Abstract

Introduction: NICE Clinical Guideline 144 recommends that patients with an unprovoked VTE, who do not have signs or symptoms of cancer on initial investigation, be considered for further investigation with an abdomino-pelvic CT to exclude occult malignancy. This study aimed to evaluate numbers of scans performed in a UK teaching hospital and outcomes, following this recommendation.

Methods: Retrospective review of CT scans performed before and after publication of the NICE guidance in 2012. CT reports and case notes were analysed. Type and stage of malignancy, treatment and other relevant findings were documented. For the 2014 data set, all incidental radiological findings and follow-up recommendations were reviewed.

Results: The annual number of CT scans requested for “unprovoked VTE”, rose by 142% following publication of NICE Clinical Guideline 144. In the 2011 - 2012 data set, 21 patients were included, one of which was found to have a malignancy, which was clinically overt at the time of diagnosis i.e. not occult. Five patients (23.8%) had incidental findings requiring further investigation. In the 2014 –2015 data set, 51 patients were included, five (9.8%) of which were found to have malignancy. In retrospect, all showed signs/symptoms of potential malignancy on initial investigation. No occult malignancies were detected in the patients correctly referred. Incidental findings warranting further investigation were reported in ten cases (19.6%). On review, follow-up advice was deemed incorrect in four of these.

Conclusion: Addition of an abdomino-pelvic CT scan in patients with a first unprovoked VTE and no signs or symptoms of cancer on initial investigation, significantly increased the number of scans and incidental findings, but did not pick up any additional occult malignancies.

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References

1. NICE (2012) Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing. Clinical guideline 144. National Institute for Health and Clinical Excellence, London. http://guidance.nice.org.uk/cg144.
2. Sorensen HT et al. The risk of a diagnosis of cancer after primary deep venous thrombosis or pulmonary embolism. NJEM Med 1998; 338:116-73.
3. White RH, Chew HK, Zhou H et al. Incidence of venous thromboembolism in the year after the diagnosis of cancer in 528,693 adults. Arch Intern Med 2005; 165:1782-7.
4. Carrier M, Le Gal G, Wells PS, Fergusson D, Ramsay T, Rodger MA. Systematic review: the Trousseau syndrome revisited: should we screen extensively for cancer in patients with venous thromboembolism? Ann Intern Med 2008; 149:323-33.
5. Carrier M et al. Screening for Occult Cancer in Unprovoked Venous Thromboembolism. NJEM Med (2015) DOI: 10.1056/NEJMoa1506623
6. Kelly ME et al. Incidental findings detected on emergency abdominal CT scans: a 1-year review. Abdom Imaging 2015;40(6):1853-7
7. Van Doormaal FF et al. Is extensive screening for cancer in idiopathic venous thromboembolism warranted? J Thromb Haemost 2001; 9:79-84.
8. Davies HE et al. The risks of radiation exposure related to diagnostic imaging and how to minimise them. BMJ 2011; 342, d947.
9. Watson HG et al. Guideline on aspects of cancer-related venous thrombosis. Br J Haematol 2015; 170(5):640-8
10. Robertson L et al. Effect of testing for cancer on cancer- and venous thromboembolism (VTE)-related mortality and morbidity in patients with unprovoked VTE. Cochrane Database Syst Rev. 2015 Mar 6; 3:CD010837
11. Berland LL et al. Managing incidental findings on Abdominal CT: White Paper of the ACR Incidental Findings Committee. Journal of the American College of Radiology. 2010; 7 (10): 754-773.