Prevalence
of neoplasms in 415 patients with deep venous thrombosis
(Portuguese
PDF version)
Miriam
Aparecida Linares,1 Tais Elisabete Rodrigues,1 Karen Kazue
Hirato,1 Juliana D. de Oliveira,2 Selma Regina Oliveira
Raimundo,3 José Maria Pereira de Godoy4
1.
Resident physician, Angiology and Cardiovascular Surgery Service,
Faculdade de Medicina Estadual de São José do Rio Preto
(FAMERP), São José do Rio Preto, SP, Brazil.
2.
Undergraduate student, FAMERP, São José do Rio Preto,
SP, Brazil.
3.
Assistant Professor, Angiology and Cardiovascular Surgery Service,
FAMERP, São José do Rio Preto, SP, Brazil.
4.
Physician. Associate professor, Angiology and Cardiovascular Surgery
Service, FAMERP, São José do Rio Preto, SP, Brazil.
Correspondence:
José Maria Pereira de Godoy
Rua Floriano Peixoto, 2950
CEP 15020-010 - São José do Rio Preto, SP, Brazil
E-mail: godoyjmpiopreto.com.br
ABSTRACT
Objective:
The purposes of this study were to assess the prevalence of neoplasms
in 415 patients with deep venous thrombosis and to identify its
different types.
Method:
The presence of neoplasms in 415 patients with deep venous thrombosis
of the lower limbs was evaluated in a prospective study. The age
of patients treated in the vascular surgery department varied from
11 to 92 years with mean age of 55.2 years. Diagnosis of thrombosis
was performed using a duplex scan and, in case of doubt, the results
were confirmed by phlebology. Clinical history and physical examination
were performed for all patients. Biochemical, imaging and surgical
examinations, as well as biopsies, were performed when required.
Among the main laboratorial tests, in cases of clinical suspicion,
there were thoracic x-ray, endoscopy, abdominal ultrasound, computerized
tomography and magnetic resonance. Specific clinical evaluations
were requested for urological and gynecological complaints. All
patients with previous histories of neoplasms were excluded from
the investigation.
Results:
A total of 58 (13.9%) neoplasms were detected in 415 patients suffering
from deep venous thrombosis, 27.5% of which developed in the gastrointestinal
tract, 15.5% in the gynecological system, 8.6% in the respiratory
system, 6.8% in the tegumental system, 3.4% in the skeletal system,
1.7% retroperitoneal and 1.7% in the reticuloendothelial system.
Conclusion:
As a conclusion, we may say that patients suffering from deep venous
thrombosis present with a high incidence of neoplasms, suggesting
that screening is a procedure of great importance.
Key
words: prevalence, neoplasms, thrombosis.
J
Vasc Br 2004;3(4):347-50
Neoplasms
are known as independent risk factors for deep venous thrombosis (DVT).1,2
Among mechanisms that trigger them off are the synthesis of procoagulant
factors produced by tumoral cells, monocytes or macrophages; platelet
aggregation abnormalities; antineoplastic therapy, and comorbities such
as venous stasis.3-5 Venous stasis can be
a consequence of complications that limit patients to their beds and
thus reduce their mobility. Coagulation activation is found in around
90% of patients with neoplasms. However, mechanisms of hypercoagulability
are less clear.6,7 Around 10 to 15% of patients
with cancer present venous thromboembolism.8,9
DVT has been reported as the first clinical manifestation of a neoplasm.
Therefore, it constitutes a paraneoplastic syndrome.5,9,10
Lung, pancreatic, stomach, intestinal, ovarian, and prostatic neoplasms
are most commonly associated with thromboembolism.11,12
The purposes
of this study were to assess the prevalence of neoplasms in 415 patients
with DVT and to identify its different types.
MATERIALS
AND METHODS
The presence
of neoplasms in 415 consecutive patients who had DVT of lower limbs
was evaluated in a prospective study performed in a vascular surgery
service. Two hundred and twenty-one patients were female, and 194 were
male. Ages ranged from 11 to 92 years, and mean age was 55.2 years.
