Risk and prognosis of cancer after upper-extremity deep venous thrombosis: A population-based cohort study

Two cases of vertebral perfusion disturbances in computer tomography imitating metastatic lesions in the course of superior vena cava thrombosis

Skeletal metastases are frequently observed in various malignancies. In some cases, they are asymptomatic and can be found incidentally in various imaging methods in patients without known malignant tumors. In this case study 2 cases of vertebral perfusion disturbances are presented that imitate vertebral metastatic lesions in computer tomography in the course of superior vena cava thrombosis. The first patient was referred to our clinic for chest and abdominal computer tomography (CT) for staging due to a known tumor in the anterior mediastinum. The second patient was referred for chest CT due to swelling in the upper extremity and neck, with the suspected diagnosis of a tumor or pulmonary embolism. In both cases, CT scans showed metastases suspected lesions in the upper thoracic vertebral bodies. In both cases, additionally, the thrombosis of superior vena cava (SVC) and vena brachiocephalica was confirmed (in the first case due to tumor compression in the upper mediastinum, in the second case due to the presence of pacemaker leads). In control CT scans after anticoagulation treatment, there were no suspected lesions in the vertebral bodies, which confirmed the diagnosis of vertebral perfusion disturbances in the course of SVC thrombosis in both patients. In conclusion, in rare cases of metastases suspected lesions of thoracic vertebral bodies in contrast-enhanced computer tomography among patients with a diagnosis of superior vena cava thrombosis vertebral perfusion disturbances should be included in differential diagnosis protocol.

A Risk of Venous Thromboembolism Algorithm as a Predictor of Venous Thromboembolism in Patients with Colorectal Cancer

Cancer patients experience an increased risk of venous thromboembolism (VTE). In this study, we investigated a risk of venous thromboembolism algorithm (RVTA) in patients with colorectal cancer and evaluated its ability to predict the prognosis of colorectal cancer. We retrospectively analyzed clinical data from 345 patients with colorectal cancer from January 2015 to December 2018 at the Shanghai Cancer Center to develop the RVTA. Additionally, the 345 patients were followed until December 2020 for prognostic analysis. The RVTA included the following variables: (a) platelet count, (b) blood transfusion history, (c) metastasis, (d) multiple chemotherapy regimens, and (e) the D-dimer level. Good predictive efficiency was observed for the RVTA (AUC was 0.825; 95% CI was 0.721 to 0.930). The median progression-free survival (PFS) of patients who had a score less than 4 (0-3), defined as the low-risk group, was significantly longer than that of the high-risk group, which included patients who had a score greater than 4 (4-8) (26 vs ten months, P < .001). The RVTA was a valuable predictor for VTE risk and had prognostic value in colorectal cancer.

Upper extremity deep venous thrombosis prevalence in the NHS Grampian Medical Ambulatory clinic: diagnostic, therapeutic, and prognostic considerations in oncology patients

Introduction

Whilst upper extremity deep vein thromboses (UEDVT) account for approximately 5 to 10% of all cases of DVT, rigorous guidelines regarding diagnosis and management of presenting patients remain to be developed. The association of UEDVT with concurrent asymptomatic pulmonary embolism as well as the first presentation of malignancy deems essential rigorous research and clinical guideline development to ensure optimal patient care.

Methods

This retrospective audit study is the first to provide estimates of UEDVT prevalence in the North-East Deanery main hospital centre, Aberdeen Royal Infirmary (ARI).

Results

Of the 605 patients attending the ARI Ambulatory Emergency Care (AEC) clinic with clinical suspicion of UEDVT, 38 (6.2%) had a confirmatory diagnosis. Underlying malignancy, presence of PICC line, and cardiovascular co-morbidities were identified as common confounding factors. Subclavian vein with concurrent extension to primarily the cephalic vein thrombosis was identified as the most commonly thrombosed venous territories. Importantly, oncology patients were found to have poorer survival outcomes following an UEDVT, in comparison to patients with other significant co-morbidities (cardiovascular, chronic renal disease, inflammatory bowel disease): HR 5.814 (95%CI 1.15, 29.25), p 0.012. Lastly, genetic associations were drawn between patient genetic status as tested for other co-morbidities and prothrombotic cellular cascades, suggesting rigorous VTE assessment in patients identified with congenital or acquired mutations, namely, in CALR, JAK, MSH 2/6, MYC, and FXN.

