Clinical picture of 10 patients with cancer-associated severe venous limb ischemia
| Pt no. . | Age/ sex . | Cancer . | Initial thrombosis/ thromboses . | Platelet count (×109/L) increase on heparin; heparin course 1, 2, or 3 . | Platelet count fall (%) off heparin (nadir) . | Thrombotic event(s) during warfarin; warfarin course 1 or 2 . | Peak INR . |
|---|---|---|---|---|---|---|---|
| 1 | 66F | Lung | CVA, DVT-R | 1, yes (328 to 682) | 1, 82% (121) | 1, PE, DVT-L→ VLG-L | 7.2 |
| 2 | 46M | Unknown | DVT-R | 1, yes (232 to 493) | 1, 66% (166) | 1, PCD-R | 6.5 |
| Primary*† | 2, yes (166 to 714) | 2, 83%‡ (80) | 2, VLG-R | 4.0 | |||
| 3, yes (80 to 667) | |||||||
| 3 | 78M | Pancreatic*† | DVT-R | 1, yes (102 to 205) | 1, 70% (61) | 1, VLG-R | 6.6 |
| 4 | 68F | Gastric*† | DVT-R, PE | 1, NA | 1, 40% (101) | 1, VLG-R | 9.6 |
| 2, yes (101 to 202) | 2, 36% (130) | ||||||
| 5 | 69F | Ovarian*† | DVT-R | 1, yes (211 to 313) | 1, 48% (164) | 1, PCD-R, WISN | 4.6 |
| 6 | 49F | Ovarian*† | CVA, DVT-L | 1, yes (138 to 703) | 1, 63% (257) | 1, VLG-L, AKA | 4.5 |
| 2, yes (257 to 1096) | 2, 64%‡ (319) | ||||||
| 7 | 64M | Lung* | DVT-R | 1, yes (353 to 571) | 1, 86% (50) | 1, PCD-R | 6.5 |
| 2, yes (50 to 545) | 2, VLG-R, BKA | 3.9 | |||||
| 8 | 61F | Lung† | DVT-R, DVT-L | 1, NA (outpatient) | 1, 69% (48) | 1, PCD-R§ | 4.6 |
| 2, yes (48 to 206) | |||||||
| 9 | 51M | Lung*† | DVT-L | 1, NA (outpatient) | 1, NA (145) | 1, PCD-L | 4.2 |
| 2, yes (145 to 564)|| | |||||||
| 10 | 64M | Pancreatic* | CVA, DVT-L, PE | 1, yes (97 to 304) | 1, 60% (110) | 1, MI, VLG-L | 8.9 |
| Pt no. . | Age/ sex . | Cancer . | Initial thrombosis/ thromboses . | Platelet count (×109/L) increase on heparin; heparin course 1, 2, or 3 . | Platelet count fall (%) off heparin (nadir) . | Thrombotic event(s) during warfarin; warfarin course 1 or 2 . | Peak INR . |
|---|---|---|---|---|---|---|---|
| 1 | 66F | Lung | CVA, DVT-R | 1, yes (328 to 682) | 1, 82% (121) | 1, PE, DVT-L→ VLG-L | 7.2 |
| 2 | 46M | Unknown | DVT-R | 1, yes (232 to 493) | 1, 66% (166) | 1, PCD-R | 6.5 |
| Primary*† | 2, yes (166 to 714) | 2, 83%‡ (80) | 2, VLG-R | 4.0 | |||
| 3, yes (80 to 667) | |||||||
| 3 | 78M | Pancreatic*† | DVT-R | 1, yes (102 to 205) | 1, 70% (61) | 1, VLG-R | 6.6 |
| 4 | 68F | Gastric*† | DVT-R, PE | 1, NA | 1, 40% (101) | 1, VLG-R | 9.6 |
| 2, yes (101 to 202) | 2, 36% (130) | ||||||
| 5 | 69F | Ovarian*† | DVT-R | 1, yes (211 to 313) | 1, 48% (164) | 1, PCD-R, WISN | 4.6 |
| 6 | 49F | Ovarian*† | CVA, DVT-L | 1, yes (138 to 703) | 1, 63% (257) | 1, VLG-L, AKA | 4.5 |
| 2, yes (257 to 1096) | 2, 64%‡ (319) | ||||||
| 7 | 64M | Lung* | DVT-R | 1, yes (353 to 571) | 1, 86% (50) | 1, PCD-R | 6.5 |
| 2, yes (50 to 545) | 2, VLG-R, BKA | 3.9 | |||||
| 8 | 61F | Lung† | DVT-R, DVT-L | 1, NA (outpatient) | 1, 69% (48) | 1, PCD-R§ | 4.6 |
| 2, yes (48 to 206) | |||||||
| 9 | 51M | Lung*† | DVT-L | 1, NA (outpatient) | 1, NA (145) | 1, PCD-L | 4.2 |
| 2, yes (145 to 564)|| | |||||||
| 10 | 64M | Pancreatic* | CVA, DVT-L, PE | 1, yes (97 to 304) | 1, 60% (110) | 1, MI, VLG-L | 8.9 |
All 10 patients were diagnosed as having metastatic cancer. All 10 patients tested negative for HIT in the SRA; additionally, patients 1, 6, 7, 8, 9, and 10 tested negative in the IgG-specific PF4/heparin ELISA; whereas patient 4 tested positive by ELISA (but did not have HIT based on the negative SRA and platelet count increase when UFH was restarted following the negative SRA test result). Only patient 3 tested strongly positive by PF4/heparin ELISA (3.24 units; normal <0.45 units), but the SRA was repeatedly negative, and cancer-associated DIC was judged a more probable diagnosis than HIT. No serum was available from patients 2 and 5 for testing in the PF4/heparin ELISA.
AKA, above-knee amputation; BKA, below-knee amputation; CVA, cerebrovascular accident (thrombotic stroke); F, female; L, left; M, male; MI, myocardial infarction; NA, not available; Pt, patient; R, right; UFH, unfractionated heparin; WISN, warfarin-induced skin necrosis (ie, central or nonacral skin necrosis).
Diagnosis of cancer was not known or suspected at time of presentation of initial thrombosis.
Pathology was available and showed adenocarcinoma (except patient 5, which showed ovarian clear cell carcinoma). For patients 1, 7, and 10, for whom pathology was not available, clinical and radiologic features were strongly indicative of metastatic cancer (which was diagnosed by the attending physicians), and which was not pathologically proven in part because of the aggressive thrombotic events, including limb ischemic necrosis, which resulted in decision for palliative treatment rather than further investigations and therapy.
Abrupt platelet count fall and thrombotic event (PE, patient 2; DVT-R, patient 6) while heparin was interrupted for biopsy.
Although progression of both R and L DVT occurred while on warfarin, PCD occurred in the R limb, which had more extensive thrombosis (from calf veins to common femoral vein) than L limb (from calf veins to superficial femoral vein).
Thrombotic event (DVT-R) without thrombocytopenia exacerbation within 24 hours of holding danaparoid for bronchoscopy/biopsy.