Venous Ultrasound in the Oncology Patient - HD

Introduction

My name is Don DeSalvo.
I'm a radiologist.
I work at the Dana-Farber Cancer Institute in Boston.
And I'll be talking to you today about venous ultrasound in the oncology patient.

Hello, I'm gonna be talking to you about venous ultrasound in the oncology patient.
My name is Don de Salvo.
I have no financial disclosures,
but I will make the disclaimer that my practice
is exclusively in outpatient oncology setting.
And some of the comments and
recommendations I may be making may be not applicable
to all patient populations, but I will try
and make those differences apparent as we go along.

Outline of Presentation

So the overall outline here,
we're gonna be looking at venous ultrasound uses in
oncology, and I'm gonna take a case-based approach.
We'll concentrate on peripheral extremity thrombosis, issues
and veins, and we'll first look at catheter related
clot, isolated cath thrombosis.
The importance of waveforms
for diagnosing central lesions,
and what I think is an interesting problem
of rule low and slow flow.
I'll then look at some examples of
how ultrasound can be used as a problem solving tool for,
questions that are raised
by more sophisticated techniques such as CT and MRI.
And finally, other things to think about when the
requisition says rule out deep venous thrombosis
and you don't think you're seeing a thrombus.

Oncology as the Perfect Storm for Venous Thromboembolic Disease

So I like to think of oncology as sort of the perfect storm
for talking about venous thromboembolic disease.
And that's because we interact at all three points
of the classic Virchow's triad.
Beginning with endothelial injury,
there's the presence of central venous catheters
that can injure the endothelium.
Chemotherapy, radiation,
all can have direct effects on the endothelium.
It's well known that there is procoagulant activation
by tumor cells or by the chemotherapy agents themselves.
And for the stasis issue,
we can have sometimes vascular compression by tumor masses.
In addition, frequently these patients are quite debilitated
and immobile and that could also promote stasis.

Historical Context and Statistics on Cancer and Venous Thrombosis

I think the relationship between cancer
and venous thrombosis has been known
for quite some time, and Trousseau in 1865 first made the connection
that now bears his name as Trousseau's syndrome,
and that was unexplained migratory thrombophlebitis frequently subsequently found out to be caused
by an unsuspected visceral malignancy.
And I think we can clearly state by lots of data
that have occurred since then that roughly 10%
of so-called idiopathic venous thrombosis will turn out
to have as its cause occult cancer.
And certainly unsuspected pulmonary emboli are twice
as common in the cancer patients
as in the general population.
And I think this second observation is really only apparent
with the use of more sophisticated techniques such
as CT angiograms.
And also I want to touch a little bit subsequently on
what the relationship is between,
so the newer targeted chemotherapy agents
and venous thrombosis.

Mechanisms of Thrombosis in Cancer

This slide here shows a
diagram taken from a New England Journal review
article about mechanisms of thrombosis in cancer.
And we can see that there are multiple entry
points into the problem.
If we just look at chemotherapy in the upper left hand
corner of the slide, we see that it can either directly cause endothelial disruption
or via the intermediary interleukins
and tumor necrosis factors.
If we then look at malignant cells or the activated modified
monocytes
or macrophages, we can see that any of these can
interact with the complicated clotting cascade that we see.
And so the interrelationship
between all these factors sometimes makes it very difficult
to tease out what the relative contributions of each may be.

Case 1: 78-Year-Old Man with Leg Swelling and Pulmonary Emboli

I like to start out with this opening case
because I think it nicely illustrates some of the themes
that we'll be talking about subsequently. This was a 78-year-old man
with atherosclerotic coronary vascular disease.
He presented to the emergency department
with new right leg swelling,
and 15 days prior to this,
he had undergone cardiac catheterization and stent.
So a lower extremity venous ultrasound was performed.
And here we see tracings coming from the right
common femoral vein.
And this vein had abundant flow
was fully compressible,
and I didn't show, I'm not showing you all the rest of it,
but it was similar all the way down the leg.
So this was assumed to be a normal exam.
The patient was sent home
and in three days he came back with new dyspnea
and chest pain, and the subsequent CT pulmonary angiogram
showed the reason why he has bilateral pulmonary emboli.
Looking down in the pelvis, we can see
that there's a thrombosis of his right external iliac vein.
And then the final surprise was of this unsuspected cystic
and solid mass in his anterior mediastinum.
This led to a workup with PET CT
and we see that this was clearly a PET avid lesion.
The patient subsequently underwent a thoracotomy,
and this was excised and this was thymic carcinoma.
I think this case teaches two important points.
One is of the asymmetric loss of peripheral pulsatility
as an indirect sign of proximal pelvic thrombus.
And secondly, the unsuspected underlying tumor
as a so-called etiology for thromboembolism.

