Occult Malignancy In Patients Research Articles

Investigation of unprovoked venous thromboembolism: a case for a tempered approach?

To investigate and review the diagnostic yield for occult malignancy in patients who underwent abdominopelvic computed tomography (CT) after the diagnosis of unprovoked venous thromboembolism (VTE) with reference to the guidelines set by The National Institute for Health and Clinical Excellence (NICE). We retrospectively reviewed all unprovoked VTE diagnosed within a large teaching hospital over a period of 21 months for subsequent imaging investigations and cancer diagnoses. The primary outcome was confirmed cancer diagnosis; patients were followed for a minimum of 12 months. Three hundred and five unprovoked VTEs were diagnosed in the study period, 31% of all VTEs. Of this cohort, 73.1% underwent further imaging for exclusion of occult malignancy. Fifteen (4.9%) cancers were diagnosed; with no subsequent malignancy reported in a 12-month follow-up period of the remaining 290 patients. Of the 15 cancers, seven were post-pulmonary emboli, all of which were identified on the initial CT pulmonary angiogram, thus abdominopelvic CT only was used to locate the primary and to undertake staging. Eight were post-deep-vein thrombosis (DVT). Thus the diagnostic yield for malignancy on abdominopelvic CT post-unprovoked VTE was 2.3%. The majority of diagnosed cancers were advanced with 80% dying in the follow-up period with a mean survival of 3.4 months. The pick-up rate of occult malignancy on abdominopelvic CT post-unprovoked VTE in the present study was 2.3%, far less than the generally quoted rate of 10%; however, similar to other rates in the literature. The benefit abdominopelvic CT brings to the diagnosis of occult malignancy post-unprovoked VTE is irresolute.

Risk factors predictive of occult cancer detection in patients with unprovoked venous thromboembolism

AbstractRisk factors predictive of occult cancer detection in patients with a first unprovoked symptomatic venous thromboembolism (VTE) are unknown. Cox proportional hazard models and multivariate analyses were performed to assess the effect of specific risk factors on occult cancer detection within 1 year of a diagnosis of unprovoked VTE in patients randomized in the Screening for Occult Malignancy in Patients with Idiopathic Venous Thromboembolism (SOME) trial. A total of 33 (3.9%; 95% CI, 2.8%-5.4%) out of the 854 included patients received a new diagnosis of cancer at 1-year follow-up. Age ≥ 60 years (hazard ratio [HR], 3.11; 95% CI, 1.41-6.89; P = .005), previous provoked VTE (HR, 3.20; 95% CI, 1.19-8.62; P = .022), and current smoker status (HR, 2.80; 95% CI, 1.24-6.33; P = .014) were associated with occult cancer detection. Age, prior provoked VTE, and smoking status may be important predictors of occult cancer detection in patients with first unprovoked VTE. This trial was registered at www.clinicaltrials.gov as #NCT00773448.

Guidance for the prevention and treatment of cancer-associated venous thromboembolism

Venous thromboembolism (VTE) is a highly prevalent complication of malignancy with emerging changes in incidence, diagnosis and treatment paradigms. This manuscript, initiated by the Anticoagulation Forum, provides clinical guidance based on existing guidelines and consensus expert opinion where guidelines are lacking. We address a) the appropriate workup to search for occult malignancy in patients with idiopathic VTE, b) identification of high-risk cancer patients for primary thromboprophylaxis, c) the appropriate immediate and long-term treatment for people with cancer diagnosed with acute thromboembolism, d) the appropriate duration of anticoagulation and e) the appropriate treatment strategy in patients with recurrent VTE on anticoagulation. Areas of controversy and future directions in this field are highlighted.

