1 / 35


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.

Download Presentation


An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.


Presentation Transcript

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

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. Lower Limb DVT Upper Limb DVT

  7. 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

  8. 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

  9. Risk Factors • Homocystinuria • Polycythemiarubravera • Thrombocytosis • Inherited disorders of coagulation • Drug abuse • Oral contraceptives

  10. 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.

  11. 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

  12. TYPE of CANCERS with  DVT • Pancreas • Lung • Breast • GI tumor • Prostate • Multiple Myeloma • Lymphoma • Leaukaemia

  13. 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.


  15. 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 )

  16. 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

  17. 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

  18. Well’s Score

  19. Well’s Score…contd


  21. 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


  23. D-dimer • Compression USG (sensitivity is ~99.5%) • Venogram

  24. Investigations of Suspected DVT

  25. 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

  26. USG of Rt. Popliteal Vein

  27. COMPLICATIONS VTE can cause • death from PE or, among survivors • Ch. thromboembolic Pulmonary HTN • Postphlebitic/Post thrombotic/Chronic venous insufficiency± Ulceration

  28. Management Prophylactic management: Non Pharmacological: • Early mobilization of all patients • Intermittent pneumatic compression • Mechanical foot pumps • Graduated compression stockings.

  29. Prophylactic management (Contd) Pharmacological: (Moderate to High risk of DVT) • Low molecular weight heparins (eg. Enoxaparin) • Unfractionated heparin • Fondaparinux • Apixaban • Dabigatran • Rivaroxaban • Warfarin • Aspirin

  30. 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.

  31. 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

  32. 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

  33. 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.

  34. 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.


More Related