All patients underwent a duplex scan and, in case of doubt concerning
diagnosis, phlebography was performed as well.13
Criteria considered to show the presence of DVT by duplex scan included:
presence of spontaneous flow, absence of phasicity of flow, and flow
velocity. Clinical history, physical and biochemical examinations, imaging,
biopsies, and surgeries were performed when indicated. All diagnoses
of neoplasms were confirmed by histology. Thoracic radiography, endoscopy,
abdomen ultrasound, computerized tomography, and magnetic resonance
were required in cases of clinical suspicion, as well as urological
evaluation for men and gynecological evaluation for women. All patients
who presented DVT were included in the study. Patients with previous
diagnosis of neoplasm were excluded. For statistical evaluation we calculated
percentages and mean values.
RESULT
Fifty-eight neoplasms were detected in 415 patients, indicating a prevalence of 13.9%, 27.5% of which developed in the gastrointestinal tract, 17.2% in the gynecological system, 17.2% in the central nervous system, 15.5% in the urological system, 8.6% in the respiratory system, 6.8% in the tegumental system, 3.4% in the skeletal system, 1.7% in the retroperitoneal system, and 1.7% in the reticuloendothelial system.
DISCUSSION
This study
detected a high prevalence of neoplasms in patients with DVT (13.9%),
when the prevalence of congenital thrombophilia, such as the deficiency
of antithrombin III, protein C, and protein S, was evaluated at the
vascular surgery service of our hospital.13-15
The result of this study emphasizes that thrombotic events are significant
paraneoplastic manifestations. On the other hand, more intense prophylaxis
should be considered in cases of patients with neoplasms and exposed
to risk factors, such as surgery, immobilization in bed, chemotherapy,
catheter implantation, and others. The literature associates idiopathic
thromboembolism with neoplasms in 7 to 8% of the cases. It can increase
to 17% in cases of rethrombosis.16
When screening
for cancer in venous thrombosis patients, an attentive clinical evaluation
should be considered, as neoplasms may not be manifested yet. The examination
may include digital rectal examination, fecal occult blood test, urine
tests, blood cell count, renal function test, carcinoembryonic antigen
test, thoracic radiography, and gynecological and urological evaluation.
Invasive and costly examinations, like abdomen ultrasound, computerized
tomography, magnetic resonance, and endoscopy should be considered in
each case, depending on the clinical suspicion.
Another
factor to be considered is that an association of venous thromboembolism
with neoplasms presents a worse prognosis, and it is already proved
that an early diagnosis does not increase life expectancy. Besides,
we should consider the psychological aspects of a routine invasive investigation.3,17,18
In the
present study, the gastrointestinal tract, and the gynecological and
urological systems were most affected. The central nervous system also
had a high rate of occurrences, which can be interpreted as an alert
for this kind of occurrence. Lungs, as isolated organs, were of great
importance. With respect to isolated organs, the lungs were importantly
affetcted, justifying the need for careful screening.
Initial
treatment of DVT in patients with cancer does not differ from the treatment
given to other patients.19 It should continue
for 6 months after the first episode of DVT is reported, but in cases
of thromboembolic recurrence, anticoagulation should be extended.20
In some types of cancer, anticoagulation is recommended for an indefinite
time. However, there is no consensus about that and, therefore, an individualized
evaluation of each case is the best indication. Patients with cancer
have a higher risk of rethrombosis and bleeding. Thus, a trade-off must
be considered between risks and anticoagulation therapy.
The Fundamental
Research in Oncology and Thrombosis (FRONTLINE) made the first global
survey of thrombosis and cancer. The study analyzed items such as the
anticoagulation therapy after an episode of pulmonary thromboembolism
(PTE) in surgical or clinical patients. The duration of anticoagulation
ranged from 3 to 6 months (63% for PTE in surgical patients, 72% for
DVT in clinical patients, and 58% for PTE in clinical patients). In
19% of the patients anticoagulation was present for 7 to 12 months,
and in 18% for an indefinite time.21,22
CONCLUSION
As a conclusion,
we may say that patients suffering from DVT present a high prevalence
of neoplasms, suggesting individualized screening.
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