There seems to be no indication ofr chest MRI. There are no clincal findigns or potential diagnoses that would invovle the chest and need to be excluded. A search for malignancy is not generally recommended for DVT. The incidence of new cancers in patients diagnosed with idiopathic venous thromboembolism (VTE) is approximately 4-10%. There are no studies to establish that screening for malignancy in patients with VTE is beneficail. Two studies published in the Journal of Thrombosis and Haemostasis support this conclusion.
The first study by Monreal and colleagues, was a prospective cohort follow-up study in which the primary goal was to assess the sensitivity of diagnostic work-up for occult malignancy in patients with VTE. Their extensive work-up included medical history, physical exam (included pelvic, rectal, and breast exams), laboratory tests, or chest X-ray. Cancer was diagnosed in 34 patients (3.9%) which translates into a sensitivity of identifying malignancy by routine examination of 55.7% (95% CI, 43.3-67.5%).. Some patients had cancer markers (PSA, CA125) and abdomino-pelvic ultrasonography and identified malignancies in 13 additional patients for a sensitivity of 48.1% (95% CI, 30.7-66.0%).
The randomized multicenter clinical trial conducted by Piccioli and colleagues, was designed to compare extensive screening for occult malignancy with no screening in patients with acute idiopathic VTE. The primary outcome evaluated cancer related mortality and the secondary outcome evaluated the cluster of cancer-related mortality, documented residual malignancy, or recurrent malignancy at 24 months. The study had accrued a total of 201 patients (99 extensive screening, 102 control group) at the time it was terminated. Cancer related mortality occurred in 2% of the extensive screening group compared to 3.9% in the control group, an absolute difference of 1.9% (95% CI, -5.5-10.9%). The secondary outcome event occurred in 5.1% of the patients in the extensive screening group versus 7.9% of the control patients, an absolute difference of 2.8% (95% CI, -6.3-13.4%).
In conclusion, there is no consensus that any screening for malignancy needs to be perfomred in DVT. IN individual cases of idiopathic DVT in your patients withotu risk fctors, screenign may be warranted. The extent of the diagnostic work-up in these patients should include a routine examination and should be performed in accordance with current screening recommendations.
Monreal M, Lensing AWA, Prins MH, Bonet M, Fernandez-Llamazares J, et al. Screening for occult cancer in patients with acute deep vein thrombosis or pulmonary embolism. J Thromb Haemost. 2004;2:876-881.
Piccioli A, Lensing AWA, Prins MH, Falanga A, Scannapieco GL, et al. Extensive screening for occult malignant disease in idiopathic venous thromboembolism: a prospective randomized clinical trial. J Thromb Haemost. 2004;2:884-9.