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Nouhravesh N, Strange JE, Sindet-Pedersen C, Holt A, Tønnesen J, Andersen CF, Nielsen SK, Grove EL, Nielsen D, Schou M, Lamberts M. Impact of breast-, gastrointestinal-, and lung cancer on prognosis in patients with first-time pulmonary embolism: A Danish nationwide cohort study. Int J Cardiol 2024; 406:132001. [PMID: 38561107 DOI: 10.1016/j.ijcard.2024.132001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/28/2024] [Accepted: 03/29/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Pulmonary embolism (PE) is described as a prognostic factor in patients with cancer however, the prognostic impact of PE remains unknown. This study investigated, the 1-year prognosis following PE in patients with breast-, gastrointestinal-, or lung cancer stratified by cancer status. METHODS All Danish patients with first-time PE from 2008 to 2018 were included. Cancer status was categorized as no cancer, history of cancer, non-active cancer and active cancer. Unadjusted and age-stratified 1-year risk of death was estimated using the Kaplan-Meier estimator. Cause of death was reported using the Aalen-Johansen method. RESULTS Of 35,679 patients with PE, 18% had a breast-, gastrointestinal-, or lung cancer. Patients with cancer were older compared with no cancer (69.8 years [IQR: 56.2-79.8]). One-year risk of death (95% confidence interval) for active breast-, gastrointestinal-, and lung cancer was 49.5% (44.0%-54.9%), 75.0% (72.5%-77.4%) and 80.1% (78.0%-82.3%) respectively, compared with 18.9% (18.4%-19.3%) for no cancer. Age-stratified analysis revealed no association with increasing age in non-active lung cancer and all active cancers. Further, non-cardiovascular death accounted for an increasing proportion by cancer status (no cancer < history of cancer < non-active cancer < active cancer). CONCLUSIONS One-year risk of death was dependent on both cancer type and status; no association with age was found for patients with active cancers. Non-cardiovascular death was leading in non-active and active cancers. Thus, the occurrence of first-time PE could be regarded as a marker of cancer severity for patients with breast-, gastrointestinal-, and lung cancer.
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Affiliation(s)
- Nina Nouhravesh
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark.
| | - Jarl E Strange
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark; Department of Cardiology, Rigshospitalet, University of Copenhagen, Denmark
| | | | - Anders Holt
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark; Department of Epidemiology and Biostatistics, School of Population Health, University of Auckland, 85 Park Road, Grafton, Auckland 1142, New Zealand
| | - Jacob Tønnesen
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark
| | | | - Sebastian K Nielsen
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Dorte Nielsen
- Department of Oncology, Herlev-Gentofte University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health, Copenhagen University, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health, Copenhagen University, Copenhagen, Denmark
| | - Morten Lamberts
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark
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Philippe D, Bernard A, Ricolfi F, Béjot Y, Duloquin G, Comby PO, Guenancia C. Prevalence of major embolic findings and incidental findings on early cardiac CT in patients with suspected ischemic stroke. Diagn Interv Imaging 2024:S2211-5684(24)00047-0. [PMID: 38431431 DOI: 10.1016/j.diii.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE The purpose of this study was to assess the type and prevalence of stroke and non-stroke-related findings diagnosed on early cardiac computed tomography (CT) in patients with suspected stroke. The secondary objective was to assess the clinical consequences on the management of patients with non-stroke-related conditions identified by early cardiac CT. MATERIALS AND METHODS This single-center, retrospective, observational study included 1111 consecutive patients with suspected ischemic stroke between November 2018 and March 2020 who underwent cardiac CT examination in addition to the usual brain CT protocol (i.e., non-enhanced brain CT, perfusion brain CT when needed, aortic arch and supra-aortic CT angiography, and post contrast brain CT). There were 562 women and 549 men with a median age of 74 years (range: 60-85 years). Of these, 415 (415/1111; 37.4%) patients had ischemic stroke and 692 (692/1111; 62.3%) had no stroke. Cardiac CT examinations were retrospectively reviewed for cardiac CT findings at high embolic risk and clinically significant extracardiac incidental findings. RESULTS Among 1111 included patients, 89 (89/1111; 8.0%) had a stroke-related condition identified on early cardiac CT. This was significantly more frequent in patients with ischemic stroke (66/415; 15.9%) by comparison with those without ischemic stroke (23/696; 3.3%) (P < 0.001), with 41 patients (41/415; 9.9%) diagnosed with left atrial thrombus. Cardiac CT revealed a clinically significant non-stroke-related finding in 173 patients (173/1111; 15.6%), including 17 pulmonary embolisms (1.5%), seven suspicious pulmonary lesions (0.6%), and three breast lesions suspected to be malignant (0.3%). Twenty out of 173 patients (20/173; 11.5%) with incidental findings on early cardiac CT had a change in their management. CONCLUSION This study shows that adding early cardiac CT to brain CT during the acute phase of an ischemic stroke leads to a higher rate of etiological diagnoses and highlights the major interest of looking at the bigger picture.
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Affiliation(s)
- Diane Philippe
- Department of Radiology, University Hospital, 21709 Dijon, France
| | | | - Frédéric Ricolfi
- Department of Radiology, University Hospital, 21709 Dijon, France
| | - Yannick Béjot
- PEC2 EA7460, Université de Bourgogne et de Franche-Comté, 21709 Dijon, France; Department of Neurology, University Hospital, 21709 Dijon, France
| | - Gauthier Duloquin
- PEC2 EA7460, Université de Bourgogne et de Franche-Comté, 21709 Dijon, France; Department of Neurology, University Hospital, 21709 Dijon, France
| | - Pierre-Olivier Comby
- Department of Radiology, University Hospital, 21709 Dijon, France; Department of Neurology, University Hospital, 21709 Dijon, France
| | - Charles Guenancia
- PEC2 EA7460, Université de Bourgogne et de Franche-Comté, 21709 Dijon, France; Department of Cardiology, University Hospital, 21709 Dijon, France.
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Affiliation(s)
- Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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Yoo JH, Park SH, Oh HC, Ha JW, Yoon HK. Efficacy of pulse oximetry for early diagnosis of pulmonary embolism after total knee arthroplasty. Knee Surg Relat Res 2024; 36:6. [PMID: 38246998 PMCID: PMC10801930 DOI: 10.1186/s43019-023-00207-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 12/26/2023] [Indexed: 01/23/2024] Open
Abstract
INTRODUCTION Early diagnosis and aggressive treatment of pulmonary embolism (PE) are crucial for preventing severe complications after total knee arthroplasty (TKA). This study aimed to examine the efficacy of measuring oxygen saturation (SpO2) using a pulse oximeter for early diagnosis of PE after total knee arthroplasty (TKA). MATERIALS AND METHODS We consecutively examined 1645 patients who underwent TKA between January 2015 and November 2019. Postoperative SpO2 was measured with a pulse oximeter, which was stopped if SpO2 was maintained at ≥ 95% until postoperative day 2 (POD2). To diagnose PE, computed tomographic pulmonary angiography (CTPA) was performed for specific indications, including persistently low SpO2 < 95% (group 1), sudden decrease in SpO2 (group 2), and decrease in SpO2 after POD3 with presenting symptoms (group 3). Also, we divided the patients into unilateral, simultaneous and sequential TKA groups and compared the results with specific statistical techniques. RESULTS Of the 1645 patients who underwent TKA, there were 20 patients with PE (1.2%), and symptomatic PE was observed in only 4 patients (0.24%). CTPA was performed in 58 (3.5%) patients, of whom 20 were diagnosed with PE. In groups 1 (n = 34), 2 (n = 21), and 3 (n = 3), CTPA was performed 2.4, 2.6, and 8.3 days after TKA, respectively, and 12, 8, and 0 patients were diagnosed with PE, respectively. Of the 782, 416, and 447 unilateral, simultaneous, and sequential (done in same admission with interval 1 or 2 weeks) patients with TKA, 38, 18, and 2 received CTPA, and 13, 6, and 1 were diagnosed with PE, respectively. All patients diagnosed with PE have persistently low SpO2 < 95% (group 1), or sudden decrease in SpO2 (group 2) until POD2. Of the patients diagnosed with PE, SpO2 decreased without the presentation of symptoms in 16 patients (11 and 5 from groups 1 and 2, respectively) and with the presentation of symptoms, such as mild dyspnea and chest discomfort, in 4 patients (1 and 3 from groups 1 and 2, respectively). CONCLUSIONS Measuring SpO2 using a pulse oximeter until POD2 was an effective method for early diagnosis of PE after TKA. No case of morbidity or mortality was observed after early diagnosis with early stage CTPA and management of PE. We recommend measuring SpO2 with a pulse oximeter for early diagnosing of PE in TKA.
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Affiliation(s)
- Ju-Hyung Yoo
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Ilsan-ro 100, Ilsandong-gu, Goyang, 10444, South Korea
- Department of Orthopedic Surgery, Seran Hospital, Seoul, Korea
| | - Sang-Hoon Park
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Ilsan-ro 100, Ilsandong-gu, Goyang, 10444, South Korea.
| | - Hyun-Cheol Oh
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Ilsan-ro 100, Ilsandong-gu, Goyang, 10444, South Korea
| | - Joong-Won Ha
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Ilsan-ro 100, Ilsandong-gu, Goyang, 10444, South Korea
| | - Han-Kook Yoon
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Ilsan-ro 100, Ilsandong-gu, Goyang, 10444, South Korea
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Lakshmi A, Shah R, Begaj A, Jayarajan R, Ramachandran S, Morgan B, Faust G, Patel N. NICE 2022 guidelines on the management of melanoma: Update and implications. J Plast Reconstr Aesthet Surg 2023; 85:401-413. [PMID: 37572388 DOI: 10.1016/j.bjps.2023.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 07/09/2023] [Accepted: 07/16/2023] [Indexed: 08/14/2023]
Abstract
AIMS In July 2022, NICE updated the guidelines on the management of melanoma by lowering the number of follow-up appointments and sentinel lymph node biopsy (SLNB) but increasing the number of scans. This study aims to evaluate the implications of executing the new guidelines in terms of cost-effectiveness and personnel. METHODS All patients newly diagnosed with melanoma in 2019 at a regional skin cancer specialist center were reviewed. Data were analyzed for their journey on an idealized pathway modeled over a 5-year follow-up period when adhering to both the previous and new guidelines. Differences in the management of melanoma were elucidated by comparing these changes. The cost was quantified on a perpatient basis and the financial implication on each department was considered. RESULTS One hundred and ten patients were diagnosed with melanoma in 2019, stages I-III. The changes ease the burden on plastic surgery and dermatology; however, increased pressure is faced by radiologists and histopathologists. An overall cost benefit of £141.85 perpatient was calculated, resulting in a decrease of 1.22 hospital visits on average and an increase in the time spent there (19.55 min). The additional expenses of implementing the new guidelines due to the added BRAF tests, CT, and ultrasound scans are outweighed by savings from the reduction in follow-up appointments and SLNB. CONCLUSION The focus has shifted to less invasive procedures for lower melanoma stages and fewer follow-up appointments, at the expense of more genetic testing and imaging. This paper serves as a useful baseline for other centers to plan their service provision and resource allocation to adhere to the updated guidelines.
