Core Messages

If no triggering event can be identified for a patient with deep vein thrombosis, an unknown cancer should be considered as a cause. Rosemary Poulose and L. Christian Napp, MD, et al from Hannover Medical School in Germany recalled this in a recent journal article. They recounted the medical history of a 72-year-old woman.

The Patient’s History

The woman had been treated on an inpatient basis for 3 months for paranoid schizophrenia. The authors reported that the patient had refused subcutaneous thrombosis prophylaxis, which was indicated because of insufficient mobility. Three months after being admitted to the clinic, she complained of sudden-onset pain and swelling of the right leg.

Findings

  • Swelling of the entire right lower leg and foot, which transitioned into a hard, nonmoveable, space-occupying mass dorsal to the knee

  • Intact peripheral perfusion, motor function, and sensory function

  • Movement of the right knee slightly impaired

  • Payr test and Meyer sign negative

  • Laboratory tests: elevated D-dimer (1.58 mg/L; normal value, 0 to 0.5 mg/L)

  • Ultrasound: cyst-like space-occupying mass at the right popliteal fossa

  • Duplex ultrasound: thrombosis of the right popliteal vein up to the middle third of the fibular veins

  • Thrombosis therapy: anticoagulation with subcutaneous tinzaparin as well as a compression dressing, then change to edoxaban after 5 days.

Additional Findings and Diagnosis

  • X-ray examination of the right knee joint: popliteal soft tissue tumor with “popcorn-like” opacities, not clearly able to be distinguished from the posterior tibia on x-ray

  • CT scan with venous contrast medium phase: medullary continuity of the space-occupying mass and bordering chondroid matrix calcification

  • MRI: space-occupying mass also with medullary continuity of the base as well as a typical chondroid signal pattern of the cap with strong hyperintensity; compression of the popliteal vein.

Diagnosis: thrombosis of the popliteal vein and secondary degenerated cartilaginous exostosis (chondrosarcoma) of the tibia.

Therapy: surgical tumor resection; continuation of anticoagulation started before procedure.

Discussion

According to the authors, when thrombosis is diagnosed, a known malignant tumor is present in around 15% of cases and an unknown malignant tumor in around 3%–15% of cases. The most common cancers linked to a high risk of venous thromboembolism include malignant tumors of the brain, pancreas, lungs, and gastrointestinal tract.

The authors further explained that the guidelines of the Working Group of Scientific Medical Societies recommend, “aside from basic laboratory testing, an individual approach and initial completion of age-specific and sex-specific screenings where applicable, also including chest x-ray and abdominal ultrasound.”

Cartilaginous exostoses (osteochondromas) are benign bone tumors that can degenerate, which are then referred to as secondary chondrosarcomas. Poulose et al stated that chondrosarcomas account for about 20% of malignant bone tumors. There have been rare cases of chondrosarcomas infiltrating into vessels and metastasizing, which can lead to thromboembolisms.

This article was translated from Univadis Germany.

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