Risk Factors Predictive of Occult Cancer Detection in Patients with Unprovoked Venous Thromboembolism

▪Background: Venous thromboembolism (VTE) may be the earliest sign of cancer. Risk factors associated with the presence of an occult cancer in patients with a first acute unprovoked VTE are unknown. We sought to assess the risk factors predictive of occult cancer detection in patients with a first unprovoked symptomatic VTE.Methods:Post-hoc, pre-defined analyses of the multicenter open-label randomized controlled trial - Screening for Occult Malignancy in Patients with Idiopathic Venous Thromboembolism (SOME) trial (Carrier M et al. N Engl J Med 2015). The trial compared comprehensive computed tomography (cCT) of the abdomen and pelvis in addition to limited occult-cancer screening (complete history and examination, basic laboratory testing, chest radiography, and breast, cervical and prostate cancer screening) with limited occult-cancer screening alone in patients with a first unprovoked episode of VTE. Cox proportional hazard models were used to analyze the effect of specific risk factors on the outcome of occult cancer within 12 months of a diagnosis of unprovoked VTE. Multivariable analysis was performed using Cox proportional hazard models that included all variables that achieved a p value of < 0.20 in univariate analyses.Results: A total of 854 patients were randomized to limited occult cancer screening only, or limited occult cancer screening in combination with a cCT. The mean age was 54 years and 67.4% were males. A total of 33 (3.9%; 95% C.I. 2.8-5.4) patients received a new diagnosis of cancer at 12 months follow-up. Age ≥ 60 years, compared to age < 60 years, was a predictor of cancer with a corresponding hazard ratio (HR) of 2.90 (95% C.I. 1.44-5.83, p=0.003). A previous provoked VTE in patients was also associated with a higher risk of developing cancer (HR=3.57, 95% C.I. 1.38-9.25, p=0.009). Patients with an unprovoked deep vein thrombosis (DVT), compared to either those with a pulmonary embolism (PE) only or both DVT and PE, seemed more likely to have a diagnosis of cancer. However, this trend was not statistically significant. (Table 1) These results were confirmed on multivariable analysis. Patients exhibiting one of these characteristics had a three-fold higher risk of occult cancer compared with patients without these characteristics. (Table 1)Conclusion: Age at unprovoked VTE diagnosis (≥ 60 years) and prior provoked VTE are predictors of occult cancer, and could potentially be used to identify a group of patients with unprovoked VTE at high risk of underlying cancer. Table 1Risk factors of occult malignancy among patients with a first unprovoked symptomatic VTE.Patients without cancer (%) (n = 821)Patients with cancer (%) (n = 33)Univariate analysis Hazard Ratio (95% C.I.)P valueMultivariable analysis Hazard Ratio (95% C.I.)P valueAge at diagnosis ≥ 60 years288 (35.1)20 (60.6)2.90 (1.44-5.83)0.0033.0 (1.47-5.99)0.002Male sex555 (67.6)21 (63.6)0.72 (0.35-1.46)0.358--Prior provoked VTE42 (5.1)5 (15.2)3.57 (1.38-9.25)0.0093.8 (1.46-10.03)0.006Type of current VTEDVT only444 (54.3)24 (72.7)1.91 (0.89-4.12)0.0972.1 (0.97-4.51)0.061PE only271 (33.1)7 (21.2)0.60 (0.26-1.38)0.229--DVT + PE103 (12.6)2 (6.1)0.54 (0.13-2.24)0.392--Baseline medicationsOral contraceptive pill48 (5.8)0 (0.0)----Exogenous estrogen18 (2.2)1 (3.0)1.51 (0.21-11.07)0.685--Antiplatelet agent39 (4.8)1 (3.0)0.62 (0.09-4.56)0.641--Oral anticoagulant688 (83.8)26 (78.8)0.66 (0.29-1.53)0.337--LMWH391 (47.7)15 (45.5)0.68 (0.34-1.36)0.275--VTE, venous thromboembolism; DVT, deep vein thrombosis; PE, pulmonary embolism; LMWH, low molecular weight heparin DisclosuresLazo-Langner:Pfizer: Honoraria, Other: Participated in studies funded by this organization, Speakers Bureau; LEO Pharma: Honoraria, Other: Participated in studies funded by this organization; Boehringer Ingelheim: Honoraria, Other: Participated in studies funded by this organization; Bayer: Honoraria, Other: Participated in studies funded by this organization; Daiichi-Sankyo: Other: Participated in studies funded by this organization; Novartis: Other: Participated in studies funded by this organization; Celgene: Other: Participated in studies funded by this organization; Alexion: Research Funding. Shivakumar:Bayer: Honoraria. Routhier:Sanofi-Aventis: Research Funding. Douketis:Janssen: Consultancy; Bristol-Myers Squibb: Consultancy, Honoraria; Pfizer: Honoraria; Sanofi-Aventis: Honoraria; Daiichi-Sankyo: Consultancy; Actelion: Consultancy; Biotie: Other: Advisory board; The Medicines Company: Other: Advisory board; Bayer: Consultancy; Boehringer Ingelheim: Consultancy, Honoraria. Carrier:LEO Pharma: Consultancy, Research Funding; BMS: Research Funding; Bayer: Consultancy; Pfizer: Consultancy.