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Affiliation(s)
- Aiswarya Lakshmi
- University of Cambridge, School of Clinical Medicine, United Kingdom.
| | - Rahul Shah
- University of Cambridge, School of Clinical Medicine, United Kingdom
| | - Ardit Begaj
- Plastic Surgery Department, University Hospitals of Leicester, United Kingdom
| | - Rajshree Jayarajan
- Plastic Surgery Department, University Hospitals of Leicester, United Kingdom
| | | | - Bruno Morgan
- Radiology Department, University Hospitals of Leicester, United Kingdom
| | - Guy Faust
- Oncology Department, University Hospitals of Leicester, United Kingdom
| | - Nakul Patel
- Plastic Surgery Department, University Hospitals of Leicester, United Kingdom
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Migita S, Okumura Y, Fukuda I, Nakamura M, Yamada N, Takayama M, Maeda H, Yamashita T, Ikeda T, Mo M, Yamazaki T, Hirayama A. Rivaroxaban treatment for asymptomatic venous thromboembolism: insights from the J'xactly study. Thromb J 2023; 21:88. [PMID: 37599351 PMCID: PMC10440934 DOI: 10.1186/s12959-023-00528-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/02/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND An established treatment strategy for asymptomatic pulmonary embolism (PE) or deep vein thrombosis (DVT) remains uncertain in Japan; therefore, in this study, we clarify the characteristics and outcomes of symptomatic compared to asymptomatic patients with PE or DVT. METHODS This prospective, multicenter sub-analysis of the J'xactly study in Japan included 1,016 patients (mean age, 68; 41% male) with venous thromboembolism (VTE) treated with rivaroxaban. RESULTS Asymptomatic PE patients (47% of PE patients) were more likely to have active cancer and asymptomatic proximal DVT at lower severity than symptomatic PE patients, despite no differences in age, sex, or the proportion receiving intensive 30 mg/day-rivaroxaban. Patients with asymptomatic DVT (34% of DVT patients) were older, had higher rates of female sex, active cancer, and distal DVT, and received shorter, less intense rivaroxaban treatment. Incidences did not differ between asymptomatic and symptomatic PE patients for recurrent symptomatic VTE (hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.22-1.62; P = 0.31) or major bleeding (HR, 0.68; 95% CI, 0.20-2.33; P = 0.58), nor between asymptomatic and symptomatic DVT patients for recurrent symptomatic VTE (HR, 0.56; 95% CI, 0.23-1.40; P = 0.21) and major bleeding (HR, 1.47; 95% CI, 0.54-3.97; P = 0.45). CONCLUSIONS The real-world composite adverse event rate for treatment with rivaroxaban, as physician-adjusted for dose and duration, was similar for asymptomatic and symptomatic patients regardless of the presence of PE or DVT, suggesting a favorable safety profile for potential rivaroxaban treatment for asymptomatic VTE.
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Affiliation(s)
- Shohei Migita
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Ikuo Fukuda
- Department of Cardiology, Keimeikai Yokawa Hospital, Miki, Japan
| | | | - Norikazu Yamada
- Department of Cardiology, Kuwana City Medical Center, Kuwana, Japan
| | | | - Hideaki Maeda
- Department of Heart and Vascular Center, Ukima Central Hospital, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, International University of Health and Welfare, Tokyo, Japan
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Wang Y, Liu Z, Li Q, Xia L, Wang Y, Jiang D, Chen X, Zheng Y, Liu W, Wang D, Xue D. Prognosis of incidental pulmonary embolism vs. symptomatic pulmonary embolism in cancer patients: a single-center retrospective cohort study in China. Thromb J 2023; 21:64. [PMID: 37280671 PMCID: PMC10245445 DOI: 10.1186/s12959-023-00502-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 05/15/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND The incidence of incidental pulmonary embolism (IPE) has greatly increased, but its clinical characteristics and outcomes are still controversial. This study aimed to compare the clinical characteristics and outcomes between cancer patients with IPE and patients with symptomatic pulmonary embolism (SPE). PATIENTS/METHODS Clinical data of 180 consecutive patients with cancer complicated with pulmonary embolism admitted to Beijing Cancer Hospital from July 2011 to December 2019 were retrospectively collected and analysed. General characteristics, diagnosis time of pulmonary embolism (PE), location of PE, concurrent deep venous thrombosis, anticoagulant treatment, impact of PE on anti-tumor treatment, recurrent venous thromboembolism, rate of bleeding after anticoagulation therapy, survival and risk factors of IPE were compared with SPE. RESULTS Of 180 patients, 88 (49%) had IPEs and 92 (51%) had SPEs. Patients with IPE and SPE did not differ in age, sex, tumor type, or tumor stage. Median diagnosis times of IPE and SPE after cancer were 108 (45, 432) days and 90 (7, 383) days, respectively. Compared to SPE, IPE tended to be central (44% versus 26%; P < 0.001), isolated (31.8% versus 0.0%; P < 0.001), and unilateral (67.1% versus 12.8%; P < 0.00). The rate of bleeding after anticoagulation therapy did not differ between IPE and SPE. Patients with IPE had a better prognosis than patients with SPE in terms of 30-, and 90-day mortality, as well as overall survival after diagnosis of PE (median: 314.5 vs. 192.0 days, log-rank P = 0.004) and cancer (median: 630.0 vs. 450.5 days, log-rank P = 0.018). SPE (compared to IPE) was an independent risk factor for poor survival after diagnosis of PE in multivariate analysis (hazard ratio [HR] = 1.564, 95% confidence interval [CI]: 1.008-2.425, p = 0.046). CONCLUSIONS IPE accounts for nearly one half of PE cases among Chinese cancer patients. With active anticoagulation treatment, IPE is expected to achieve better survival rates than SPE.
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Affiliation(s)
- Yanfei Wang
- Peking University Cancer Hospital and Beijing Cancer Institute, Day Oncology Unit, Key Laboratory of Malignant Tumor Pathogenesis and Transformation Research, Ministry of Education, Ministry of Education, Beijing, China
| | - Zhongfen Liu
- Peking University Cancer Hospital and Beijing Cancer Institute, Department of Supportive Care, Key Laboratory of Malignant Tumor Pathogenesis and Transformation Research, Ministry of Education, Beijing, China
| | - Qiuyu Li
- Peking University Third Hospital, Department of Respiratory and Critical Care Medicine, Beijing, China
| | - Lina Xia
- Peking University Cancer Hospital and Beijing Cancer Institute, Department of Supportive Care, Key Laboratory of Malignant Tumor Pathogenesis and Transformation Research, Ministry of Education, Beijing, China
| | - Yunyi Wang
- Peking University Cancer Hospital and Beijing Cancer Institute, Day Oncology Unit, Key Laboratory of Malignant Tumor Pathogenesis and Transformation Research, Ministry of Education, Ministry of Education, Beijing, China
| | - Danfeng Jiang
- Peking University Cancer Hospital and Beijing Cancer Institute, Day Oncology Unit, Key Laboratory of Malignant Tumor Pathogenesis and Transformation Research, Ministry of Education, Ministry of Education, Beijing, China
| | - Xiaoyan Chen
- Peking University Cancer Hospital and Beijing Cancer Institute, Day Oncology Unit, Key Laboratory of Malignant Tumor Pathogenesis and Transformation Research, Ministry of Education, Ministry of Education, Beijing, China
| | - Yanqun Zheng
- Peking University Cancer Hospital and Beijing Cancer Institute, Day Oncology Unit, Key Laboratory of Malignant Tumor Pathogenesis and Transformation Research, Ministry of Education, Ministry of Education, Beijing, China
| | - Wei Liu
- Peking University Cancer Hospital and Beijing Cancer Institute, Day Oncology Unit, Key Laboratory of Malignant Tumor Pathogenesis and Transformation Research, Ministry of Education, Ministry of Education, Beijing, China
- Peking University Cancer Hospital and Beijing Cancer Institute, Department of Supportive Care, Key Laboratory of Malignant Tumor Pathogenesis and Transformation Research, Ministry of Education, Beijing, China
| | - Dan Wang
- Peking University Cancer Hospital and Beijing Cancer Institute, Medical Department, Key Laboratory of Malignant Tumor Pathogenesis and Transformation Research, Ministry of Education, Beijing, China.
| | - Dong Xue
- Peking University Cancer Hospital and Beijing Cancer Institute, Medical Department, Key Laboratory of Malignant Tumor Pathogenesis and Transformation Research, Ministry of Education, Beijing, China.
- Peking University Cancer Hospital and Beijing Cancer Institute, Department of Integrated Traditional Chinese and Western Medicine, Key Laboratory of Malignant Tumor Pathogenesis and Transformation Research, Ministry of Education, 100142, Beijing, China.
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Barca-Hernando M, Lopez-Ruz S, Marin-Romero S, Elias-Hernandez T, Otero-Candelera R, Jara-Palomares L. Comparison of long-term complications in cancer patients with incidental and acute symptomatic venous thromboembolism. Front Cardiovasc Med 2023; 10:1118385. [PMID: 37273873 PMCID: PMC10237269 DOI: 10.3389/fcvm.2023.1118385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/28/2023] [Indexed: 06/06/2023] Open
Abstract
Background Clinical practice guidelines recommend that patients with incidental venous thromboembolism (VTE) receive the same anticoagulant therapy as those with symptomatic VTE. We aimed to compare the rate of complications between cancer patients with incidental and symptomatic VTE through a long-term follow-up cohort. Methods We performed a post hoc analysis of prospective studies of cancer patients with VTE between 2008 and 2019, with the primary outcome of rates of recurrent VTE and clinically relevant bleeding (CRB) in incidental and symptomatic VTE groups. Results In total, 796 patients were included, of which 42.8% had incidental VTE. No significant differences were noted in the rate of recurrent VTE (0.4 per 100 patients/month vs. 0.5 per 100 patients/month; p = 0.313) and in the rate of CRB (0.6 per 100 patients/month vs. 0.5 per 100 patients/month; p = 0.128) between patients with incidental VTE and symptomatic VTE, respectively. At six-month follow-ups, the cumulative incidence of CRB was significantly higher in patients with incidental VTE than that in those with symptomatic VTE (7.9% vs. 4.4%, respectively; OR: 1.8; 95% CI: 1.01-3.2). Conclusion Cancer patients with incidental VTE had similar rates of CRB and VTE recurrence in long-term follow-up compared with patients with symptomatic VTE. At six-month follow-ups, patients with incidental VTE had a higher cumulative incidence of CRB than those with symptomatic VTE.
