Pulmonary Embolism

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See also: Deep Vein Thrombosis

Pulmonary embolism (PE) is a common complication of advanced cancer. It may be detected incidentally or it may cause symptoms of dyspnoea, chest pain, haemotpysis or sudden death. As in all palliative medicine, the decision about whether or not to investigate and treat a pulmonary embolus is based on numerous factors including the likely prognosis of the patient given his or her terminal illness, the patient's functional status and the patient's wishes. There will be times when investigation and treating is not appropriate, for example, in a person who appears to be in the last few days of life, however, given that PE can cause very distressing symptoms and is life-threatning, treatment is usually appropriate in most other patients.

Pathogenesis and Epidemiology

DVTs and PE are more likely to develop if there are issues with any of the following:

  • Immobility and venous stasis
  • Hypercoagulability of the blood
  • Inflammation of the vascular wall

Cancers are a major risk factor for DVTs, primarily through causing hypercoagulability, but also, as the disease progresses, through causing fatigue with immobility. Cancers especially associated with PEs include pancreas cancer and ovarian cancer.

Clinical Features

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Investigations

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Management

Anti-coagulation

The usual treatment of pulmonary embolism is anticoagulation aiming to reduce the risk of further extension of (and prevent new / recurrent) pulmonary emboli. The risk of treatment with anticoagulation is of course bleeding and in cancer patients this risk is significantly higher than in non-cancer patients. None-the-less, due to a high risk of further life-threatening pulmonary emboli, it is usually appropriate to treat PE (including those found incidentally) with anti-coagulation (untreated symptomatic pulmonary embolism confers around a 30% risk of death; the risk of death of not treating incidentally found PE is not known).

Initial treatment

Immediate therapy with low-molecular weight heparin (LMWH) is the standard initial treatment. Unfractionated heparin via IV infusion is an alternative treatment typically reserved for patients with significantly impaired renal function (i.e. estimated GFR < 30 ml/minute).


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