Case Study: Swollen Leg with Anemia in an Obese Policeman Leads to Discovery of Cecal Cancer

Summary

We report a case of cecal cancer in an obese policeman, who presented with recurrent deep venous thrombosis and unexplained anemia. The deep venous thrombosis was thought to be due to long hours of standing (professional hazard) and obesity. Investigations for thrombophilia came back negative, but when a thorough investigation was done in search of the cause of his unexplained anemia, an occult cancer of the cecum was diagnosed. A right hemicolectomy was performed with lymph node clearance. The postoperative period was uneventful. We highlight that an unsuspected cecal malignancy may present with deep venous thrombosis. It is uncommon for hollow viscus cancers to present with deep vein thrombosis, but recurrent DVT or thrombosis with unexplained anemia should raise suspicion of an underlying ominous pathology.

Background

Deep venous thrombosis (DVT) is a serious condition, which may have life-threatening consequences, at times. It results from the interplay of a number of predisposing factors and may be the overt manifestation of several underlying pathologies. Recurrent attacks of DVT may occur due to defects in synthesis of coagulation factors or other secondary causes, the most important of which is an underlying malignancy. When the provoking factors are obvious, diagnosis of the primary pathology is easy, and the management is prompt. In absence of a demonstrable predisposing cause (unprovoked DVT), extensive work-up is necessary for diagnosis of the primary pathology. In spite of the extensive investigations, some cases may still elude diagnosis and remain classified as idiopathic. In many of these cases, malignancy may be revealed at a later date, and at an advanced stage. Diagnostic delay may also occur if provoking factors of DVT coexist with an occult malignancy. A strong clinical suspicion is important for its timely management.

Case Presentation

A 45-year-old traffic policeman presented with pain and swelling in his left lower limb associated with a mild fever for the last 7 days. He reported having similar swelling of the contralateral limb one year back, which had subsided with expectant treatment and bed rest. There was no history of dyspepsia, hematemesis/melena, hematochezia, irregular bowel or bladder habits, or loss of appetite or weight. His job involved long hours of standing (7-8 hours per day at a stretch), and he denied any history of hypertension, diabetes, alcohol intake, drug or tobacco consumption, or any history of surgery. There was also no history of such complaints in any member of his family. Examination revealed pallor, mild fever, a BMI of 32.3, and a diffusely swollen left lower limb. The rest of the general examination was unremarkable. The lower limb was diffusely swollen, mild ankle edema was present, and the skin of the lower limb was warm, stretched, shiny, and showed evidence of blanching. There was no evidence of varicose veins, scars of healed ulcers, or petechiae and ecchymoses. Calf tenderness was absent and inguinal lymph nodes were not enlarged. The contralateral limb was apparently normal. Examinations of the abdomen, external genitalia, hernial sites, and rectum were unremarkable. A duplex ultrasound scan was ordered, which showed an acute thrombus in the[s2If !is_user_logged_in()]…

[/s2If][s2If is_user_logged_in()] left femoral vein extending into the external iliac vein. The tests for thrombophilia (anti-thrombin III, cardiolipin antibody, factor V Leiden, protein C and S, and homocysteinemia) were negative. However, he did have microcytic, hypochromic anemia (Hb = 7.2 g/dl), a low total RBC count (2.71 million/mm3), low mean corpuscular volume (62.3 fL) and mean corpuscular Hb (16.2 pg), a reversed albumin/globulin ratio (2.6/5.4), a raised platelet count (569,000/mm3), and a high serum alkaline phosphatase level (416 IU/dl).

Differential Diagnosis

  • Cellulitis of the left lower limb
  • Filarial lymphangitis of left leg

Treatment

Figure-1-DVT-with-caecal-cancer-redThe patient was advised absolute bed rest and was started on daily subcutaneous injections of low-molecular-weight heparin (enoxaparin 1 mg/kg). A work-up was done for the cause of the unexplained anemia. The gastroduodenoscopy, X-ray of the chest, and prostatic evaluation (sonological and biochemical) were unremarkable. A contrast CT scan of the abdomen finally revealed a focal endophytic mass lesion in the cecum with eccentric thickening of the cecal wall (See Figure 1). There was no evidence of ascites, lymph node involvement, or hepatic secondaries. A colonoscopic biopsy and histopathological examination confirmed adenocarcinoma. Abdominal exploration showed a tumor (6×4 cm) in the cecum. A formal right hemicolectomy with lymph node clearance was done. The histopathological examination showed a well-differentiated adenocarcinoma with pericolonic lymph nodal spread.

Outcome and Follow Up

The patient had an uneventful postoperative period. After three years of follow-up, he has been disease-free and healthy.

