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Deep Vein Thrombosis & Malignancy Department of Radiation Oncology Presented by Dr. Muhammad Zubaer Hussain. Incidence. About 600,000 hospitalizations per year occur for DVT in the United States. 100,000 to 300,000 VTE-related deaths occur annually in the United States.

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Incidence

Deep VeinThrombosis&MalignancyDepartment of Radiation OncologyPresented byDr. Muhammad Zubaer Hussain


Incidence

Incidence

  • About 600,000 hospitalizations per year occur for DVT in the United States.

  • 100,000 to 300,000 VTE-related deaths occur annually in the United States.

  • Approximately 1 person in 20 develops a DVT in the course of his or her lifetime.


In hospital vte

In-hospital VTE

In hospitalized patients, the incidence of venous thrombosis is considerably higher and varies from 20-70%.

The in-hospital case- fatality rate for VTE is 12% rising to 21% in elderly persons.

Venous thrombosis is second leading cause of death in cancer patients.


Lower limb dvt

Lower Limb DVT

  • Although most DVT is occult and resolves spontaneously without complication,

  • It is the underlying source of 90% of acute PEs

  • PE occurs in approximately 10% of patients with acute DVT and can cause up to 10% of in hospital deaths.

  • Cause 25,000 deaths per year in the United States.


Upper limb dvt

Upper Limb DVT

  • Asymmetry in the supraclavicularfossa or in the circumference of the upper arms.

  • A prominent superficial venous pattern may be evident on the anterior chest wall.


Lower limb dvt1

Lower Limb DVT

Upper Limb DVT


Risk factors

Risk Factors

  • Age(In elderly persons, the incidence is increased 4-fold)

  • Immobilization longer than 3 days

  • Pregnancy and the postpartum period

  • Major surgery in previous 4 weeks

  • Plane/car trips (> 4 hours) in previous 4 wks

  • Cancer (30%)

  • Previous DVT


Risk factors contd

Risk Factors…Contd

  • Stroke (DVT is found in 53% of paralyzed limbs, compared with only 7% on the nonaffected side.)

  • Acute myocardial infarction (AMI)

  • Congestive heart failure (CHF)

  • Sepsis

  • Nephrotic syndrome

  • Ulcerative colitis

  • Multiple trauma

  • CNS/spinal cord injury

  • Burns


Risk factors1

Risk Factors

  • Homocystinuria

  • Polycythemiarubravera

  • Thrombocytosis

  • Inherited disorders of coagulation

  • Drug abuse

  • Oral contraceptives


Malignancy dvt

Malignancy & DVT

  • Malignancy is noted in as many as 30% of patients with venous thrombosis.

  • 90% of cancer patients having some abnormal coagulation factors.

  • Chemotherapy may increase the risk of venous thrombosis by affecting the vascular endothelium, coagulation cascades, and tumor cell lysis.

  • The incidence has been shown to increase in those patients undergoing longer courses of therapy.


Aetiology of dvt in cancer patients

AETIOLOGY of DVT inCANCER PATIENTS

  • Hypercoagulable State

    • Increased plasma levels of Clotting factors

    • Cancer procoagulant

    • Tissue factor

    • Cytokines

    • Inrceasedplasminogen activator

  • Surgical Intervertion

  • Chemotherapy

  • Prolonged Immobilization


Type of cancers with dvt

TYPE of CANCERS with  DVT

  • Pancreas

  • Lung

  • Breast

  • GI tumor

  • Prostate

  • Multiple Myeloma

  • Lymphoma

  • Leaukaemia


Postoperative venous thrombosis

Postoperative venous thrombosis

  • Varies depending on a multitude of patient factors, including the type of surgery undertaken.

  • Without prophylaxis, general surgery operations typically have an incidence of DVT around 20% in benign disease, whereas 36% in cancer patients.


Diagnosis

DIAGNOSIS


Symptoms and signs

Symptoms and Signs

Lower limb DVT characteristically starts with

  • Pain (50%)

  • Swelling

  • An increase in temperature and

  • Dilatation of the superficial veins.