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Affiliation(s)
- María Barca-Hernando
- Respiratory Department, Medical Surgical Unit of Respiratory Diseases, Hospital Virgen del Rocio, Sevilla, Spain
| | - Sergio Lopez-Ruz
- Respiratory Department, Medical Surgical Unit of Respiratory Diseases, Hospital Virgen del Rocio, Sevilla, Spain
| | - Samira Marin-Romero
- Respiratory Department, Medical Surgical Unit of Respiratory Diseases, Hospital Virgen del Rocio, Sevilla, Spain
| | - Teresa Elias-Hernandez
- Respiratory Department, Medical Surgical Unit of Respiratory Diseases, Hospital Virgen del Rocio, Sevilla, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Remedios Otero-Candelera
- Respiratory Department, Medical Surgical Unit of Respiratory Diseases, Hospital Virgen del Rocio, Sevilla, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Luis Jara-Palomares
- Respiratory Department, Medical Surgical Unit of Respiratory Diseases, Hospital Virgen del Rocio, Sevilla, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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Nouhravesh N, Sindet-Pedersen C, Kümler T, Schou M, Lamberts MK, Højen AA. “No one told me anything about it and I cannot explain it”: Illness perception in symptomatic and asymptomatic patients with cancer-associated thrombosis. Thromb Res 2022; 220:125-130. [DOI: 10.1016/j.thromres.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/19/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
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The incidence and clinical characteristics of pulmonary embolism in oncologic patients. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2022. [DOI: 10.1186/s43168-022-00167-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Abstract
Background
For various types of cancer in oncologic patients, the clinical features of pulmonary embolism (PE) are unknown. The purpose of the study is to identify pulmonary embolism incidence and type among oncologic patients along with evaluating any associated clinical variables.
Patients and methods
A prospective cohort study was conducted on 540 patients who had various types of cancers and attended to a 1-day care unit of oncology in King Fahd Hospital, Kingdom of Saudi Arabia. Chest CT with contrast and CT pulmonary angiography was applied when indicated.
Results
This study was conducted on 540 patients who have different types of cancers; among them, 24 (4.44%) developed PE. Pulmonary embolism was reported in 50% of patients who had seminoma and germ cell tumor, while in cancer larynx, it was represented in 33.4% of them. Moreover, PE was less common among patients who had cancer colon, prostate, and breast (6.68%, 4.7%, and 2.54%, respectively). Seven patients with PE (1.3%) were diagnosed incidentally during cancer staging, while 17 patients (3.14%) had symptomatic PE. Eighty-four percent of the PE cases were diagnosed within the first 6 months of cancer diagnosis, while 4/24 (16%) of the PE cases were diagnosed throughout patient follow-up within the first year of diagnosis. Chest pain and dyspnea were the common presentations in confirmed PE either symptomatic or incidental group.
Conclusions
Low-risk PE was the most frequent degree; massive and sub-massive PE was uncommon in oncologic patients. Dyspnea and chest discomfort are concerning signs of PE in cancer. Meticulous care during the first 6 months for cancer patients to pick up pulmonary embolism is recommended.
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Benelhaj NE, Hutchinson A, Maraveyas A, Johnson MJ. Cancer patients' experiences of the diagnosis and treatment of incidental pulmonary embolism (a qualitative study). PLoS One 2022; 17:e0276754. [PMID: 36282838 PMCID: PMC9595511 DOI: 10.1371/journal.pone.0276754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 10/12/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The diagnosis of symptomatic cancer-associated thrombosis often causes distress and alarm for patients, especially for those unaware of the risk, or the signs and symptoms to look out for. There are few data about cancer patients' experiences of incidentally diagnosed pulmonary embolism (IPE), where lack of warning (recognised signs, symptoms) may cause delayed diagnosis and aggravate distress. OBJECTIVES To explore cancer patients' experience of the diagnosis of and living with incidental pulmonary embolism treated with anticoagulation. METHODS A qualitative study using modified grounded theory approach. Semi-structured interviews were conducted as part of a mixed- methods prospective observational survey study of consenting patients with IPE. Data were subjected to thematic analysis. The qualitative findings are presented. FINDINGS Eleven participants were interviewed (mean age 68.3 years, range 38-82 years; various forms of cancer and stages). Three major themes and one cross-cutting theme were generated. Theme (1): IPE is experienced in the context of cancer and concomitant comorbidities. Issues are understood in the shadow of-and often overshadowed by-current serious illness. Theme (2): Being diagnosed with IPE. Misattribution to cancer or other comorbidities caused delay in help-seeking and diagnosis. Theme (3): Coping with anticoagulation. Participants' incorporated anticoagulation treatment and its effects into their daily routine with acceptance and stoicism. Finally, the cross-cutting theme relates to a lack of information and uncertainty, contributing to distress throughout the experience. CONCLUSION The diagnosis of IPE was upsetting and unexpected. Expert and timely information was valued by those with IPE. Education called for about the increased risk of cancer-associated thrombosis and the signs and symptoms to be aware of.
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Affiliation(s)
- Naima E. Benelhaj
- Hull York Medical School, University of Hull, Hull, United Kingdom
- * E-mail:
| | - Ann Hutchinson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Anthony Maraveyas
- Queen’s Centre for Oncology and Haematology, Hull and East Yorkshire Hospitals NHS Trust, Hull, United Kingdom
| | - Miriam J. Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
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12
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Mędrek S, Szmit S. Are cardiovascular comorbidities always associated with a worse prognosis in patients with lung cancer? Front Cardiovasc Med 2022; 9:984951. [PMID: 36211566 PMCID: PMC9537604 DOI: 10.3389/fcvm.2022.984951] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 09/01/2022] [Indexed: 12/01/2022] Open
Abstract
Many factors contribute to mortality in lung cancer, including the presence of concomitant cardiovascular disease. In the treatment of early stage of lung cancer, the presence of comorbidities and occurence of cardiotoxicity may be prognostic. The effect of cardiotoxicity of radiotherapy and chemoradiotherapy on overall survival has been documented. Acute arterial and venous thromboembolic events seem to correlate with the degree of the histological malignancy, its clinical advancement, and even with optimal cardiac treatment, they may influence the survival time. In the case of high-grade and advanced lung cancer stage especially in an unresectable stadium, the prognosis depends primarily on the factors related to the histopathological and molecular diagnosis. Electrocardiographic and echocardiographic abnormalities may be prognostic factors, as they seem to correlate with the patient's performance status as well as tumor localization and size.
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Affiliation(s)
- Sabina Mędrek
- Department of Cardiology, Subcarpathian Oncological Center, Brzozów, Poland
- *Correspondence: Sabina Mędrek
| | - Sebastian Szmit
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
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13
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Viteri Jusué A, Domínguez Fernández S, Pérez Persona E, Poza de Celis R. Urgent and unexpected findings in oncology and hematology patients: A practical approach to imaging. RADIOLOGIA 2022; 64:464-472. [PMID: 36243446 DOI: 10.1016/j.rxeng.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/09/2021] [Indexed: 06/16/2023]
Abstract
Urgent and unexpected findings are very common in oncology and haematology patients. This article reviews the most important points included in the European Society of Radiology's guidelines and proposes a practical approach to reporting and communicating these findings more efficiently. This approach is explained with illustrative examples. Radiologists can provide added value in the management of these findings by helping referring clinicians reach the best decisions. To this end, it is essential to know the imaging manifestations of the most common findings that must be reported urgently, such as the specific toxicity of different treatments, the complications of tumours and catheters, infections, and thrombosis. Moreover, it is crucial to consider the individual patient's treatment, risk factors, clinical situation, and immune status.
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Affiliation(s)
- A Viteri Jusué
- Servicio de Radiodiagnóstico, Hospital Universitario Araba, Vitoria-Gasteiz, Spain.
| | | | - E Pérez Persona
- Servicio de Hematología, Hospital Universitario Araba, Vitoria-Gasteiz, Spain
| | - R Poza de Celis
- Servicio de Oncología Radioterápica, Hospital Universitario Araba, Vitoria-Gasteiz, Spain
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14
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Azour L, Ko JP, Toussie D, Gomez GV, Moore WH. Current imaging of PE and emerging techniques: is there a role for artificial intelligence? Clin Imaging 2022; 88:24-32. [DOI: 10.1016/j.clinimag.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/23/2022] [Accepted: 05/02/2022] [Indexed: 11/26/2022]
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15
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Aramberri M, Benegas M, Sanchez M, Muñoz-Guglielmetti D, Zamora C, García-Villa A, Diaz-Pedroche C, Font C. Saddle Pulmonary Embolism in Patients with Cancer in the Era of Incidental Events: Clinical Findings and Outcomes in a Single Centre Cohort. TH OPEN 2022; 6:e267-e275. [PMID: 36299808 PMCID: PMC9800169 DOI: 10.1055/s-0042-1755605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/04/2022] [Indexed: 11/15/2022] Open
Abstract
Background There is scarce information regarding the prevalence and clinical impact of saddle pulmonary embolism (PE) in patients with cancer. Objectives This study aimed to assess the prevalence, clinical findings, and short-term outcomes of patients with cancer-related saddle PE including acute symptomatic and unsuspected events. Patients/Methods Consecutive patients with cancer-related PE (March 1, 2006-October 31, 2014) were retrospectively reviewed by a chest radiologist to assess PE burden and signs of right ventricular (RV) overload. The clinical outcomes within 30 days were evaluated according to saddle versus nonsaddle PE. Results Thirty-six (12%) out of 289 patients with newly diagnosed cancer-related PE presented with saddle PE. Saddle PE was found in 21 cases (58%) with acute symptomatic PE and the remaining 15 cases (42%) were found as unsuspected findings. Patients with saddle PE had more frequently experienced a previous thrombotic event (31 vs. 13%; p =0.008), and it occurred more frequently as an acute symptomatic event (58 vs. 39%; p =0.025) compared with those with nonsaddle PE. Signs of RV overload including RV/left ventricle ratio ≥1 (22 vs. 4%; p <0.001) and interventricular septum displacement (53 vs. 20%; p <0.001) were also more common in patients with saddle PE compared with nonsaddle PE. Overall, PE-related mortality, venous thromboembolism recurrence, and major bleeding within 30 days were found to be similar according to saddle versus nonsaddle PE. Conclusion Saddle PE is not uncommon in patients with cancer-related PE including in those with unsuspected PE. Similar 30-day outcomes were found according to saddle versus nonsaddle PE in our cohort.
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Affiliation(s)
- Mario Aramberri
- Department of Internal Medicine, Hospital de Galdakao-Usansolo, Galdakao, Spain
| | - Mariana Benegas
- Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Marcelo Sanchez
- Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Carles Zamora
- Department of Medical Oncology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Adrián García-Villa
- Department of Internal Medicine, Hospital Nuestra Señora del Prado, Talavera de la Reina, Spain
| | - Carmen Diaz-Pedroche
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Carme Font
- Department of Medical Oncology, Hospital Clinic de Barcelona, Barcelona, Spain
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16
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Ahuja J, Palacio D, Jo N, Strange CD, Shroff GS, Truong MT, Wu CC. Pitfalls in the imaging of pulmonary embolism. Semin Ultrasound CT MR 2022; 43:221-229. [PMID: 35688533 DOI: 10.1053/j.sult.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pulmonary embolism (PE) can present with a wide spectrum of clinical symptoms that can overlap considerably with other cardiovascular diseases. To avoid PE related morbidity and mortality, it is vital to identify this disease accurately and in a timely fashion. Several clinical criteria have been developed to standardize the diagnostic approach for patients with suspected PE. Computed tomographic pulmonary angiogram has significantly improved the detection of pulmonary embolism and is considered the imaging modality of choice to diagnose this disease. However, there are several potential pitfalls associated with this modality which can make diagnosis of PE challenging. In this review, we will discuss various pitfalls routinely encountered in the diagnostic work up of patients with suspected PE, approaches to mitigate these pitfalls and incidental pulmonary embolism.
