Clinical Commander

All dossiers
cardio.dvt.cancer-screening-incidental.v1

Incidental DVT on cancer-staging imaging

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.dvt.core.v1 — narrowed to INCIDENTAL DVT discovered on cancer-staging or surveillance cross-sectional imaging. ~5-10% of cancer patients have incidental DVT/PE on staging CT (lung, pancreatic, gastric, colorectal, ovarian dominate). Treatment principle (ACCP 2021 + ITAC 2022): incidental cancer-DVT treated SAME as symptomatic — full therapeutic AC while cancer remains active; DOAC vs LMWH choice follows CARAVAGGIO / Hokusai-Cancer subgroup logic. Workup specialization: confirm with US for proximal lesions; concurrent CT-PA if pulmonary nodule + DVT (occult PE common in cancer); active screen for anatomic compression (May-Thurner, paraspinal mass, IVC tumor thrombus extension). Catheter-associated UEDVT subset: keep catheter if functional + ongoing chemotherapy access need; AC duration is for catheter retention plus minimum 3 months total. Manifest pointer reuses cardio.dvt.core.v1 manifest. Design-brief pointer reuses parent (incidental-specific differences documented inline). Status INTEGRATED. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 18 incidental-DVT variant.

Entry points (4)

  • imaging
    Incidental DVT noted on CT chest/abdomen/pelvis ordered for cancer staging or restaging — patient asymptomatic in the involved limb
    incidental_dvt_on_staging_ct
  • imaging
    Incidental DVT on surveillance MRI for known malignancy
    incidental_dvt_on_surveillance_mri
  • imaging
    Catheter-associated upper-extremity DVT noted on chest CT in patient with PICC or port for active chemotherapy
    catheter_associated_uedvt_on_imaging
  • imaging
    IVC tumor thrombus extension (renal cell, HCC, adrenal cortical) with associated bland-thrombus DVT
    ivc_tumor_thrombus_with_dvt_on_imaging

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Older patients higher cancer-VTE recurrence and bleed risk
  • cancer_type_and_stagerequired
    history • used at TREATMENT
    Cancer type drives DOAC vs LMWH choice; luminal GI / intracranial / GU favor LMWH; staging informs prognosis + AC duration shared decision
  • cancer_treatment_statusrequired
    history • used at CONTEXT
    Active chemotherapy / immunotherapy / radiation modifies bleed risk + drug interactions; remission status informs eventual AC discontinuation
  • central_venous_catheter_presentrequired
    history • used at TREATMENT
    PICC or port presence drives the catheter-associated UEDVT pathway — keep catheter if functional + ongoing access need; AC for catheter duration plus minimum 3 mo
  • compression_usrequired
    imaging • used at INITIAL_WORKUP
    Confirm DVT location and burden (proximal vs distal) when initial finding was on CT and limb is asymptomatic; informs surveillance-only vs treat decision per ACCP 2021
  • ct_chest_pa_if_concurrent_pe_concern
    imaging • used at INITIAL_WORKUP
    CT-PA when DVT discovered alongside pulmonary nodules or unexplained dyspnea — rule out concurrent occult PE in same encounter (high rate in cancer)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline platelet count; chemotherapy-induced thrombocytopenia modifies AC dosing or contraindicates AC if severe
  • creatininerequired
    lab • used at TREATMENT
    eGFR for DOAC dosing; cancer patients often have CKD or AKI from chemotherapy or contrast
  • mucosal_bleed_historyrequired
    history • used at RED_FLAGS
    Mucosal bleed history (especially GI/GU cancers) shifts choice from DOAC to LMWH

12-phase flow (10)

