Diagnosis of cancer-associated vascular disorders

Expert perspectives on pathological findings in vasculitis

Pathological findings are important in the diagnosis of vasculitis. However, due to the rarity of the disease, standard textbooks usually devote only a few pages to this topic, and this makes it difficult for clinicians not specializing in vasculitis to fully understand the pathological findings in vasculitis. To address the paucity of information, we present representative pathological findings in vasculitis classified in the 2012 Revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides (CHCC2012). The CHCC2012 classifies 26 vasculitides into seven categories: (1) large-vessel vasculitis, (2) medium-vessel vasculitis, (3) small-vessel vasculitis, including antineutrophil cytoplasmic antibody-associated vasculitis and immune complex small-vessel vasculitis, (4) variable-vessel vasculitis, (5) single-organ vasculitis, (6) vasculitis associated with systemic disease, and (7) vasculitis associated with probable aetiology. Moreover, representative pathological findings of vasculitis-related diseases and non-inflammatory vasculopathy not mentioned in the CHCC2012 are also presented. This will be useful for clinicians to refer to typical pathological findings of vasculitis in daily practice.

Thrombocytosis predicts poor prognosis of Asian patients with colorectal cancer: A systematic review and meta-analysis

BACKGROUND

There is no study analyzing and evaluating the prognostic role of thrombocytosis in Asian patients with colorectal cancer (CRC).

METHODS

A systematic search of articles (PubMed, Embase, and the Cochrane Library) was performed to identify studies using the terms Platelet count, Thrombocytosis, Thrombocytoses, Thrombocythemia or Thrombocythemias with colon, colonic, rectal, rectum, colorectal and prognostic, prognosis, survival or outcome.

RESULTS

Thirteen eligible studies with 3964 patients were included. Thrombocytosis was associated with a poorer overall survival (HR of 1.88 [95% CI: 1.24-2.85; P = .003] with univariate analyses, HR of 2.07 [95% CI: 1.2-3.56; P = .008] with multivariate analyses), disease-free survival (HR of 2.58 [95% CI: 1.87-3.57; P < .00001] with multivariate analyses) and cancer specific survival (HR of 2.55 [95% CI: 1.68-3.85; P < .00001]) in Asian patients with CRC. Thrombocytosis had a significant association with female gender, tumor location in the colon, higher pathological T-stage, pathological positive N-stage, but not with lymphatic involvement and venous involvement.

CONCLUSION

The present meta-analysis demonstrates that thrombocytosis is a potentially useful tool for predicting poor survival in Asian patients with CRC, especially for overall survival.

Leukocytoclastic Vasculitis in a Patient With Rheumatoid Arthritis

Leukocytoclastic vasculitis is a small vessel vasculitis that is usually confined to the skin with rare extracutaneous manifestation. While this condition can be idiopathic, it has been linked with systemic autoimmune conditions, malignancies, infections, and drugs. In this paper, we present a case of a patient who presented with leukocytoclastic vasculitis many years after her diagnosis of rheumatoid arthritis. It is important that physicians investigate leukocytoclastic vasculitis, as the condition, while often idiopathic, can be a presentation of something more sinister such as malignancy or systemic autoimmune condition.

High platelet × C-reactive protein level multiplier is a negative prognostic marker in rectal cancer treated by neoadjuvant chemoradiotherapy

PURPOSE

The clinical significance of the platelet count × C-reactive protein level multiplier (P-CRP) in patients with locally advanced rectal cancer (LARC) undergoing neoadjuvant chemoradiotherapy followed by curative surgery has not been fully evaluated.

METHODS

In this retrospective study, the correlation between the P-CRP and prognosis was evaluated in 135 patients with LARC. We also performed a subgroup analysis limited to patients with pathological TNM stage III [ypN(+)] LARC.

RESULTS

The cut-off value of the P-CRP for prognosis was set at 4.11. The high and low P-CRP groups comprised 39 (28.89%) and 96 (71.11%) patients, respectively. Among the investigated clinicopathological factors, the serum carcinoembryonic antigen level and presence of recurrence were significantly associated with the P-CRP value. In the Kaplan-Meier analysis, both overall survival (OS) and disease-free survival (DFS) were shorter in the high P-CRP group (p < 0.0001 and p = 0.0002, respectively; log-rank test). Multivariate analysis using a Cox proportional hazards model showed that a high P-CRP was an independent prognostic factor for OS [hazard ratio (HR) 29.20; 95% confidence interval (CI), 3.42-294.44; p = 0.0024] and DFS (HR 5.89; 95%CI 1.31-22.69; p = 0.023) in patients with LARC. In addition, a high P-CRP predicted poor OS and DFS in patients with pathological TNM stage III [ypN(+)] LARC (p = 0.0001 and p = 0.0012, respectively; log-rank test).

CONCLUSIONS

The P-CRP is a promising predictor of survival and recurrence in patients with LARC treated by neoadjuvant chemoradiotherapy followed by curative surgery.

Paraneoplastic Syndromes Associated with Laryngeal Cancer

OBJECTIVES

Paraneoplastic syndromes occur rarely in association with laryngeal cancer. When present, the syndrome may be the first sign of the malignancy. The aim of the present study was to review and report on all published cases in the international literature.

METHODS

A search of PubMed was conducted for "paraneoplastic syndromes in laryngeal cancer" without any restrictions on language or publication year. The full texts of all relevant articles were reviewed and all cases of paraneoplastic syndromes associated with any type of laryngeal cancer were extracted and analyzed.

RESULTS

We identified 59 cases of paraneoplastic syndromes related to laryngeal cancer in the literature published from 1963 until recently. There were 46 squamous cell carcinomas and 10 neuroendocrine carcinomas. Twenty-two of the paraneoplastic syndromes involved the endocrine system, 21 were dermatologic or cutaneous, 8 neurologic, 5 osteoarticular or rheumatologic, 1 ocular, 1 muscular, and 1 hematologic. Treatment strategies included surgery, radiotherapy, chemotherapy, and often multimodal therapy, depending on the histology and stage of the laryngeal cancer.

CONCLUSIONS

Because of their rarity, paraneoplastic syndromes associated with laryngeal cancer are difficult to diagnose. By presenting and systematically reviewing all published cases in the international literature, the present review may help clinicians to recognize them and to suspect the diagnosis of laryngeal cancer at an earlier stage than otherwise might be possible.

Modified neutrophil-platelet score as a promising marker for stratified surgical and oncological outcomes of patients with gastric cancer

PURPOSE

Gastric cancer (GC) is a common malignancy, especially in East Asian countries. There is emerging evidence that circulating neutrophil and platelet levels correlate with cancer progression. We evaluated the short- and long-term outcomes of GC patients systemically, to compare the original neutrophil-platelet score (NPS) and our modified NPS (mNPS).