Case 2: Patient on Avastin Therapy with Asymptomatic PE

This next case is actually much more illustrative
of the typical patient we see at the Dana-Farber.
This is a patient being treated
with metastatic adenocarcinoma of unknown primary,
and he is undergoing a restaging examination.
He's on ongoing Avastin therapy, he's having excellent tumor
response, and the patient is completely asymptomatic,
and this is a routine restaging and what do we see?
But actually a right lower lobe pulmonary embolus on this
coronal image to the left
and a little ground glass opacity on the lung windows,
likely indicating a lower lobe infarct.
The rest of his scan was also remarkable
for a filling defect in his left common iliac vein
consistent with thrombus.
So when we see this we need to go into high overdrive,
we say, call up the docs.
Okay, we've got a PE, we've got infarct
and lower extremity venous thrombosis.
My god, what do we do? And this would get the oncologist
excited and they would say, okay,
we stopped the chemotherapy.
We treat this until it resolves.
And so I think this gets to the whole issue.
Well, what is the relationship between chemotherapy
and venous thrombosis?

Chemotherapy and Venous Thrombosis

Now, the conventional chemo,
or a so-called cytotoxic chemo, has agents
that directly interfere with DNA replication.
These are alkylating agents anti-metabolites,
and these are known to have direct endothelial injury,
and that's the likely mechanism
for why these are the increased incidents.
However, if we look at the newer so-called molecular
targeted chemotherapies,
these are actually acting against cell surface receptors,
VEGF receptors, tyrosine kinase receptors.
And these blockages of these receptors leads
to changes in the intracellular pathway,
which disrupts the mechanisms
that are needed for tumor growth.
But then the next question is, well,
do these targeted chemotherapies increased venous
thrombosis relative to conventional?
And I think this is an example of a gradual learning curve
because the early case report said yes emphatically,
and when they looked at bevacizumab
or Avastin plus chemo in one group of patients
who were being treated for colorectal carcinoma
and compared it to those with conventional,
you had a higher rate.
And this was 23%.
But the mechanism
of this so-called increased venous
thrombosis is really not known.
And what happened ultimately is
that the oncologist would have this treatment dilemma.
The tumor is shrinking, it's beating RECIST criteria
for response, and yet we have venous thrombosis
on these restaging studies.
What do we do? And I think finally now,
and here actually, as an example of such a case, so this two images through the liver,
the upper clearly this patient who's being treated,
who has breast cancer with mets to the liver being treated
with Taxol Avastin, these lesions are shrinking.
The patient is responding.
However, on this same follow up on the chest portion
of this follow-up study,
we see a left lower lobe pulmonary embolus.
So what do we do?
And I think this is emblematic
of the dilemma that clinicians were faced.
And I think now what I wanna leave you
with is the thought is vascular toxicity
or so-called toxicity, perhaps a biomarker
for treatment response?
I think if we look at the example
of graft versus host disease,
post stem cell transplantation, we see a perfect model
that yes, we wanna see this so-called graft versus host
disease that tells us that the stem cell transplant has
worked and that hopefully will be then active against the
patient's leukemia lymphoma.
And I just put these other two articles,
both presumably related to adverse events, hypertension,
or with pneumonitis.
And both of these are occurring in groups of patients
who are showing a positive response.
And so I think we're still on this learning curve,
but certainly for now, the response is yes,
the oncologists want to know about the thrombi
and the emboli that we see,
but if the patient's responding, they'll simply treat
with low molecular weight heparin, and
because the chemotherapy seems to be working
and in fact what we may be seeing is increased tumor cell
destruction, more tissue necrosis factor as the cause
for the thrombosis, which is really not the effect directly
of the Avastin.

