La p o r a nk a s u s

DEEP VEIN THROMBOSIS SEBAGAI MANIFESTASI SINDROMA PARANEOPLASTIK DARI KANKER PARU
Ke t u t S u e g a Di v i s i He ma t o l o g i On k o l o g i Me d i k , Ba g i a n / S M FI l muP e n y a k i t Da l a m F K Un u d / RS UPS a n g l a hDe n p a s a r , Ba l i Ema i l : k s u e g a @y a h o o .c o m
ABS TRACT Th r o mb o t i ce v e n ti np a t i e n twi t hc a n c e ri sa c o mmo nf e a t u r ei nc o n t r a r yt ot h ep r e s e n t a t i o no ft h o mb o t i cd i s o r d e r s t h a tp a r to fp a r an e o p l a s t i cs y n d r o mea sas o l e l y i n i t i a ls y mp t o mo fa no c c u l tma l i g n a n c y . Th eu n d e r l y i n g me c h a n i s mt h a t a s s o c i a t i n gb e t we e nc a n c e ra n dt h r o mb o s i sa swe l la sb e t we e nc a n c e ra n dp a r a n e o p l a s t i cs y n d r o mei sn o tc l e a r l yu n d e r s t o o d y e t . On eo ft h o s ec a n c e r st h a tf r e q u e n t l ya s s o c i a t e d wi t hp a r a n e o p l a s t i cs y n d r o mei sl u n gc a n c e r . Wer e p o r t e d a4 6y e a r so l d wo ma nt h a tp r e s e n t si n i t i a l l yb e c a u s eo fas wo l l e nl e f tl e ga n d t e n d e r n e s sa l o n gt h el e g . Ot h e re x a mi n a t i o n swi t h i nn o r ma l f i n d i n gi n c l u d i n gn o r ma l c h e s t xr a y .I na p p r o x i ma t e l yay e a rl a t e r , t h ep a t i e n t e x p e r i e n c e sd i s t u r b i n gc o u g hwi t hb l o o ds t r e a k , a c c o mp a n y wi t hs h o r t n e s so fb r e a t h .S h e wa sa l s oc o mp l a i n i n go fs h a r pc h e s tp a i ne s p e c i a l l y wh e nt a k i n g ad e e pb r e a t h . Af t e rs e v e r a le x a mi n a t i o n sp e r f o r me ds u c ha sb r o n c h o s c o p ywi t hb r o n c h i a lwa s h i n g , t r a n s t h o r a c a l b i o p s y , s o n o g r a p h i cs t u d y , e c h o c a r d i o g r a p h y , c h e s t CT s c a n , t h i sp a t i e n t wa sf i n a l l yd i a g n o s eo f h a v i n ga d v a n c e dl u n gma l i g n a n c y . Hi s t o l o g i cf i n d i n gwa s c o mf i r m wi t ha d e n oc a r c i n o map o o r l yd i f f e r e n t i a t e d . Hewa st r e a t e du n d e r6 c o n c e c u t i v ec y c l e so fg e mz i t a b i nc o mb i n e dwi t h c a r b o p l a t i n . De s p i t ec o mp l e t e dc h e mo t h e r a p yt r e a t me n t , s h eb e c a mewo r s t a n dd i e db e c a u s eo fr e s p i r a t o r yf a i l u r e . Ke y wo r d s : t h r o mb o t i ce v e n t , p a r a n e o p l a s t i cs y n d r o me , l u n gc a n c e r

P ENDAHULUAN DVT ( Deep Vein T h romb os is )a d a l a ht r o mb o s i s v e n ad a l a my a n gt e r j a d ia k i b a ta d a n y aa k t i v a s ip r o s e s 14 k o a g u l a s i p a d aa l i r a nv e n ay a n gs t a s i s . DVT b e r s a ma s a mad e n g a nP E( Pulmonary Emb oli) me r u p a k a ns a l a h s a t up e n y e b a b mo r t a l i t a sd a n mo r b i d i t a s . Wa l a u p u n h u b u n g a na n t a r at r o mb o s i sd a nk a n k e rs u d a hd i k e n a l s e j a kj a ma nd a h u l uk a l aa k a nt e t a p ime k a n i s mey a n g 5, 6 me n d a s a r i n y as e c a r ap a s t i b e l u md i k e t a h u i . Ke j a d i a n VTE ( Venous T h romb os is Ev ent )b e r k i s a ra n t a r a 15 20 %d a r is e l u r u hk a n k e r , b a h k a na n g k al e b i ht i n g g i 7 , 8 d i t e mu k a np a d as t u d i p o s t mo r t e m( 3050 %) . VTE y a n gt i n g g i b a n y a kd i h u b u n g k a nd e n g a nk a n k e r s a l u r a n 126