METHODS

We analyzed the original pre-operative NPS and the mNPS of 621 GC patients.

RESULTS

Racial differences between the United Kingdom and East Asian countries accounted for compelling deviation in classification using the original NPS, which could not reliably stratify the prognoses of Japanese GC patients. We developed the mNPS using appropriate cutoff levels for pre-operative neutrophils and platelets, and demonstrated that the pre-operative mNPS was significantly correlated with all of the well-established clinicopathological factors for disease development, including advanced T stage, venous and lymphatic vessel invasion, lymph node/peritoneal /distant metastasis, and tumor-node-metastasis stage. The pre-operative mNPS could stratify prognostication for both overall survival (OS) and disease-free survival (DFS): a high pre-operative mNPS was an independent prognostic factor for the OS and DFS of GC patients and also an independent predictor of post-operative surgical site infection after gastrectomy.

CONCLUSION

Calculating the mNPS could help clinicians to stratify the surgical and oncological risks of patients with GC.

Paraneoplastic vasculitis in patients with metastatic renal cell carcinoma

BACKGROUND

A paraneoplastic syndrome is observed in 5% to 10% of cancer patients. Paraneoplastic vasculitis (PV) in metastatic renal cell carcinoma (mRCC) patients has been poorly investigated.

AIMS

In our case series study, we evaluated the incidence and development of PV in patients with mRCC.

METHODS AND RESULTS

Patients were required to have previously untreated clear-cell or papillary mRCC and no evidence of autoimmune diseases or venous thrombosis in history. Patients had a careful examination including Doppler ultrasonography of the blood vessels and skin punch biopsy in the presence of suspicious skin rash. Sixteen (8.2%) of 196 patients were diagnosed with PV, which was manifested clinically by leukocytoclastic vasculitis on the lower extremities. Skin biopsy confirmed vasculitis. Progression-free survival and overall survival were significantly better in patients without PV.

CONCLUSIONS

PV is not rare paraneoplastic syndrome in mRCC. Leukocytoclastic vasculitis was the most common type of PV in this study.

The clinical use of the platelet/lymphocyte ratio and lymphocyte/monocyte ratio as prognostic predictors in colorectal cancer: a meta-analysis

BACKGROUND

Conflicting evidence exists regarding the effects of platelet/lymphocyte ratio (PLR) and lymphocyte/monocyte ratio(LMR) on the prognosis of colorectal cancer (CRC) patients. This study aimed to evaluate the roles of the PLR and LMR in predicting the prognosis of CRC patients via meta-analysis.

METHODS

Eligible studies were retrieved from the PubMed, Embase,andChina National Knowledge Infrastructure (CNKI) databases, supplemented by a manual search of references from retrieved articles. Pooled hazard ratios (HR) with 95% confidence intervals (95% CI) were calculated using the generic inverse variance and random-effect model to evaluate the association of PLR and LMR with prognostic variables in CRC, including overall survival (OS), cancer-specific survival (CSS) and disease-free survival (DFS).

RESULTS

Thirty-three studies containing 15,404 patients met criteria for inclusion. Pooled analysis suggested that elevated PLR was associated with poorer OS (pooled HR = 1.57, 95% CI: 1.41 - 1.75, p< 0.00001, I2=26%) and DFS (pooled HR = 1.58, 95% CI: 1.31 - 1.92, p< 0.00001, I2=66%). Conversely, high LMR correlated with more favorable OS (pooled HR = 0.59, 95% CI: 0.50 - 0.68, p< 0.00001, I2=44%), CSS (pooled HR = 0.54, 95% CI: 0.40 - 0.72, p< 0.00001, I2=11%) and DFS (pooled HR = 0.82, 95% CI: 0.71- 0.94,p=0.005, I2=29%).

CONCLUSIONS

Elevated PLR was associated with poor prognosis, while high LMR correlated with more favorable outcomes in CRC patients. Pretreatment PLR and LMR could serve as prognostic predictors in CRC patients.

Elevated platelet count as predictor of recurrence in rectal cancer patients undergoing preoperative chemoradiotherapy followed by surgery

The impact of systemic inflammatory response (SIR) on prognostic and predictive outcome in rectal cancer after neoadjuvant chemoradiotherapy (CRT) has not been fully investigated. This retrospective study enrolled 89 patients with locally advanced rectal cancer who underwent neoadjuvant CRT and for whom platelet (PLT) counts and SIR status [neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR)] were available. Both clinical values of PLT and SIR status in rectal cancer patients were investigated. Elevated PLT, NLR, PLR, and pathologic TNM stage III [ypN(+)] were associated with significantly poor overall survival (OS). Elevated PLT, NLR, and ypN(+) were shown to independently predict OS. Elevated PLT and ypN(+) significantly predicted poor disease-free survival (DFS). Elevated PLT was identified as the only independent predictor of DFS. PLT counts are a promising pre-CRT biomarker for predicting recurrence and poor prognosis in rectal cancer.

Prognostic factors from a randomized phase III trial of paclitaxel and carboplatin versus paclitaxel and cisplatin in metastatic or recurrent cervical cancer: Japan Clinical Oncology Group (JCOG) trial: JCOG0505-S1

PURPOSE

The Japan Clinical Oncology Group (JCOG) trial JCOG0505 demonstrated the statistically significant non-inferiority of paclitaxel plus carboplatin (TC) to paclitaxel plus cisplatin (TP) in terms of overall survival (OS) in metastatic or recurrent cervical cancer. In that trial, patients were randomly assigned, adjusting for institution and known prognostic factors. The objective of this ancillary study was to evaluate the appropriateness of the adjustment factors used to have randomly assigned treatments and to investigate new potentially useful prognostic factors of paclitaxel plus platinum for future randomized trials in metastatic or recurrent cervical cancer.

METHODS

The study subjects comprised 244 eligible patients in the JCOG0505 who were merged to have received either TC or TP. The effects of the following factors on OS were investigated using a Cox regression model taking into consideration the adjustment factors used in randomization in this trial (e.g., performance status [PS]) and other baseline factors, including platinum-free interval (PFI), pretreatment hemoglobin levels (PHLs), and pretreatment platelet counts (PPCs).

RESULTS

The median follow-up was 17.6 months, and median OS was 18.0 months. The hazard ratio was 1.83 in patients with a PS of 1 or 2 (vs. 0; P = 0.0004; 95 % confidence interval [CI] 1.31-2.55), 2.92 in patients with a PFI of <6 months (vs. PFI of ≥12 months; P < 0.0001; 95 % CI 1.73-4.91), 2.09 in patients with a PFI of <12 months (vs. PFI of ≥12 months; P = 0.0034; 95 % CI 1.28-3.44), and 0.69 in patients with PHL higher than or equal to the median value (vs. less than the median; P = 0.016; 95 % CI 0.51-0.93). No significant differences were obtained for PPC or the other known factors.