Case 3: Pancreatic Cancer with Neck Swelling (Internal Jugular Vein Thrombosis)

Okay, let's turn to our first case dealing now
with a more conventional peripheral disease.
This is a patient with pancreatic cancer
who has new right neck swelling.
And if we look at this clip through the right
just internal jugular vein, we see a nice slow flow.
We see echogenic material slowly moving in a normal
direction, at least in this vein going from head to toe.
We come to this sinus where we see these venous valves,
which are barely moving
and posterior to the backside of valve.
We see increased echogenicity
that is actually not moving at all.
If we then do our compression, we see
that this part does not compress.
And this is actually acute internal
jugular venous thrombosis.
And I think it beautifully illustrates the
evolution of this process.
The clot initially attaches
to valves located at the venous sinuses,
and they're typically found in the distal IJV
and the proximal subclavian.
And the altered flow within the sinus leads to stasis.
And what I think is not often mentioned is
that hyperacute clot may actually be echogenic not the sort
of hypoechoic
or anechoic that we typically expect to see.
And this can actually mimic these
slowly moving echoes.
But the key difference is that this is not compressible.
A secondary sign is that those valves are barely moving
and so-called frozen valves.
And we can click again, we can see that here on this
back image where this valve is barely moving.
So this then needs treatment.

Case 4: Lymphoma with Arm Swelling and Central Line (Upper Extremity DVT)

This next case also gets at the issue
of upper extremity DVT,
but this patient had lymphoma, right arm swelling
and a central line was inserted one month ago.
And on this motion clip, we can see the central catheter
at the junction between the axillary
and subclavian vein
and where the cephalic vein is also joining.
And we can see that there's extensive clot all along this
and extending into the proximal subclavian.
This is acute left axillary vein thrombosis
and it's related to her subclavian catheter.
And this again
would definitely require anticoagulation therapy.
Whether or not the catheter can stay in,
I think depends upon how badly it's needed,
but also catheter removal would be considered.

Statistics on Upper Extremity Deep Venous Thrombosis

So the idea of upper extremity deep venous thrombosis,
so it used to be a considerably rare
diagnosis relative to lower extremity.
However, the prevalence is now clearly increased
between 18 and 47%.
And it's largely due to the presence
of central venous lines.
And if we look at the population of those with DVT,
between 28 and 61% have a central line.
If you look conversely at everybody
with central venous lines, either easily 12 to 23% go on
to get deep thrombosis.
And the subsequent pulmonary embolism risk is considerable
between 13 and 17%.

Study on Catheter-Associated Venous Thrombosis

So the issue of catheter associated venous thrombosis was
nicely studied by this group from Memorial Sloan Kettering.
They looked at 573 consecutive upper extremity sonograms
over a 26 month period, all referred
because of suspicions of thrombosis.
The thrombosis prevalence in this group was quite
high, 40%.
And when they looked at those with
or without central venous line, twice
as many had central venous lines in this group.
The age, sex,
and cancer type were not correlated with the risk
of deep venous thrombosis.
And the risk of subsequent pulmonary embolism from the
thrombus was between eight and 14%.

Lower Extremity Deep Venous Thrombosis: Calf Veins Debate

We'll now move on to a consideration
of lower extremity issues.
And this is a 50-year-old woman with multiple myeloma
undergoing thalidomide chemotherapy and new calf swelling.
And when we hear those words, myeloma
and thalidomide, our antenna go up
because those are both separate risk factors for thrombosis.
And if we look at this compression clip
of the left calf, we can see beautiful compression
of the more superficially located posterior tibs.
But the peroneal veins don't compress at all.
And I always like to confirm this with a coronal view.
And here on this coronal view, we can see non-compressible,
distended peroneal veins
and the intervening peroneal artery.
So this gets to the issue of do we look at calf veins
and do we treat calf venous thrombosis?
And I've sort of lined up the yeses and the nos.
The yes on the left hand side,
the no on the right hand side,
and amongst the YES group, it is part
of the Intersocietal Commission
for Accreditation of Vascular Labs.
It's part of their accreditation protocol.
The belief in this group is
that deep venous thrombosis is systemic disease,
which begins in the calf distal deep venous thrombosis is
actually more common and distal deep venous thrombosis may
actually have a worse prognosis.
And we'll see that on the next slide.
And the American College of Chest Physicians now recommends
treating this on the disagreement or the no side.
We should note that the AIUM protocol does not specifically
include the calf veins in their imaging protocol.
However, they importantly say
that if there are symptoms related to the calf,
and if there's high risk groups, namely those with cancer
positive D dimer or history of venous thrombosis,
then you should extend the exam.
But the thinking in this group of people is
that it's the central thrombi
that produce symptomatic pulmonary emboli,
rather the central thrombi, not the peripheral thrombi
that produce symptomatic PEs.
And so if you have any questions,
just have the patient come back again for a repeat study.
There's extra time needed,
although I think those of us that do this now recognize
that like anything else, if you do them enough,
it really doesn't take that much extra time.
But I think if we look at the data from this next study
that I'm gonna cite, I think hopefully I'll convince those
of you that maybe don't routinely look at calf veins
to reconsider your position.
This was an interesting study of roughly 1900 patients
with lower extremity deep venous thrombosis,
some of whom went on to PE.
It was over a five year period from a single
university hospital in Grenoble.
And this was not a cancer hospital.
They did a complete leg ultrasound
and then chest CT as indicated,
and there were roughly almost equal amounts of distal DVT,
meaning just in the calf compared to the proximal group.
Pulmonary emboli rates were quite high, 39%.
But interestingly, they followed these groups
for two years looking at mortality, recurrence
of deep venous thrombosis and subsequent malignancy risk.
They divided them into four groups, the distal DVT
or the calf group, unilateral and bilateral,
and the proximal DVT unilateral bilateral.
And interestingly, the bilateral
calf DVT group compared
to the proximal had the same two year mortality,
which was quite high, 67 to 72%.
They had the same recurrence risk for DVT,
and actually their malignancy rate was slightly higher.
So I think these are three compelling reasons to think
that we should be routinely looking at calf veins when
patients are referred for a venous ultrasound.
And I hope this may convince some of you to do it.