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Affiliation(s)
- Jitesh Ahuja
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Diana Palacio
- Department of Radiology, The University of Texas Medical Branch, UTMB. Galveston TX
| | - Nahyun Jo
- Department of Radiology, The University of Texas Medical Branch, UTMB. Galveston TX
| | - Chad D Strange
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Girish S Shroff
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mylene T Truong
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carol C Wu
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
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17
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Bazarbashi S, Alkhaldi T, Aseafan M, Melaibari M, Almuhisen S, Alharbi S, Alghabban A, Aljumaa J, Eldali A, Maraiki F, Owaidah T, Alzahrani H. Thromboembolic Events Burden in Patients With Solid Tumors and Their Predisposing Factors. Cureus 2022; 14:e23624. [PMID: 35386484 PMCID: PMC8967125 DOI: 10.7759/cureus.23624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction: The relationship between cancers and thromboembolic events is well established. In our study, we aim to determine the burden of thromboembolic events in patients with solid tumors and identify the risk factors related to their development. Materials & Methods: Data on patients with solid tumors and thromboembolism between January 2013 and September 2014 were collected and analyzed. Results: During the study period 174 patients were identified. Of which, 172 (98.9%) had venous thrombus embolism, 137 (79%) were diagnosed with deep vein thromboses, 67 (38.5%) with pulmonary embolism, 84 (48.3%) were symptomatic and 90 (51.7) were incidental at diagnosis. The most common patients and disease characteristics were female sex, high body mass index (BMI), metastatic stage, colorectal and breast primaries, and anti-neoplastic therapy. Conclusion: Our study confirmed the high burden of thromboembolic events in cancer patients and the relevant factors associated with its development.
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18
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Loftus JR, Hu Z, Morin BR, Hobbs SK, Francis CW, Khorana AA, Rubens DJ, Kaproth-Joslin KA. Vascular Imaging in the Asymptomatic High-risk Cancer Population: A Role for Thrombosis Screening and Therapy Management. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:225-236. [PMID: 33772825 DOI: 10.1002/jum.15701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 03/07/2021] [Accepted: 03/11/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES We retrospectively examined the venous thromboembolism (VTE) events diagnosed in the Prophylaxis of High-Risk Ambulatory Cancer Patients Study (PHACS), a multi-center randomized trial, to assess the value of screening vascular imaging for the diagnosis of incidental VTE in high-risk cancer patients. METHODS A total of 117 asymptomatic cancer patients with a Khorana score ≥3 starting a new systemic chemotherapy regimen were enrolled in a prospective randomized control trial. Patients underwent baseline venous ultrasound (US) of the lower extremities (LEs) and screening contrast-enhanced chest computed tomography (CT). Those without preexisting VTE were then randomized into observation or dalteparin prophylaxis groups and were screened with serial US every 4 weeks for up to 12 weeks and imaged with contrast-enhanced chest CT at 12 weeks. Any additional imaging performed during the study period was also evaluated for VTE. RESULTS Baseline prevalence of incidental VTE was 9% (n = 10) with 58% percent of VTEs diagnosed by screening US. Incidence of VTE in the randomized phase of the trial was 16% (n = 16) with 21% (n = 10) of patients in the control arm and 12% (n = 6) of patients in the dalteparin arm developing VTE, a non-significant 9% absolute risk reduction (HR = 0.69, 95% CI 0.23-1.89). Sixty-nine percent of these patients were asymptomatic with 31% of patients diagnosed by screening US. CONCLUSIONS Adding screening US to routine oncologic surveillance CT in high-risk ambulatory cancer patients with a Khorana score ≥3 can lead to increased VTE detection, with potential for decreased morbidity, mortality, and health care spending.
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Affiliation(s)
- James Ryan Loftus
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Zhongxia Hu
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Burke R Morin
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Susan K Hobbs
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Charles W Francis
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Alok A Khorana
- Department of Hematology and Oncology, Cleveland Clinic Main Campus, Cleveland, Ohio, USA
| | - Deborah J Rubens
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
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19
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Giustozzi M, Connors JM, Ruperez Blanco AB, Szmit S, Falvo N, Cohen AT, Huisman M, Bauersachs R, Dentali F, Becattini C, Agnelli G. Clinical characteristics and outcomes of incidental venous thromboembolism in cancer patients: Insights from the Caravaggio study. J Thromb Haemost 2021; 19:2751-2759. [PMID: 34260816 PMCID: PMC9290511 DOI: 10.1111/jth.15461] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/03/2021] [Accepted: 07/12/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Clinical guidelines advise similar anticoagulant treatment for symptomatic and incidental cancer-associated venous thromboembolism (VTE). We investigated clinical features and outcomes of cancer patients with incidental or symptomatic VTE randomized in the Caravaggio study. OBJECTIVES We performed a predefined sub-analysis of the Caravaggio study in order to investigate the clinical features and outcomes of incidental and symptomatic VTE in patients with cancer. The relative efficacy and safety of apixaban and dalteparin in patients with incidental and symptomatic VTE was also assessed. METHODS The Caravaggio study compared apixaban to dalteparin for the 6-month treatment of cancer-associated VTE. The primary efficacy and safety outcomes were recurrent VTE and major bleeding. RESULTS Two hundred thirty patients (20%) had incidental and 925 (80%) symptomatic VTE. Pulmonary embolism with or without deep vein thrombosis as index event, colorectal cancer, Eastern Cooperative Oncology Group (ECOG) score of 0, and locally advanced or metastatic cancer were more frequent in patients with incidental VTE. Deep vein thrombosis as index event, hematological cancer, and ECOG score of 2 were more frequent in patients with symptomatic VTE. Ten patients (4.3%) with incidental and 68 (7.4%) with symptomatic VTE had recurrent VTE (hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.29-1.10). Major bleeding occurred in 12 (5.2%) patients with incidental VTE and in 33 (3.6%) patients with symptomatic VTE (HR 1.43, 95% CI 0.74-2.77). When comparing apixaban to dalteparin in patients with symptomatic and incidental VTE, the HR for recurrence was 0.73 (95% CI 0.45-1.19) and 0.41 (95% CI 0.11-1.56), respectively, and the HR for major bleeding 0.93 (95% CI 0.47-1.83) and 0.96 (95% CI 0.31-2.96), respectively. CONCLUSIONS Compared to cancer patients with symptomatic VTE, those with incidental VTE have different clinical features at presentation, with a numerically lower incidence of recurrent VTE and a numerically higher incidence of major bleeding.
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Affiliation(s)
- Michela Giustozzi
- Internal Vascular and Emergency Medicine – Stroke UnitUniversity of PerugiaPerugiaItaly
| | - Jean M. Connors
- Brigham and Womens’s HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | | | - Sebastian Szmit
- Department of Pulmonary CirculationThromboembolic Diseases and CardiologyCentre of Postgraduate Medical EducationEuropean Health CentreOtwockPoland
| | - Nicolas Falvo
- Service d’Exploration Vasculaire et de Phlébologie InterventionnelleCHU DijonDijonFrance
| | - Alexander T. Cohen
- Guy’s and St Thomas’ NHS Foundation Trust, HospitalKing’s College LondonLondonUK
| | - Menno Huisman
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | | | - Francesco Dentali
- Department of Medicine and SurgeryInsubria UniversityASST SettelaghiVareseItaly
| | - Cecilia Becattini
- Internal Vascular and Emergency Medicine – Stroke UnitUniversity of PerugiaPerugiaItaly
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine – Stroke UnitUniversity of PerugiaPerugiaItaly
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20
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Abstract
Pulmonary CTA is a ubiquitous study interpreted by radiologists with different levels of experience in a variety of practice settings. Pulmonary embolism (PE) can range from an incidental and clinically insignificant finding to a clinically significant thrombus that can be managed on an outpatient basis to a potentially fatal condition requiring immediate medical or invasive management. Accordingly, a clear and concise pulmonary CTA report should effectively communicate the most pertinent findings to help the treating medical team diagnose or exclude the diagnosis of PE and provide information to guide appropriate management. In this expert panel narrative review, we discuss the purpose of the radiology report for pulmonary CTA, the optimal report format, the relevant findings that need to be addressed and their clinical significance.
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21
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Stevens SM, Woller SC, Baumann Kreuziger L, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest 2021; 160:e545-e608. [PMID: 34352278 DOI: 10.1016/j.chest.2021.07.055] [Citation(s) in RCA: 328] [Impact Index Per Article: 109.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/11/2021] [Accepted: 07/08/2021] [Indexed: 01/06/2023] Open
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22
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Takaki JKT, Ford JS, Yoon HC. Recommended D-Dimer Use in Suspected Pulmonary Embolism Is Insufficient to Curb the Long-Term Overutilization of CT Pulmonary Angiography. J Am Coll Radiol 2021; 18:1517-1524. [PMID: 34273279 DOI: 10.1016/j.jacr.2021.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/30/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this study was to determine whether the authors' emergency medicine department has seen a significant change in CT pulmonary angiography (CTPA) utilization or positive rates for pulmonary embolism (PE) over a 10-year period for the 2 years before and 8 years after the implementation of patient population-specific D-dimer recommendations. METHODS A retrospective chart review was performed among all patients belonging to a geographically isolated health maintenance organization who underwent CTPA for the evaluation of acute PE in the emergency department between 2010 and 2019. The positive rate for acute PE among these studies was calculated and stratified by serum D-dimer value collected within 48 hours previously. RESULTS A total of 6,013 CT pulmonary angiographic studies were reviewed, of which 40.2% had serum D-dimer ≥ 1.0 μg/mL (positive rate 10.6%), 42.5% did not have serum D-dimer drawn (positive rate 7.3%), and 17.2% had serum D-dimer < 1.0 μg/mL (positive rate 0.6%). There was a significant increase in positivity on CTPA in 2012 with the health group's formal recommendation of a D-dimer cutoff of 1.0 μg/mL. This improvement also corresponded with fewer orders for CTPA after a negative D-dimer result. However, in the following years, CTPA utilization and percentage positivity were found to be reverting to the prerecommendation statistics. CONCLUSIONS The failure to mandate the use of serum D-dimer with a higher threshold value for patients who are to undergo CTPA for possible PE has resulted in poor lasting compliance despite promising early results. A firmer approach is likely necessary to yield positive long-term outcomes.