Breast MRI in detecting primary malignancy of patients presenting with axillary metastases and negative X-ray mammography

Objective To evaluate the role of breast MRI in detecting the primary malignancy in patients presenting solely with axillary lymph node metastases. Methods Thirty-three patients with axillary lynph node metastases but negative findings on either physical examination or mammography underwent breast MRI to identify occult breast carcinoma. MRI of the breast was assessed according to BI-RADS criteria. The pathologic diagnosis was made according to the standard criteria by the WHO Classification of Tumor. Results Among 33 patients presenting solely with axillary metastases, 30 patients underwent modified radical mastectomy. Primary breast carcinoma was proven in 17 patients. MRI detected lesions in 16 patients, including 10 masses and 6 non-mass lesions. Size of the masses ranged from 0. 5 to 2. 6 cm (mean 1.5 cm). Six lesions were smaller than 1.5 cm in size. Non-mass lesions showed ductal enhancement in 4 cases and segmental enhancement in 2 cases. One patient with tumor detected by histopathology showed no abnormal enhancement on MRI. No tumor was found at mastectomy in the other 13 womeu, and negative MR findings were revealed in 9. Four cases with suspicious enhancement on MRI had no corresponding primary foci on pathology. Three patients didn't undergo surgical procedure. The sensitivity, specificity, and accuracy of MRI in the diagnosis of the primary malignancy were 94. 1%,69. 2%, and 83.3%, respectively. Conclusions Small size of mass and ductal or segmental enhancement of non-mass lesion were common MR features of occult malignancy. MRI showed high sensitivity and accuracy in diagnosing occult breast carcinoma. Breast MRI should be taken in search of occult malignancy in patients with axillary metastases. Key words: Breast neoplasms; Neoplasm metastasis; Lymph nodes; Magnetic resonance imaging

Positron emission tomography combined with computed tomography as a screening tool for occult malignancy in patients with unprovoked venous thromboembolism: an observational study.

