0; 95% CI, 1.3‐3.4). The SOME score was calculated in 925 patients, of whom 37 (4.0%) were diagnosed with cancer. The pooled area under the ROC curve was 0.56 (95% CI, 0.46‐0.65; I2 = 46%). Of the 161 patients (17%) classified as high risk (≥2 points), eight (5.0%) were diagnosed with cancer compared with 29 of 764 (3.8%) low‐risk patients (HR, 1.2; 95% CI, 0.55‐2.7). ConclusionsThe predictive discriminatory performance of both scores is poor. When used dichotomously, the RIETE score is able to discriminate between low‐ and high‐risk patients. Because this is largely driven by advanced age, these results do not support the use of these scores in daily clinical practice.

Value of 18F-FDG PET/CT in the detection of occult malignancy in patients with dermatomyositis

AimDermatomyositis (DM) is an inflammatory myopathy in adults that is strongly associated with malignancy. The aim of this study was to evaluate whether whole-body 18F-FDG PET/CT imaging can offer a standard option searching for underlying malignancy in DM patients. MethodsSeventy-five patients diagnosed with DM were referred to our department for whole-body 18F-FDG PET/CT to determine whether the patients suffered from malignant tumor. All PET images were analyzed by two experienced nuclear medicine physicians separately. ResultsAccording to the 18F-FDG PET/CT results, 19 patients were suspected to suffer from malignant tumor, then biopsy was performed. Of the 19 patients, 17 patients were confirmed to have malignant tumor. The pathological types were: nasopharyngeal carcinoma, rectal cancer, lung cancer, colon cancer, gastric cancer, gallbladder cancer, kidney cancer, ovarian cancer, breast cancer, lymphoma and vertebral metastatic adenocarcinoma of unknown origin. No malignancy was found for the 56 PET-negative patients during follow-up. For the age between 17 patients with malignancy and 58 patients without malignancy, no significant difference was observed. Conclusion18F-FDG PET/CT may be a sensitive and effective method in determining whether the patients with DM suffered from malignant tumor.

Trousseau’s syndrome with arterial thrombosis and venous thromboembolism in a patient with ovarian cancer

Background: Trousseau syndrome (TS), first described in 1865 refers to coagulopathy associated with underlying malignancy. It is the second leading cause of death among cancer patients. Deep vein thrombosis and superficial thrombophlebitis are the common manifestations of TS while arterial thrombosis is seen rarely. We present a patient with TS presenting with concomitant arterial and venous thrombosis. Case presentation: A 73 years old otherwise healthy lady presented with swelling of right lower limb with gangrenous toes. Investigations revealed right lower limb Deep Vein Thrombosis (DVT) and arterial thrombosis with underlying ovarian malignancy. Her investigation findings excluded paradoxical embolism, vasculitis and other thrombotic conditions. Surgical resection of the tumor was done, but attempted inferior vena caval filter insertion failed. Postoperatively, she developed pulmonary embolism, which was managed with anticoagulation. Unfortunately she developed ascending gangrene of the right leg with fatal sepsis. Conclusion: Concomitant arterial and venous thrombosis is a rare manifestation of TS. It is important to suspect underlying occult malignancy in patients presenting with arterial or venous thrombosis.

Effect of occult cancer screening on mortality in patients with unprovoked venous thromboembolism

IntroductionUnprovoked venous thromboembolism (VTE) may be the first manifestation of an underlying cancer. We aimed to determine whether extensive screening for occult cancer in patients with unprovoked VTE was effective in reducing overall mortality among VTE patients included in prospective cancer screening studies. MethodsThis pre-specified analysis of a systematic review and individual patient data meta-analysis included prospective studies comparing extensive screening with limited screening strategies for detection of occult malignant disease in unprovoked VTE patients. Overall mortality was calculated and compared according to the allocated screening strategies. ResultsAmong 1830 included patients, occult cancer was detected either at screening or during a 2-year follow-up period in 98 (5.4%, 95% CI 4.4 to 6.5). Twenty-seven out of the 56 patients (48.2%) diagnosed with cancer in the extensive screening group died during follow-up as compared with 23 out of 42 patients (54.8%) in the limited screening group (HR, 0.83; 95% CI, 0.48–1.45). Subgroup analyses according to time of cancer diagnosis (i.e. at screening vs. during follow-up) and according to whether cancer was diagnosed by limited screening or more extensive testing yielded similar results. ConclusionIn this individual patient data meta-analysis of clinical trials on limited vs. extensive screening, extensive screening for occult malignancy in patients with unprovoked VTE was not effective in reducing overall mortality. Diagnosing an occult cancer in unprovoked VTE patients was associated with a poor outcome.

Risk Scores for Occult Cancer in Patients with Venous Thromboembolism: A Post Hoc Analysis of the Hokusai-VTE Study.

