Diagnosis of venous thromboembolic disease in cancer patients

Venous thromboembolic disease is a common but likely underdiagnosed condition in the cancer patient population. Timely and accurate diagnosis of venous thromboembolism is imperative due to the unacceptable morbidity and mortality associated with a misdiagnosis. Because diagnosis of the condition based on clinical grounds alone is unreliable, physicians should select an appropriate objective diagnostic test to confirm or refute their clinical impressions. Compression duplex ultrasound is the best initial imaging test for both suspected upper- and lower-extremity deep venous thrombosis. Magnetic resonance venography (MRV) is a valid alternative when ultrasound is inconclusive, but contrast venography remains the "gold standard." Suspected pulmonary embolism should be initially evaluated by helical (spiral) computed tomography (CT) or ventilation/perfusion lung scintigraphy, the former being preferred in cases of obvious pulmonary or pleural disease. Indeterminate studies should prompt performance of contrast pulmonary angiography. Inferior vena cava thrombosis is also best assessed by contrast venography, with MRV and CT reserved as alternative imaging modalities. Evidence to date suggests that D-dimer assays remain unreliable in excluding venous thromboembolism in cancer patients. A newer latex agglutination D-dimer assay may prove to be clinically useful in this setting.