Venous thromboembolism (VTE) can be the first clinical manifestation of an occult malignancy. We aimed to assess the value, in daily practice, of positron emission tomography combined with computed tomography (PET-CT) for occult malignancy diagnosis in patients with unprovoked VTE.All PET-CTs performed over 5-years period (from January 2009 to October 2013) in adult patients followed in the Department of Internal Medicine (Bichat Hospital, Paris, France) were retrospectively reviewed. Clinical history, imaging findings, and additional diagnostic tests performed because of PET-CT findings were analyzed.From January 2009 to October 2013, PET-CT was performed for malignancy diagnosis in 67 consecutive patients with unprovoked VTE. Seventeen patients were excluded because of congenital or acquired thrombophilia, known cancer, estrogen use, inability to confirm VTE diagnosis, or missing data. Fifty patients (25 women; mean age, 65.2 ± 15.9 years) were included. VTE was a first episode in 84% of cases. In 22 (44%) patients, PET-CT showed increased uptake suspicious for malignancy. After additional procedures, malignancy was confirmed in 12/22 patients. In all cases of confirmed malignancies, conventional computed tomography scan (CT-scan) had similar diagnosis yield, as compared with PET-CT. In 10/22 cases, the suspected diagnosis of malignancy could not be confirmed despite extensive workup including specialist visits (n = 5), magnetic resonance imaging (n = 4), gastrointestinal tract endoscopy (n = 3), endometrial biopsies (n = 2), and hysterectomy (n = 1). The cost of additional diagnosis procedures performed because of false positive PET-CT amounted to є1956/patient. Interestingly, considering CT-scan findings only, no further investigation would have been scheduled. No patient with negative or false positive PET-CT was diagnosed with cancer during a mean follow-up of 22 ± 13.6 months.A diagnosis strategy based on PET-CT screening for malignancy in patients with unprovoked VTE had limited diagnosis value and may lead to unnecessary alarming and money- and time-consuming investigations.

Maladies auto-immunes et cancers. Deuxième partie : maladies auto-immunes au cours des cancers et de leur traitement

Autoimmune diseases may reveal or occur during the course of a neoplasia or its treatment. Autoimmune cytopenia, especially haemolytic anaemia, is common in lymphoproliferative disorders such as chronic lymphoid leukemia. The link between cancer and myositis is well established. Dermatomyositis is associated with an increased relative risk of cancer of 3.4 to 4.4. A combination of detection of antibodies against p155 and TEP-computed tomography may be the best approach to ascertain the presence of occult malignancy in patients with dermatomyositis. A cutaneous or a systemic vascularitis may reveal a cancer, most often a haematological malignancy such as hairy cell leukemia. Paraneoplastic polyarthritis have been described in particular with adenocardinoma of the lungs. Underlying neoplasia should be considered in male smokers patients with new onset polyarthritis and poor health status. The prevalence of autoimmune conditions in myelodysplastic syndromes is 10 to 30%. Vasculitis and relapsing polychondritis are the most commonly reported manifestations. Immune manifestations can also be related to treatment. The most common treatment complications are autoimmune haemolytic anaemia with fludarabine and thyroiditis related to interferon and cervical radiotherapy.

FDG-PET/CT in the evaluation of paraneoplastic neurologic syndromes

Paraneoplastic neurologic syndromes (PNS) are a rare, heterogeneous group of complications associated with malignancy, unrelated to direct tumor invasion or metastasis, that may be immune-mediated. The aim of this article is to provide an overview of PNS and outline the value of 2-deoxy-2-[18F]fluoro-D-glucose PET/CT in the evaluation of patients with a PNS. 2-deoxy-2-18F-fluoro-D-glucose PET/CT is valuable to identify or exclude an occult malignancy in patients with suspected paraneoplastic syndromes.

A pilot study utilizing whole body 18 F-FDG-PET/CT as a comprehensive screening strategy for occult malignancy in patients with unprovoked venous thromboembolism

Background Approximately 7-10% of patients with unprovoked VTE will be diagnosed with cancer within 12 months. Although cancer screening has been proposed in these patients, the optimal strategy remains unclear. In a pilot study, we prospectively investigated the use of FDG-PET/CT to screen for occult malignancy in 40 patients with unprovoked VTE. Materials/Methods Patients were initially screened for occult malignancy with a focused history, physical, and laboratory evaluation. Patients underwent whole body FDG-PET/CT and were followed for up to two years for a new diagnosis of cancer. The total costs of using FDG-PET/CT as a comprehensive screening strategy were determined using 2010 Medicare reimbursement rates. Results Completion of FDG-PET/CT imaging was feasible and identified abnormal findings requiring additional evaluations in 62.5% of patients. Occult malignancy was evident in only one patient (cancer incidence 2.5%) and FDG-PET/CT imaging excluded malignancy in the remainder of patients. No patients with a negative FDG-PET/CT were diagnosed with malignancy during an average (± SD) follow-up of 449 (± 311) days. The use of FDG-PET/CT to screen for occult malignancy added $59,151 in total costs ($1,479 per patient). The majority of these costs were due to the cost of the FDG-PET/CT ($1,162 per patient or 78.5% of total per-patient costs). Conclusions FDG-PET/CT may have utility for excluding occult malignancy in patients with unprovoked VTE. The costs of this comprehensive screening strategy were comparable to other screening approaches. Larger studies are needed to further evaluate the utility and cost-effectiveness of FDG-PET/CT as a cancer screening strategy in patients with unprovoked VTE.

