以静脉血栓为首发表现的实体恶性肿瘤的临床特点及初筛方法

Study on clinical features and primary screening methods of solid malignancies with venous thrombosis as the initial manifestation

目的探讨以静脉血栓为首发表现的实体恶性肿瘤的临床特征及初筛方法,提高对静脉血栓的实体恶性肿瘤病因的诊断意识。方法回顾性分析收治的35例因静脉血栓形成为首发表现的实体恶性肿瘤患者(观察组)以及同期收治的38例非恶性肿瘤和易栓症因素的深静脉血栓形成患者(对照组)的临床资料。分析观察组的恶性肿瘤特征及对比两组的凝血功能、血常规及静脉血栓特点。结果观察组有5例(14.3%)患者肿瘤分期为Ⅰ~Ⅱ期,30例(85.7%)为Ⅲ~Ⅳ期;其中腺癌27例(77.1%),非腺癌8例(22.9%);联合应用肿瘤标记物癌胚抗原(CEA)、肿瘤糖类抗原19-9(CA199)、肿瘤糖类抗原125(CA125)的实体恶性肿瘤初筛敏感度为80.0%(28/35)。观察组D-二聚体和中性粒细胞淋巴细胞比率(NLR)分别为10.4(4.6,21.3)mg/L和4.4(3.7,7.6),对照组分别为5.5(3.1,10.3)mg/L和3.0(2.1,4.7),差异有统计学意义(P<0.05);NLR的ROC曲线下面积(AUC)为0.714(P<0.05),最佳界值为3.62,其敏感度为80%;观察组与对照组的D-二聚体阳性率分别为94.3%和100.0%,差异无统计学意义(P>0.05)。观察组具有诱因者仅1例(2.9%),对照组有13例(34.2%),差异有统计学意义(P<0.05);观察组22例(62.9%)单下肢深静脉血栓形成(DVT),13例(37.1%)双下肢DVT和颈静脉血栓形成,6例(17.1%)合并有肺栓塞、上腔静脉血栓、下腔静脉血栓或浅静脉血栓形成,而对照组38例(100%)均为单侧下肢DVT,差异有统计学意义(P<0.05);观察组的中央型、周围型和混合型血栓分别为25.0%、31.8%及43.2%,对照组分别为18.4%、21.1%和60.5%,差异无统计学意义(P>0.05);观察组1处静脉血栓有18例(51.4%),2处及以上静脉血栓有17例(48.6%),对照组38例(100%)均为1处静脉血栓形成,差异有统计学意义(P<0.05)。结论在无明显诱因下出现的双下肢深静脉血栓或全身多处静脉血栓形成的患者,应考虑存在中晚期实体恶性肿瘤因素可能。CEA、CA199、CA125联合筛查及结合NLR值可提高实体恶性肿瘤的初筛敏感率。

Objective To investigate the clinical features and primary screening methods of solid malignancies with venous thrombosis as the initial manifestation,so as to improve the diagnostic consciousness of solid malignancy factor for venous thrombosis.Methods A retrospective analysis was conducted on 35 cases of solid malignancy with venous thrombosis as the initial manifestation(observation group)and 38 cases of deep venous thrombosis without malignant tumor or thrombophilia(control group)in recent 5 years.The clinical data included the characteristics of malignant tumor in observation group,and the coagulation function,blood routine and the feature of venous thrombosis in two groups were analoyzed.Results There were 5 cases(14.3%)of malignancy in Stage Ⅰ-Ⅱ,30 cases(85.7%)in Stage Ⅲ-Ⅳ.There were 27 cases(77.1%)of adenocarcinoma and 8 cases(22.9%)of non-adenocarcinoma in observation group.Combined application of tumor markers CEA,CA199 and CA125 showed a sensitivity rate of 80.0%(28/35)in primary screening for solid malignancies.The D-dimers and neutrophil to lymphocyte ratio(NLR)were 10.4(4.6,21.3)mg/L and 4.4(3.7,7.6),respectively,in observation group;and those were 5.5(3.1,10.3)mg/L and 3.0(2.1,4.7),respectively,in control group(P<0.05).The area under ROC curve(AUC)of NLR was 0.714(P<0.05);and as the optimal threshold was 3.62,the sensitivity was 80%.The positive rates of D-dimers were 94.3% and 100.0% in observation group and control group,respectively(P>0.05).There was only 1 case(2.9%)with identifiable risk factor for venous thromboembolism(VTE)in observation group and 13 cases(34.2%)in control group(P<0.05).There were 22 cases(62.9%)of single lower extremity deep vein thrombosis(DVT),13 cases(37.1%)of both lower extremities DVT and jugular vein thrombosis,and 6 cases(17.1%)accompanied by pulmonary embolism,superior vena cava thrombosis,inferior vena cava thrombosis or superficial vein thrombosis in observation group;and 38 cases(100%)all had single lower extremity DVT in control group(P<0.05).Central,peripheral and mixed thrombosis were 25.0%,31.8% and 43.2%,respectively,in observation group;and 18.4%,21.1% and 60.5%,respectively,in control group(P>0.05).There were 18 cases(51.4%)had venous thrombosis in one position,17 cases(48.6%)in 2 or more positions in observation group;while there were all cases(100%)had venous thrombosis 1 position in control group(P<0.05).Conclusion Patients with both lower extremities DVT or multiple venous thrombosis without identifiable risk factor should be considered the possibility of moderate advanced solid malignancies.Combined screening of CEA,CA199,CA125 and NLR value can improve the sensitivity of primary screening for solid malignancies.