Case 5: Myelodysplastic Syndrome with Arm Swelling (Waveform Analysis)

Or this next case, we will move back into the upper extremity.
This is a woman with myelodysplastic syndrome.
She'd had a bone marrow transplant.
She came in having complaints
of right arm swelling for two days.
Now this patient had had a Hickman catheter inserted one
month ago and then subsequently removed.
So unlike our opening case
or actually our second case, the catheter is now out.
And if nothing else, I think we learn.
And so here I'm gonna, unlike that opening case,
I'm gonna show you a very flat right subclavian vein
tracing, and it's the opposite side showing normal
pulsatility.
So this was a very concerning,
this is so-called monophasic tracing.
And when we say monophasic,
we don't mean monophasic in the sense of
what the arterial tracings are.
This is just a completely flat tracing with no variability.
If we carry it more proximally, we again see
that this is a very flat monophasic tracing.
And if we're able to get a small face transducer
and look at the right brachiocephalic vein, what do we see
markedly increased velocity and very high flow rates.
And this image has lots of aliasing,
but if we up our pulse repetition frequency as we do here,
we can then see what's really happening.
And here we have a rather tight stenosis, we see evidence
of thrombus formation
and these frozen valves again, right at this point
of presumed catheter induced deep venous thrombosis,
which is now in its possibly its evolution phase,
but on the basis of this symptoms this woman
has, this needs to be treated.
So what this is then partially occlusive thrombus,
and it shows us, again, as the opening case did,
the importance of waveform analysis as indirect evidence
for disease that's more proximal
to the catheter that we're looking at.
And so if we have our probe in the subclavian vein,
we wanna look at what's happening between it and the heart.
And that's what frequently the area that we can't see.
And it's especially critical when we're looking at upper
extremity deep venous thrombosis
because subclavian veins are just not compressible.
And even if there's a unilateral exam, we have
to look at both proximal vessels
and loss of symmetry is the best predictor for subsequent
stenosis
or occlusion in the part of the vein that we can't see
between where we are and the heart.