The Incidence of Occult Malignant Diseases in Patients With Deep Venous Thrombosis of the Pelvis and Lower Limb

In 318 patients (155 men, 163 women) with an average age of 58.8 years (range 16-97 years), a retrospective study was carried out to determine the incidence of occult malignancies in patients with deep venous thrombosis affecting the pelvis and lower limb, confirmed by phlebography or duplex ultrasonography. It was found that, overall, 7.5% of all patients had occult malignant diseases, the most common being bronchial carcinoma (16%), colonic and renal carcinomas (12% each), and prostatic and pancreatic carcinoma (8% each). Of the patients with occult malignancy, 88% were older than 55 years. This fact shows that acute phlebothromboses may be a paraneoplastic early syndrome more often than was previously thought, and that patients older than 50 should always be screened for the presence of a tumor.

Malignancy and myositis: novel autoantibodies and new insights

Currently available data support the idea that inflammatory myopathies, particularly dermatomyositis, are paraneoplastic diseases. Cancer screening is usually recommended in patients with these conditions, but there is no consensus regarding how and how often screening should be performed. This review will address recent advances in our understanding of the relationship between cancer and myositis and describe new data regarding the best approach for cancer screening in myositis patients. A newly described autoantibody to a 155-kDa nuclear protein, identified as transcription intermediary factor 1-gamma (TIF1-γ), has proven useful for cancer screening in patients with dermatomyositis. Occult tumor detection by PET/computed tomography (PET/CT) seems to be a good alternative to broad conventional screening. A combination of both methods, detection of autoantibodies against p155 and PET/CT study, may be the best approach to ascertain the presence of occult malignancy in patients with dermatomyositis. Advances in immunology and imaging techniques are increasing the accuracy of occult malignant cancer detection in dermatomyositis patients. Nevertheless, the diagnosis of cancer in this population remains elusive in some cases. Further investigation is needed to improve our knowledge of the link between myositis and cancer.

Acute Stroke Patients Have Occult Malignancy More Often than Expected

The aim of the present study was to investigate the frequency of having occult malignancy in patients with acute ischemic stroke and their clinical characteristics. We retrospectively enrolled 1,714 consecutive ischemic stroke patients within 7 days of onset. The patients were divided into two groups: the Non-M group had no malignancy, and the M group had malignancy. We compared the clinical characteristics of the two groups. Of 1,714 ischemic stroke patients, 51 patients (3.0%; M group) were newly diagnosed as having malignancy. The M group was significantly older than the Non-M group (p = 0.009). Hemoglobin (Hb) was less and D-dimer was higher in the M group than in the Non-M group (p < 0.001). The patients with both D-dimer ≧1.3 ng/dl and Hb <12.8 g/dl more frequently had occult malignancy than patients without (p = 0.0088).