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Affiliation(s)
| | - James S Ford
- Department of Emergency Medicine, Hawaii Permanente Medical Group, Honolulu, Hawaii
| | - Hyo-Chun Yoon
- Department of Radiology, Hawaii Permanente Medical Group, Honolulu, Hawaii
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23
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Dos Santos Fernandes CJC, Couturaud F. Moving forward for incidental pulmonary embolism in cancer patients. Eur Respir J 2021; 58:58/1/2004630. [PMID: 34215661 DOI: 10.1183/13993003.04630-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/11/2021] [Indexed: 11/05/2022]
Affiliation(s)
| | - Francis Couturaud
- Internal Medicine and Chest Diseases, Hopital de la Cavale Blanche, Brest, France
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24
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Signorelli SS, Oliveri Conti G, Carpinteri G, Lumera G, Fiore M, Dattilo G, Gaudio A, Ferrante M. Venous thromboembolism in hospital emergency room. A retrospective study on climatic effect. ENVIRONMENTAL RESEARCH 2021; 197:110950. [PMID: 33737078 DOI: 10.1016/j.envres.2021.110950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 06/12/2023]
Abstract
Several cardiovascular conditions exhibit seasonality in frequency and mortality, but little is known about the seasonality of Venous ThromboEmbolism (VTE), a very relevant medical condition, and seasonal influences are still conflicting. Patients having co-morbidities, individual suffered from dyspnea, swelling, edema of lower limb, pain (chest, lower limbs) are admitted frequently to the hospital emergency room (HER), particularly. Both mark a potential risk for VTE, that can be increased also by seasonality. A four years retrospective analysis (2016-2019) was carried out in individuals and patients admitted to the HER of the Hospital of Catania (a Mediterranean city of Sicily, Italy) to evaluate the VTE frequency and its seasonal differences, common symptoms, potential usage of some common laboratory tests. Dyspnea, swelling, edema of lower limb and pain (chest, lower limbs) were considered to suspect pulmonary embolism (PE) or for deep vein thrombosis of lower limb (DVT). Platelet count, platelet volume, fibrinogen, C-reactive protein, and D-dimer were considered. VTE frequency per year was 2.9/10,000 (2016), 4.9/10,000 (2017) 3.6/10,000 (2018), and 5.1/10,000 (2019) respectively. Dyspnea was highly frequent for PE, edema and lower limb pain were frequent in DVT patients. Fibrinogen, C reactive protein, and D-dimer values were found raised in all the VTE patients. Platelet volume was found higher in DVT than PE VTE events that occurred in warm periods were modestly greater (57 VTE: 38 DVT, 19 PE) compared to cold months (52 VTE: 34 DVT, 18 PE). Our results could be explained by the increased sweating due to the high temperatures, which in turn, can affect both on plasma concentration and on hematocrit value coupled to the reduction in atmospheric pressure determining both a hyper-coagulative condition. Climate seasonal characteristics, and environmental conditions in Catania city (Sicily) may be as reasonable items in expecting on different VTE rates in warm period compared to cold. This study highlights no specific symptoms, and confirms the common lab tests for individuals and patients admitted to HER as simple and helpful tools in initiating none or mini-invasive diagnostic strategy for the VTE. Finally, the climate/seasonality coupled with latitude can have a direct influence on the incidence of DVT.
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Affiliation(s)
- Salvatore Santo Signorelli
- Department of Clinical and Experimental Medicine. University of Catania, Italy; Internal Medicine Unit. University Hospital "G. Rodolico", Catania, Italy.
| | - Gea Oliveri Conti
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia". University of Catania, Italy.
| | - Giuseppe Carpinteri
- Emergengy Medicine Division. University Hospital "G. Rodolico", Catania, Italy
| | - Giovanni Lumera
- Department of Clinical and Experimental Medicine. University of Catania, Italy; Internal Medicine Unit. University Hospital "G. Rodolico", Catania, Italy
| | - Maria Fiore
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia". University of Catania, Italy
| | - Giuseppe Dattilo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Agostino Gaudio
- Department of Clinical and Experimental Medicine. University of Catania, Italy
| | - Margherita Ferrante
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia". University of Catania, Italy
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25
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Viteri Jusué A, Domínguez Fernández S, Pérez Persona E, Poza de Celis R. Urgent and unexpected findings in oncology and hematology patients: a practical approach to imaging. RADIOLOGIA 2021; 64:S0033-8338(21)00086-2. [PMID: 33985767 DOI: 10.1016/j.rx.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/29/2022]
Abstract
Urgent and unexpected findings are very common in oncology and hematology patients. This article reviews the most important points included in the European Society of Radiology's guidelines and proposes a practical approach to reporting and communicating these findings more efficiently. This approach is explained with illustrative examples. Radiologists can provide added value in the management of these findings by helping referring clinicians reach the best decisions. To this end, it is essential to know the imaging manifestations of the most common findings that must be reported urgently, such as the specific toxicity of different treatments, the complications of tumors and catheters, infections, and thrombosis. Moreover, it is crucial to consider the individual patient's treatment, risk factors, clinical situation, and immune status.
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Affiliation(s)
- A Viteri Jusué
- Servicio de Radiodiagnóstico, Hospital Universitario Araba, Vitoria-Gasteiz, España.
| | | | - E Pérez Persona
- Servicio de Hematología, Hospital Universitario Araba, Vitoria-Gasteiz, España
| | - R Poza de Celis
- Servicio de Oncología Radioterápica, Hospital Universitario Araba, Vitoria-Gasteiz, España
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2021; 41:543-603. [PMID: 31504429 DOI: 10.1093/eurheartj/ehz405] [Citation(s) in RCA: 2020] [Impact Index Per Article: 673.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Wildman-Tobriner B, Ngo L, Mammarappallil JG, Konkel B, Johnson JM, Bashir MR. Missed Incidental Pulmonary Embolism: Harnessing Artificial Intelligence to Assess Prevalence and Improve Quality Improvement Opportunities. J Am Coll Radiol 2021; 18:992-999. [PMID: 33607067 DOI: 10.1016/j.jacr.2021.01.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/08/2021] [Accepted: 01/10/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Incidental pulmonary embolism (IPE) can be found on body CT. The aim of this study was to evaluate the feasibility of using artificial intelligence to identify missed IPE on a large number of CT examinations. METHODS This retrospective analysis included all single-phase chest, abdominal, and pelvic (CAP) and abdominal and pelvic (AP) CT examinations performed at a single center over 1 year, for indications other than identification of PE. Proprietary visual classification and natural language processing software was used to analyze images and reports from all CT examinations, followed by a two-step human adjudication process to classify cases as true positive, false positive, true negative, or false negative. Descriptive statistics were assessed for prevalence of IPE and features (subsegmental versus central, unifocal versus multifocal, right heart strain or not) of missed IPE. Interrater agreement for radiologist readers was also calculated. RESULTS A total of 11,913 CT examinations (6,398 CAP, 5,515 AP) were included. Thirty false-negative examinations were identified on CAP (0.47%; 95% confidence interval [CI], 0.32%-0.67%) and nineteen false-negative studies on AP (0.34%; 95% CI, 0.21%-0.54%) studies. During manual review, readers showed substantial agreement for identification of IPE on CAP (κ = 0.76; 95% CI, 0.66-0.86) and nearly perfect agreement for identification of IPE on AP (κ = 0.86; 95% CI, 0.76-0.97). Forty-nine missed IPEs (0.41%; 95% CI, 0.30%-0.54%) were ultimately identified, compared with seventy-nine IPEs (0.66%; 95% CI, 0.53%-0.83%) identified at initial clinical interpretation. CONCLUSIONS Artificial intelligence can efficiently analyze CT examinations to identify potential missed IPE. These results can inform peer-review efforts and quality control and could potentially be implemented in a prospective fashion.
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Affiliation(s)
- Benjamin Wildman-Tobriner
- Director Abdominal Imaging Fellowship, Department of Radiology, Duke University Medical Center, Durham, North Carolina.
| | - Lawrence Ngo
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | | | - Brandon Konkel
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Jacob M Johnson
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Mustafa R Bashir
- Vice Chair of Research, Department of Radiology, Duke University Medical Center, Durham, North Carolina; Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Center for Advanced Magnetic Resonance Development, Duke University Medical Center, Durham, North Carolina
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Cost of Venous Thromboembolic Disease in Patients with Lung Cancer: Costecat Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18020394. [PMID: 33419138 PMCID: PMC7825488 DOI: 10.3390/ijerph18020394] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/01/2021] [Accepted: 01/03/2021] [Indexed: 12/15/2022]
Abstract
Background: Patients with lung cancer (LC) are at significantly higher risk of developing venous thromboembolism (VTE), which may lead to increased use of health resources and the cost of the disease management. The main aim of the study was to determine the cost of the management of VTE events in patients with LC treated with Low Molecular Weight Heparins (LMWH) in Spain. Methods: Costecat was an observational, ambispective pharmacoeconomic study. Patients with LC, with a first episode of VTE (symptomatic or incidental) in treatment with LMWH, were recruited from six third-level hospitals and followed up for six months. Sociodemographic, clinical and resource use variables of VTE-related implications and its treatment were collected. Direct healthcare costs and direct non-healthcare costs were recorded. Data collection was documented in an electronic case report. Costs (€2018) were estimated from the healthcare perspective. Statistical analysis was performed using the statistical program R 3.4.3 version (30 November 2017). Results: Forty-seven patients were included. Mean age was 65.4 years, 66.0% were male. The percentage of patients with LC who had metastatic disease was 78.7%. Twenty-three patients (48.9%) needed hospital admissions due to thromboembolic episode. Total average cost of patients with cancer associated VTE (CAT) was €10,969.6 per patient/semester. The hospitalizations represent 65.8% of total costs (7207.3 € SD 13,996.9 €), followed by LMWH therapy which represents 18.6% (2033.8 € SD:630.5 €). Conclusions: Venous thromboembolism episodes induce an economic impact on patients and healthcare systems. Direct healthcare costs are the major burden of the total cost, in which hospitalizations are the main drivers of cost.
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Peris M, López-Nuñez JJ, Maestre A, Jimenez D, Muriel A, Bikdeli B, Weinberg I, Ay C, Mazzolai L, Lorenzo A, Monreal M. Clinical characteristics and 3-month outcomes in cancer patients with incidental versus clinically suspected and confirmed pulmonary embolism. Eur Respir J 2020; 58:13993003.02723-2020. [DOI: 10.1183/13993003.02723-2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/30/2020] [Indexed: 01/18/2023]
Abstract
BackgroundCurrent guidelines suggest treating cancer patients with incidental pulmonary embolism (PE) similarly to those with clinically suspected and confirmed PE. However, the natural history of these presentations has not been thoroughly compared.MethodsWe used the data from the RIETE (Registro Informatizado de Enfermedad TromboEmbólica) registry to compare the 3-month outcomes in patients with active cancer and incidental PE versus those with clinically suspected and confirmed PE. The primary outcome was 90-day all-cause mortality. Secondary outcomes were PE-related mortality, symptomatic PE recurrences and major bleeding.ResultsFrom July 2012 to January 2019, 946 cancer patients with incidental asymptomatic PE and 2274 with clinically suspected and confirmed PE were enrolled. Most patients (95% versus 90%) received low-molecular-weight heparin therapy. During the first 90 days, 598 patients died, including 42 from PE. Patients with incidental PE had a lower all-cause mortality rate than those with suspected and confirmed PE (11% versus 22%; OR 0.43, 95% CI 0.34–0.54). Results were consistent for PE-related mortality (0.3% versus 1.7%; OR 0.18, 95% CI 0.06–0.59). Multivariable analysis confirmed that patients with incidental PE were at lower risk of death (adjusted OR 0.43, 95% CI 0.34–0.56). Overall, 29 (0.9%) patients developed symptomatic PE recurrences, and 122 (3.8%) had major bleeding. There were no significant differences in PE recurrences (OR 0.62, 95% CI 0.25–1.54) or major bleeding (OR 0.78, 95% CI 0.51–1.18).ConclusionsCancer patients with incidental PE had a lower mortality rate than those with clinically suspected and confirmed PE. Further studies are required to validate these findings, and to explore optimal management strategies in these patients.