Waveform Analysis in Venous Ultrasound

So just briefly review, what are the two types of
waveform analysis we look at?
There's both.
There are some that are related to spontaneous with normal respiration,
and these include phasicity, which consists
of respiratory variation.
As we take in a breath, the intrathoracic pressure falls
and the flow rate increases into the thoracic space
with expiration, the reverse happens.
And pulsatility is a direct reflection
of the cardiac events in the right atrium.
And both of these assess for what we call upstream patency
or patency between where we are in the heart.
Second thing we do is response to maneuvers.
And I'm always impressed how most residents always know about the distal maneuvers,
namely augmentation, looking for
how are things distal to where we're looking.
However, proximal information is just as important.
And typically what we'll do here is Valsalva
or sniff maneuvers looking for decreases in flow in patients in veins that are completely open
between where we are and the right heart.
And so here are just normal diagrams
of these two phenomenon.
The respiratory phasicity note takes place over multiple cycles,
but gradually we're seeing increase in flow and inspiration
and then diminution in expiration, whereas the beat
to beat variability gets at the cardiac events
on the right side of the heart.
And note that in the proximal subclavian vein,
these are more exaggerated
and typically they will diminish as we get further away from the heart.
A more distally, and this is an expected finding.
So asymmetry of waveforms, it's important
to compare the most proximal waveforms,
whether you're dealing with arms or legs for symmetry.
And loss of one component of either phasicity
or pulsatility is of questionable significance.
But both components absent is significant.
And here we have to think about either extrinsic compression
from nodal disease or an intrinsic process such
as thrombosis or stenosis
as we just saw in the case we looked at.
And if we have symmetric dampening at the most proximal
vessels that we're looking at, then we have
to think even more centrally whether there's extrinsic
or intrinsic disease in either the superior
or inferior vena cava.

Case 6: Ovarian Cancer with Leg Swelling (Extrinsic Compression)

So this next case gets at the lower extremities
and extrinsic compression.
This is a 54-year-old woman
with metastatic ovarian cancer.
She has new left leg swelling.
If we look at the left common femoral vein tracing,
not too bad, maybe a little bit flatness,
but when we compare it to the other side,
it's definitely flattened.
So this means that we have
to think about something more proximal.
And if we carry the examination up into the pelvis,
we can clearly see there is a nodal mass sitting right here
in the left obturator region.
Here we have some ascites in a compressed bladder
if we take a tracing right at this point,
we again see a extremely flat tracing in the left
external iliac vein.
And the CT confirms the findings that yes,
we have a large left obturator nodal mass leading to the flat tracing.
And so again, we have the explanation.

Study on Monophasic Waveforms

So just then as a review, the monophasic waveform
in the common femoral vein, a nice study that came out
of the University of Alabama was a retrospective review over
a five year period of almost 3000 patients.
And in that group they identified 124 monophasic common
femoral vein waveforms.
They found almost 40% were due to iliac
deep venous thrombosis.
Another 21% were due to extrinsic compression, either due
to pregnancy, lymph nodes, hematoma.
This was not exclusively a cancer group
and there was iliac stenosis or hypoplasia,
and about 5% in a full 36%, they never found a cause.
So unfortunately,
we may not always know why it's monophasic,
but at least I think this study again shows
that it's important to extend the examination approximately
through whatever means you have either with ultrasound
or with another imaging technique.
Typically CT would be suggested.

Case 7: Colorectal Cancer with Leg Swelling (Roulea Phenomenon)

All right, this next case deals with a gentleman
with metastatic colorectal cancer presenting
with new right leg swelling.
And if we look at this tracing from the popliteal fossa,
we see beautiful pulsatility in the popliteal artery.
But there are slowly swirling echogenic foci within the vein.
If we do a compression,
we can see this is completely compressible.
Unlike that case we saw of internal jugular vein hyperacute clot.
So there's no clot here.
If we look at this in the sagittal plane, we clearly see
that yes, most of the flow is directed towards the head
as we expect, but there's actual columning and
actually reversal of flow for short periods
of time in the cardiac cycle.
So what do we do with this? This is red cell echogenicity
or the rouleau phenomenon.
This has been well known for many years.
A beautiful study back in 1983 in the in vitro setting
proved that this was a marker
of red cell aggregate formation.
It's not due to individual cells or microbubbles.
And they found in multiple settings that this was always due
to low shear rates, which in turn was related
to low velocity and we meant low by zero
to two centimeters per second.
Now these investigators recommended
that in the in vitro setting, elevated hematocrit
or elevated serum proteins
or macromolecules might play a factor,
but they conclusively show
that the predominant effect was due to low velocity.
So then these rouleau are specular echoes
that should be in the normally anechoic vessels.
They compress. Normally we can see motion with real time,
but what is their exact significance?
It's a little uncertain. Certainly we see this in slow flow
states or frank reflux.
It is said to be related to hypercoagulable states,
but what is its actual risk for thrombosis?
I think we really don't have good studies on this,
but at least in our patient population,
because they are already high risk,
I specifically state this in the report
and say there are increased rouleau formation,
strongly suggestive of slow flow
and close interval follow up, particularly with change
of symptoms is recommended.
And in this particular case, lo
and behold, one week later there was a pulmonary embolus,
this patient had not been treated.