CONCLUSIONS

In addition to the known prognostic factor of PS, which was used as an adjusting factor, a PFI of <12 months and lower PHL were newly demonstrated to be associated with poor outcomes in patients with metastatic or recurrent cervical cancer. These new prognostic factors should be validated in future prospective trials.

CLINICAL TRIAL INFORMATION

UMIN-CTR[ http://www.umin.ac.jp/ctr/ ] ID: C000000335.

Paraneoplastic Syndromes in Patients with Cancer of the Larynx and Hypopharynx

Paraneoplastic syndromes may be the first sign of a malignancy. They are systemic, nonmetastatic manifestations associated with a variety of malignant neoplasms and occurring in a minority of cancer patients. These associations of symptoms and signs are not directly related to the site or local manifestations of a malignant tumor or its metastases, but their recognition may facilitate the detection of malignancies or recurrences. Paraneoplastic syndromes are categorized into 6 types: Dermatologic or cutaneous, endocrine, hematologic, neurologic, osteoarticular or rheumatologic, and ocular. Different oncotypes have rarely been associated with paraneoplastic syndromes in patients with cancer of the larynx and hypopharynx. The world literature has been reviewed.

Chemotherapy Response Rates Among Patients With Endometrial Cancer Who Have Elevated Serum Platelets

OBJECTIVE

This retrospective study evaluates the influence of serum platelet count on chemotherapy response rates among women with endometrial cancer.

METHODS

From 3 separate cancer centers, a total of 318 patients with endometrial cancer who received postoperative chemotherapy between June 1999 and October 2009 were retrospectively identified. Endometrioid, serous, clear cell, and carcinosarcoma histologies were included. Patients were classified as having an elevated platelet count if their serum platelet count was greater than 400 × 10⁹/L at the time of initial diagnosis. Primary outcome was chemotherapy response, classified as either complete or partial/refractory. Secondary outcomes were disease-free and disease-specific survival. χ² Test and Student t test were performed as appropriate. Kaplan-Meier curves and Cox proportional hazards models were used to assess serum platelet effect on survival.

RESULTS

There were 125 deaths, 76 recurrences, and 48 disease progressions. Of the total group, 53 (16.7%) were categorized as having an elevated platelet count. An elevated platelet count was associated with a lower chemotherapy response rate in univariate analysis (hazard ratio [HR], 2.8; 95% 95% confidence interval [CI], 1.46-5.38; P < 0.01). Multivariate analysis showed elevated platelets to be independently associated with decreased disease-free survival (HR, 2.24; 95% CI, 1.26-3.98; P < 0.01) but not disease-specific survival (HR, 1.03; 95% CI, 0.56-1.88, P = 0.93).

CONCLUSIONS

Patients with endometrial cancer who have an elevated serum platelet count greater than 400 × 10⁹/L may have lower chemotherapy response rates and are at increased risk for recurrence when compared with patients with a count within the reference range.

Prognostic significance of thrombocytosis, platelet parameters and aggregation rates in epithelial ovarian cancer

AIM

The aim of this study is to investigate the impact of preoperative platelet counts, parameters and aggregation rates (maximal aggregation rate: MAR) on prognosis in patients with epithelial ovarian cancer (EOC).

METHODS

Preoperative platelet count, parameters and MAR in 182 EOC patients, 122 patients with benign ovarian tumor and 150 healthy women were retrospectively analyzed. The correlation between thrombocytosis, platelet parameters, MAR and clinicopathological factors were evaluated in EOC.

RESULTS

Forty-five (24.73%) EOC patients had preoperative thrombocytosis in this study. The mean platelet count in the EOC group was significantly higher than that of benign and healthy groups (P < 0.001). The MAR in the EOC group was significantly higher than that in the healthy group (71.96% vs 57.03%, P = 0.025). The platelet parameters (mean platelet volume, platelet distribution width, thrombocytocrit and large platelet ratio) were consistently higher in the EOC group than those in the benign and healthy groups, but the differences were insignificant. A significant correlation between thrombocytosis and MAR was observed in EOC patients (r = 0.694, P < 0.001). EOC patients with thrombocytosis were found to have significantly higher grade (P = 0.048), more advanced stage (P = 0.045), higher level carbohydrate antigen-125 (P = 0.007) and greater likelihood of suboptimal cytoreduction (P = 0.035). EOC patients with both thrombocytosis and high MAR were found to have shorter progression-free survival (P = 0.001)and overall survival (P = 0.004). The combination of thrombocytosis and MAR, as well as stage and optimal cytoreduction, retained significance as an independent prognostic factor for overall survival.

CONCLUSION

Thrombocytosis, accompanied by increasing of platelet aggregation rates, is associated with more aggressive tumor biology in EOC. The combination of thrombocytosis and MAR is an independent negative prognostic factor for overall survival in EOC patients.

A case of MPO- and PR3-ANCA-negative pauci-immune renal-limited small-vessel vasculitis associated with endometrial neuroendocrine small cell carcinoma

A 69-year-old woman was admitted to our hospital for rapid increase in serum creatinine level with microscopic hematuria and nephrotic-range proteinuria. Three months prior to admission, she became aware of atypical genital bleeding, leading her gynecologist to suspect endometrial cancer. Light microscopy examination of renal biopsy revealed crescentic glomerulonephritis with peritubular capillaritis. Immunofluorescence microscopic examination did not detect any significant staining, and no electron-dense deposits were detected by electron microscopy. No autoantibodies, including anti-myeloperoxidase- or anti-proteinase3-anti-neutrophil cytoplasmic antibodies were detected. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy and was found to have endometrial neuroendocrine small cell carcinoma (NSCC), stage 1B. In her clinical course, her serum creatinine level gradually improved without immunosuppression therapy. Endometrial NSCC is a rare endometrial malignancy. This is the first case report of vasculitis associated with NSCC originating from the uterus.

Impact of pretreatment thrombocytosis on blood-borne metastasis and prognosis of gastric cancer

BACKGROUND

Thrombocytosis has been associated with malignancies and poor prognostic implications in cancer patients. In the present study the prognostic significance of pretreatment platelet (PLT) level was assessed with regard to recurrence and survival in patients with primary gastric adenocarcinoma.

METHODS

The authors reviewed the prospective data of 1593 gastric cancer patients who received curative gastrectomy with extended lymphadenectomy. The correlations of PLT level with recurrence and overall survival were evaluated by both univariate and multivariate analyses.