Venous thromboembolism (VTE) may be the first sign of an undiagnosed cancer. In patients with unprovoked VTE, the risk is approximately 5% in the year following VTE diagnosis. Cancer-specific screening is therefore often considered in these patients, but the optimal screening strategy remains controversial. Recently, two risk classification scores have been proposed that may help in identifying patients at high risk of occult cancer in whom extensive screening may be warranted. In the present post hoc analysis of the Hokusai-VTE study, we evaluated the performance of the Registro Informatizado de Pacientes con Enfermedad TromboEmbólica (RIETE) and Screening for Occult Malignancy in Patients with Idiopathic Venous Thromboembolism (SOME) scores for occult cancer in patients with acute VTE. A total of 8,032 patients were included in the analysis of whom 218 (2.7%; 95% confidence interval [CI], 2.4-3.1) developed cancer between 30-day and 12-month follow-up. The c-statistics of the RIETE and SOME scores were 0.62 (95% CI, 0.57-0.66) and 0.59 (95% CI, 0.55-0.62), respectively. In patients classified as 'high risk', the cumulative incidence of cancer diagnosis during follow-up was 2.9% (95% CI, 2.1-3.9) for the RIETE score and 2.7% (95% CI, 1.9-3.7) for the SOME score, corresponding to hazard ratios of 1.8 (95% CI, 1.3-2.5) and 1.5 (95% CI, 1.04-2.2), respectively. In conclusion, the performance of both scores was poor. When used dichotomously, the scores were able to identify a group of patients with a significantly higher risk of occult cancer, although it remains unknown whether this translates into improved clinical important outcomes.

Risk factors of occult malignancy in patients with unprovoked venous thromboembolism

Venous thromboembolism (VTE) can occur as the first manifestation of an underlying occult malignancy. It remains unclear whether or not a better selection of high risk patients might lead to more efficient occult cancer screening strategies.Our aim was to assess the predictors of occult malignancy diagnosis in patients with unprovoked VTE.Univariate analyses were performed to assess the effect of candidate predictors on occult cancer detection in patients enrolled in a prospective, multicenter, randomized, controlled study (MVTEP study) whose primary aim was to compare a limited screening strategy with a strategy combining limited screening and FDG PET/CT in patients with unprovoked VTE. This trial is completed and registered with ClinicalTrials.gov, number NCT00964275.Between March 3, 2009, and August 18, 2012, 399 patients were included. Five patients withdrew consent and refused the use of their data, and no VTE was confirmed in 2 patients who were excluded from this analysis. A total of 25 (6.4%) out of the 392 analysed patients received a new diagnosis of malignancyduring the 2-years follow-up. Age≥50years (p=0.01), male gender (p=0.04), leukocytes count (p=0.01), and platelets count (p=0.03) were associated with occult cancer detection. Patients with leukocytosis or thrombocytosis had a risk of cancer way above 10%. Previous VTE and smoker status (combining previous and current smokers) were not associated with occult cancer diagnosis (p>0.05).Demographic characteristics (age and sex), and laboratory tests (high platelets and leukocytes counts) may be associated with cancer detection in patients withunprovoked VTE.

Extensive screening for occult malignancy in unprovoked venous thromboembolism: A meta-analysis

BackgroundThe present meta-analysis aimed to evaluate the efficacy and sensitivity of an extensive screening strategy for occult malignant diseases in patients with unprovoked venous thromboembolism (VTE). MethodsWe conducted a systematic search of PubMed, Cochrane, EMBASE, and relevant article references. Meta-analysis was used to pool weighted relative risks (RR) for the rate of missed diagnosis, all-cause mortality, and cancer-related mortality. Heterogeneity test was performed using the inconsistency index. Furthermore, pooled analysis of the sensitivity and the proportion of false-positive findings of PET/CT were conducted. ResultsA total of 5 controlled studies were included with 1,115 and 1,159 unprovoked VTE patients receiving limited or extensive screening strategy, respectively. The risk of missed diagnosis (RR, 0.51; 95% CI, 0.20–1.28; P=0.15) was not significantly different between the limited and extensive screening group. Moreover, there was no statistically significant difference in all-cause mortality (RR, 0.86; 95% CI, 0.58–1.27; P=0.44) and cancer-related mortality (RR, 0.86; 95% CI, 0.46–1.62; P=0.65) between the two groups. The pooled sensitivity and proportion of false-positive findings of PET/CT as a screening tool for occult malignancy in patients with unprovoked VTE was 95% (95% CI, 38%–100%) and 33% (95% CI, 20%–47%), respectively. ConclusionsExtensive screening strategy did not show a clinically significant benefit over limited screening strategy. Considering the high cost and the additional physical and emotional harm, current evidence did not support extensive screening for each patient in the setting.