Conclusions

Overall, this study offers the first report of UEDVT presentations in the UK with no restrictions of patient performance status or underlying co-morbidities and provides a rounded clinical picture of patient characteristics, diagnosis, management, and prognostic associations in view of rigorous guideline development.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11845-021-02775-0.

D-dimer level for ruling out peripherally inserted central catheter-associated upper extremity deep vein thrombosis and superficial vein thrombosis

AIMS

To examine the effectiveness of D-dimer values to be used as an independent diagnostic marker for excluding peripherally inserted central catheter-associated upper extremity deep vein thrombosis and superficial vein thrombosis.

DESIGN

This was a retrospective case-cohort study.

METHODS

Records were reviewed for 281 patients who underwent peripherally inserted central catheter insertion between 1 October 2017 and 1 October 2019. According to the modified Wells score after peripherally inserted central catheter insertion, the patients who had low vein thrombosis risk underwent a D-dimer test and colour Doppler ultrasound.

RESULTS

Among 281 patients, 180 patients (64%, 95% CI: 58.2%-69.4%) had negative D-dimer results and 39 of 180 patients had vein thrombosis despite having a negative D-dimer result, resulting in a failure rate of 21.7% (95% CI: 16.3%-28.3%). The negative predictive value of peripherally inserted central catheter-associated vein thrombosis in the cancer group (80.0%, 95% CI: 73.2%-85.4%) was higher than that of the non-cancer group (60.0%, 95% CI: 35.7%-80.2%). The negative predictive value of peripherally inserted central catheter-associated deep venous thrombosis (84.9%, 95% CI: 78.7%-89.6%) was lower than that of the PICC-associated superficial venous thrombosis (91.0%, 95% CI: 85.4%-94.6%).

CONCLUSION

The D-dimer levels maybe should not be used as a diagnostic index to rule out peripherally inserted central catheter-associated upper extremity vein thrombosis.

Invited Review: Optimal Management of Upper Extremity DVT: Is Venous Thoracic Outlet Syndrome Underrecognized?

BACKGROUND

UEDVT accounts for approximately 10% of all cases of deep vein thrombosis. In the most widely referenced general review of deep vein thrombosis (DVT the American Academy of Chest Physicians essentially recommend that upper extremity DVT (UEDVT) essentially be treated identically to that of lower extremity DVT, with anticoagulation being the default therapy. Unfortunately, the medical literature does not well differentiate between DVT in the arm and the leg, and does not emphasize the effects of the costoclavicular junction (CCJ) and the lack of effect of gravity, to the point where UEDVT due to extrinsic bony compression at the CCJ is classified as "primary."

METHODS

Comprehensive literature review, beginning with both Medline and Google Scholar searches in addition to collected references, then following relevant citations within the initial manuscripts studied. Both surgical and medical journals were explored RESULTS: It is proposed that effort thrombosis be classified as a secondary cause of UEDVT, limiting the definition of primary to that which is truly idiopathic. Other causes of secondary UEDVT include catheter- and pacemaker-related thrombosis (the most common cause, but often asymptomatic), thrombosis related to malignancy and hypercoagulable conditions, and the rare case of thrombosis due to compression of the vein by a focal malignancy or other space-occupying lesion. In true primary UEDVT and in those secondary cases where no mechanical cause is present or can be corrected, anticoagulation remains the treatment of choice, usually for three months or the duration of a needed catheter. However, evidence suggests that many cases of effort thrombosis are likely missed by a too-narrow adherence to this protocol.