Ultrasound as a Problem-Solving Tool for CT and MRI

Alright, next to turn to some examples of ultrasound
as a problem solving tool for other modalities.
And with CT we get lots of referrals
for filling defects.
Is this thrombus or pseudothrombus?
And we'll also get referrals from MRI
for incidental findings.
Most commonly we see it with breast MRI
because of the incidental what I call UFOs
or unexplained bright objects that are seen on that study.

Cases of Filling Defects on CT: Pseudothrombus vs. True Thrombus

So this case I'm gonna show you for the CT two examples,
patients both with lymphoma undergoing chemotherapy.
And here in this image through the lower pelvis,
we see a filling defect in the right common femoral vein,
highly suggestive of thrombus.
However, if we look at the coronal projection, we can see
that this filling defect is actually somewhat elongated.
It's sitting exactly in the center of the vein,
which we'll see can be important clues as to the nature.
Also note there are multiple lymph nodes all around, both iliac vessels consistent
with his known diagnosis of lymphoma.
The second patient, same exact story,
lymphoma under treatment.
And we see at the junction of the internal jugular
and the subclavian veins a rounded filling defect,
which is actually eccentric
and closely adherent to the wall.
So if we turn back to the first case
and we look again at that coronal view, we show
that this is elongated,
but there's a second important clue
that we're just coming into,
which is the greater saphenous vein.
And if we move just one click further anteriorly in the coronal plane,
we can actually see that at the point of junction is
where this low intensity or
apparent filling defect seems to start.
And again, here are all the nodes.
This patient came to ultrasound because of a suspicion.
And we can see on this static image we have the greater
saphenous vein coming in right at its junction
with the common femoral vein.
And here is one of those nodes sitting right next to it.
And there is an apparent area of lack
of flow right at the junction.
But if we drop our velocity scale
or use simple augmentation maneuvers,
we see this area completely fills out.
And this is an area of just of slow flow.
So that first case is actually a pseudothrombus.
It's a flow artifact due to differential mixing either
of opacified or unopacified blood in the case of CT
or due to altered flow dynamics right at the junction
where there's commonly slow flow.
And we typically will see these at the junction of vessels.
And one of the clues at least on CT, is the elongated shape
and it's very central location.
By contrast, case six B was a true thrombus.
And there we recognize important features at least on CT,
are the irregular edges and its expansile nature
and the fact that it's eccentrically placed related
to a mural or edge of the wall or near a venous valve.
And here is the accompanying ultrasound on this case
and clearly was a thrombus sitting right on the valve at the
junction between the internal jugular vein and subclavian.

Case from Breast MRI: Superficial Venous Aneurysm

Next an example of a referral from a patient
who had underwent a breast MRI a high risk patient.
This patient had a chest MRI for evaluation
of brachial plexus involvement
and a separate question of a possible left
axillary node was raised.
And here is that coronal MRI T2 weighted post contrast.
And we can see that this apparently enhancing
oblong soft tissue structure is right in the epitrochlear fossa.
Sent her an ultrasound
and we were surprised we were expecting to see a node too,
but actually we could see that there was low,
very slow flow coming from exactly at this point
and there was a connection to a superficial brachial vein.
And with an augmentation maneuver we can see
that this beautifully expanded
and this is merely a forearm superficial venous aneurysm.

Alternative Diagnoses When Not DVT

Okay, what if it's not DVT?
So we'll conclude by looking at some examples
of other things we may see when the suspicion,
clinical suspicion is a DVT either looking at
separate neoplasms or chemotherapy effects.

Case: Melanoma Recurrence Mimicking Swelling

So this next case was a woman with a history
of melanoma of the left heel.
It had been excised several years ago
and there was no evidence of disease
and she presented with new left lower extremity swelling.
Well, during the examination we can see that the veins
and arteries were perfectly fine,
but there was a hypoechoic rounded structure right in the
mid thigh right adjacent to the vessels.
Weren't sure was this cystic solid by dropping
to a lower frequency transducer
and using sensitivity for lower flow such
as power Doppler affords.
As we can see that this is actually an ovoid structure
and there are small, tiny vessels that we can see within it.
This again, raised the suspicion of recurrent disease
and a subsequent PET CT showed
that actually we were just looking
at the tip of the iceberg.
This is the lesion we were seeing,
but the PET CT found many, many more.
And this is an example of melanoma in transit,
a rapid spread of melanoma up the,
from the site of distal to a more proximal nodal disease.

