Pulmonary Embolism In Cancer Patients Research Articles

Clinical decision rule and D-dimer have lower clinical utility to exclude pulmonary embolism in cancer patients

Patients with malignancy frequently present with clinically suspected pulmonary embolism (PE). However, the safe and efficient combination of a clinical decision rule (CDR) and D-dimer test to rule out PE performs less well in patients with malignancy. We examined potential explanations and analysed whether elevating the D-dimer cut-off could improve the clinical utility. We used data on consecutive patients with suspected PE included in a multicenter management study. The performance of the Wells CDR and the D-dimer test was compared between patients with and without malignancy and multivariable analysis was used to compare the weights of the CDR variables. Furthermore, we combined the CDR (cut-off ≤4) with different D-dimer cut-off levels for the exclusion of PE. Of 3,306 patients with suspected PE, 475 (14%) had cancer. The Wells rule variables were less diagnostic in cancer patients. Increasing the D-dimer cut-off level to 700 μg/l for all ages or using an age-dependent cut-off resulted in an increase in the proportion of patients in whom PE could be excluded from 8.4% to 13% and 12%, respectively. The corresponding false-negative rates were 1.6% (95% confidence interval 0.3-8.7%) and 0.0% (0.0-6.3%). The Wells CDR and D-dimer perform less well in patients with suspected PE if they have cancer. Individual variables in the Wells rule are less diagnostic in cancer patients than in non-cancer patients with suspected PE. A CDR combined with an age-dependent D-dimer cut-off shows a modest improvement of the strategy in cancer patients.

Characteristics and Outcomes of Pulmonary Embolism IN CANCER PATIENTS and IN PATIENTS without CANCER.

Abstract 5065 BackgroundVenous thromboembolism (VTE), a frequent complication in cancer and, occasionally, a harbinger of occult cancer, is one of the leading causes of death in cancer patients. VTE recurs with a three-fold greater frequency in cancer patients than in patients who do not have cancer, and requires long-term anticoagulation. There is a two-fold greater risk of bleeding complications in these patients compared to patients who do not have cancer. Because pulmonary embolism (PE) is a life-threatening sequel of VTE, we sought to evaluate the hypothesis that cancer patients suffer from extensive pulmonary embolism (involving central pulmonary artery or bilateral pulmonary arteries) and to determine if we could detect differences in two clinical outcomes, length of stay (LOS) and mortality. Patients and MethodsThis retrospective cohort of subjects with pulmonary embolism (PE) was developed using data beginning in January 2003 to December 2007 at a 680 bed, urban teaching hospital. The cohort of 118 patients with PE diagnosed with CT angiogram yielded 41 patients in cancer group (20 males and 21 females) and 47 (23 males and 24 females) patients in non cancer group. Other baseline characteristics gathered for the two groups included age, gender, race, co-morbidities, ambulatory status and therapeutic interventions. Criteria for being assigned to the “central PE” were a filling defect in the pulmonary arteries or the main stem. Patients who showed filling defects in both central and peripheral vessels were also assigned to the “central PE”. All other patients with filling defects in one or more peripheral vessels were assigned to the “peripheral PE” group. ResultsThe baseline characteristics did not show significant differences between the groups. Our data demonstrated that central PE was strongly associated with the cancer group (26/41; 63.4%) compared with 15 of 47 (31.9%) in the non-cancer group (OR = 3.70; 95% CI: 1.53 to 8.95; p = 0.0051). The common cancers associated with VTE were genito–urinary (13) followed by gastro-intestinal (10), then lung and breast (6 in each group). LOS was significantly greater in the cancer group (median: 9d; IQR: 7-19d) compared to non-cancer group (median: 7d; IQR: 5-11d; p = 0.032. We detected no significant difference in overall mortality between the two groups (p = 0.11). Kaplan-Meier analysis of survival, similarly, demonstrated no significant difference (95% CI of HR: 0.62 to 3.18; p = 0.42) ConclusionCancer patients appear to be at a higher risk for central PE and have longer stay in the hospital after diagnosis than patients without cancer. However, in this study we did not detect increased mortality over a twelve-month observation period. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

PULMONARY EMBOLISM IN CANCER: IS IT DIFFERENT FROM PATIENTS WITHOUT CANCER?

PURPOSE: Venous thromboembolism (VTE) is a frequent complication in cancer and is one of the leading causes of death. VTE recurs three-fold more frequently in cancer patients than in patients who do not have cancer. We studied the characteristics of pulmonary embolism in cancer patients and non-cancer patients.

Differences in the clinical presentation, severity, and treatment outcome for symptomatic versus asymptomatic pulmonary embolism in cancer patients

20688 Background: Pulmonary embolism (PE) is a common complication in cancer patients (pts). However, the incidence and outcome of symptomatic (sym) versus (vs.) asymptomatic (asym) PE in cancer pt...