High Rates of Occult Fallopian Tube Cancer Diagnosed at Prophylactic Bilateral Salpingo-Oophorectomy

To determine the rate of occult malignancy in patients undergoing prophylactic bilateral salpingo-oophorectomy in Northern Sydney. A retrospective case series of 45 consecutive patients who underwent prophylactic bilateral salpingo-oophorectomy between 2004 and March 2008. Five (11%) cases of occult neoplasia were found in 45 patients. This included 3 cases of micro-invasive serous carcinoma of the fallopian tube, 1 case of in situ carcinoma in the fallopian tube and 1 case of metastatic breast cancer in the ovary. All cases of primary neoplasia were in the fimbrial end of the fallopian tube. The importance of complete removal of the fallopian tubes and ovaries and the rigorous systematic pathological examination of these specimens are demonstrated in this case series. It supports emerging evidence that the fimbrial end of the fallopian tube is an important site of genesis of cancer in BRCA1/2 mutation carriers.

Paraneoplastic dermatological manifestation of gastrointestinal malignancies

Numerous dermatological disorders have been associated with underlining malignancies of the gastrointestinal (GI) tract. Such cutaneous manifestations might have an important diagnostic value if they are the sole expressions of otherwise asymptomatic carcinomas. The recognition of some typical paraneoplastic dermatologic disorders can lead to the prompt diagnosis of the underlying malignancy, timely administration of therapy, and ultimately, better prognosis. In this review we discuss the most common paraneoplastic dermatological syndromes from the perspective of the practicing gastroenterologist. We also outline a comprehensive practical approach for the evaluation for occult malignancy in patients presenting with cutaneous findings potentially associated with GI cancers.

Occult Malignancy in Patients With Suspected Paraneoplastic Neurologic Syndromes: Value of Positron Emission Tomography in Diagnosis

OBJECTIVE To determine the value of positron emission tomography (PET) in diagnosing occult malignancies in patients with paraneoplastic neurologic syndromes (PNSs) at Mayo Clinic's site in Rochester, MN. PATIENTS AND METHODS We retrospectively reviewed the medical charts of all 107 patients who underwent PET from January 1, 2000, to July 31, 2006, for the indication of suspected PNS. Three patients did not meet inclusion criteria. PET results were considered positive if increased fludeoxyglucose F 18 uptake indicated malignancy (24 patients). Results from computed tomography were interpreted as positive if any suspect lesion was consistent with malignancy (26 patients). RESULTS One hundred four patients with PNS were identified from the PET central database; 73 patients had at least 1 positive result for paraneoplastic antibody, and 31 had antibody-negative PNS. Malignancy was confirmed pathologically in 10 patients, of whom 8 had positive PET results. There were 2 cases of confirmed malignancy (fallopian tube adenocarcinoma and spindle cell uterine carcinoma) for which PET results were negative. Two patients with positive PET results declined biopsy. Computed tomography was able to identify 3 of the 10 malignancies detected. Five cases of malignancy were detected only by PET. All patients with confirmed malignancy had positive results for at least 1 paraneoplastic antibody. One patient with positive results for PNS antibody and negative PET results was diagnosed as having small cell carcinoma on a follow-up PET scan after 27 months. PET had sensitivity, specificity, positive predictive value, and negative predictive value of 80%, 67%, 53%, and 88%, respectively. CONCLUSION PET scan was shown to be more sensitive than computed tomography for detecting occult malignancy (confirmed by positive test results for autoantibody) among patients with suspected PNS. The greatest clinical utility of PET could be in its high negative predictive value. To determine the value of positron emission tomography (PET) in diagnosing occult malignancies in patients with paraneoplastic neurologic syndromes (PNSs) at Mayo Clinic's site in Rochester, MN. We retrospectively reviewed the medical charts of all 107 patients who underwent PET from January 1, 2000, to July 31, 2006, for the indication of suspected PNS. Three patients did not meet inclusion criteria. PET results were considered positive if increased fludeoxyglucose F 18 uptake indicated malignancy (24 patients). Results from computed tomography were interpreted as positive if any suspect lesion was consistent with malignancy (26 patients). One hundred four patients with PNS were identified from the PET central database; 73 patients had at least 1 positive result for paraneoplastic antibody, and 31 had antibody-negative PNS. Malignancy was confirmed pathologically in 10 patients, of whom 8 had positive PET results. There were 2 cases of confirmed malignancy (fallopian tube adenocarcinoma and spindle cell uterine carcinoma) for which PET results were negative. Two patients with positive PET results declined biopsy. Computed tomography was able to identify 3 of the 10 malignancies detected. Five cases of malignancy were detected only by PET. All patients with confirmed malignancy had positive results for at least 1 paraneoplastic antibody. One patient with positive results for PNS antibody and negative PET results was diagnosed as having small cell carcinoma on a follow-up PET scan after 27 months. PET had sensitivity, specificity, positive predictive value, and negative predictive value of 80%, 67%, 53%, and 88%, respectively. PET scan was shown to be more sensitive than computed tomography for detecting occult malignancy (confirmed by positive test results for autoantibody) among patients with suspected PNS. The greatest clinical utility of PET could be in its high negative predictive value.