RESULTS

Thrombocytosis (≥ 40 × 10(4)/ μL), present in 6.4% of the patients prior to curative surgery, was more frequently associated with advanced T and N classification, larger tumor size, anemia, and leukocytosis (p < 0.05). In patients with pretreatment thrombocytosis compared to those without it, five-year survival rate was worse (56.9% vs. 65.5%; p = 0.043), and recurrence rate was higher mainly due to the frequent hematogenous spread (51.0% vs. 34.5%; p < 0.001). Furthermore, risk of blood-borne metastasis was almost three-fold higher in patients with pretreatment thrombocytosis (Odds ratio 2.83 [95% CI 1.67-4.77], p < 0.001).

CONCLUSIONS

Pretreatment thrombocytosis correlated significantly with poor prognosis and can be used as an independent predictor of recurrence by blood-borne metastasis in gastric cancer.

Subclavian thrombosis in a patient with advanced lung cancer: a case report

Introduction

Lung cancer is now considered the most common cause of death among cancer patients. Although target biological regimens have emerged in recent years for non-small cell lung carcinoma, the survival and quality of life of patients with this condition still remain low. The five-year survival rate for all stages of lung cancer is 17% or less.

Case presentation

We describe the case of a 53-year-old Caucasian woman who was diagnosed with advanced stage IIIa (T2aN₂M₀) non-small cell lung carcinoma (adenocarcinoma) and underwent a complete left upper lobectomy three years ago. After two and a half years of follow-up, she suddenly presented with facial edema and venous distension and was immediately treated for superior vena cava syndrome. Because of a diagnostic check, a major clot was detected in the right subclavian vein. Our patient was informed about treatment options, and she was taken to the catheterization laboratory for percutaneous stenting of the superior vena cava to restore superior vena cava patency.

Conclusion

Lung cancer has a vast number of complications. Superior vena cava syndrome and thrombosis should be considered upon the presentation of a patient with obstructive symptoms. In this case report, even though we expected the clot to be on the side of the former lesion, it was present on the opposite side. Treatment should also start immediately in these patients with clinical suspicion of thrombosis to avoid further complications, even in cases with a differential diagnosis problem. Finally, although patients with non-small cell lung carcinoma have a high incidence of thromboembolic events, anticoagulant treatment is given only as maintenance therapy after a first event occurs.

Blood plasma handling for protein analysis

Blood handling routines have been worked out that result in consistent protein analytic results in clinical practice. It would seem reasonable to build on this experience when devising handling routines for new protein biomarker discovery. Consequently, normal blood sample handling precautions apply to blood sample handling for new biomarker discovery. The blood sample handling protocol mentioned below describes room temperature, or 4°C, platelet poor EDTA plasma collected within 90 min of venipuncture, handled, and screened to eliminate hemolysis. DNA can be isolated from the "buffy coat" that results as blood cells are sedimented to isolate the plasma.

Intramural myocardial hemorrhagic rupture in a patient with metastatic cancer and myocardial infarction

A 77-year-old man with anterior ST-elevated myocardial infarction and lateral myocardial rupture underwent successful percutaneous revascularization. Cardiac magnetic resonance imaging (MRI) and positron emission tomography (PET) unveiled a disseminated metastatic cancer, likely responsible not only for a prothrombotic paraneoplastic syndrome but also for ventricular metastasis and myocardial rupture. The patient unfortunately died because of noncardiovascular complications of cancer.

Subclinical thrombosis of the ascending aorta: a possible paraneoplastic syndrome

Thrombosis of the ascending aorta is a rare, potentially lethal complication. We report the case of a 56-year-old woman with a massive but subclinic thrombosis of the ascending aorta after two cycles of chemotherapy due to an epidermoid lung carcinoma stage T3 N2 M0. An emergent aortic thrombectomy was performed under deep hypothermic circulatory arrest. This thrombotic event occurred in an arterial vessel with high laminar flow, which is extremely uncommon and did not present any clinical manifestation.

Renal cell carcinoma presenting as Henoch-Schönlein purpura with leukocytoclastic vasculitis, hematuria, proteinuria and abdominal pain

Some infectious, rheumatic, allergic diseases, and malignancies have been associated with leucocytoclastic vasculitis (LCV). LCV and cancer occur most frequently in patients with hematological malignancies such as lymphomas and leukemias. There have been a few prior cases reported of LCV associated with renal cell carcinoma (RCC). A 25-year-old male patient was referred from the department of dermatology and nephrology because of recurrent petechiae on both lower legs for several months; the patient also had a tumor of the left kidney. The findings on the skin biopsy were compatible with the diagnosis of LCV. The patient was diagnosed as having Henoch-Schönlein purpura (HSP) with LCV. A CT scan performed due to abdominal pain revealed a mass on the upper pole of the left kidney. A partial nephrectomy of the left kidney including the tumor was performed. The pathology report was consistent with a clear cell type of renal cell carcinoma, Fuhrman's grade 2; the tumor measured 0.9 x 0.8 cm and focal segmental glomerulosclerosis was noted in non-neoplastic regions. Here, we report a case of LCV associated with RCC presenting as HSP. This case illustrates the importance of evaluating patients for an underlying malignancy when HSP or LCV is diagnosed.

Thrombocytosis associated with malignant ovarian lesions within a pediatric/adolescent population

STUDY OBJECTIVE

To determine if there is an association between pediatric ovarian malignancies and elevated platelet counts:

DESIGN

Retrospective chart review.

SETTING

Large referral children's hospital.

PARTICIPANTS

154 patients taken to the operating room between February 1993 and February 2006 with an adnexal mass where ovarian tissue was submitted for pathological analysis.

MAIN OUTCOME MEASURES

The principle outcome was the presence of ovarian malignancy.

RESULTS

We found that there is an increase in thrombocytosis among individuals with ovarian malignancy, with as high as 33% of those with ovarian germ cell tumors demonstrating preoperative thrombocytosis.

CONCLUSION

These results suggest that thrombocytosis may be a useful marker for ovarian malignancy in this population. Further studies will be needed to determine if there is any prognostic value to thrombocytosis among these patients, with a potential value for counseling and future intervention based on these findings.

Eosinophilic colitis in a patient with advanced transitional cell carcinoma of the bladder: a paraneoplastic syndrome?

Eosinophilia associated with tumors is extremely rare. The exact underlying pathogenetic mechanisms are not well understood; limited data have been reported about granulocyte colony-stimulating factor and interleukin-5 in the development of eosinophilia. We report a patient with marked eosinophilia, leukocytosis, and eosinophilic colitis presenting with bloody stool. The subsequent diagnosis was advanced high-grade transitional cell carcinoma of the bladder. Leukocyte count, eosinophil count, and colonoscopic findings returned to normal after surgical removal of the tumor. To our knowledge, eosinophilic colonic infiltration as a manifestation of transitional cell bladder carcinoma has not been previously reported.

