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

superficial migratory thrombophlebitis +/- arterial thromboembolism Etiology: - associated with visceral malignancy - may be occult malignancy with superficial migratory thrombophlebitis presenting prior to a diagnosis of malignancy Epidemiology: 1) rare 2) 10% of patients with pancreatic cancer Pathology: 1) excess thrombin generation 2) thrombocytopenia 3) chronic disseminated intravascular coagulation (DIC) 4) hypercoagulable state - superficial venous thrombophlebitis - arterial thromboembolism 5) generally associated with adenocarcinoma a) pancreatic cancer 24% b) lung cancer 20% c) stomach cancer 12% d) acute leukemia 9% e) colorectal carcinoma 5% f) prostate cancer ? 6) mucins produced by adenocarcinoma may trigger syndrome by reacting with leukocyte & platelet selectins, resulting in platelet-rich microthrombi Genetics: - the MET oncogene upregulates plasminogen activator inhibitor type-1 & cyclooxygenase-2 resulting in migrans thrombophlebitis [4] Clinical manifestations: - superficial migratory thrombophlebitis +/- arterial thromboembolism - fever is not a feature - renal insufficiency is not a featur Laboratory: 1) complete blood count (CBC) shows thrombocytopenia - anemia & leukopenia may be noted 2) PT & aPTT may be prolonged or normal, INR may be elevated 3) increased fibrin degradation products a) elevated D-dimer b) diminished plasma fibrinogen - may be elevated with inflammatory process - progressively diminishes with DIC Management: 1) the hypercoagulable state is not relieved by anticoagulation with warfarin 2) heparin, especially LMW heparin (Levonox), may be more appropriate in these patients - heparin blocks selectin recognition of ligands

Related

disseminated intravascular coagulation (DIC) Trousseau's sign

General

hypercoagulability associated with malignancy syndrome

References

  1. Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
  2. Schiller G, in: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  3. UpToDate 14.1 http://www.utdol.com
  4. McCarthy N Trousseau's sign Nature Reviews Cancer. 2005. May 1 https://www.nature.com/articles/nrc1624 - Boccaccio C et al. The MET oncogene drives a genetic programme linking cancer to haemostasis. Nature 2005. 434:396-400 https://www.nature.com/articles/nature03357