Venous thromboembolism and cancer.

A 64-year-old man with prostate cancer who recently underwent radical retropubic prostatectomy presented to the emergency department with sudden-onset exertional dyspnea and chest heaviness. On physical examination, he was tachy-cardic with a heart rate of 110 beats per minute, normotensive with a blood pressure of 100/76 mm Hg, and hypox-emic with an oxygen saturation of 88% on room air. Left lower extremity edema and calf tenderness were noted. Contrast-enhanced chest computed tomography demonstrated bilateral seg-mental pulmonary embolism (PE) without right ventricular enlargement. A left lower extremity venous ultrasound documented left femoral, popliteal, and calf deep vein thrombosis. Case Presentation 2: A 70-year-old woman with renal cell carcinoma underwent resection of a solitary right upper lobe metastatic pulmonary nod-ule and was referred to the Vascular Medicine clinic after surveillance chest computed tomography performed 1-month postoperatively demonstrated a right lobar PE. She noted fatigue since her surgery but denied any dys-pnea or chest discomfort. On physical examination, her heart rate was 82 beats per minute, blood pressure was 102/66 mm Hg, and oxygenation was 96% on room air. Cardiac and pulmonary examinations were unremarkable. Overview Although the association between cancer and venous thromboembo-lism (VTE) was first noted in 1823 by Bouillard, Trousseau provided the most detailed early description in 1865. VTE is now recognized as a common cause of morbidity and mortality in patients with cancer. Increasing life expectancy attributable to advances in cancer therapy and greater use of imaging for cancer surveillance have contributed to the growing incidence of VTE in patients with malignancy. The rate of symptomatic VTE in patients with cancer who have been hospitalized approaches 5%. 1 VTE, especially when unpro-voked, may herald an impending diagnosis of cancer in a subset of patients without known malignancy. Although the frequency of VTE is considered highest among patients with solid tumors, hematologic malignancies also increase the risk. Cancer-related therapies including chemotherapy and erythropoiesis-stimulating agents further increase the risk of VTE. Frequently used in a variety of cancers, vascular endothelial growth factor receptor inhib-itors and epidermal growth factor receptor inhibitors have also been associated with VTE. Tamoxifen doubles the risk of VTE. Indwelling central venous cathe-ters for the administration of chemother-apy, antibiotics, and parenteral nutrition represent a common risk factor for VTE in patients with cancer. Validated bedside risk stratification tools such as the Khorana score 2 are available to identify patients with cancer who are at a particularly high risk …