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Lawson P, Raskin S, Soffer S, Marom E, Berger R, Amitai MM, Kharizman T, Konen E, Klang E. Incidental pulmonary embolism in CT scans of oncological patients with metastatic disease undergoing clinical trials: frequency and linkage with onset of disease progression (PE-PD association). Br J Radiol 2020; 93:20200591. [DOI: 10.1259/bjr.20200591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Objectives: We aimed to analyze the association between the onsets of PE and of progressive disease (PD) in CT scans of oncological patients undergoing clinical trials. Methods: We retrospectively searched our oncological clinical trials database (1/2012 - 6/2017). We retrieved patients who underwent protocol baseline and follow-up CT scans. RECIST 1.1 categories of response were calculated for each scan at interpretation. The entire dataset was searched for reports with incidental PE. For patients with incidental PE, we collected all the scans conducted up to and including the scan with PE. For each scan, we retrieved the recorded RECIST 1.1 category. We excluded patients with PE at baseline. The frequency of incidental PE in oncological clinical trial patients was calculated. For patients with incidental PE, we evaluated the association between PE and PD. Results: During the study period, 1,070 patients underwent 3,818 CTs. The total number of follow-up months was 7,292 months. 18 patients developed incidental PE during follow-up. Thus, the frequency of incidental PE in oncological clinical trial patients was 3% per year of follow-up. Patients with incidental PE underwent 60 scans up to development of PE. Of 42 non-baseline scans, 6/6 (100%) PD showed PE, and 5/36 (13.9%) non-PD showed PE, making PE onset associated with PD onset (p < 0.001). Conclusion: In oncological clinical trials, the frequency of incidental PE is 3% per year of follow-up. The onset of incidental PE is linked to the onset of PD. Advances in knowledge: Incidental PE is associated with the onset of disease progression. Radiologists interpret oncological scans should be aware of the association between PE and PD.
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Affiliation(s)
- Philip Lawson
- Department of Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Tel Aviv University, Sackler Faculty of Medicine, Ramat Gan, Israel
| | - Stephen Raskin
- Department of Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Tel Aviv University, Sackler Faculty of Medicine, Ramat Gan, Israel
| | - Shelly Soffer
- Tel Aviv University, Sackler Faculty of Medicine, Tel Aviv-Yafo, Israel
| | - Edith Marom
- Department of Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Tel Aviv University, Sackler Faculty of Medicine, Ramat Gan, Israel
| | - Raanan Berger
- Department of Oncology, The Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Tel Aviv University, Sackler Faculty of Medicine, Ramat Gan, Israel
| | - Marianne Michal Amitai
- Department of Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Tel Aviv University, Sackler Faculty of Medicine, Ramat Gan, Israel
| | - Tehila Kharizman
- Department of Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Tel Aviv University, Sackler Faculty of Medicine, Ramat Gan, Israel
| | - Eli Konen
- Department of Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Tel Aviv University, Sackler Faculty of Medicine, Ramat Gan, Israel
| | - Eyal Klang
- Department of Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Affiliated to Tel Aviv University, Sackler Faculty of Medicine, Ramat Gan, Israel
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Mount Sinai, New York, United States
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Prognostic Significance of Incidental Deep Vein Thrombosis in Patients with Cancer Presenting with Incidental Pulmonary Embolism. Cancers (Basel) 2020; 12:cancers12082267. [PMID: 32823554 PMCID: PMC7463961 DOI: 10.3390/cancers12082267] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 01/13/2023] Open
Abstract
In symptomatic acute pulmonary embolism (PE), the presence of deep vein thrombosis (DVT) is a risk factor for 30- and 90-day mortality. In patients with cancer and incidental PE, the prognostic effect of concomitant incidental DVT is unknown. In this retrospective study, we examined the effect of incidental DVT on all-cause mortality in such patients. Adjusted Cox multivariate regression analysis was used for relevant covariates. From January 2010 to March 2018, we included 200 patients (mean age, 65.3 ± 12.4 years) who were followed up for 12.5 months (interquartile range 7.4-19.4 months). Of these patients, 62% had metastases, 31% had concomitant incidental DVT, and 40.1% (n = 81) died during follow-up. All-cause mortality did not increase in patients with DVT (hazard ratio [HR] 1.01, 95% confidence interval [CI] 0.43-2.75, p = 0.855). On multivariate analysis, weight (adjusted HR 0.96, 95% CI 0.92-0.99, p = 0.032), and metastasis (adjusted HR 10.26, 95% CI 2.35-44.9, p = 0.002) were predictors of all-cause mortality. In conclusion, low weight and presence of metastases were associated with all-cause mortality, while presence of concomitant DVT was unrelated to poorer survival.
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Nicholson M, Chan N, Bhagirath V, Ginsberg J. Prevention of Venous Thromboembolism in 2020 and Beyond. J Clin Med 2020; 9:jcm9082467. [PMID: 32752154 PMCID: PMC7465935 DOI: 10.3390/jcm9082467] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/18/2020] [Accepted: 07/27/2020] [Indexed: 02/06/2023] Open
Abstract
Venous thromboembolism (VTE) is the third most common cause of vascular mortality worldwide and comprises deep-vein thrombosis (DVT) and pulmonary embolism (PE). In this review, we discuss how an understanding of VTE epidemiology and the results of thromboprophylaxis trials have shaped the current approach to VTE prevention. We will discuss modern thromboprophylaxis as it pertains to genetic risk factors, exogenous hormonal therapies, pregnancy, surgery, medical hospitalization, cancer, and what is known thus far about VTE in COVID-19 infection.
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Incidental pulmonary embolism in oncologic patients-a systematic review and meta-analysis. Support Care Cancer 2020; 29:1293-1302. [PMID: 32621266 PMCID: PMC7843533 DOI: 10.1007/s00520-020-05601-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/25/2020] [Indexed: 02/06/2023]
Abstract
Purpose Incidental pulmonary embolism (IPE) is a common finding on computed tomography (CT). IPE is frequent in oncologic patients undergoing staging CT. The aim of this analysis was to provide the pooled frequency of IPE and frequencies of IPE in different primary tumors. Methods MEDLINE, SCOPUS, and EMBASE databases were screened for studies investigating frequency of IPE in oncologic staging CT up to February 2020. Overall, 12 studies met the inclusion criteria and were included into the present study. Results The pooled analysis yielded a total of 28,626 patients. IPE was identified in 963 patients (3.36%, 95% CI = 3.15; 3.57). The highest frequency was found in prostate cancer (8.59%, 95%CI = 3.74; 13.44), followed by hepatobiliary carcinoma (6.07%, 95%CI = 3.09; 9.05) and pancreatic cancer (5.65%, 95%CI = 3.54; 7.76). The lowest frequencies were identified in tumors of male reproductive organs (0.79%, 95%CI = 0.21; 1.37) and hematological diseases (1.11% 95%CI = 0.74; 1.48). Conclusion The overall frequency of IPE in oncologic patients was 3.36%. There are considerable differences in regard to primary tumors with the highest frequency in prostate cancer and pancreatic and hepatobiliary carcinomas.
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Denault MH, Morin-Thibault LV, Kermelly SB, Labbé C. Prevention and Treatment of Thromboembolic Events in Patients with Cancer: Advances and Challenges. Am J Respir Crit Care Med 2020; 202:124-127. [DOI: 10.1164/rccm.201909-1782rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Marie-Hélène Denault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Quebec, Canada
| | | | - Sophie B. Kermelly
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Quebec, Canada
| | - Catherine Labbé
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Quebec, Canada
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Dormagen JB, Verma N, Fink KR. Imaging in Oncologic Emergencies. Semin Roentgenol 2020; 55:95-114. [PMID: 32438984 DOI: 10.1053/j.ro.2019.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Nupur Verma
- Department of Radiology, University of Florida, Gainesville, FL
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Kabrhel C, Rosovsky R, Garvey S. Special Considerations in Pulmonary Embolism: Clot-in-Transit and Incidental Pulmonary Embolism. Crit Care Clin 2020; 36:531-546. [PMID: 32473697 DOI: 10.1016/j.ccc.2020.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This article describes 2 relatively rare, but complex situations in pulmonary embolism (PE): clot-in-transit (CIT), incidental PE (IPE). CIT describes a venous thromboembolism that has become lodged in the right heart. CIT is associated with high mortality and presents unique challenges in management. Incidental PE (IPE) describes PE diagnosed on imaging performed for another indication. The treatment is complex because there is often a disconnect between the PE severity on imaging and lack of severity of the clinical presentation. We summarize the available literature and aid clinicians as they manage patients with PE across the clinical severity spectrum.
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Affiliation(s)
- Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA.
| | - Rachel Rosovsky
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Shannon Garvey
- Boston University School of Medicine, 72 E Concord Street, Boston, MA 02118, USA
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Ishida T, Takahashi K, Sugiyama K, Hamabe Y, Mimura M, Suzuki T, Uchida H. How common is pulmonary embolism compared to acute myocardial infarction among patients with severe mental illnesses? Psychiatry Clin Neurosci 2020; 74:277-278. [PMID: 31930689 DOI: 10.1111/pcn.12978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 12/23/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Takuto Ishida
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.,Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Kie Takahashi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.,Department of Neuropsychiatry, Tokyo Saiseikai Chuo Hospital, Tokyo, Japan
| | - Kazuhiro Sugiyama
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yuichi Hamabe
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Takefumi Suzuki
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.,Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
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Renzi M, Stafoggia M, Michelozzi P, Davoli M, Forastiere F, Solimini AG. Short-term exposure to PM 2.5 and risk of venous thromboembolism: A case-crossover study. Thromb Res 2020; 190:52-57. [PMID: 32302781 DOI: 10.1016/j.thromres.2020.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 01/10/2020] [Accepted: 03/09/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Short-term exposure to air pollution increases the risk of cardiovascular mortality and morbidity but little evidence is available on pollution effects on venous thromboembolism (VTE), a common vascular disease. METHODS We conducted a case-crossover analysis of all urgent hospitalizations for deep vein thrombosis (DVT) or pulmonary embolism (PE) among patients >35 years during the period 2006 to 2017 in Rome (Italy). We examined whether 1) short-term exposure to particulate matter with aerodynamic diameter <2.5 μg (PM2.5) increases the risk of hospitalization for DVT or PE, and 2) if the associations are modified by the period of the year (warm and cold seasons), sex, age and comorbidity. RESULTS We found that short-term exposure to PM2.5 was associated with an increase of PE hospitalization risk of during the warm season (April to September) of 19.6% (95% confidence intervals: 8.3, 31%) per 10 μg/m3, while no statistically significant effects were displayed during the cold season or the whole year or for DVT hospitalizations. The effect of PM2.5 remained significant (%change: 21.3; 95%CI: 5.4, 39.5) after adjustment for nitrogen dioxide (NO2) co-exposure (a marker of traffic sources) and when limiting to primary diagnosis of PE (%change: 19.1; 95%CI: 4.2, 36.1). Age, sex and comorbid conditions did not modify the association. CONCLUSIONS Our results suggested a positive association between short-term exposure to PM2.5 and pulmonary embolism during the warm period of the year while no evidence emerged for deep vein thrombosis.
