Diagnosing pulmonary embolism: experience with spiral CT pulmonary angiography in gynecologic oncology.

OBJECTIVES: To review our experience with the diagnosis and prognosis of pulmonary embolism (PE) in gynecologic oncology patients. METHODS: Spiral CT pulmonary angiography (CTPA) studies on gynecologic oncology patients were collected from our radiology database from 6/2001 to 6/2003. Patient charts were retrospectively reviewed. Data were abstracted relative to presenting symptoms, demographics and laboratory and diagnostic evaluations. Patient data were compared using chi-square contingency tables and logistic regression analysis. Survival was studied using the Kaplan-Meier method and the log rank test. The effect of PE on survival was adjusted using a proportional hazards regression model. RESULTS: One-hundred and eleven CTPA studies were performed over 2 years and 25 patients were diagnosed with PE. Both PE (n = 25) and non-PE (n = 86) groups were similar for age, race, BMI and cancer diagnosis. Tachycardia (P = 0.02, OR = 3.03 [95% CI 1.16-7.94]) and leukocytosis (P = 0.04, OR = 2.93[95% CI 1.05-8.18]) were more frequent among PE patients and confirmed as independently prognostic of PE. All other clinical and laboratory findings were similar between patients with and without PE. Overall survival for patients with and without PE was 63% versus 94%, respectively, at 2 years (P = 0.02). CONCLUSION: In a gynecologic oncology patient with high clinical suspicion for PE, our clinical pre-test probability was 23.0%. Two-year mortality rates were 6-fold higher for patients diagnosed with PE. The significant overlap in clinical presentations, multiple risk factors and higher mortality rates encourage the aggressive diagnosis and treatment of PE among this population. Further work is needed to reduce the incidence and mortality rate of PE

The Incidence of Pulmonary Embolism after Gynecologic Oncologic Surgery.

5089 Background: Pulmonary embolism is a major morbidity following surgery for malignancy. The purpose of this study was to determine the risk of developing a pulmonary embolism in patients having major abdominal surgery during the peri and post-operative period (6 weeks) and to compare cancer and benign subgroups. Methods: The H. Lee Moffitt Cancer Center database was reviewed retrospectively to identify gynecologic oncology patients who had surgery between July 2001-June 2003. These patients were sorted by major or minor procedure, and further by malignant versus benign diagnosis. Pulmonary embolism in post-operative patients was determined from the time of surgery through 6 weeks post-operatively. The diagnosis of pulmonary embolism was confirmed by either a CTPA or V/Q scan. All patients received prophylaxis with sequential compression devices (SCD) and early ambulation. Benign and malignant groups were compared with chi square analysis. This study was IRB approved. Results: A total of 1374 patients were identified between July 2001-June 2003. Chart review identified 1009 major cases and 365 minors. Of the 1009 major surgical cases 836 were exploratory laparotomies with 523 cancer cases and 313 benign cases. In patient with a diagnosis of cancer, 23/523 (4.4%) were diagnosed with pulmonary embolism. In patients with a benign diagnosis, 1/313(0.3%) were diagnosed with a pulmonary embolism. The difference between those with and without cancer was determined to be significant. (p=.0006) Conclusion: We determined the rate of post-operative pulmonary embolism in patients with cancer who have major abdominal surgery to be 4.4%. This rate persisted despite vigorous use of SCD’s and early ambulation. Preventative measures are needed in this subgroup of patients to attempt to decrease this high rate of post-operative pulmonary embolism

Pulmonary embolism after major abdominal surgery in gynecologic oncology.

OBJECTIVE: To estimate the incidence and prognostic significance of postoperative pulmonary embolism after gynecologic oncology surgery. METHODS: All patients who underwent gynecologic oncology surgery from June 2001 to June 2003 and received venous thromboembolism prophylaxis with only intermittent pneumatic compression and early ambulation were identified from our database. Patients were grouped by procedure (major/minor abdominal or nonabdominal surgery), diagnosis (malignant/nonmalignant), and cancer subtype. Groups were compared by chi2 analysis and logistic regression. Survival was studied with the Kaplan-Meier method and Mantel-Byar test. RESULTS: A total of 1,373 surgical patients were identified over the 2-year period, including 839 major abdominal surgery cases and 534 minor abdominal surgery or nonabdominal surgery cases. Of the 839 patients, 507 had a diagnosis of cancer, and 332 were benign. The incidence of pulmonary embolism among cancer patients undergoing major abdominal surgery was 4.1% (21/507) compared with 0.3% (1/332) among patients undergoing major abdominal surgery with benign findings (P \u3c .001, odds ratio [OR] 13.8, 95% confidence interval [CI] 1.9-102.1). The incidence of pulmonary embolism among patients undergoing minor/nonabdominal surgery was 0.4% (2/536). Cancer diagnosis and age more than 60 years were identified as risk factors for pulmonary embolism (P = .009, OR 0.31, 95% CI 0.13-0.74). One-year survival for patients with and those without pulmonary embolism were 48.0% +/- 12% and 77.0% +/- 2%, respectively. CONCLUSION: Patients with cancer undergoing major abdominal surgery and using pneumatic compression for thromboembolic prophylaxis had a 14-fold greater odds of developing a pulmonary embolism compared with patients with benign disease. Randomized studies are needed to determine whether additional prophylactic measures may benefit this high-risk group of patients. LEVEL OF EVIDENCE: II-3