Utilization Of Ventilation / Perfusion Lung Scan In A Cancer Hospital

Utilization Of Ventilation / Perfusion Lung Scan In A Cancer Hospital

Cancer patients and characteristics of pulmonary embolism

Objective To check the hypothesis that cancer patients suffer from extended pulmonary embolism (PE) more frequently than patients without cancer we analysed PEs proved by computed tomography (CT)-imaging. Patients and methods One hundred and fifty consecutive CT scans at the University Hospital of Essen from March 2002 until December 2004 which proved a definite case of pulmonary embolism were retrospectively reviewed (79 men, 71 women; mean age 57 ± 15 years). Underlying disease and blood parameters were included (haemoglobin, haematocrit, fibrinogen and total protein, if determined within 48 h before the CT scans). Results Patients with malignant disease were older (59 ± 12 years vs. 54 ± 19 years, p = 0.05) and tend to have a higher rate of central PEs (52% vs. 34%, p = 0.08) than patients without malignancies. The odds of a central PE in cancer patients was about twice as high as in patients without a malignant disease (Odds ratio: 2.08, 95%-confidence interval: 1.06–4.10; age-adjusted Odds ratio 1.88, 95%-confidence interval: 0.92–3.84). Additional adjustment for the clinical information dyspnoea, inhospital patient and clinically expected PE did not deteriorate the odds. Thrombus density determined in patients with central PE only shows a trend towards a lower density in patients with malignant disease (52 ± 13 HE vs. 45 ± 15 HE, p = 0.13). There is no statistical evidence that thrombus density is related to one of the blood parameters or even blood density measured in the pulmonary artery. Conclusion Although this is a retrospective study including a small number of patients it shows that cancer patients are at a higher risk for central PE than patients without cancer. Characteristics of the intrapulmonal thrombus in cancer and non-cancer patients seem to be different.

PO-102 Incidental, asymptomatic, unsuspected pulmonary embolism in cancer patients: case reports

PO-102 Incidental, asymptomatic, unsuspected pulmonary embolism in cancer patients: case reports

Pulmonary Embolism in Cancer Patients Is Associated with Lower Severity of Illness and Lower Mortality Rates with Increasing Use of CT Scans.

Pulmonary embolism (PE) is a major cause of morbidity and mortality in patients with cancer (CA). However, predicting which CA patients will develop PE is not possible and thromboprophylaxis is infrequently used. In order to define the incidence and clinical characteristics of CA patients with PE, we analyzed discharge data from all patients with PE collected by the Pennsylvania Health Care Cost Containment Council (PHC4) from 1997–2001. The analyses included all PE discharges with ICD-9 codes 415.11 and 415.19, excluding pregnant patients and all second or later PE admissions. Cancer diagnoses were enumerated by ICD-9 codes 140–239 and diagnostic procedures by revenue codes for computerized tomographic (CT) (including spiral CT) scans. Of 33,036 PE patients identified in this period, one-quarter had cancer, among whom PE incidence increased marginally, from 1,589 (24.0%) in 1997 to 2,262 (25.4%) in 2001, p = 0.072. CA patients were more likely to be Caucasian, OR 1.22, p<0.001, greater than 70 years of age, OR 1.16, p<0.001, and male, OR 1.19, p<0.001. CA of the lung was the most common CA type associated with PE, 1150 (17.7%), followed by CA of the digestive tract, 1150 (17.4%); genitourinary tract, 832 (12.6%); and lymphatic/hematopoetic tissues, 771 (11.7%). CT scans were performed with increasing frequency in CA PE patients, from 27.7% in 1997 to 50.0% in 2001, p < 0.001, and more frequently in Caucasians than in blacks, OR =1.61, p<0.001, and in those 70 years or younger, OR =1.91, p<0.001. At the same time, MediQual Atlas severity of illness scores decreased over time, from a mean 2.6 in 1997 to 2.3 in 2001, p<0.001, with a significant decrease in the two higher categories, 65.8% vs. 38.1%, and an increase in the three lowest categories, 34.2% to 61.9%, p<0.001. CA patients were less likely than non-CA patients to have other risk factors for PE, i.e. trauma, 3.7% vs. 8.1%, p< 0.001, or congestive heart failure, 12.9% vs. 20.8%, p<0.001. Although CA patients had higher mortality rates than non-CA PE patients, OR 1.86, p<0.001, these rates decreased from 23.3% in 1997 to 18.6% in 2001, p<0.001. In conclusion, patients with cancer account for one fourth of all PE, and they are typically elderly Caucasian males with cancer of the lung or digestive tract. The increasing use of CT scans in this group is associated with lower severity of illness scores and decreasing mortality rates, which suggest PE may be diagnosed earlier. Consideration of early thromboprophylaxis among CA patients at risk for PE may improve health outcomes.

