Pulmonary embolism (PE) is a common cause of death in patients with cancer.1 In recent years, the extensive use of scheduled CT for tumor assessment has led to increasing diagnoses of incidental PE in this population. Thus, the current clinical spectrum of PE may vary from sudden life-threatening events to unsuspected radiologic findings on scheduled CT scans.2,3 In several series of patients with acute symptomatic PE, cancer has been identified as a predictor for adverse outcomes.4,5 Several factors, such as the greater risk of recurrence and bleeding, may influence this poor prognosis compared with similar patients without cancer.6 Similar to the introduction of outpatient therapy for deep venous thrombosis (DVT), the latest evidence-based guidelines from the American College of Chest Physicians7 suggest that early discharge may be appropriate for selected patients with low-risk PE (evidence-based grade 2B). However, this recommendation is based on observational and retrospective studies8-10 and some randomized trials including only symptomatic events11,12 in which patients with cancer were underrepresented.
Several prognostic scales, such as the Pulmonary Embolism Severity Index (PESI),13 the Geneva Prognostic Score (GPS),14 a simplified PESI version,15 and others,16 have been validated to predict short-term PE-related mortality. However, these scales classify almost all patients with cancer as high-risk, limiting their discriminatory power in these patients. This fact has led to the search for specific prognostic scales, such as the POMPE-C17 and the model derived from the Registro Informatizado de la Enfermedad Tromboembólica Venosa (RIETE registry).18 However, these scales have not been validated for incidental PE, and their clinical utility in selecting patients suitable for home treatment has not been prospectively evaluated.
Therefore, it remains of great interest to identify patients with cancer and low-risk PE who could be candidates to receive ambulatory treatment, and to integrate this practice within the continuum of care in the cancer population. The goal of the present study was to describe the feasibility of ambulatory treatment of symptomatic or incidental PE in a prospective cohort of consecutive patients with cancer selected for outpatient management based on a pragmatic set of exclusion criteria. The authors also retrospectively compared the prognostic performance of the PESI, GPS, POMPE-C, and RIETE scales to predict mortality and identify patients who could be safely treated at home.
LaporteSMismettiPDecoususH. Clinical predictors for fatal pulmonary embolism in 15,520 patients with venous thromboembolism: findings from the Registro Informatizado de la Enfermedad Tromboembolica Venosa (RIETE) registry. Circulation2008;11:1711–1716.
HuttenBPrinsMGentM. Incidence of recurrent thromboembolic and bleeding complications among patients with venous thromboembolism in relation to both malignancy and achieved international normalized ratio: a retrospective analysis. J Clin Oncol2000;18:3078–3083.
KearonCAklEAComerotaAJ. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest2012;141(Suppl):e419S–494S.
SquizzatoAGalliMDentaliF. Outpatient treatment and early discharge of symptomatic pulmonary embolism: a systematic review. Eur Respir J2009;33:1148–1155.
AujeskyDRoyPMVerschurenF. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomized, non-inferiority trial. Lancet2011;378:41–48.
DonzéJLe GalGFineMJ. Prospective validation of the Pulmonary Embolism Severity Index: a clinical prognostic model for pulmonary embolism. Thromb Haemost2008;100:943–948.
WickiJPerrierAPernegerTV. Predicting adverse outcome in patients with acute pulmonary embolism: a risk score. Thromb Haemost2000;84:548–552.
JimenezDAujeskyDMooresL. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med2010;170:1383–1389.
JakobssonCJimenezDGomezV. Validation of a clinical algorithm to identify low-risk patients with pulmonary embolism. J Thromb Haemost2010;8:1242–1247.
KlineJARoyPMThanMP. Derivation and validation of a multivariate model to predict mortality from pulmonary embolism with cancer: the POMPE-C tool. Thromb Res2012;129:e194–199.
Den ExterPLGomezVJimenezD. A clinical prognostic model for the identification of low-risk patients with acute symptomatic pulmonary embolism and active cancer. Chest2013;143:138–145.
Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators. JAMA1990;263:2753–2759.
BüllerHRAgnelliGHullRD. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on antithrombotic and thrombolytic therapy. Chest2001;126:401–428.
KearonCKhanSRAgnelliG. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians evidence-based clinical practice guidelines (8th Edition). Chest2008;133:454–545.
SchulmanSKearonC. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost2005;3:692–694.
DeLongERDeLongDMClark-PearsonDL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics1998;44:837–845.
SiragusaSArcaraCMalatoA. Home therapy for deep vein thrombosis and pulmonary embolism in cancer patients. Ann Oncol2005;16:136–139.
AgenoWSteidlLMarchesiC. Selecting patients for home treatment of deep vein thrombosis: the problem of cancer. Haematologica2002;87:286–291.
ZondagWMosICCreemers-SchildD. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost2011;9:1500–1507.
PaneeshaSMcManusAAryaR. Frequency, demographics and risk (according to tumour type or site) of cancer-associated thrombosis among patients seen at outpatient DVT clinics. Thromb Haemost2010;103:338–343.
SinghRSousouTMohileS. High rates of symptomatic and incidental thromboembolic events in gastrointestinal cancer patients. J Thromb Haemost2010;8:1879–1881.
SunJMKimTSLeeJ. Unsuspected pulmonary emboli in lung cancer patients: the impact on survival and the significance of anticoagulation therapy. Lung cancer2010;69:330–336.
Di NisioMFerranteNDe TursiM. Incidental venous thromboembolism in ambulatory cancer patients receiving chemotherapy. Thromb Haemost2010;104:1049–1054.
FontCFarrúsBVidalL. Incidental versus symptomatic venous thrombosis in cancer patients: a prospective observational study of 340 consecutive patients. Ann Oncol2011;22:2101–2106.
O’ConnellCIBoswellWDDuddalwarV. Unsuspected pulmonary emboli in cancer patients: clinical correlates and relevance. J Clin Oncol2006;24:4928–4932.
Den ExterPLHoojerJDekkersOM. Risk of recurrent venous thromboembolism and mortality in patients with cancer incidentally diagnosed with pulmonary embolism: a comparison with symptomatic patients. J Clin Oncol2011;29:2405–2409.