Cutaneous vascular disorders associated with internal malignancy

This article provides a detailed review of the vascular manifestations affecting the skin in relationship to internal malignancies. Vascular abnormalities heralding internal malignancies can be divided into three main categories, consisting of disorders related to vascular dilatation (flushing, palmar erythema, and telangiaectasia), and disorders related to vascular occlusion or hypercoagulability states (purpura, cutaneous ischemia, and thrombophlebitis). Entities are discussed according to etiology. The treatment of these entities is mostly related to treating the underlying malignancy. The goal of this article is to enlighten the practicing dermatologist about the association of these vascular manifestations with internal malignancy, thus leading to prompt initiation of the proper workup and management.

Paraneoplastic syndromes in patients with primary head and neck cancer

Paraneoplastic syndromes represent the clinical manifestations of the indirect and remote effects produced by tumor metabolites or other products. The clinical spectrum of the various paraneoplastic syndromes related to primary malignancies of the head and neck region is presented. A review of the literature on paraneoplastic syndromes in patients with primary head and neck cancer was carried out. Paraneoplastic syndromes related to primary malignancies of the head and neck region can be categorized as: endocrine, cutaneous or dermatologic, hematologic, neurologic, osteoarticular or rheumatologic, ocular syndromes. Sometimes, paraneoplastic syndromes can be more serious than the consequences of the primary tumor itself and can precede, follow or be concurrent to the diagnosis of a malignancy; moreover, they can dominate the clinical picture and thus lead to errors with respect to the origin and type of the primary tumor. Physicians who deal with cancer-associated syndromes should be able to differentiate the paraneoplastic syndromes from the benign disorders that mimic them. Patients with a suspected paraneoplastic disorder should undergo a complete panel of laboratory studies, in addition to imaging studies and endoscopy. Identification of paraneoplastic syndromes allow the clinician to make an early diagnosis and to provide adequate treatment of tumors, with a favorable oncologic outcome and improved life expectancy for the patient. These syndromes can follow the clinical course of the tumor and thus be useful for monitoring its evolution.

Bisphosphonate Treatment of Tumor-Induced Hypercalcemia in a Toddler: Case Report and Review of Related Literature

OBJECTIVE

To describe the initial manifestations and treatment of parathyroid hormone-related peptide (PTH-rP)-induced hypercalcemia in a toddler with a malignant rhabdoid tumor.

METHODS

We report a case of a 2-year-old boy presenting with poor appetite, lethargy, and a 1.5-kg weight loss during a 2-week period. On examination, the child was found to have a right upper quadrant abdominal mass. Laboratory studies revealed severe hypercalcemia. We review the patients' clinical course and management of hypercalcemia.

RESULTS

Initial evaluation revealed no cardiovascular instability. An abdominal mass was identified on physical examination. Initial laboratory studies revealed elevated levels of total and ionized calcium, low phosphorus, microcytic anemia, and elevated erythrocyte sedimentation rate. Saline diuresis with furosemide was begun. Abdominal ultrasonography revealed a large right renal tumor. Because of refractory hypercalcemia, intravenously administered bisphosphonate was used. Within 12 hours after bisphosphonate infusion, the serum calcium level declined from 14.9 mg/dL to 10.9 mg/dL. The furosemide dose was decreased and finally discontinued 2 days after bisphosphonate administration. Because of development of a femoral thrombosis, definitive surgical intervention was delayed. During that time, serum calcium levels again increased and necessitated administration of a second bisphosphonate dose. At surgical treatment, a right renal tumor was identified, and frozen section pathology revealed a rhabdoid tumor. After tumor resection, calcium levels were stable. Other laboratory studies performed at admission revealed suppressed PTH, normal vitamin D and calcitonin levels, and elevated PTH-rP.

CONCLUSION

Hypercalcemia in a toddler is a rare event and can be attributable to humoral factors released by malignant tumors. Hypercalcemia in the pediatric population can be treated effectively with bisphosphonates when conservative measures fail.

The prognostic significance of thrombocytosis in uterine papillary serous carcinomas

OBJECTIVES

We have shown that preoperative thrombocytosis (platelet counts >400 x 10(9)/l) is an independent poor prognostic factor in epithelial ovarian cancers (EOC) and is associated with worse survival. In light of the similarities between uterine papillary serous carcinomas (UPSC) and EOC, we sought to determine the incidence of thrombocytosis in UPSC and examine associations with clinico-pathologic features and survival.

METHODS

68 patients with UPSC were identified between 1996 and 2004 at 3 institutions. After IRB approval, records were retrospectively reviewed and data analyzed using Chi-squared and Cox proportional hazards model; survival was analyzed by the method of Kaplan and Meier.

RESULTS

8/68 (12%) patients had thrombocytosis at primary diagnosis. Patients with thrombocytosis were found to have more advanced stage disease (p=0.002) and ascites >1 L (p<0.0001). Of the 21 patients with stage IV disease, those with normal preoperative platelet counts demonstrated a greater likelihood of optimal tumor resection to less than 1 cm residual disease (13/15 versus 1/6 in patients with thrombocytosis, p<0.002). Patients with thrombocytosis had a shorter disease-free interval (17 months versus median survival not yet reached, p=0.0067) and overall survival (24 versus 45 months, p=0.0026). On multivariate analysis, thrombocytosis retained significance as a poor prognostic indicator in patients after controlling for age and stage (p=0.04).

CONCLUSIONS

Thrombocytosis may be a marker of aggressive tumor biology in UPSC. Platelet-secreted growth factors may promote aggressive cancer phenotype through contribution to metastasis, invasion, and primary tumor growth.

Prognostic significance of thrombocytosis in node-negative colon cancer

Several clinical studies have shown that thrombocytosis is a poor prognostic factor in some types of cancer, but data about the impact of thrombocytosis on prognosis in patients with colon cancer are very limited. We investigated the prevalence and prognostic effect of pre-operative thrombocytosis, defined as a platelet count > 400 x 10(9)/l, retrospectively in patients with node-negative colon cancer. Out of 198 patients, 24 (12.1%) had thrombocytosis, and its presence correlated with tumour depth and lymphatic invasion. Univariate analysis revealed that disease-free survival and overall survival were shorter in patients with pre-operative thrombocytosis than those without thrombocytosis. On multivariate analysis, thrombocytosis alone retained significance as a poor prognostic factor for both disease-free survival and overall survival. In conclusion, this study shows an association between thrombocytosis and poor survival in patients with node-negative colon cancer. The preoperative platelet count may help to identify patients with an unfavourable prognosis in this subgroup.

