Abstract
The clinical significance of isolated subsegmental pulmonary embolism (SSPE) remains an area of controversy. In cancer patients, venous thromboembolism (VTE) is common and is a major cause of morbidity and mortality. The management of overt VTE in cancer patients is well established, nevertheless the management of incidentally diagnosed PE and especially SSPE, an increasingly frequent finding with the ubiquity of thin-slice computed tomography is less well defined. We have surveyed current attitudes towards treating SSPE in cancer patients among oncologists, respiratory and palliative care physicians. The survey was conducted between September 2012 and May 2013. Physicians surveyed were asked to select their management plan from options available depending on the site, number, symptoms, and in the presence of previous VTE. 154 physicians responded. We observed differences in the attitudes towards treatment between different specialties. In the adjuvant setting, oncologists were more likely to immediately anticoagulate for a single SSPE than palliative care physicians or chest physicians (84 vs 46 vs 56 %, respectively, p = 0.001). In the metastatic setting the differences were smaller (89 vs 69 vs 76 %, respectively, p = 0.057) but palliative care physicians remained less likely to immediately anticoagulate even in the case of multiple-site SSPE (85 vs 96 %, p = 0.014). Despite the unknown clinical significance of SSPE, and the likelihood that even in cancer patients some of these SSPEs may have trivial effects on prognosis if left untreated, the majority of the physicians surveyed would opt for anticoagulation in patients with unsuspected SSPE regardless of its extent.
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References
Nordstrom M, Lindblad B, Anderson H et al (1994) Deep venous thrombosis and occult malignancy: an epidemiological study. BMJ 308:891–894
Noble S, Pasi J (2010) Epidemiology and pathophysiology of cancer-associated thrombosis. Br J Cancer 102:S2–S9
DeMonaco NA, Dang Q, Kapoor WN et al (2008) Pulmonary embolism incidence is increasing with use of spiral computed tomography. Am J Med 121:611–617
Dentali F, Ageno W, Becattini C et al (2010) Prevalence and clinical history of incidental, asymptomatic pulmonary embolism: a meta-analysis. Thromb Res 125:518–522
Sebastian AJ, Paddon AJ (2006) Clinically unsuspected pulmonary embolism: an important secondary finding in oncology CT. Clin Radiol 61:81–85
Larici AR, Calandriello L, Maggi F et al (2007) Prevalence of incidental pulmonary emboli in oncology patients. Radiology 245:921–922
Browne AM, Cronin CG, English C et al (2010) Unsuspected pulmonary emboli in oncology patients undergoing routine computed tomography imaging. J Thorac Oncol 5:798–803
Cronin CG, Lohan DG, Keane M et al (2007) Prevalence and significance of asymptomatic venous thromboembolic disease found on oncologic staging CT. AJR Am J Roentgenol 189:162–170
Gladish GW, Choe DH, Marom EM et al (2006) Incidental pulmonary emboli in oncology patients: prevalence, CT evaluation, and natural history. Radiology 240:246–255
O’Connell CL, Boswell WD, Duddalwar V et al (2006) Unsuspected pulmonary emboli in cancer patients: clinical correlates and relevance. J Clin Oncol 24:4928–4932
Maraveyas A, Johnson M (2009) Does clinical method mask significant VTE-related mortality and morbidity in malignant disease? Br J Cancer 100:1837–1841
Weiner RS, Schwartz LM, Woloshin S (2013) When a test is too good: how CT pulmonary angiograms find pulmonary emboli that do not need to be found. BMJ 347:f3368
Lee AY, Levine MN, Baker RI et al (2003) Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 349:146–153
Khorana AA, Francis CW, Culakova E et al (2007) Thromboembolism is a leading cause of death in cancer patients receiving outpatient chemotherapy. J Thromb Haemost 5:632–634
den Exter PL, Hooijer J, Dekkers OM et al (2011) Risk of recurrent venous thromboembolism and mortality in patients with cancer incidentally diagnosed with pulmonary embolism: a comparison with symptomatic patients. J Clin Oncol 29:2405–2409
den Exter PL, Jiménez D, Kroft LJ et al (2012) Outcome of incidentally diagnosed pulmonary embolism in patients with malignancy. Curr Opin Pulm Med 18:399–405
National Institute for Health and Care Excellence. Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing. London: National Institute for Health and Care Excellence; 2012. http://www.nice.org.uk/guidance/CG144/chapter/introduction. Accessed 9 July 2014
Gurney JW (1993) No fooling around: direct visualization of pulmonary embolism. Radiology 188:618–619
Ogren M, Bergqvist D, Wahlanden K et al (2006) Trousseau’s syndrome-what is the evidence? A population based autopsy study. Thromb Haemost 95:541–545
Bozas G, Bradley RL, Avery G, et al. (2013) Pre-existing pulmonary thrombi in cancer patients diagnosed with an unsuspected pulmonary embolism. In: Reitsma P, Rosendaal F (eds) Proceedings of the XXIV congress of the international society of thrombosis and haemostasis, Wiley-Blackwell, p. 856
Carrier M, Kimpton M, Le Gal G et al (2011) The management of a subsegmental pulmonary embolism: a cross-sectional survey of Canadian thrombosis physicians. J Thromb Haemost 9:1412–1415
Johnson MJ, Sheard L, Maraveyas A et al (2012) Diagnosis and management of people with venous thromboembolism and advanced cancer: how do doctors decide? A qualitative study. BMC Med Inf Decis Mak 12:75
den Exter PL, van Roosmalen MJ, van den Hoven P et al (2013) Physicians’ management approach to an incidental pulmonary embolism: an international survey. J Thromb Haemost 11:208–213
Pesavento R, Casazza F, Filippi L et al (2013) An international survey on isolated subsegmental pulmonary embolism. Thromb Res 131:183–184
Acknowledgments
Dr. Marc Carrier, Association of Cancer Physician, Welsh Palliative Care Group, Yorkshire Thoracic Society, Welsh Thoracic Society, and ‘VTE and cancer’ working group in Hull and East Yorkshire.
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Wang Yng Lim and Georgios Bozas have contributed equally to this work.
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Lim, W.Y., Bozas, G., Noble, S. et al. Anticoagulating the subsegmental pulmonary embolism in cancer patients: a survey amongst different medical specialties. J Thromb Thrombolysis 40, 37–41 (2015). https://doi.org/10.1007/s11239-014-1143-9
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DOI: https://doi.org/10.1007/s11239-014-1143-9