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Affiliation(s)
- Matteo Renzi
- Department of Epidemiology, Health Authority Service, ASL Rome 1, Rome, Italy.
| | - Massimo Stafoggia
- Department of Epidemiology, Health Authority Service, ASL Rome 1, Rome, Italy; Institute of Environmental Medicine, Karonlinska Instituet, Stockholm, Sweden
| | - Paola Michelozzi
- Department of Epidemiology, Health Authority Service, ASL Rome 1, Rome, Italy
| | - Marina Davoli
- Department of Epidemiology, Health Authority Service, ASL Rome 1, Rome, Italy
| | | | - Angelo G Solimini
- Department of Public Health and Infectious Diseases, University of Rome "La Sapienza", Rome, Italy
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Lee GD, Ju S, Kim JY, Kim TH, Yoo JW, Lee SJ, Cho YJ, Jeong YY, Jeon KN, Lee JD, Kim HC. Risk Factor and Mortality in Patients with Pulmonary Embolism Combined with Infectious Disease. Tuberc Respir Dis (Seoul) 2020; 83:157-166. [PMID: 32185917 PMCID: PMC7105430 DOI: 10.4046/trd.2019.0037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 08/24/2019] [Accepted: 01/21/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Infectious conditions may increase the risk of venous thromboembolism. The purpose of this study was to evaluate the risk factor for combined infectious disease and its influence on mortality in patients with pulmonary embolism (PE). METHODS Patients with PE diagnosed based on spiral computed tomography findings of the chest were retrospectively analyzed. They were classified into two groups: patients who developed PE in the setting of infectious disease or those with PE without infection based on review of their medical charts. RESULTS Of 258 patients with PE, 67 (25.9%) were considered as having PE combined with infectious disease. The sites of infections were the respiratory tract in 52 patients (77.6%), genitourinary tract in three patients (4.5%), and hepatobiliary tract in three patients (4.5%). Underlying lung disease (odds ratio [OR], 3.69; 95% confidence interval [CI], 1.926-7.081; p<0.001), bed-ridden state (OR, 2.84; 95% CI, 1.390-5.811; p=0.004), and malignant disease (OR, 1.867; 95% CI, 1.017-3.425; p=0.044) were associated with combined infectious disease in patients with PE. In-hospital mortality was higher in patients with PE combined with infectious disease than in those with PE without infection (24.6% vs. 11.0%, p=0.006). In the multivariate analysis, combined infectious disease (OR, 4.189; 95% CI, 1.692-10.372; p=0.002) were associated with non-survivors in patients with PE. CONCLUSION A substantial portion of patients with PE has concomitant infectious disease and it may contribute a mortality in patients with PE.
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Affiliation(s)
- Gi Dong Lee
- Department of Internal Medicine, Saint Carollo Hospital, Suncheon, Korea
| | - Sunmi Ju
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ju Young Kim
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Tae Hoon Kim
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Jung Wan Yoo
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Seung Jun Lee
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Yu Ji Cho
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Yi Yeong Jeong
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Kyung Nyeo Jeon
- Department of Diagnostic Radiology, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Jong Deog Lee
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ho Cheol Kim
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea.
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Yoo HHB, Nunes‐Nogueira VS, Fortes Villas Boas PJ. Anticoagulant treatment for subsegmental pulmonary embolism. Cochrane Database Syst Rev 2020; 2:CD010222. [PMID: 32030721 PMCID: PMC7004894 DOI: 10.1002/14651858.cd010222.pub4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute pulmonary embolism (PE) is a common cause of death, accounting for 50,000 to 200,000 deaths annually. It is the third most common cause of mortality among the cardiovascular diseases, after coronary artery disease and stroke. The advent of multi-detector computed tomographic pulmonary angiography (CTPA) has allowed better assessment of PE regarding visualisation of the peripheral pulmonary arteries, increasing its rate of diagnosis. More cases of peripheral PEs, such as isolated subsegmental PE (SSPE) and incidental PE, have thereby been identified. These two conditions are usually found in patients with few or none of the classic PE symptoms such as haemoptysis or pleuritic pain, acute dyspnoea or circulatory collapse. However, in patients with reduced cardiopulmonary reserve, classic PE symptoms can be found with isolated SSPEs. Incidental SSPE is found casually in asymptomatic patients, usually by diagnostic imaging performed for other reasons (for example routine CT for cancer staging in oncology patients). Traditionally, all PEs are anticoagulated in a similar manner independent of their location, or number and size of the thrombi. It has been suggested that many patients with SSPE may be treated without benefit, increasing adverse events by a possible unnecessary use of anticoagulants. Patients with isolated SSPE, or incidental PE, may have a more benign clinical presentation compared to those with proximal PEs. However, the clinical significance in patients, and their prognosis, needs to be studied to evaluate whether anticoagulation therapy is required. This is the second update of the Cochrane systematic review published in 2014. OBJECTIVES To assess the effectiveness and safety of anticoagulation therapy versus control in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 November 2019. We also undertook reference checking to identify additional studies. SELECTION CRITERIA We included randomised controlled trials of anticoagulation therapy versus control in patients with SSPE or incidental SSPE. DATA COLLECTION AND ANALYSIS Two review authors inspected all citations identified to ensure reliable assessment. If relevant studies were identified, we planned for two review authors to independently extract data and to assess the methodological quality of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We did not identify any studies that met the inclusion criteria. AUTHORS' CONCLUSIONS There is no evidence from randomised controlled trials to assess the effectiveness and safety of anticoagulation therapy versus control in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE. Well-conducted research is required before informed practice decisions can be made.
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Affiliation(s)
- Hugo HB Yoo
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Vania Santos Nunes‐Nogueira
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Paulo J Fortes Villas Boas
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
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41
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Xiao X, Wang Y, Gao Y, Xie Q, Zhou X, Lin L, Dekkers IA, Lamb HJ. Abdominal visceral adipose tissue is associated with unsuspected pulmonary embolism on routine CT scans in patients with gastrointestinal cancer. Br J Radiol 2019; 92:20190526. [PMID: 31595778 DOI: 10.1259/bjr.20190526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Unsuspected pulmonary embolism (UPE) has been increasingly diagnosed as an incidental finding on CT scans for routine staging in cancer patients. Previous studies suggest that obesity is an independent risk factor for venous thromboembolism in patients with malignant tumors. In this study, we aimed to investigate the association between abdominal adipose tissue, especially visceral adipose tissue (VAT) and the occurrence of UPE in hospitalized patients with gastrointestinal cancer. METHODS Routine contrast-enhanced chest and abdominal CT scans of 1974 patients were retrospectively assessed for the presence of UPE, of which 58 patients were identified with UPE and 108 non-UPE patients were selected as the non-UPE control group based on several matching criteria. Abdominal adipose tissue was measured by volumes of VAT and subcutaneous adipose tissue (SAT) at the navel level. RESULTS VAT, SAT, indwelling venous catheters, surgery, chemotherapy, and bed rest or immobilization were associated with the occurrence of UPE. Higher VAT volumes were associated with increased risk of UPE (odds ratio: 1.96; 95% confidence interval: 1.25, 3.06; p = 0.003) adjusting body mass index (BMI), bed rest or immobilization, surgery, chemotherapy and smoking, while SAT was not associated with UPE adjusting the same confounders (p = 0.117). No statistical association was found between BMI and UPE (p = 0.102). CONCLUSION Higher VAT rather than SAT is associated with an increased risk of unsuspected pulmonary embolism on routine CT scans in hospitalized gastrointestinal cancer patients. ADVANCES IN KNOWLEDGE Our findings indicate that VAT is a stronger risk factor for unsuspected pulmonary embolism than BMI and SAT in hospitalized patients with gastrointestinal cancer.
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Affiliation(s)
- Xiaojuan Xiao
- Department of Radiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Yao Wang
- Department of Radiology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital, Kunming, China
| | - Ying Gao
- Department of Radiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiuxia Xie
- Department of Radiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Xuhui Zhou
- Department of Radiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Ling Lin
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ilona A Dekkers
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Áinle FN, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Respir J 2019; 54:13993003.01647-2019. [DOI: 10.1183/13993003.01647-2019] [Citation(s) in RCA: 509] [Impact Index Per Article: 101.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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43
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Kruger PC, Eikelboom JW, Douketis JD, Hankey GJ. Pulmonary embolism: update on diagnosis and management. Med J Aust 2019; 211:82-87. [PMID: 31216072 DOI: 10.5694/mja2.50233] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition, mandating urgent diagnosis and treatment. The symptoms of PE may be non-specific; diagnosis therefore relies on a clinical assessment and objective diagnostic testing. A clinical decision rule can determine the pre-test probability of PE. If PE is "unlikely", refer for a D-dimer test. If the D-dimer result is normal, PE can be excluded. If D-dimer levels are increased, refer for chest imaging. If PE is "likely", refer for chest imaging. Imaging with computed tomography pulmonary angiogram is accurate and preferred for diagnosing PE, but may detect asymptomatic PE of uncertain clinical significance. Imaging with ventilation-perfusion (VQ) scan is associated with lower radiation exposure than computed tomography pulmonary angiogram, and may be preferred in younger patients and pregnancy. A low probability or high probability VQ scan is helpful for ruling out or confirming PE, respectively; however, an intermediate probability VQ scan requires further investigation. The direct oral anticoagulants have expanded the anticoagulation options for PE. These are the preferred anticoagulant for most patients with PE because they are associated with a lower risk of bleeding, and have the practical advantages of fixed dosage, no need for routine monitoring, and fewer drug interactions compared with vitamin K antagonists. Initial parenteral treatment is required before dabigatran and edoxaban.
