Solid cancer patients have higher risk to get Venous Thromboembolism (VTE) compared to normal population, particularly on solid cancer patients with histopathology type of adenocarcinoma, advanced stage, cancer treatment, and immobilized. VTE can be in the form of Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE). PE incident in cancer patients resulted in high mortality between 30 to 80% and often not properly diagnosed because 81% of the cases did not show any symptoms.

This is a serial case from six cancer patients who were diagnosed with PE. According to the Revised Geneva Score, three patients were in the category of high risk, and three patients were in moderate risk of PE. All six patients had elevated D-dimer value, and therefore, according to the algorithm from the International Societyon Thrombosis and Hemostasis (ISTH) in 2017, the confirmation of PE diagnosis is to be done by performing gold standard imaging test, where perfusion lung scan is considered one of it. All six patients had the type of cancer histopathology of adenocarcinoma, with advanced stage, had various VTE risk factors, and showed symptoms, such as shortness of breath, pleuritic chest pain, swelling on extremity, and hemoptysis. Patients who were diagnosed with PE received anticoagulant treatment according to the standard therapy.

Vigilance must be exercised if PE is suspected, particularly in cancer patients with high or moderate Revised Geneva Score. It is expected that screening will lead to adequate management which then result on the reduction of mortality due to PE.

Keywords: Venous thromboembolism, pulmonary embolism, solid cancer.

1. Anderson Jr FA, Spencer FA. Risk factors for venous thromboembolism. Circulation. 2003 Jun 17;107(23_suppl_1):I-9.
2. Khalil J, Bensaid B, Elkacemi H, Afif M, Bensaid Y, Kebdani T. Venous thromboembolism in cancer patients : an underestimated major health problem. World J Surg Oncol. 2015;13: p1–17.
3. Falanga A, Zacharski L. Deep vein thrombosis in cancer: The scale of the problem and approaches to management. Ann Oncol. 2005;16: p696–701.
4. Heit JA. Cancer and venous thromboembolism : Scope of the Problem. Cancer Control 2005; p12:5–10.
5. Khorana AA. Cancer-associated thrombosis: updates and controversies. American Society of Hematology. 2015: p626–30.
6. Ay C, Marosi C, Chiriac A-L, Vormittag R, Simanek R, Quehenberger P, et al. Prediction of venous thromboembolism in cancer patients. Blood. 2010;116: p5377–82.
7. Streiff MB. Association between cancer types, cancer treatments, and venous thromboembolism in medical oncology atients. Clinical Advances in Hematology & Oncology. 2013;11(6): p349–57.
8. Ashrani AA, Gullerud RE, Petterson TM, Marks RS, Bailey KR, Heit JA. Risk factors for incident venous thromboembolis in active cancer patients: A population based case-control study. Thromb Res. 2016;139: p29–37.
9. Gade IL, Braekan SK, Naes IA, Hansen JB, Cannegieter SC, Overvad K, et all. The impact of initial cancer stage on the incidence of venous thromboembolism: the Scandinavian Thrombosis and Cancer (STAC) Cohort. J of Thromb and Haemost. 2017;15(8): p1567–75.
10. Buller HR, Van Doormaal FF. Sluis V, Kamphuisen PW. Cancer and thrombosis: from molecular mechanisms to clinical presentations. J of Thromb and Haemost. 2007;5: p246–54.
11. Noble S, Pasi J. Epidemiology and pathophysiology of cancer-associated thrombosis. Br J Cancer. 2010;102: S2–9.
12. Blom JW, Osanto S, Rosendaal FR. The risk of a venous thrombotic event in lung cancer patients : higher risk for adenocarcinoma than squamous cell carcinoma. J of Thromb and Haemost. 2004;2: p1760–5.
13. Vitale C, D’Amato M, Calabrò P, Stanziola AA, Mormile M, Molino A. Venous thromboembolism and lung cancer: a review. Multidiscip Respir Med. 2015;10(28): p1–9.
14. Sweet PH, Theodore III, John A, Masliah E, Witucki P. Fatal pulmonary embolism update : 10 years of autopsy experience at an academic medical center. J R Soc Med Sh Rep. 2013;4: p1–5.
15. O'Connell CL, Boswell WD, Duddalwar V, Caton A, Mark LS, Vigen C, Liebman HA. Unsuspected pulmonary emboli in cancer patients: clinical correlates and relevance. Journal of Clinical Oncology. 2006 Oct 20;24(30):4928-32.
16. Task Force Members: Konstantinides S V, Germany C, France ND, Uk DF, et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. European Heart Journal. 2014;10: p1-48.
17. Gary T, Belaj K, Hafner F, Froehlich H, Samonigg H, Pilger E, et all. Asymptomatic deep vein thrombosis and superficial vein thrombosis in ambulatory cancer patients : impact on short-term survival. B J Cancer 2012;107: p1244–8.
18. Mozaheb Z. Cancer and thrombosis. J Hematol Thrombo Dis. 2014;2(6):p8–11
19. Timp JF, Braekkan SK, Versteeg HH, Cannegieter SC. Epidemiology of cancer-associated venous thrombosis. Blood. 2017;122(10): p1712–24.
20. Streiff MB. Association between cancer types, cancer treatments, and venous thromboembolism in medical oncology atients. Clinical Advances in Hematology & Oncology. 2013;11(6): p349–57.
21. Ashrani AA, Gullerud RE, Petterson TM, Marks RS, Bailey KR, Heit JA. Risk factors for incident venous thromboembolis in active cancer patients: A population based case-control study. Thromb Res. 2016;139: p29–37.
22. Levitan N, Dowlati A, Remick SC, et all. Rates of initial and recurrent thromboembolic disease among patients with malignancy versus those without malignancy: risk analysis using Medicare claim data. Medicine. 1999;78: 285-91.
23. Ceriani E, et Clinical prediction rules for pulmonary embolism: a systematic review and meta-analysis. J Throm b Haemost 2010; 8: 957–70.
24. Lucassen W, etal. Clinical decisionrules for excluding pulmonary embolism: a meta-analysis. Ann Intern Med 2011; 155: 448–60.
25. Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, Perrier A. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Annals of internal medicine. 2006 Feb 7;144(3):165-71.
26. Kyrle PA, Eichinger S. Deep vein thrombosis. Lancet. 2005;365: p1163–74.
27. Klok FA, Kruisman E, Spaan J, Nijkeuter M, Righini M, Aujesky D. Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism. J Thromb and Haemost. 2008;6: p40–4.
28. Righini M, Ebadi HR, Gal GL. Diagnosis of acute pulmonary embolism. J Thromb and Haemost. 2017;15: p1251–61
29. Bajc M, Miniati M, Jögi J, Stein PD. Perfusion SPECT in patients with suspected pulmonary embolism. European journal of nuclear medicine and molecular imaging. 2013 Sep 1;40(9):1432-7.

Noviana Joenputri, MD

Division of Hematology and Medical Oncology, Department of Internal Medicine,

Dharmais Cancer Hospital, Indonesia

Letjen S.Parman St No.84-86, RT.4/RW.9

South Bambu City, Palmerah, West Jakarta City, Jakarta 11420