Case: Thigh Swelling Due to Liposarcoma with Venous Invasion

This next case was a man with a sudden right thigh swelling.
There was a question of possibly a focal mass.
This study was done on the outside,
but beautifully shows distension of both the femoral
and deep femoral veins on the right side filled
with echogenic material exactly consistent with acute venous thrombosis.
Patient was subsequently begun on anticoagulation therapy,
but symptoms did not abate.
And one month later this is what he looked like still
with this hugely distended, apparently clot filled veins.
And at this point there was now much more question
of whether there was a mass at this site
that was palpable.
A subsequent MRI here showed,
unfortunately this was a thigh liposarcoma
with venous invasion.
And I think part of the difficulty in making this diagnosis
is that although this we're using color Doppler,
there is no flow that's evident in these clot.
But I think this is where contrast ultrasound will really
help us because it's already been shown in cases
of hepatoma and portal vein thrombosis.
That contrast ultrasound can clearly show malignant portal venous invasion versus bland thrombus.
And I think the same thing will be true in the
peripheral veins as well.

Case: Popliteal Fullness Due to Lymphoma Recurrence

This next patient was a 57-year-old woman
with popliteal fullness and pain.
She had a prior diagnosis
of non-Hodgkin's lymphoma currently in remission.
And when we looked at her from the popliteal fossa,
it looked like there was this very large,
almost completely anechoic mass was this fluid.
This mass was actually large enough
that extended up into the adductor canal.
And when we looked anteriorly
with a lower frequency
transducer, we actually could see this.
No, this was clearly a solid
ovoid mass putting on color show
that this was vascularized coming from the
femoral artery directly feeding this.
And with her past history, this was very worrisome
for recurrent disease and this was proven
by a subsequent PET CT
where we can see a markedly PET avid lesion in the
left popliteal fossa.
And again, there was, this was actually again,
just the tip of the iceberg.
I'm not showing you the rest of the PET CT,
but she had additional sites as well from her recurrence.

Case: Arm Pain and Chest Wall Swelling Due to Myonecrosis (Radiation Recall)

Well, this last case was a patient
with Hodgkin's disease.
He came in with new left arm pain and chest wall swelling.
He was undergoing chemotherapy
for unfortunately a recurrent disease.
He had initially been treated with chemo and radiation
and undergone stem cell transplantation.
And the most recent relapse was being treated
with gemcitabine.
When we looked at him, his vein
and artery looked fine in his upper extremity.
But when we scan over the area of extensive pain,
which was his pectoralis, we could see
that there was marked abnormality throughout his
entire pectoralis.
We were losing the normal fibrillar texture.
This muscle was greatly expanded
and abnormally echogenic when we looked and did comparisons between the right and left side.
The both sides were actually abnormal appearing
with absence of the normal fibrillary texture
and they were also unusually vascular,
but the left side clearly more than the right.
Well, this raised lots of concern that he had unfortunately
yet another recurrence this time to the muscles.
He went on to a biopsy
and surprisingly, this was myonecrosis.
And this is a phenomenon that is actually quite well known
to the oncology colleagues,
but I think not well known to us,
gemcitabine is a nucleoside analog.
It enhances radiation effects.
And radiation recall is when there's a short interval
between radiation and subsequent cytotoxic chemotherapy.
The skin is the most commonly affected
and it typically causes a dermatitis.
But anything deeper that was in the radiation field,
including muscle and internal organs can
be affected in this case.
In this unfortunate gentleman, it was the myonecrosis
that predominated diagnosis is important
because it requires withdrawal
of the chemotherapy in institution
of anti-inflammatory drugs.

Summary

So in summary, I'd like to say
that we've looked at the relationship between cancer
and venous thrombosis
and how cancer augments it either
through its underlying procoagulant activities
or through the treatment chemotherapy, central venous lines.
And I hope I've at least opened the door about the issue
of targeted chemotherapy and whether
or not this really is an adverse effect,
but actually maybe telling us that we've got actually
a positive response.
We've looked at calf deep venous thrombosis
and realized this should be part of protocols, especially
for high risk groups and should be treated.
We've shown the importance of careful attention
to Doppler waveforms
for central vein thrombosis or compression.
We've seen examples of
how sonography can be a problem solving tool for CT and MRI
and we've pointed out some alternative diagnoses
to deep venous thrombosis.

Well, I'd like to thank you for your attention.