Occult Malignancy in Patients With Suspected Paraneoplastic Neurologic Syndromes: Value of Positron Emission Tomography in Diagnosis

To determine the value of positron emission tomography (PET) in diagnosing occult malignancies in patients with paraneoplastic neurologic syndromes (PNSs) at Mayo Clinic's site in Rochester, MN. We retrospectively reviewed the medical charts of all 107 patients who underwent PET from January 1, 2000, to July 31, 2006, for the indication of suspected PNS. Three patients did not meet inclusion criteria. PET results were considered positive if increased fludeoxyglucose F 18 uptake indicated malignancy (24 patients). Results from computed tomography were interpreted as positive if any suspect lesion was consistent with malignancy (26 patients). One hundred four patients with PNS were identified from the PET central database; 73 patients had at least 1 positive result for paraneoplastic antibody, and 31 had antibody-negative PNS. Malignancy was confirmed pathologically in 10 patients, of whom 8 had positive PET results. There were 2 cases of confirmed malignancy (fallopian tube adenocarcinoma and spindle cell uterine carcinoma) for which PET results were negative. Two patients with positive PET results declined biopsy. Computed tomography was able to identify 3 of the 10 malignancies detected. Five cases of malignancy were detected only by PET. All patients with confirmed malignancy had positive results for at least 1 paraneoplastic antibody. One patient with positive results for PNS antibody and negative PET results was diagnosed as having small cell carcinoma on a follow-up PET scan after 27 months. PET had sensitivity, specificity, positive predictive value, and negative predictive value of 80%, 67%, 53%, and 88%, respectively. PET scan was shown to be more sensitive than computed tomography for detecting occult malignancy (confirmed by positive test results for autoantibody) among patients with suspected PNS. The greatest clinical utility of PET could be in its high negative predictive value.

Evaluation of serum tumour markers concentrations in patients with homozygous β-thalassaemia in relation to demographical, clinical and biochemical parameters

Increased life expectancy in patients with homozygous beta-thalassaemia consequently increases the risk for neoplastic diseases. This study was conducted to assess the levels of five common tumour markers in thalassaemic patients and to investigate possible correlations to demographical, clinical and laboratory data. Eighty-five patients (44 female and 41 male) with homozygous beta-thalassaemia (mean age = 27.92 +/- 12.5), on regular blood transfusions and adequate chelation treatment, and 60 sex and age- matched healthy controls were enrolled in the study. Blood samples for the determination of carcinoma antigen (CA) 15.3, CA 125, CA 19.9, carcinoembryonic antigen (CEA) and alpha-fetoprotein (a-FP) were collected from every subject. Results showed that 69% of the thalassaemic patients had abnormal levels of CA 15.3, whereas only sporadic cases had increased levels of CA 125 and CA 19.9. On the contrary, all controls had normal levels of CA 15.3, CA 19.9 and CA 125. CEA and a-FP were within reference ranges both in the thalassaemic and in the control group. Levels of CA 15.3 were significantly lower in patients aged less than 20 years compared to older patients. Male patients had significantly increased levels of CA 15.3 compared to female patients. Relatively recent studies show an increased expression of CA 15.3 on progenitor cells of the erythroid lineage and increased amounts of circulating progenitor cells even in well-transfused thalassaemic patients. However, it seems that there are also other factors contributing to this phenomenon. In conclusion, our results indicate that CA 15.3 seems to be an unreliable marker of occult malignancy in patients with beta-thalassaemia. However, more studies are needed to support these preliminary results.

