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hypercoagulability associated with malignancy

Epidemiology: 1) 11% of patients with malignancy (overall) a) pancreatic cancer 30% 2) 2nd leading cause of death in cancer patients Pathology: - see Trousseau's syndrome - tumor cells release thrombogenic microparticles that can result in thrombin generation even when vitamin K-dependent procoagulants are decreased - thrombin generation coupled with warfarin-induced decreases in protein C & protein S may result in massive thrombosis [2] Clinical manifestations: 1) migratory superficial thrombophlebitis (Trousseau's syndome) 2) deep vein thrombosis, splanchnic vein thrombosis 3) marantic endocarditis (thrombotic, non-bacterial) 4) disseminated intravascular coagulation 5) thrombotic microangiopathy - hemolytic uremic syndrome 6) arterial thrombosis Differential diagnosis: - thrombosis may also occur by a) external compression of vessels by tumor b) invasion of vessels by tumor - renal cell carcinoma invades the inferior vena cava in 5-9% of patients Management: 1) the hypercoagulable state may not be relieved by anticoagulation with warfarin - progression of DVT to limb ischemia & gangrene may occur in patients with cancer-associated hypercoagulability treated with warfarin [2] 2) heparin, especially LMW heparin (Levonox), may be more appropriate in these patients - heparin blocks selectin recognition of ligands 3) reduction of tumor burden

Related

splanchnic vein thrombosis (SVT)

Specific

Trousseau's syndrome; Trousseau's sign of malignancy; thrombophlebitis migrans

General

hypercoagulability

References

  1. UpToDate 14.1 http://www.utdol.com
  2. Green D Limb Gangrene in Cancer Patients Receiving Warfarin. NEJM Journal Watch. June 4, 2015 Massachusetts Medical Society (subscription needed) http://www.jwatch.org - Warkentin TE et al. Warfarin-induced venous limb ischemia/gangrene complicating cancer: A novel and clinically distinct syndrome. Blood 2015 May 15 PMID: 25979950