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Affiliation(s)
- Paul C Kruger
- Fiona Stanley Hospital, Perth, WA.,PathWest Laboratory Medicine, Perth, WA.,Population Health Research Institute, Hamilton, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, Canada.,Hamilton Health Sciences, Hamilton, Canada
| | - James D Douketis
- Hamilton Health Sciences, Hamilton, Canada.,St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, Canada
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44
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Thiruganasambandamoorthy V, Sivilotti MLA, Rowe BH, McRae AD, Mukarram M, Malveau S, Yagapen AN, Sun BC. Prevalence of Pulmonary Embolism Among Emergency Department Patients With Syncope: A Multicenter Prospective Cohort Study. Ann Emerg Med 2019; 73:500-510. [PMID: 30691921 DOI: 10.1016/j.annemergmed.2018.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 11/09/2018] [Accepted: 12/03/2018] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE The prevalence of pulmonary embolism among patients with syncope is understudied. In accordance with a recent study with an exceptionally high pulmonary embolism prevalence, some advocate evaluating all syncope patients for pulmonary embolism, including those with another clear cause for their syncope. We seek to evaluate the pulmonary embolism prevalence among emergency department (ED) patients with syncope. METHODS We combined data from 2 large prospective studies enrolling adults with syncope from 17 EDs in Canada and the United States. Each study collected the results of pulmonary embolism-related investigations (ie, D-dimer, ventilation-perfusion scan, or computed tomography [CT] pulmonary angiography) and 30-day adjudicated outcomes: pulmonary embolism or nonpulmonary embolism outcome (arrhythmia, myocardial infarction, serious hemorrhage, and death). RESULTS Of the 9,374 patients enrolled, 9,091 (97.0%; median age 66 years, 51.9% women) with 30-day follow-up were analyzed: 547 (6.0%) were evaluated for pulmonary embolism (278 [3.1%] had D-dimer, 39 [0.4%] had ventilation-perfusion scan, and 347 [3.8%] had CT pulmonary angiography). Overall, 874 patients (9.6%) experienced 30-day serious outcomes: 818 patients (9.0%) with nonpulmonary embolism serious outcomes and 56 (prevalence 0.6%; 95% confidence interval 0.5% to 0.8%) with pulmonary embolism (including 8 [0.2%] out of 3521 patients diagnosed during the index hospitalization and 7 [0.1%] diagnosed after the index visit). Eighty-six patients (0.9%) died, and 4 deaths (0.04%) were related to pulmonary embolism. Only 11 patients (0.1%) with a nonpulmonary embolism serious condition had a concomitant pulmonary embolism. CONCLUSION The prevalence of pulmonary embolism is very low among ED patients with syncope, including those hospitalized after syncope. Although an underlying pulmonary embolism may cause syncope, clinicians should be cautious about indiscriminate investigations for pulmonary embolism.
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Affiliation(s)
- Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada.
| | - Marco L A Sivilotti
- Department of Emergency Medicine and Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Muhammad Mukarram
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Susan Malveau
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - Annick N Yagapen
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - Benjamin C Sun
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
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45
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Matsuoka Y, Morimatsu H. Incidence Rates of Postoperative Pulmonary Embolisms in Symptomatic and Asymptomatic Patients, Detected by Diagnostic Images ― A Single-Center Retrospective Study ―. Circ J 2019; 83:432-440. [DOI: 10.1253/circj.cj-18-0729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yoshikazu Matsuoka
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
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46
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Riondino S, Ferroni P, Zanzotto FM, Roselli M, Guadagni F. Predicting VTE in Cancer Patients: Candidate Biomarkers and Risk Assessment Models. Cancers (Basel) 2019; 11:cancers11010095. [PMID: 30650562 PMCID: PMC6356247 DOI: 10.3390/cancers11010095] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 12/07/2018] [Accepted: 01/08/2019] [Indexed: 02/07/2023] Open
Abstract
Risk prediction of chemotherapy-associated venous thromboembolism (VTE) is a compelling challenge in contemporary oncology, as VTE may result in treatment delays, impaired quality of life, and increased mortality. Current guidelines do not recommend thromboprophylaxis for primary prevention, but assessment of the patient's individual risk of VTE prior to chemotherapy is generally advocated. In recent years, efforts have been devoted to building accurate predictive tools for VTE risk assessment in cancer patients. This review focuses on candidate biomarkers and prediction models currently under investigation, considering their advantages and disadvantages, and discussing their diagnostic performance and potential pitfalls.
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Affiliation(s)
- Silvia Riondino
- Interinstitutional Multidisciplinary Biobank, IRCCS San Raffaele Pisana, 00166 Rome, Italy.
- Department of Systems Medicine, Medical Oncology, University of Rome Tor Vergata, 00133 Rome, Italy.
| | - Patrizia Ferroni
- Interinstitutional Multidisciplinary Biobank, IRCCS San Raffaele Pisana, 00166 Rome, Italy.
- Department of Human Sciences & Quality of Life Promotion, San Raffaele Roma Open University, 00166 Rome, Italy.
| | - Fabio Massimo Zanzotto
- Department of Enterprise Engineering, University of Rome "Tor Vergata", 00133 Rome, Italy.
| | - Mario Roselli
- Department of Systems Medicine, Medical Oncology, University of Rome Tor Vergata, 00133 Rome, Italy.
| | - Fiorella Guadagni
- Interinstitutional Multidisciplinary Biobank, IRCCS San Raffaele Pisana, 00166 Rome, Italy.
- Department of Human Sciences & Quality of Life Promotion, San Raffaele Roma Open University, 00166 Rome, Italy.
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47
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Dai L, Shi G, Li Y, Zhao B. Values of thoracic contrast-enhanced computed tomography in detecting incidental pulmonary thromboembolism in patients with malignant tumors. Oncol Lett 2019; 17:355-359. [PMID: 30655774 PMCID: PMC6313221 DOI: 10.3892/ol.2018.9578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 10/04/2018] [Indexed: 11/20/2022] Open
Abstract
This study aimed to evaluate the values of thoracic multi-slice spiral computed tomography (CT) in the diagnosis of incidental pulmonary thromboembolism (IPTE) in patients with malignant tumors. The clinical data and imaging features of a total of 1,684 patients with malignant tumors, treated in the Fourth Hospital of Hebei Medical University, were analyzed retrospectively in order to investigate the types of malignancies, the patients' clinical features, and the emboli-preferred sites. Among the 1,684 patients, 60 patients had experienced IPTE (3.56%), 35 were females (58.33%), 25 were males (41.67%). Lung cancer had the highest incidence (n=22, 36.67%). The most common site of IPTE was the left lower lobe of pulmonary artery (n=46, 76.67%). The imaging results revealed that in 5 patients (8.33%) IPTE did not occur. Thoracic multi-slice spiral CT has a high detection rate of IPTE in patients with malignant tumors. Early diagnosis is helpful for early clinical treatment and has significant importance for patients' prognosis.
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Affiliation(s)
- Lijuan Dai
- Department of Radiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, P.R. China
| | - Gaofeng Shi
- Department of Radiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, P.R. China
| | - Yang Li
- Department of Radiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, P.R. China
| | - Bo Zhao
- Department of Radiology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, P.R. China
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48
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Caraiani C, Pop A, Calin A, Ciobanu L, Militaru C, Berghe A, Badea R. Incidental findings during follow-up scans in oncological patients. ACTA ACUST UNITED AC 2018; 91:293-299. [PMID: 30093807 PMCID: PMC6082604 DOI: 10.15386/cjmed-931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 12/04/2017] [Indexed: 12/04/2022]
Abstract
Background and aim To assess the prevalence of incidental findings during follow-up scans of patients with oncologic pathology. Methods 499 follow-up scans from different patients with cancer pathology were retrospectively analyzed. Findings which were not suspected by the clinician or known from previous scans were considered as incidental lesions. We excluded lesions that were already suspected by the clinician or were already recorded in the patient’s history before the initial computed tomography (CT) scan. The CT scans were performed on two different machines (“Siemens Somatom Sensation, 64 slices, Erlangen, Germany” and “Siemens Somatom Emotion, 16 slices, Erlangen, Germany”). Most of the patients had a native scan followed by a thoraco-abdominal-pelvic image acquisition after the injection of intravenous contrast media. Results 28% of the patients had unsuspected incidental findings. The prevalence of incidental findings was similar: 56.6% of them were found in men and 43.4% in female patients. In 6 cases (1.2%) the presence of unsuspected pulmonary embolism was discovered. From these cases, 5 (83.3%) had metastatic disease at the moment of the follow-up CT scan and 1 (16.6%) had metastasis-free disease. In 17 patients out of 499 (3.4%) we incidentally made an important discovery which either changed the cancer therapy or required immediate treatment. Conclusion Incidental findings are not rare in oncological patients and the radiologist has to be aware of their presence in order not to overlook them and to correctly diagnose them.
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Affiliation(s)
- Cosmin Caraiani
- Medical Imaging Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Anamaria Pop
- Gastroenterology and Hepatology Department, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Adriana Calin
- Radiology Department, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Lidia Ciobanu
- Gastroenterology and Hepatology Department, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania.,Gastroenterology and Hepatology Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | | | - Alexandra Berghe
- Medical Informatics and Biostatistics Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Radu Badea
- Medical Imaging Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Gastroenterology and Hepatology Department, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
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Uhrig M, Simons D, Schlemmer HP. Incidental pulmonary emboli in stage IV melanoma patients: Prevalence in CT staging examinations and improved detection with vessel reconstructions based on dual energy CT. PLoS One 2018; 13:e0199458. [PMID: 30001367 PMCID: PMC6042704 DOI: 10.1371/journal.pone.0199458] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 06/07/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Malignancy is the strongest predictor for venous thromboembolism. Dual energy CT (DECT) can support assessment of pulmonary emboli (PE) by providing vessel reconstructions (DECT-VR) and highlighting thrombi. Purpose was to determine prevalence and risk factors of PE in staging examinations of stage IV-melanoma patients and to evaluate the potential of DECT-VR to improve PE diagnosis. MATERIAL AND METHODS This retrospective study was approved by IRB. Contrast-enhanced, conventional grey scale CT (cCT) and DECT-VR of 200 stage IV-melanoma patients were reviewed by three radiologists in consensus. Overall prevalence was determined. One-sided Wilcoxon-test was performed to compare the number of detected emboli between cCT and cCT with supplementary DECT-VR. Frequencies of risk factors were compared with χ2 test. RESULTS On cCT, 9 PE were detected (6 patients, correlating to 3% of the study population with 0.05 emboli per patient). With the supplementary DECT-VR, number of diagnosed emboli increased from 9 to 17 (p < 0.05) (in total 9 patients, correlating to 0.09 emboli per patient). Emboli on DECT-VR were mainly subsegmentally (7 of 8). There was no significant difference in the frequency of risk factors. CONCLUSIONS The prevalence of pulmonary emboli in our cohort of 200 stage IV melanoma patients was 5%. DECT-VR improved significantly diagnosis of PE, especially when located subsegmentally.
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Affiliation(s)
- Monika Uhrig
- German Cancer Research Center (DKFZ), Department of Radiology, Heidelberg, Germany
- * E-mail:
| | - David Simons
- German Cancer Research Center (DKFZ), Department of Radiology, Heidelberg, Germany
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50
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Wang T, Li A, Garcia D. Managing thrombosis in cancer patients. Res Pract Thromb Haemost 2018; 2:429-438. [PMID: 30046747 PMCID: PMC6046582 DOI: 10.1002/rth2.12102] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 03/04/2018] [Indexed: 12/11/2022] Open
Abstract
Venous thromboembolism is a major complication in cancer patients. The basis for the strong association between cancer and thrombosis remains incompletely understood, and the optimal approaches to both the treatment and the prevention of cancer-associated thrombosis are evolving. Here we review several important topics related to cancer-associated thromboembolism, including the pathogenesis, prevention, and management of this disease. Wherever possible, we include evidence from clinical trials, including the results of recently published trials that compared direct oral anticoagulants to low-molecular-weight heparin for the treatment of cancer-associated thrombosis.
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Affiliation(s)
- Tzu‐Fei Wang
- Division of HematologyThe Ohio State UniversityColumbusOHUSA
| | - Ang Li
- Division of HematologyUniversity of Washington School of MedicineSeattleWAUSA
| | - David Garcia
- Division of HematologyUniversity of Washington School of MedicineSeattleWAUSA
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