Fatal pulmonary embolism and fatal bleeding in cancer patients with venous thromboembolism: findings from the RIETE registry.

To examine the clinical characteristics and outcomes of cancer patients with venous thromboembolism (VTE) in order to identify factors that place these patients at an increased risk for fatal pulmonary embolism (PE) or fatal bleeding. Registro Informatizado de la Enfermedad Trombo Embólica (RIETE) is a prospective registry of consecutive patients with symptomatic, objectively confirmed, acute VTE. Up to January 2006, a total of 14 391 patients with symptomatic acute VTE were enrolled in RIETE, of whom 2945 (20%) had cancer. During the 3-month follow-up period the frequency of fatal PE in cancer patients was 2.6%, and that of fatal bleeding 1.0%. These frequencies were significantly higher than in VTE patients without cancer (1.4% and 0.3%, respectively). In patients with cancer, abnormal renal function, metastatic disease, recent major bleeding and recent immobility for >or= 4 days (42% of the 108 patients who died from PE or bleeding had recent immobility) were factors independently associated with an increased risk for both fatal PE and fatal bleeding. In addition, PE diagnosis on admission was an independent risk factor for fatal PE, while body weight < 60 kg was an independent risk factor for fatal bleeding. Both fatal PE and fatal bleeding are more common in cancer patients with VTE than in those patients without cancer. In cancer patients, abnormal renal function, metastatic disease, recent major bleeding and recent immobility for >or= 4 days are associated with an increased risk for both fatal PE and fatal bleeding.

Clinical usefulness of D-dimer testing in cancer patients with suspected pulmonary embolism

Limited data are available about the diagnostic value of D-dimer testing in cancer patients with clinically suspected pulmonary embolism (PE). Therefore, we evaluated i) the safety and clinical usefulness of an ELISA D-dimer test to rule out PE in cancer patients compared with non-cancer patients and ii) whether adopting a higher D-dimer cut-off value might increase the usefulness of D-dimer in cancer patients. We analysed data from two outcome studies which enrolled 1,721 consecutive patients presenting in the emergency department with clinically suspected PE. Presence of an active malignancy was abstracted from the database. All patients underwent a sequential diagnostic work-up including an ELISA D-dimer test and a 3-month followup. Sensitivity and predictive value (NPV) were 100% in both cancer and non-cancer patients. PE was ruled out by a negative D-dimer test in 494/1,554 (32%) patients without cancer, and in 18/164 (11%) patients with a malignancy. At cut-off values varying from 500 to 900 microg/l, the sensitivity was unchanged (100%, 95% CI: 93% to 100%) and the specificity increased from 16% (95% CI: 11% to 24%) to 30% (95% CI: 22% to 39%). The 3-month thromboembolic risk was 0% (95% CI: 0% to 18%) in cancer patients with a negative D-dimer test. ELISA D-dimer appears safe to rule out pulmonary embolism in cancer patients but it is negative in only one of ten patients at the usual cut-off value. Increasing the cut-off value of D-dimer in cancer patients might increase the test's clinical usefulness.

VENA CAVA FILTERS IN CANCER PATIENTS: EXPERIENCE WITH 50 PATIENTS

To study the immediate and late results obtained from the implantation of vena cava filters in cancer patients with deep vein thrombosis concomitant with neoplasia. This was a retrospective evaluation of 50 patients with an association of cancer and deep venous thrombosis who underwent interruption of the inferior vena cava and the insertion of permanent vena cava filters. The indications for the procedure, filter implantation technique, early and late complications related to the operation, and the clinical evolution were evaluated. The most frequent indication for filter implantation was the contraindication for full anticoagulant treatment (80%). The femoral vein was the preferred access route (86% of the patients). There were no complications related to the surgical procedure. During the follow-up, the following complications were observed: 1 episode of nonfatal pulmonary thromboembolism, 2 cases of occlusion of the inferior vena cava, and 1 case of thrombus retained in the device. Twenty patients (40%) died due to progression of the neoplasm. Interruption of the inferior cava vein using an endoluminal filter is a procedure with a low rate of complications. It is a safe and efficient measure for preventing pulmonary embolism in cancer patients who have deep vein thrombosis of the lower limbs.

Cardiology patient pages. Pulmonary embolism and deep vein thrombosis.