Metastatic carcinoma presenting with concomitant eosinophilia and thromboembolism

A case of a 58-year-old female patient who presented with significant blood eosinophilia and thromboembolic events is described. The patient was eventually diagnosed as suffering from a disseminated malignancy of gastrointestinal origin. Immunohistochemical studies of the tumor are presented. These studies show that tumor cells produce interleukin-3 and -5 and granulocyte macrophage-colony stimulating factor. These cytokines are known to support differentiation, proliferation, and survival of eosinophils. Their secretion is the probable explanation for the appearance of high blood eosinophilia in this patient. To the best of our knowledge, combined blood eosinophilia and thromboembolism as presenting manifestations of a solid tumor have never been reported.

Cutaneous lymphocytic vasculitis as the presenting feature of acute lymphoblastic leukemia

The authors describe a patient with precursor B-cell acute lymphoblastic leukemia who presented with a 3-week history of indurated or ulcerative, purpuric lesions distributed mainly on her legs. A skin biopsy demonstrated a T-cell-mediated lymphocytic vasculitis. After the patient started chemotherapy, the skin lesions abated but she became febrile and a blood culture revealed cryptococci. The cryptococcal infection was successfully treated first with amphotericin B and later with fluconazole. The relationship between lymphocytic vasculitis and acute lymphoblastic leukemia may be an example of paraneoplastic association because both conditions seem to have appeared at about the same time, and both followed a parallel course. Lymphocytic vasculitis may also reflect a new manifestation of host-leukemia interaction.

Cancer and thrombosis revisited

Remarkable progress has been made since the first description of the association between cancer and thrombosis by Trousseau over 100 years ago. Now, it is clear that there is a two-way connection between coagulation and cancer as tumor results in alterations in hemostatic balance, and thrombosis may promote tumor cell growth. A variety of clinical thrombotic syndromes may present in cancer patients including local and systemic venous and arterial thromboses. More evidence is now being gathered on the potential of antithrombotic regimens to prolong survival of cancer patients. Whether the use of novel antithrombotic drugs may result in a better outcome remains to be determined.

Temporal concurrence of vasculitis and cancer: A report of 12 cases

OBJECTIVE

Vasculitis has been associated with solid organ and hematologic cancer. The rarity of these associations, and in many reports the lack of temporal relationships, has led to skepticism about vasculitis being a paraneoplastic syndrome. The objective of the present study was to review cases of concurrent vasculitis and cancer at the Cleveland Clinic Foundation over an 18.5-year period and explore evidence that would support the notion of vasculitis being a type of paraneoplastic disease.

METHODS

Retrospective review of the records of all patients diagnosed with vasculitis and cancer within 12 months of each other was performed using an ICD-9 diagnostic data base at the Cleveland Clinic Foundation. Patients with known chronic autoimmune disease or serologic evidence of hepatitis B or C infection were excluded. A standardized data collection instrument was used to document information about presentation, treatment, and course of illness.

RESULTS

During the 18.5 years of our study, more than 15 million inpatients and outpatients were seen at the Cleveland Clinic. Of these, 2,800 patients had vasculitis independent of cancer, more than 69,000 patients had cancer, and 69 patients had been identified who had both malignancies and systemic vasculitis. Only 12 patients were identified in whom both vasculitis and cancer occurred within the same 12 months. Mean age was 65 years (range 45-79). There was no gender preference (M = F). In 8 of the 12 cases, diagnoses were made within 3 months of each other. In 6 of the patients, the diagnoses of both processes were made within 1 month. Ten of the 12 patients had vasculitis 1 to 3 months prior to or concurrent with the diagnosis of cancer. Six of the 12 patients had solid organ tumors, 4 had lymphoma, 1 had leukemia, and 1 had multiple myeloma. The most common vasculitis was cutaneous leukocytoclastic vasculitis (LCV), which occurred in 7 cases. Four cases of LCV were associated with solid organ tumors. Other vasculitides included giant cell arteritis (n = 2), polyarteritis nodosa (n = 2), and Wegener's granulomatosis (n = 1). The response of the vasculitis to glucocorticoid and cytotoxic therapy varied. Complete remission of vasculitis occurred in 4 of the patients, partial improvement occurred in 4 patients, and no improvement was noted in 4 patients. Complete remission occurred in 3 of the 4 patients in whom vasculitis and cancer were treated concurrently. Eight of 10 patients in whom followup was greater than 2 months demonstrated concordance of disease activity and treatment response for both cancer and vasculitis.

CONCLUSION

The close temporal relationship of cancer and vasculitis in our patients adds to circumstantial evidence of vasculitis at times being a paraneoplastic condition. Failure of a vasculitis to respond to conventional therapy should raise questions about underlying malignancy. Effective treatment of the cancer enhances the likelihood of improvement in vasculitis.

CT evaluation of renovascular disease

Computed tomography (CT) plays an important role in evaluation and management of primary renovascular disease. Nonenhanced CT is useful for demonstrating renal hemorrhage, renal parenchymal or vascular calcifications, and masses. Contrast material-enhanced CT is essential to identify global or regional nephrographic abnormalities resulting from the vascular process (eg, renal infarcts, ischemia secondary to renal artery stenosis, arteriovenous communications). In addition, renal manifestations of a systemic disease (eg, vasculitis, thromboembolic disease) can be seen at CT. In trauma, occlusion of the main renal artery can be accurately diagnosed with contrast-enhanced CT. In cases of spontaneous renal hemorrhage without an apparent cause (eg, vasculitis, coagulopathy), a careful CT study should be performed to exclude renal cell carcinoma. The presence of fat in a hemorrhagic renal mass larger than 4 cm in diameter is characteristic of angiomyolipoma complicated by hemorrhage. Acute renal vein thrombosis appears as a clot in a distended renal vein, whereas renal vein retraction with collateral vessels is highly indicative of chronic thrombosis. Helical CT, especially with multiplanar two-dimensional and three-dimensional reconstruction following an intravenous injection of iodinated contrast material, has greatly improved our ability to directly image the proximal renal arteries and detect vascular lesions.

The significance of thrombocytosis in patients with locally advanced cervical carcinoma: a Gynecologic Oncology Group study

OBJECTIVE

The aim of this study was to determine the incidence of thrombocytosis and its possible impact on survival probability among women with locally advanced cervical carcinoma.

METHODS

The database of 294 patients with Stages IIB-IVA cervical carcinoma without periaortic node metastasis who were treated with standardized radiation therapy and concurrent hydroxyurea or misonidazole was analyzed. Pretreatment platelet counts were available for 291 patients who are the subject of this study.

