From the Guidelines
The appropriate diagnostic workup for an 87-year-old female presenting with right lower extremity edema and a history of cancer and thromboembolic disease is to start with a comprehensive medical history and physical examination (H&P), followed by venous ultrasound as the preferred initial imaging method for diagnosing deep vein thrombosis (DVT) 1.
Key Diagnostic Steps
- Comprehensive medical H&P: To identify any clinically overt signs/symptoms that could represent an acute DVT, such as swelling, pain, or erythema in the affected extremity 1.
- Laboratory tests: Including CBC with platelet count, PT, aPTT, fibrinogen, and liver and kidney function tests to evaluate the patient's coagulation status and overall health 1.
- Venous ultrasound: As the initial imaging method for diagnosing DVT, which has been shown to detect asymptomatic DVT of the lower extremities in patients with advanced cancer 1.
Additional Imaging Modalities
- Contrast-enhanced CT venography (CTV): May be used if ultrasound results are negative or indeterminate, particularly for diagnosing femoropopliteal DVT or detecting thrombus in large pelvis veins and the inferior vena cava (IVC) 1.
- Magnetic resonance venogram (MRV) with contrast: May be used as an alternative to CTV, with higher sensitivity for proximal DVT than distal DVT, and equivalent sensitivity and specificity to ultrasound for diagnosing DVT 1.
Important Considerations
- High clinical suspicion: For patients with a high suspicion of DVT, early initiation of anticoagulation should be considered while awaiting results from imaging studies 1.
- Repeat imaging: If initial imaging results are negative or indeterminate, repeat venous ultrasound or other imaging modalities may be necessary to exclude progressive DVT 1.
- Invasive venography: May be considered in certain cases, such as when performed in conjunction with pharmacomechanical thrombectomy/thrombolysis, but has largely been replaced by less invasive methods like ultrasound and MRV 1.
From the Research
Diagnostic Approach
The diagnostic workup for an 87-year-old female presenting with right lower extremity edema and a history of cancer and thromboembolic disease should involve a thorough history and physical examination, as well as a carefully considered laboratory and imaging evaluation 2.
Considerations for Cancer and Thromboembolic Disease
Given the patient's history of cancer, it is essential to consider the risk of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE) 3, 4, 5. The patient's cancer type and site should be taken into account, as certain types of cancer are associated with a higher risk of VTE 3.
Diagnostic Evaluation
The diagnostic evaluation should include:
- A thorough history and physical examination to identify potential causes of edema 2
- Laboratory tests to rule out other causes of edema, such as liver or kidney disease
- Imaging studies, such as ultrasound or computed tomography, to evaluate for DVT or other vascular abnormalities 5
- Consideration of the patient's cancer type and site, as well as their history of thromboembolic disease, to guide the diagnostic evaluation and management plan 3, 4, 5
Management of VTE in Cancer Patients
The management of VTE in cancer patients can be challenging, and may require the use of low-molecular-weight heparins (LMWHs) or other anticoagulants 5, 6. The patient's risk of bleeding and recurrence of VTE should be carefully considered when developing a management plan 5, 6.
Key Points
- A thorough history and physical examination are essential in evaluating a patient with lower extremity edema 2
- The patient's history of cancer and thromboembolic disease should be carefully considered in the diagnostic evaluation and management plan 3, 4, 5
- Imaging studies and laboratory tests should be used to evaluate for potential causes of edema and to guide management 2, 5
- The management of VTE in cancer patients requires careful consideration of the patient's risk of bleeding and recurrence of VTE 5, 6