The heart pumps oxygenated blood through the aorta to smaller arteries. After the blood supplies nutrients to vital organs, it returns through veins for reoxygenation in the lungs (Figures 1 and 2⇓). Blood clots called deep vein thrombi (DVT) often develop in the deep leg veins. Pulmonary embolism (PE) occurs when clots break off from vein walls and travel through the heart to the pulmonary arteries. The broader term venous thromboembolism (VTE) refers to DVT, PE, or to a combination of both. Figure 1. The arterial (red) and venous systems (blue) are depicted. The left ventricle (LV) ejects oxygenated blood into the aorta, which circulates blood to vital organs. Deoxygenated blood travels through the venous system to the right atrium, right ventricle, and pulmonary artery. Adapted with permission from MediClip, Clinical Cardiopulmonary Images 1997, CCP01026.TIF, Williams & Wilkins, Baltimore, Md. Figure 2. Deoxygenated blood returns to the heart and lungs for reoxygenation. SVC indicates superior vena cava; IVC, inferior vena cava; RA, right atrium; RV, right ventricle; and PA, pulmonary artery. Adapted with permission from MediClip, Clinical Cardiopulmonary Images 1997, CATHRHT.TIF, Williams & Wilkins, Baltimore, Md. VTE poses a public health threat with an estimated incidence in the United States of 250 000 to 2 million cases per year. Predisposition to VTE arises from acquired conditions, inherited disorders, or both. Many of the acquired risk factors can be modified, thus lessening the likelihood of PE or DVT. Long-haul air travel is the most talked-about risk factor for PE. Other acquired risk factors include obesity, …

Sudden death from massive pulmonary tumor embolism due to hepatocellular carcinoma

Massive pulmonary embolism in cancer patients can be due to detached thrombi or tumor. Pulmonary tumor embolism is often undiagnosed antemortem. We report a 52-year-old Chinese man admitted for management of hepatocellular carcinoma (HCC). Computerized tomography showed tumor involvement of hepatic vein and inferior vena cava. He died suddenly on the day of admission. At autopsy the main pulmonary arteries of both lungs were blocked by large tumor emboli, the immediate cause of death. Although rapid death in patients with HCC is usually caused by intraperitoneal hemorrhage from spontaneous rupture of tumor, massive pulmonary tumor embolism should also be considered in these patients, especially when antemortem evidence of hepatic vein and/or inferior vena cava invasion is present.

Clinical suspicion of autopsy-proven thrombotic and tumor pulmonary embolism in cancer patients

Cancer patients are prone to both thrombotic and tumor pulmonary embolism (PE). To identify similarities and differences in their clinical features, we reviewed all autopsies from 1978 to 1982 at Brigham and Women's Hospital and the Dana Farber Cancer Institute. Of 73 patients with solid mallgnant tumors and PE, 56 had major thrombotic PE and 17 had major tumor embolism to the lungs. Of the 56 with cancer and thrombotic PE, 25 (45%) had the correct diagnosis suspected antemortem. By contrast, only 1 of 17 (6%) patients with tumor embolism was diagnosed correctly antemortem ( p = 0.005). Most presenting symptoms, signs, laboratory values, and associated conditions were not markedly different in patients with thrombotic PE and tumor embolism. These findings indicate that tumor PE is more difficult to diagnose clinically and may be misdiagnosed as thrombotic PE. Finally, these data suggest that in all cancer patients, the presence of both thrombotic and tumor PE should be considered because of similarities in their clinical features.

Anticoagulants, venous thromboembolism, and the cancer patient.

The records of 32 cancer patients who were treated with heparin sodium and warfarin sodium for thromboembolic disease were reviewed. Standard techniques for anticoagulation were neither safe nor effective. Sixteen patients experienced 21 different hemorrhagic complications. Eight patients had major hemorrhages that led to cessation of therapy or death. Six of 32 patients had pulmonary embolisms while receiving anticoagulants. It is suggested that venous interruption may be a safer and more effective method of prophylaxis against pulmonary embolism in cancer patients.

Fatal pulmonary embolism in cancer patients: is heparin prophylaxis justified?

The incidence of fatal and nonfatal pulmonary embolism (PE) was evaluated in a series of 578 patients, to quantify the suspected higher risk in cancer patients of death from massive PE when compared with patients not having cancer. PE occurred in 13% and was fatal in 8% of noncancer patients. It occurred in 17% and was fatal in 14% (P less than .05) of cancer patients. Of these cases of PE, 75% occurred in patients with adenocarcinoma and 62% in those having tumors of the pancreas, breast, large bowel, prostate, lung, and ovary. One of every seven hospitalized cancer patients died not of cancer but of PE, and 60% of all patients who died of massive PE had localized cancer or limited metastatic disease which would have allowed for reasonably long survival in absence of lethal PE. Accordingly, we strongly suggest use of prophylactic anticoagulation in hospitalized cancer patients having otherwise good prospects for reasonably long survival.