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Pulmonary embolism in oncologic patients: frequency and embolus burden of symptomatic and unsuspected events.

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Pulmonary embolism in oncologic patients: frequency and embolus burden of symptomatic and unsuspected events.

Acta Radiol. 2013 Jul 17;

Authors: Bach AG, Schmoll HJ, Beckel C, Behrmann C, Spielmann RP, Wienke A, Abbas J, Surov A

Abstract
BACKGROUND: Pulmonary embolism (PE) is a common cause of morbidity and mortality in oncologic patients. Furthermore, PE is an unsuspected finding in many cases.
PURPOSE: To determine the frequency and embolus burden of PE in a consecutive oncologic patient group including symptomatic as well as incidental and initially unreported events.
MATERIAL AND METHODS: In a retrospective, single-center study from June 2005 to January 2010 all patients with an oncologic disease (ICD-10 code C00 to C96) that received at least one contrast-enhanced computed tomography (CT) examination of the chest were reviewed. The study group included 3270 patients with 6780 examinations. A validated pulmonary artery obstruction index (Mastora score) was used to assess embolus burden.
RESULTS: PE was found in 240 of 3270 (7.3%) oncologic patients. The frequency was highly variable among different malignancies ranging from 0% to 25%. In the present study about half of all PE were unsuspected. The mean embolus burden was significantly higher in symptomatic PE than in unsuspected PE (P <0.001). The risk of developing a PE was 1.5 times higher in patients with metastases compared to patients without metastases (P <0.005). Age and sex had no influence on PE risk and embolus burden.
CONCLUSION: PE is a frequent unsuspected finding in staging examinations: particularly in patients with malignancies of the ovary, brain, and pancreas, and in patients with metastases. Therefore, the status of the pulmonary vasculature should be assessed in every staging examination that includes the chest. The effect of therapeutic actions on PE events and the unsuspected finding of PE in follow-up CT examinations require further prospective studies.

PMID: 23864061 [PubMed - as supplied by publisher]

Venous thromboembolic disease.

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Venous thromboembolic disease.

Surg Clin North Am. 2013 Aug;93(4):983-95

Authors: Suwanabol PA, Hoch JR

Abstract
Venous thromboembolic disease is extremely common. Conventional treatment with anticoagulation alone aims to impede the progression of thrombus, and prevent recurrence and the development of pulmonary embolism. This is appropriate for most patients. However, in certain patient populations, this alone does not address the long-term complications of venous thromboembolic disease. Surgeons should be familiar with the surgical techniques that have been demonstrated to improve outcomes with low risk. Recent studies of catheter-directed thrombolysis have demonstrated its safety, efficacy, and possibly the superiority over standard treatment alone.

PMID: 23885941 [PubMed - in process]

Pulmonary embolism in chronic hypoxemic patients with and without secondary polycythemia - analysis of risk factors in prospective clinical study.

Aim : Prospectively evaluate the incidence of pulmonary embolism and risk factors for this life-threatening disease on chronic hypoxemic patients treated in intensive respiratory care unit.

Methods : The study enrolled 842 consecutive patients with severe exacerbation of chronic obstructive pulmonary disease or respiratory failure. The initial assessment included clinical history collection, physical examination, hematological and biochemical analysis, gas analysis, chest X ray, 12 lead electrocardiography and determination of value of D-dimer. Of all enrolled patients, 211 met the exclusion criteria. Of 631 included patients, 269 (42.6%) had normal D-dimer. D-dimer level ≥500 μg/L was found in 362 (57.5%) patients who were referred to Doppler echocardiography, lower limb color Doppler ultrasonography and thoracic multidetector helical computed tomography. According the value of hematocrit, all patients were divided in two groups: group I (100 patients) with polycythema and group II (262 patients) without polycythemia.

Results : The first outcome of the study was the significantly higher incidence of pulmonary embolism in group I of patients than in group II, 39 (39%) and 29 (11.06%), respectively. Patients in group I had significantly worse disturbance of pulmonary function and higher degree of pulmonary hypertension (58.4±3.66 vs. 30.3±9.41). Apart from polycythemia in group I, the most common risk factors were arrhythmia, absolute and varicose veins.

Conclusion : Polycythemia is a single most significant risk factor for pulmonary embolism in chronic hypoxemic patients. Value of D-dimer ≥500 μg /L, as well as presence of comorbidity, particularly vein varicose, in these patients should raise clinical suspicion of PE. Key words: chronic obstructive pulmonary disease, multidetector computed tomography, arrhythmia, varicose veins, pulmonary hypertension.

V/Q Scanning Using SPECT and SPECT/CT.

Planar ventilation-perfusion (V/Q) scanning is often used to investigate pulmonary embolism; however, it has well-recognized limitations. SPECT overcomes many of these through its ability to generate 3-dimensional imaging data. V/Q SPECT has higher sensitivity, specificity, and accuracy than planar imaging and a lower indeterminate rate. SPECT allows for new ways to display and analyze data, such as parametric V/Q ratio images.

Compared with CT pulmonary angiography, SPECT has higher sensitivity, a lower radiation dose, fewer technically suboptimal studies, and no contrast-related complications. Any nuclear medicine department equipped with a modern hybrid scanner can now perform combined V/Q SPECT with CT (using low-dose protocols) to further enhance diagnostic accuracy. V/Q SPECT (with or without CT) has application in other pulmonary conditions and in research.

Biomarkers for prediction of venous thromboembolism in cancer.

Cancer patients are at increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). The incidence among different groups of cancer patients varies considerably depending on clinical factors, the most important being tumour entity and stage.

Biomarkers have been specifically investigated for their capacity of predicting venous thromboembolism (VTE) during the course of disease. Parameters of blood count analysis (elevated leukocyte and platelet-count, decreased haemoglobin) have turned out to be useful in risk prediction. Associations between elevated levels and future VTE have been found for D-Dimer, prothrombin fragment 1+2 and soluble P-selectin and also for clotting factor VIII and the thrombin generation potential. The results for tissue factor (TF)-bearing microparticles are heterogeneous, an association with occurrence of VTE in pancreatic cancer might be present, whereas in other cancer entities, such as glioblastoma, colorectal or gastric carcinoma this could not be confirmed.

Risk assessment models (RAM) were developed that include clinical and laboratory markers. In the high risk categories patient groups with up to >20% VTE rate within 6 months can be identified.

A further improvement in risk stratification would allow better identification of patients for primary VTE prevention using indirect or novel direct anticoagulants.

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