  • Often, however, there are only minimal S/S

  • Typically unilateral but may be bilateral

    (when clot extends proximally into the inferior vena cava. )

    ( Bilateral DVT is more commonly seen in patients with underlying malignancy )


Symptoms and signs1

Symptoms and Signs

  • Most specific symptom Leg pain - Occurs in 50% of patients but is nonspecific

  • Tenderness - Occurs in 75% of patients

  • Warmth or Erythema of the skin over the area of thrombosis


Symptoms and signs contd

Symptoms and Signs …contd

  • Clinical symptoms of pulmonary embolism (PE) as the primary manifestation

  • Calf pain on dorsiflexion of the foot (Homans sign)

  • Variable discoloration of the lower extremity


Well s score

Well’s Score


Well s score contd

Well’s Score…contd


Differential diagnoses

DIFFERENTIAL DIAGNOSES


Symptoms and signs contd1

Symptoms and Signs …contd

  • Baker's cysts usually occur in patients with rheumatoid arthritis.

  • Cellulitis is usually distinguished by

    • Marked skin erythema and temperature which is localisedwithin a well-demarcated area of the leg and may be associated with an obvious source of entry of infection

    • Fever and chills

  • Postphlebitic syndrome.

    • Leg is diffusely edematous

    • skin ulceration, especially in the medial malleolus of the leg


Investigations

INVESTIGATIONS


Incidence

  • D-dimer

  • Compression USG (sensitivity is ~99.5%)

  • Venogram


Investigations of suspected dvt

Investigations of Suspected DVT


D dimer

D-dimer

  • D-dimer is a useful "rule out" test.

  • Sensitivity >80% for DVT and >95% for PE.

  • Levels increase in patients with

    • MI

    • Pneumonia

    • Sepsis


Usg of rt popliteal vein

USG of Rt. Popliteal Vein


Complications

COMPLICATIONS

VTE can cause

  • death from PE

    or, among survivors

  • Ch. thromboembolic Pulmonary HTN

  • Postphlebitic/Post thrombotic/Chronic venous insufficiency± Ulceration


Management

Management

Prophylactic management:

Non Pharmacological:

  • Early mobilization of all patients

  • Intermittent pneumatic compression

  • Mechanical foot pumps

  • Graduated compression stockings.


Incidence

Prophylactic management (Contd)

Pharmacological: (Moderate to High risk of DVT)

  • Low molecular weight heparins (eg. Enoxaparin)

  • Unfractionated heparin

  • Fondaparinux

  • Apixaban

  • Dabigatran

  • Rivaroxaban

  • Warfarin

  • Aspirin


Incidence

Prophylactic management (Contd)

Pharmacological:

  • Enoxaparin 40mg sc once daily

  • Fondaparinux 2.5 mg sc once daily

  • Apixaban PO ( Showing promising result in clinical trial)

  • Warfarin10 mg on the first and second days, with 5 mg on

    the third day; subsequent doses are titrated against the INR.


Incidence

Moderate risk of DVT:

  • Major surgery

    Or,

  • Major medical illness, e.g.

    • Heart failure

    • Myocardial infarction with complications

    • Sepsis

    • Active malignancy

    • Stroke and other conditions leading to lower limb paralysis


Incidence

High risk of DVT:

  • Major abdominal or pelvic surgery

    for malignancy

    or

    with history of DVT

    or

    known thrombophilia

  • Major hip or knee surgery

  • Neurosurgery


Management of established dvt

Management of Established DVT

  • General management:

  • Elevation of limb

  • Analgesia

  • Anticoagulant: (mainstay of treatment)

  • Inferior Vena Caval (IVC) Filters

    • CI to anticoagulation and

    • Recurrent venous thrombosis despite intensive anticoagulation.


Management of established dvt1

Management of Established DVT

  • Anticoagulant:

    Low molecular weight heparin(LMWH):

    1mg/kg sc 12 hrly

    or,

    Unfractionated heparin

    5000 U iv loading  continuous inf20U/kg/hr

    Parenteral anticoagulation should be continued for a minimum of 5 days

    Warfarin: 10 mg on the first and second days, with 5 mg on the third day; subsequent doses are titrated against the INR.


Incidence

THANK YOU


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