Occult malignancy in patients with venous thromboembolism: risk indicators and a diagnostic screening strategy

The study was designed to analyse the risk indicators for a possible underlying malignancy and to evaluate whether extensive cancer screening is necessary in all patients with venous thromboembolism or not. In total, 126 patients with idiopathic deep venous thrombosis, and 121 patients with secondary deep venous thrombosis of lower extremity and without a known malignancy were studied. A diagnostic screening workup including a clinical history, physical examination, complete blood count, blood sedimentation rate, basic biochemistry panel including hepatic and renal function tests, prostate-specific antigen, a chest X-ray and an abdominopelvic ultrasonography was performed for all patients. Suspicious findings suggesting an underlying cancer, previous history of venous thromboembolism, bilateral venous thrombosis and associated thrombosis in unusual sites were significantly more common in patients with idiopathic venous thrombosis. A malignancy was detected in 10 of the 126 patients (7.9%) without a known risk factor for deep venous thrombosis. During the follow-up period, a diagnosis of malignancy was established in two patients in the same group. The risk of an underlying malignancy in patients with idiopathic venous thromboembolism is significantly higher. A moderate screening strategy has the capacity to identify the majority of the malignancies in such patients. We advocate simple laboratory tests, a chest X-ray and an abdominopelvic ultrasonography in order to search for an occult malignancy. A more extensive screening strategy may be considered for patients with suspicious findings for cancer, recurrent or bilateral venous thromboembolism and associated thrombosis in unusual sites.

Thrombosis and Cancer: The Role of Screening for Occult Cancer and Recognizing the Underlying Biological Mechanisms

The association between cancer and thrombosis is well recognized. What is not known, however, is the exact relationship between these two common medical conditions. Although the development of venous thromboembolism (VTE) in a patient with known cancer is the most common presentation, in some patients, VTE may precede the diagnosis of malignancy by many months. The variation in clinical presentation is likely due to the heterogeneous biology of different tumor types and also reflects the limitations of detection or available diagnostic methods. Accumulating evidence now suggests that critical oncogenic events may also trigger activation of the coagulation cascade, leading to a prothrombotic environment that not only manifests as venous thromboembolic disease but also promotes the growth and progression of the malignancy. This chapter will review the evidence for screening for occult malignancy in patients presenting with unprovoked or idiopathic thrombosis, briefly outline the known biological relationships between malignancy and thrombosis, and summarize the clinical data on the potential anticancer effects of low molecular weight heparins (LMWHs).

Association of malignant disease with critical leg ischaemia

The aim of the study was to determine the prevalence of malignant disease in patients with critical leg ischaemia (CLI). : Data for all patients with CLI presenting to a tertiary vascular unit over an 18-month interval were collected prospectively. Patients with clinical, laboratory or radiological features suggestive of malignancy were evaluated further. Of 192 patients admitted with CLI, 22 (11.5 per cent) were found to have an associated malignancy; ten had lung cancer. Fifteen were anaemic on presentation. The prevalence of occult malignancy in patients with acute leg ischaemia was 16 per cent (ten of 62) compared with 9.2 per cent (12 of 130) in those with chronic CLI. Eleven of 22 of patients with CLI and malignancy died within 6 months, compared with 35 (20.6 per cent) of 170 patients with no evidence of malignancy. A high prevalence of occult cancer was found in patients presenting with CLI; this was associated with a significantly increased mortality rate at 6 months.