Discussion

In cases of acute DVT, physicians usually search for a provoking cause like pregnancy, immobility, major trauma, surgery, or sepsis, as these have a better long-term prognosis with very low incidence of recurrence [1]. When no apparent cause is found, it is labeled as idiopathic or unprovoked. In cases of unprovoked DVT, malignancy should be considered as an underlying etiology [2], since the incidence of cancers in these cases is over four times higher than that in cases of provoked DVT [3], and 40% of these cancers are metastatic at diagnosis [4]. Although it is not clear what percentage of patients with unprovoked DVT actually harbors an occult malignancy, several studies report that about 7-12% of cases presenting with DVT are later diagnosed as having an underlying cancer [3, 5]. Whatever is the cause, once developed, DVT produces both acute and long-term morbidity, as well as life-threatening complications. In the presence of a provoking factor, a coexistent occult malignancy is usually missed. Our patient was obese, and his profession involved long hours of standing, which was initially thought to be risk factors for the present episode of DVT, since there was no history to suggest any cause, and tests of thrombophilia were negative. In the past episode of DVT, the underlying cancer was probably not considered and hence was missed. It has been suggested that intensive screening be used in patients with DVT in order to most effectively detect cancers that are otherwise difficult to diagnose [6]. However, in the absence of clinical features suggestive of a specific malignancy, it is not cost-effective to extensively investigate all cases of provoked DVT for an occult malignancy that could be anywhere in the body. Moreover, as DVT is a more common manifestation of an underlying hematological malignancy (leukemias, lymphomas) and solid organ cancers (pancreas, kidney, ovary, prostate) [7, 8, 9], an occult primary cancer of the cecum may not be considered, especially in the absence of gastrointestinal symptoms. Surprisingly, in the present case, it was the search for the cause of unexplained anemia in an otherwise well-preserved patient, which led to the diagnosis of the primary cause.

In conclusion, when provoking factors of DVT are present, a coexistent subclinical cancer may be easily missed. We suggest that caution be exercised in the event of recurrent DVT, DVT with unexplained anemia, or DVT that fails to respond to treatment [10]. In these cases, the probability of finding an occult malignancy is high, and an extensive work-up is justified to prevent delay in management of a more ominous primary pathology.

Key Point

  • Deep vein thrombosis (DVT) is a serious condition
  • A DVT case should be extensively investigated, including tests of thrombophilia to ascertain the primary cause
  • If no apparent cause is found, presence of an occult malignancy should be considered
  • DVT cases that are recurrent, associated with anemia, and nonresponsive to treatment should be taken seriously for the probable presence of an occult malignancy, whether hematological, of solid organ, or of hollow viscus.

About The Author

Som BasuDr. Somprakas Basu, MBBS, MS, FAIS, FICS, FACS, FACRSI is currently an Associate Professor of General Surgery, Institute of Medical Sciences, Banaras Hindu University. A general surgeon with special interest in colorectal surgery, hernia surgery and wound healing research and interested and currently involved in research in colonic ischemia in septic peritonitis and its prevention, biofilms and its management, bio-marker for rectal cancers.

 

References (click to show/hide)

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  2. White RH. The epidemiology of venous thromboembolism. Circulation 2003;107:14-8.
  3. Hettiarachchi RJ, Lok J, Prins MH, Buller HR, Prandoni P. Undiagnosed malignancy in patients with deep vein thrombosis: incidence, risk indicators and diagnosis. Cancer 1998;83:180-5.
  4. Sorensen HT, Mellemkjaer L, Steffensen FH, Olsen JH, Nielsen GL. The risk of a diagnosis of cancer after primary deep venous thrombosis or pulmonary embolism. N Engl J Med 1998;338:1169-73.
  5. Cornuz J, Pearson SD, Creager MA, Cook EF, Goldman L. Importance of findings on the initial evaluation for cancer in patients with symptomatic idiopathic deep venous thrombosis. Ann Intern Med 1996;125:785-93.
  6. Monreal M, Lensing AW, Prins MH, et al. Screening for occult cancer in patients with acute deep vein thrombosis or pulmonary embolism. J Thromb Haemost 2004;2:876-81.
  7. Ziegler S, Sperr WR, Knobl P, et al. Symptomatic venous thromboembolism in acute leukemia: incidence, risk factors, and impact on prognosis. Thromb Res 2005;115:59-64.
  8. Khorana AA, Fine RL. Pancreatic cancer and thromboembolic disease. Lancet Oncol 2004;5:655-63.
  9. Lee AY, Levine MN. Venous thromboembolism and cancer: risks and outcomes. Circulation 2003;107:I17-I21.
  10. LaPorte D, Farber S, Sorin S, et al. When deep venous thrombosis fails to respond to therapy. J Am Board Fam Pract 2003;16:246-50.


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One Comment

  1. Dr. Valluri Ramarao
    Posted Jul 2014 at 2:41 pm | Permalink

    Yes,nice to search for malignancy.good d/d work up.useful tip.

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