RESULTS

Thrombocytosis (platelet count >400 x 10(9)/liter) was present in 86 (29.6%) of the 291 patients. A multivariate Cox proportional hazards model showed that patients without extrapelvic disease and with thrombocytosis had a 55% greater chance of dying than those without thrombocytosis (relative risk = 1.55, 95% confidence interval 1.08-2.21). Patients with thrombocytosis had larger tumors and more frequently had bilateral parametrial involvement, tumor fixation to the sidewall, and positive pelvic lymph nodes than patients without thrombocytosis. Thrombocytosis was not found to be a prognostic factor in patients with positive pelvic nodes. However, in patients with negative pelvic nodes, the presence or absence of thrombocytosis was related to survival.

CONCLUSION

Thrombocytosis is a frequent finding among patients with advanced cervical carcinoma and seems to be related to tumor burden. Among patients with locally advanced cervical carcinoma who had negative pelvic nodes, those with thrombocytosis had a poorer survival.

Leukocytoclastic vasculitis: is propranolol implicated?

Drugs frequently cause cutaneous adverse reactions. The suspected agent is sometimes difficult to identify, especially in patients receiving multidrug treatment and with underlying illnesses that may contribute to the clinical picture. In our patient, propranolol-induced leukocytoclastic vasculitis was diagnosed by exclusion.

[Venous thromboembolism and cancer]

INTRODUCTION

Thromboembolic venous disease, which includes both peripheral venous thrombosis and pulmonary embolism, is a frequent disorder in patients with cancer. Although thromboembolic manifestations may precede the diagnosis of cancer, the value of extensive clinical search for potential underlying cancer when faced with venous thromboembolic manifestations has not been demonstrated.

CURRENT KNOWLEDGE AND KEY POINTS

Clinical and biological studies have demonstrated that acquired abnormalities in blood hemostasis, especially procoagulant factors, account for the onset of thromboembolic manifestations in patients with cancer. Classical anticoagulant therapy is associated with low efficacy and tolerance in patience with cancer who are at high risk for hemorrhagic complications and recurrence of thromboembolic disease.

FUTURE PROSPECTS AND PROJECTS

Recent data suggest the value of anticoagulant therapy using either low molecular weight heparin or warfarin at low doses (INR < 2) according to the specific surgical or medical context.

Paraneoplastic syndromes in patients with laryngeal and hypopharyngeal cancers

Paraneoplastic syndromes are systemic, nonmetastatic manifestations associated with a variety of malignant neoplasms and occurring in a minority of cancer patients. Paraneoplastic syndromes in association with cancers of the larynx and hypopharynx are considered rare. The world literature is reviewed, dividing paraneoplastic syndromes into 4 main groups, ie, cutaneous (acanthosis nigricans, Bazex's syndrome, Bowen's disease, bullous pemphigoid, dermatomyositis, pruritus, Sweet's syndrome, yellow nail syndrome, and tylosis), endocrine (carcinoid syndrome, adrenocorticotropic hormone syndrome, Schwartz-Bartter syndrome, hypercalcemia), hematologic (Trousseau's syndrome), and neurologic (cerebellar degeneration, Eaton-Lambert myasthenic syndrome). A paraneoplastic syndrome may precede the clinical manifestations of a persistent or recurrent tumor or of asymptomatic metastases, and its onset may even, in a minority of cases, be the presenting sign of a malignancy. Otolaryngologists and head and neck surgeons should have a knowledge of the paraneoplastic syndromes in order to facilitate their detection of malignancies or recurrences.

Rheumatic syndromes: clues to occult neoplasia

OBJECTIVES

Rheumatic disorders associated with cancer include a variety of conditions, most of which have no features distinguishing them from idiopathic rheumatic disorders. It is generally held that an extensive search for occult malignancy in most rheumatic syndromes is not recommended unless accompanied by specific findings suggestive of malignancy. The objective of this review are to identify rheumatic syndromes associated with cancer, to call attention to features that may suggest the presence of a hidden cancer, and to examine the role to additional clinical and laboratory data as clues to the possible neoplastic cause of those syndromes.

METHODS

A MEDLINE search of the literature dealing with cancer-associated rheumatic syndromes was conducted.

RESULTS

Review of the literature identified significant progress in this area. First, the association of malignancy with certain rheumatic syndromes was convincingly established, such as asymmetric polyarthritis presenting in the elderly with an explosive onset, rheumatoid arthritis with monoclonal gammopathy, Sjögren's syndrome with monoclonality, hypertrophic osteoarthropathy, dermatomyositis, polymyalgia rheumatica with atypical features, Lambert-Eaton myasthenic syndrome, palmar fasciitis and arthritis, eosinophilic fasciitis poorly responsive to corticosteroid therapy, erythema nodosum lasting more than 6 months, and onset of Raynaud's phenomenon or cutaneous leukocytoclastic vasculitis after age 50 years. Second, the list of cancer-associated rheumatic syndromes was extended by including additional entities such as benign edematous polysynovitis, sacroiliitis, adult-onset Still's disease, dermatomyositis sine myositis, systemic sclerosis, Sweet's syndrome, osteomalacia, skeletal hyperostosis, antiphospholipid syndrome, and essential mixed cryoglobulinemia. Third, evidence was provided substantiating that certain long-standing rheumatic syndromes, in particular rheumatoid arthritis, Felty's syndrome, Sjögren's syndrome, dermatomyositis, systemic sclerosis, systemic lupus erythematosus, and temporal arteritis behave like "premalignant conditions." Fourth, it was shown that the recognized tumor markers alpha-fetoprotein, prostate-specific antigen, CA-125, CA 19-9, and CA-3 have low sensitivity and specificity in screening for occult cancer in a population of rheumatic patients, whereas the presence of a monoclonal gammopathy in rheumatoid arthritis and the monoclonal antibody 17-109 in Sjögren's syndrome are reliable signs of malignant transformation.

CONCLUSIONS

The presence of specific rheumatic syndromes and certain clinical and laboratory findings may justify a workup for hidden cancer. Studies of the epidemiology of the cancer-associated rheumatic syndromes and evaluation of the validity of aforementioned clues in prospective studies are goals for future investigations.