CONCLUSIONS

Because proper treatment of effort thrombosis drops the long-term symptomatic status rate from 50% to almost zero and these are healthy patients with a long lifespan ahead, it is proposed that a more aggressive attitude toward thrombolysis be followed in any patient who has a reasonable degree of suspicion for venous thoracic outlet syndrome.

A review of upper extremity deep vein thrombosis

This review aims to describe the epidemiology, pathophysiology, risk factors, presentation, complications, evaluation/diagnosis, and treatment of upper extremity deep vein thrombosis (UEDVT). Upper extremity deep vein thrombosis (UEDVT) accounts for 6% of cases of deep vein thrombosis (DVT). It can lead to swelling and discomfort in that extremity and can be complicated by pulmonary embolism, post-thrombotic syndrome, and recurrence of DVT. Evaluation can begin with a dichotomized Constans score and fibrin degradation product testing. Diagnosis is typically made with compression ultrasound. Anticoagulation is the mainstay of therapy. Primary UEDVT is known as Paget Schroetter Syndrome (PSS) which occurs due to venous thoracic outlet syndrome (vTOS). Anticoagulation, thrombolysis, and decompression of the venous thoracic outlet are used for treatment but the optimal strategy remains to be elucidated. Secondary UEDVT are most commonly caused by indwelling catheters and malignancy. There is an ongoing realization that UEDVT are more than simply 'leg clots in the arm.' Given the increasing incidence, research needs to be done to further our understanding of this disease state, its evaluation, and its treatment.

Venous thromboembolism and risk of cancer in users of statins: A Danish population-based cohort study

BACKGROUND

Venous thromboembolism (VTE) may be the first symptom of cancer. Statins are suggested to prevent VTE, but the risk of cancer in VTE patients using statins remains poorly understood.

OBJECTIVES

To examine if VTE is a marker of cancer in users of statins.

METHODS

We identified all Danish patients during 1996-2017 with a first-time diagnosis of VTE and a filled prescription for a statin within 90 days prior to the VTE diagnosis. We classified patients as prevalent users if the first filling of a statin occurred more than one year preceding the VTE diagnosis, and as new users if the first filling occurred within the preceding year. We computed cumulative incidences of cancer, with death as a competing risk, and age-, sex-, and calendar-period standardized incidence ratios (SIRs), comparing the observed cancer incidence with the expected based on national cancer statistics.

RESULTS

Among 9280 (85%) prevalent users of statin and 1580 (15%) new users, the one-year cumulative incidence of any cancer was 6.6 (95% CI: 6.1-7.2) for prevalent users and 6.4 (95% CI: 5.2-7.6) for new users; the corresponding SIRs were 3.1 (95% CI: 2.9-3.3) and 3.5 (95% CI: 2.9-4.3). In the second and subsequent years, the SIRs diminished and approached unity for both prevalent (1.1 [95% CI: 1.1-1.2]) and new users (1.1 [95% CI: 0.9-1.3]).

CONCLUSIONS

VTE patients using statins had a 3-fold increased rate of cancer in the first year after diagnosis. A first VTE serves as an important marker of cancer, regardless of statin use.

Long-Term Outcomes of Patients Investigated for Suspected Upper Extremities Deep Venous Thrombosis Irrespective of Imaging Results

Background

Outcome data are limited for upper extremity deep venous thrombosis (UEDVT). The outcomes of patients investigated for, but without UEDVT remain uncertain.

Methods

Retrospective analysis of clinical records of adult patients undergoing Doppler ultrasound for potential UEDVT between 1 January 2007 and 31 December 2014 was undertaken. Primary outcome was all-cause mortality. Secondary outcomes were new cancer diagnosis and thromboembolic recurrence.

Results

The final cohort (n = 528) comprised 25 primary UEDVT, 100 secondary UEDVT, 40 superficial-venous thrombosis and 363 without thrombus patients. There were 207 deaths. Survival was higher in primary than in secondary UEDVT (log-rank p < 0.0001) or those without thrombus (log-rank p = 0.001). Pre-existing cancer [hazard ratio 3.6 (95% confidence interval 1.5-8.9)] was the biggest independent predictor of mortality and leading cause of death. Developing UEDVT was a poor prognostic marker in cancer patients.

