Deep Vein Thrombosis And Occult Cancer
S Sahu, R Verma, P Sachan, D Bahl
Keywords
adenocarcinoma, deep vein thrombosis
Citation
S Sahu, R Verma, P Sachan, D Bahl. Deep Vein Thrombosis And Occult Cancer. The Internet Journal of Surgery. 2006 Volume 10 Number 2.
Abstract
A 73-year-old male presented with idiopathic bilateral lower limb oedema and mild hepatomegaly. Doppler studies of the veins showed bilateral DVT involving almost all the deep veins of the legs extending unto the lower inferior vena cava. Ultrasonography of the abdomen showed multiple necrotic metastases in the liver parenchyma. CECT of the abdomen revealed a thickened gastric wall along with multiple SOL in the liver, minimal ascites and lower IVC thrombosis. Endoscopic biopsy confirmed adenocarcinoma of the stomach in the fundus.
Patients with deep vein thrombosis (DVT) have an increased risk of an underlying malignancy. Clinical evaluation along with an extensive diagnostic work-up will help to identify the lesion and optimize the treatment.
Introduction
Malignancy and thrombosis are closely associated.1
A case with bilateral DVT of the legs and an underlying occult malignancy is reported.
Case Report
A 73-year-old male presented with painless swelling of both lower limbs since 15 days. Examination revealed a bilateral pitting lower limb edema and mild hepatomegaly. The relevant laboratory findings on admission were: Haemoglobin 6.8gm/dl, Random Blood Sugar 83mg/dl, Creatinine 0.9mg/dl. Liver function tests were within normal limits.
Doppler studies showed thrombosis of the deep veins of both lower limbs (right > left).
Further investigation by ultrasonography of the abdomen showed multiple necrotic lesions in the liver parenchyma, suggestive of necrotic metastases. CECT of the abdomen showed a thickened gastric wall along with multiple SOL of the liver, minimal ascites and IVC thrombosis at the level of the renal veins extending into the right common iliac, external iliac and femoral veins.
Upper G. I. Endoscopy showed an ulcero-proliferative growth in the fundus of the stomach.
Biopsy confirmed poorly differentiated adenocarcinoma of the stomach.
Heparin and chemotherapy with 5-flourouracil for adenocarcinoma of stomach was instituted.
Figure 1
Figure 2
Photograph showing a malignant growth in the fundus of the stomach on endoscopy in a patient with bilateral DVT.
Discussion
The association between migratory superficial thrombophlebitis and visceral malignancy was first described by Armand Trousseau in 1865.1
Wright first noted that venous thrombosis can occur before any signs and symptoms of cancer are evident.2
Proposed mechanisms of thrombosis in carcinoma include changes in antithrombotic and prothrombotic proteins, cytokine activation, endothelial dysfunction and venous stasis.3,4,5,6,7,8
Mucus-secreting adenocarcinomas, such as carcinomas of the lung, pancreas, G. I. tract and ovary, are frequently associated with thrombosis because the sialic acid moiety expressed by the tumor cells can cause non-enzymatic activation of factor 10.9,10
In 10% to 20% of patients who present with idiopathic deep vein thrombosis, there is a risk of underlying malignancy. 11
Patients who presents with deep vein thrombosis should always be investigated for underlying malignancy.
Correspondence to
Dr. Shantanu Kumar Sahu Assistant Professor Dept. of General Surgery Himalayan Institute of Medical Sciences Swami Ram Nagar Dehradun Uttaranchal 248140 Email lntshantanu@yahoo.co.in Mob. - 9412933868