The significance of measuring monocyte tissue factor activity in patients with breast and colorectal cancer

Monocytes express tissue factor (mTF) in several conditions including cancer where levels may be valuable in assessing tumour presence and progression. Using a two-stage kinetic chromogenic assay (KCA), mTF levels were measured in controls [normal subjects (n = 60) and patients undergoing hernia repair or cholecystectomy (n = 60)], in patients with benign and malignant disease of the breast (n = 83) and of the large bowel (n = 62). This was performed under fresh (resting) conditions and after incubation for 6 h without (unstimulated) and with (stimulated) Escherichia coli endotoxin. The malignant groups showed higher mTF levels than each of the three controls for resting (P < 0.05 breast, P < 0.05 colorectal) unstimulated (P < 0.05 breast, P < 0.05 colorectal) and stimulated cells (P < 0.001 breast, P < 0.01 colorectal). Similarly, the benign inflammatory groups had higher mTF levels than controls for resting (P < 0.05 colorectal), unstimulated (P < 0.05 colorectal) and stimulated cells (P < 0.01 breast, P < 0.01 colorectal). There was no significant difference between malignant and benign inflammatory groups in each organ. mTF levels showed an increase corresponding to that of histological tumour progression and were higher in non-surviving patients. In conclusion, mTF levels are raised in malignant and inflammatory disease compared to controls and patients with non-inflammatory conditions. Stimulated cells give better discrimination between the groups and may be of value in identifying high risk individuals. mTF levels showed an association with tumour grade or stage and the patients' survival time.

Monocyte tissue factor levels in patients with urological tumours: an association between tumour presence and progression

OBJECTIVE

To examine the hypothesis that increased monocyte tissue factor (mTF) levels may reflect urological tumour presence and progression.

PATIENTS, SUBJECTS AND METHODS

Using a two-stage kinetic chromogenic assay, mTF levels were measured in 60 controls (normal subjects [60] and patients awaiting hernia repair or cholecystectomy [60]), patients with benign and malignant disease of the bladder (73), or prostate (81), and in patients with and without recurrent malignant disease of the bladder (30). The levels were assessed under fresh resting conditions (baseline) and after incubation for 6 h without (unstimulated) and with (stimulated) Escherichia coli endotoxin. Each benign disease group was subdivided into inflammatory and non-inflammatory categories.

RESULTS

Patients with bladder and prostate malignancy showed significantly higher mTF levels than did each control for baseline and stimulated cells. The benign inflammatory groups for both organs had significantly higher mTF levels than had each control for baseline cells. There was no difference between malignant and benign inflammatory groups. Stimulated mTF levels showed better discrimination between the study groups. The mTF levels were associated with histological tumour progression, serum prostate specific antigen level and static bone scan images. Levels were also higher in patients with bladder cancer recurrence than in those with a normal check cystoscopy.

CONCLUSION

Stimulated mTF levels are raised in malignant and inflammatory disease compared with controls and patients with non-inflammatory conditions, and give maximal discrimination between these groups. mTF levels showed an association with tumour grade and other markers of tumour progression.

Patients with a malignant tumor have more extended thrombosis than patients without

Changes in the coagulability or rheology of the blood are supposed to cause an increased frequency of thrombosis in patients with a malignant tumor. These procoagulopathic disorders may not only increase the frequency of thrombosis but may also enlarge the extent of the thrombosis. The authors retrospectively analyzed, therefore, the extension of thrombosis in patients with and without a malignant tumor. From 1991 to 1995 in the University Hospital Essen 489 consecutive cases of thrombosis were diagnosed. The diagnosis was made by color Doppler sonography or phlebography; 230 patients (47%) suffered from a malignant tumor (110 men, 120 women). To exclude the influence of the patient's age on the extension of the thrombosis the authors distinguished three different age groups. In the tumor group aged from 21 to 40 years they found 10 large (iliacal, femoral, and crural veins), six medium (femoral and crural veins), and four small thromboses (crural veins). In the tumor group aged from 41 to 60 years they found 38 large, 24 medium, and 27 small thromboses. In the group without a tumor aged from 21 to 40 years they found seven large, 13 medium, and 28 small thromboses, and in the group aged from 41 to 60 years, 12 large, 29 medium, and 41 small thromboses. The difference between the two groups supports the assumption that in patients suffering from a malignant tumor, thromboses tend to be more extended than in patients without a malignant tumor.

Venous thromboembolism and cancer

The association of thrombosis with malignant disease has been recognized for well over 100 years. Evidence from experimental and clinical studies indicates that the haemostatic system is involved in the growth, invasion and metastasis of tumours. Laboratory parameters of haemostasis are frequently deranged in patients with cancer and overt thrombosis is common spontaneously where it may be the first sign of malignancy or secondary to therapy. The mechanisms by which coagulation activation facilitates the malignant process remain to be completely elucidated, but it is clear that cells and proteins of the coagulation and fibrinolytic systems are involved at many steps in the processes of tumour growth and dissemination. The low-molecular-weight heparins with their well-proven safety and efficacy profiles offer unique modalities for the prevention and treatment of cancer-associated thrombosis. They may also play a role in overall mortality reduction in patients with malignant disease.

Paraneoplastic syndromes in metastatic disease

OBJECTIVES

To provide an overview of selected paraneoplastic syndromes associated with metastatic disease with potential life-threatening implications, and the nursing implications of each.

DATA SOURCES

Published articles and book chapters related to paraneoplastic syndromes in metastatic disease.

CONCLUSIONS

Paraneoplastic syndromes in metastatic disease are associated with various primary tumors and can affect many organ systems. Early recognition and management can minimize the potential life-threatening effects of the syndromes.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses need to be aware of the potential for paraneoplastic syndromes that can compromise a patient's health status. Appropriate assessment and intervention of paraneoplastic syndromes can have a positive impact on patient outcomes and quality of life.

The risk of a diagnosis of cancer after primary deep venous thrombosis or pulmonary embolism

BACKGROUND

Several small studies have indicated an association between deep venous thrombosis or pulmonary embolism and a subsequent diagnosis of cancer, but the subject is controversial.

METHODS

We conducted a nationwide study of a cohort of patients with deep venous thrombosis or pulmonary embolism that was drawn from the Danish National Registry of Patients for the years 1977 through 1992. The occurrence of cancer in the cohort was determined by linkage to the Danish Cancer Registry. The expected number of cancer cases was estimated on the basis of national age-, sex-, and site-specific incidence rates.

RESULTS

A total of 15,348 patients with deep venous thrombosis and 11,305 patients with pulmonary embolism were identified. We observed 1737 cases of cancer in the cohort with deep venous thrombosis, as compared with 1372 expected cases (standardized incidence ratio, 1.3; 95 percent confidence interval, 1.21 to 1.33). Among the patients with pulmonary embolism, the standardized incidence ratio was 1.3, with a 95 percent confidence interval of 1.22 to 1.41. The risk was substantially elevated only during the first six months of follow-up and declined rapidly thereafter to a constant level slightly above 1.0 one year after the thrombotic event. Forty percent of the patients given a diagnosis of cancer within one year after hospitalization for thromboembolism had distant metastases at the time of the diagnosis of cancer. There were strong associations with several cancers, most pronounced for those of the pancreas, ovary, liver (primary hepatic cancer), and brain.

CONCLUSIONS

An aggressive search for a hidden cancer in a patient with a primary deep venous thrombosis or pulmonary embolism is not warranted.