Conclusion

There was high early mortality regardless of radiological findings, with the exception of primary UEDVT. Prospective studies evaluating aggressive treatment of underlying comorbidities in these patients are needed.

Cardiovascular disease and survival in non-small cell lung cancer: a multicenter prospective assessment

PURPOSE

Chronic inflammation contributes to cancer development via multiple mechanisms. We hypothesized that cardiovascular diseases (CVD) are also an independent risk factor for survival in non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Prospective multicenter data from 345 consecutive NSCLC patients treated from January 2013 to January 2017 were assessed. Median follow-up for all patients was 13 months (range 3-60 months). There were 109 patients with baseline heart disease (HD 32%), 149 with arterial hypertension (43%), 85 with diabetes mellitus (25%), 129 with hyperlipidemia (37%) and 45 with venous thromboembolism events (VTE 13%). A total of 289 patients (84%) were treated with platinum-based chemotherapy (CT), 300 patients (87%) received thoracic radiation therapy (RT; median radiation dose: 60 Gy [range 12-70]); and 50 (15%) patients underwent surgery.

RESULTS

Our cohort consisted of 305 men (88%) and 40 (12%) women, with a median age of 67 years (range 31-88 years). Seventy percent had a Karnofsky performance status (KPS) ≥ 80. Multivariate analyses showed a lower OS and higher risk of distant metastasis in patients with advanced stages (p = 0.05 and p < 0.001, respectively) and HD (HR 1.43, p = 0.019; and HR 1.49, p = 0.025, respectively). Additionally, patients with VTE had lower local control (HR 1.84, p = 0.025), disease-free survival (HR 1.64, p = 0.020) and distant metastasis-free survival (HR 1.73, p = 0.025).

CONCLUSIONS

HD and VTE are associated with a higher risk of mortality and distant metastasis in NSCLC patients. Chronic inflammation associated with CVDs could be an additional pathophysiologic factor in the development of distant metastasis.

Dimethyl 2,2'-[2,2'-(ethane-1,1-diyl)bis(1H-indole-3,2-diyl)]-diacetate: a small molecule capable of nano-scale assembly, inhibiting venous thrombosis and inducing no bleeding side effect

Background

Due to the discovery that deep venous thrombosis (DVT) inhibitor is of chemotherapeutic importance, the nano-property of dimethyl 2,2′-[2,2′-(ethane-1,1-diyl) bis(1H-indole-3,2-diyl)]-diacetate (DEBIC), a recently reported antitumor agent, is worthy of characterization.

Materials and methods

One-pot reaction was used to prepare DEBIC. Electrospray Ionization (+/−)-Fourier Transform-Ion Cyclotron Resonance-Mass Spectrometer (ESI(+/−)-FT-ICR-MS), quadrupole Collision Induced Dissociation (qCID) and nuclear overhauser effect spectroscopy spectra were used to present the assembly of DEBIC. Transmission electron microscopy, scanning electron microscopy, atomic force microscopy and Faraday–Tyndall effect were used to visualize the nano-property of DEBIC. Rat models were used to evaluate DVT inhibition and the bleeding reaction of DEBIC.

Results

One-pot reaction can provide DEBIC in acceptable yield and high purity. In water, rat plasma and lyophilized powders of DEBIC existed as particles of small nano-size. In vivo DEBIC inhibited DVT in a dose-dependent manner. The minimal effective dose of DEBIC was 1.7 μmol/kg. Even the dose of 36 μmol/kg/day DEBIC did not induce bleeding side effect in DVT rats like in warfarin (0.82 μmol/kg/day).

Conclusion

DEBIC is a small molecule capable of nano-scale assembly, inhibiting venous thrombosis and inducing no bleeding side effect.