hypercoagulability associated with malignancy

Epidemiology

• 11% of patients with malignancy (overall)
  • pancreatic cancer 30%
• 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

Clinical manifestations

• migratory superficial thrombophlebitis (Trousseau's syndome)
• deep vein thrombosis, splanchnic vein thrombosis
• marantic endocarditis (thrombotic, non-bacterial)
• disseminated intravascular coagulation
• thrombotic microangiopathy
  • hemolytic uremic syndrome
• arterial thrombosis

Differential diagnosis

• thrombosis may also occur by
  • external compression of vessels by tumor
  • invasion of vessels by tumor
    • renal cell carcinoma invades the inferior vena cava in 5-9% of patients

Management

• 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
• heparin, especially LMW heparin (Levonox), may be more appropriate in these patients
  • heparin blocks selectin recognition of ligands
• reduction of tumor burden

More general terms

• hypercoagulability

More specific terms

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

Additional terms

• splanchnic vein thrombosis (SVT)