  1. 1FRAME
    Incidental cancer-associated DVT — discovered on staging or surveillance imaging in asymptomatic limb. Treat the same as symptomatic cancer-DVT per ACCP 2021 + ITAC 2022; confirm with US for proximal lesions; rule out anatomic compression (May-Thurner, paraspinal mass, IVC tumor thrombus) and concurrent occult PE
    inputs: cancer_type_and_stage
    advance: incidental DVT confirmed + anatomic context understood
  2. 2ENTRY
    Review imaging for clot location (proximal vs distal vs upper-extremity vs IVC), associated anatomic findings (compression, tumor thrombus), and concurrent PE clues (pulmonary nodules, dyspnea history)
    inputs: age
    advance: imaging review complete + clinically asymptomatic confirmed
  3. 3CONTEXT
    Cancer type, stage, current treatment, prognosis (life expectancy informs AC duration); central venous catheter status (PICC, port); chemotherapy + supportive care med list for DOAC interaction screen; bleed history
    inputs: cancer_treatment_status, central_venous_catheter_present
    advance: cancer + drug + catheter context complete
  4. 4RED_FLAGS
    Severe thrombocytopenia <50K → modify AC; brain metastases → DOAC contraindicated → LMWH preferred; recent GI/GU bleed; absolute AC contraindication; IVC tumor thrombus → urology/HPB consultation for surgical strategy; concurrent occult PE on CT → adopt PE engine
    inputs: mucosal_bleed_history
    actions: pe_full
    advance: red flags screened + escalations triggered
  5. 5INITIAL_WORKUP
    LE compression US for DVT location confirmation if not clearly proximal on CT; consider CT-PA in same encounter if pulmonary nodules / dyspnea concern; CBC + BMP + LFTs + INR/PTT; review imaging for anatomic compression syndromes (May-Thurner, IVC tumor thrombus, paraspinal mass)
    inputs: compression_us, cbc, creatinine
    actions: panel.cardiac, panel.renal, le_edema
    advance: workup documented
  6. 6BRANCHING_WORKUP
    Cancer type categorization for AC choice (non-mucosal solid tumor → DOAC eligible; luminal GI / intracranial / GU → LMWH preferred); catheter-associated UEDVT → keep catheter if functional + ongoing need + AC for duration plus 3 mo minimum; IVC tumor thrombus → multidisciplinary oncology + surgical planning
    advance: AC strategy + catheter strategy + anatomic intervention plan documented
  7. 7TREATMENT
    First-line: apixaban 10 mg BID × 7 d → 5 mg BID × ≥6 mo (CARAVAGGIO PMID 32223112) OR edoxaban 60 mg daily after 5 d LMWH lead-in (Hokusai-Cancer PMID 29231094) for non-mucosal cancers. LMWH (dalteparin or enoxaparin) for luminal GI, intracranial malignancy, or DOAC contraindication (CLOT PMID 12853587). Treat incidental cancer DVT same as symptomatic per ACCP 2021
    inputs: creatinine, mucosal_bleed_history
    advance: AC initiated per cancer type + catheter status
  8. 8DISPOSITION
    Outpatient if hemodynamically stable + no concurrent PE — most incidental DVT cases manageable outpatient with oncology coordination; inpatient only for concurrent PE with hemodynamic concern, severe thrombocytopenia, or active bleed risk requiring observation
    advance: unit assigned
  9. 9MONITORING
    CBC weekly during chemotherapy; LFTs monthly; reassess cancer status every 3 mo; bleeding screen at each visit (mucosal sites); drug interaction review at each chemotherapy change; surveillance imaging at 3 mo for thrombus resolution if catheter-associated
    actions: panel.cardiac
    advance: monitoring plan documented
  10. 10FOLLOWUP
    6-month landmark: continue AC if cancer active per ITAC 2022 (indefinite while active); API-CAT 2024 extended apixaban (months 7–18) reasonable per PMID 38780119; reassess at 12 mo + ongoing per cancer status; stop only when cancer in durable remission ≥1 yr AND minimum 6 mo AC complete; for catheter-associated UEDVT — continue AC for catheter retention duration plus minimum 3 mo
    advance: extended-AC plan documented