Trousseau’s Syndrome Revisited: Should We Screen Extensively for Malignancy in Patients with Venous Thromboembolism? a Systematic Review and Meta-Analysis

Background: Identifying previously undiagnosed malignancy in patients with newly diagnosed venous thromboembolism (VTE) is important. Malignancy screening can potentially diagnose more cancers and at earlier stage, thereby preventing malignancy associated morbidity and perhaps mortality.

Purpose: To summarize the period prevalence of previously undiagnosed malignancy at baseline (within 1 month of VTE diagnosis), 6 and 12 months following VTE. To quantify the additional value of an “extensive” malignancy screening strategy at baseline compared to a more “limited” screen (history, physical exam and simple widely available tests) at baseline.

Data Source: A systematic literature search strategy was conducted using MEDLINE, EMBASE, the Cochrane Register of Controlled Trials and all EBM Reviews.

Study Selection: We selected 36 studies that reported the prevalence of undiagnosed malignancies at baseline, at 6 and 12 months. Fourteen articles and one abstract also met inclusion criteria for the assessment of “extensive” versus “limited” malignancy screening.

Data extraction: Two reviewers independently extracted data onto standardized forms.

Data Synthesis: The period prevalence of previously undiagnosed malignancy in patients with unprovoked VTE is 6.1% (95% confidence intervals (CI): 5.0 to 7.1) at baseline and 10.0% (95% CI: 8.6 to 11.3) from baseline to 12 months. An “extensive” malignancy screening strategy using computed tomography of the abdomen/pelvis significantly increases the proportion of previously undiagnosed malignancy detected from 49.4% (95% CI: 40.2 to 58.5) (limited screening alone) to 69.7% (95% CI: 61.1 to 77.8) in patients with unprovoked VTE.

Limitations: Unable to determine complication rates, cost-effectiveness and difference in morbidity and mortality associated with “extensive” screening strategies.

Conclusion: Previously undiagnosed malignancies are frequent in patients with unprovoked VTE. Malignancy screening using an “extensive” screening strategy detects more malignancies compared to a limited screening strategy. Computed tomography of the abdomen/pelvis should be considered in the diagnostic work up of previously undiagnosed malignancy in patients with unprovoked VTE.