Screening for occult cancer in idiopathic venous thromboembolism — Systemic review and meta-analysis

BackgroundIdiopathic venous thromboembolism (VTE) may be associated with an occult malignancy. Early detection of cancer might be translated to a better prognosis for these patients. However, the efficacy of extensive screening for cancer in patients with idiopathic VTE is controversial. Materials and methodsSystemic review and meta-analysis of all available prospective trials comparing extensive to limited screening for occult malignancies in patients with idiopathic VTE.Primary outcome: all-cause mortality. Secondary outcomes: cancer related mortality, early cancer diagnosis, cancer diagnosis at the end of follow up and cancer diagnosis at an early stage. Risk ratios (RR) with 95% confidence intervals (CIs) were estimated and pooled. ResultsThe study included five trials and 2287 patients. Extensive screening did not affect all-cause mortality at the end of follow up [RR 0.86 (95% CI 0.58–1.27)] or cancer-related mortality [RR 0.93 (95% CI 0.54–1.58)]. Yet, it yielded more diagnoses of cancer [RR 2.17 (95% CI 1.42–3.32)]. Rates of cancer diagnosis at an early stage did not differ statistically between the two groups [RR 1.49 (95% CI 0.86–2.56)]. However, analysis of the randomized controlled trials alone showed a tendency towards early stage cancer at diagnosis in extensive screening group in, with results almost statistically significant [RR 2.14 (95% CI 0.98–4.67), p=0.06]. ConclusionsExtensive screening for malignancy after idiopathic VTE does not affect mortality rates. Yet, it yields more cancer diagnoses shortly after the VTE event. Further research is needed to determine whether extensive screening might be proper for specific high risk populations.

Additional testing following screening strategies for occult malignancy diagnosis in patients with unprovoked venous thromboembolism

18F-Fluorodesoxyglucose Positron-Emission-Tomography combined with Computed-Tomography (FDG PET/CT) might be an attractive tool for cancer screening in patients with venous thromboembolism (VTE), allowing non-invasive whole-body imaging. One of the frequent criticisms to the use of FDG PET/CT for screening is the potential for false positive results leading to unnecessary/invasive investigations.Our aim was to compare the frequency and invasiveness of additional testing following extensive and limited screening strategies for occult malignancy in patients with unprovoked VTE.We analysed patients included in the MVTEP study, a randomized trial that compared a screening strategy based on FDG-PET/CT with a limited screening strategy for occult malignancy diagnosis in patients with unprovoked VTE. All additional diagnostic procedures following screening were recorded and classified as invasive or non-invasive.A total of 394 patients were analysed. Additional diagnostic procedures realized in patients of each group consisted of 59 tests in patients of the FDG PET/CT group versus 53 tests among the patients from the limited screening group (p=0.65). Overall, 45 (22.8%) patients in the FDG PET/CT group underwent additional diagnostic tests, versus 32 (16.2%) in the limited screening group (absolute risk difference+6.6%, 95% CI −1.3 to +14.4%, p=0.13). Sixteen (8.1%) patients in the FDG PET/CT group underwent invasive procedures, versus 6 (3%) in the limited screening group (absolute risk difference+5.1%, 95% CI +0.5 to +10.0%, p=0.03).We found no statistical difference in the number of additional procedures following each screening strategy. However, a higher number of invasive tests were performed in the FDG PET/CT group.

Major Gastrointestinal Bleeding Often Is Caused by Occult Malignancy in Patients Receiving Warfarin or Dabigatran toPrevent Stroke and Systemic Embolism From AtrialFibrillation.

Gastrointestinal (GI) bleeding in patients receiving anticoagulation agents can be causedbyoccult malignancies. We investigated the proportions and features of major GI bleeding (MGIB) events related to occult GI cancers in patients receiving anticoagulation therapy. We analyzed data from the Randomized Evaluation of Long Term Anticoagulant Therapy study (conducted between December 2005 and March 2009 in 951 clinical centers in 44 countries worldwide), which compared the abilities of dabigatran vs warfarin to prevent stroke and systemic embolism in 18,113 patients with atrial fibrillation. Two blinded gastroenterologists independently reviewed source documents of MGIB events (n= 595) that occurred during the study period. We collected data on MGIB events caused by previously unidentified GI malignancies, and compared characteristics of MGIB events in patients who received dabigatran vs warfarin (primary end point), and in patients with bleeding from cancer, vs patients bleeding from a nonmalignant or unidentified source. Of 546 unique MGIB events, 44 (8.1%) were found to be from GI cancers (34 of 398 MGIBevents in dabigatran users and 10 of 148 MGIB events in warfarin users; P= .60). Colorectal cancer accounted for 35 of 44 of all cancers identified. There were more colorectal cancer-associated MGIB events in the dabigatran group (30 of 34) than in the warfarin group (5 of 10) (P= .02), but more gastric cancer-associated MGIB events in the warfarin group (5 of 10) than in the dabigatran group (1 of 34) (P= .001). There were no differences in the short-term outcomes of cancer-related MGIB events in the dabigatran vs the warfarin group, but 75% of all cancer-related MGIB events required at least 1 bloodtransfusion and the mean hospital stay was 10.1 days. Compared with MGIB eventsfrom a nonmalignant or unidentified source, MGIB from cancer occurred sooner (343.0 vs 223.1 d; P= .003), but the bleeding was more likely to be chronic (for >7 d) (27.3% vs 63.6%; P < .001). In evaluating data from a study of the effects of anticoagulation therapy, we found approximately 1 of every 12 MGIB events to be related to an occult cancer. Approximately two thirds of cancer-related MGIB presents with chronic bleeding, and morbidity, and resource utilization ishigh.