c e r n a ,p a r u ,o v a r i u m. Di s a mp i n gj e n i sk a n k e r n y a , b e b e r a p ak o n d i s iy a n g me n y e r t a is e p e r t it i n d a k a n o p e r a s i ,p e mb e r i a nk e mo t e r a p i ,t e r a p ih o r mo n a ld a n t i n d a k a np e ma s a n g a na k s e s ( i n f u s , k a t e t e r , v e n as e n t r a l ) 6, 9 11 j u g aa k a nme n i n g k a t k a nk e j a d i a nt r o mb o s i s . Wa l a u p u n VTE me r u p a k a n ma n i f e s t a s i k l i n i ky a n gu mu m d i j u mp a ip a d as e o r a n gp e n d e r i t a k a n k e r , n a mu ns e b a l i k n y ad i t e mu k a na d a n y ak e j a d i a n VTE, t e r u t a ma DVT y a n g mu n c u l n y a me n d a h u l u i t i mb u l n y ak a n k e rp r i me r n y a me r u p a k a nk a s u sy a n g j a r a n g . Ap a b i l ad i i k u t id a l a m wa k t u y a n g c u k u p l a ma a k a n d a p a td i t e mu k a n a d a n y ak a n k e ry a n g me n d a s a r i n y a . Ke j a d i a n DVT y a n g me n d a h u l u i mu n c u l n y as e b u a hk a n k e rd i t e mu k a nb e r k i s a ra n t a r a

J Peny Dalam, Volume 12 Nomor 2 Mei 2011

7 26%, d i ma n aa n g k ai n ia k a n ma k i nt i n g g ia p a b i l a DVT n y ad i k l a s i f i k a s i k a n s e b a g a i DVT i d i o p a t i k 14 ( unp rov ok edDVT) d a nd i d a p a t k a np a d au s i al a n j u t .11DVT y a n g me n d a h u l u it i mb u l n y as u a t uk a n k e r p r i me r me n y e r u p a ik e j a d i a n s u a t u s i n d r o ma p a r a n e o p l a s t i k , d i ma n as i n d r o mai n i me r u p a k a nk u mp u l a n d a r it a n d ad a ng e j a l aa k i b a tk e r u s a k a no r g a na t a u j a r i n g a ny a n gl e t a k n y aj a u hd a r i k a n k e rp e n y e b a b n y a . Ke r u s a k a ni n i b i s ame n g e n a i h a mp i rs e mu ao r g a nd a n j a r i n g a nt u b u h .S i n d r o mai n i b i s ame n c a p a i 1015% d a r is e mu ak e g a n a s a n .S i n d r o ma i n ime n j a d ip e n t i n g k a r e n ab i s ame r u p a k a ns a t u s a t u n y ag e j a l ad a r i s e b u a h k a n k e rd a nb a h k a nb i s as e b a g a it a n d aa wa ld a r is u a t u k a n k e r ,n a mu nk a r e n ag e j a l ad a nt a n d ay a n gs a n g a t b e r v a r i a s i , s i n d r o mai n i s e r i n gt i d a kt e r d e t e k s i d e n g a n 17 b a i k .15Va r i a s i k l i n i kd a r i b e r ma c a mma c a mk e g a n a s a n d a nk a i t a n n y ad e n g a nk e j a d i a nt r o mb o s i sb a i ky a n g me r u p a k a na k i b a t k a n k e r n y aa t a u p u ny a n gme n d a h u l u i mu n c u l n y as e b u a hk a n k e r ,d i d u g aa k i b a ti n t e r a k s i a n t a r ab e r b a g a ij e n i sp r o t e i nb i o l o g i kd a r is e b u a h k a n k e r d e n g a np r o t e i nk o a g u l a s i t u b u hs e h i n g g at e r j a d i a k t i v a s ip r o s e sk o a g u l a s id a nt e r b e n t u k n y at r o mb o s i s . P e n d e r i t a k a n k e rd e n g a n VTE a k a n me mp u n y a i

p r o g n o s i sy a n gl e b i hj e l e kk a l a ud i b a n d i n g k a nd e n g a n 5, 9 , 14 k a n k e ry a n gs a may a n gt i d a kd i s e r t a i d e n g a nVTE. Be r i k u ti n ik a mil a p o r k a ns e b u a hk a s u sk a n k e r p a r uy a n gb a r ud i k e t a h u i s e t e l a hs e k i t a r s e t a h u n , d i ma n a s e b e l u mn y ap e n d e r i t ay a n gb e r s a n g k u t a nd a t a n gh a n y a d e n g a nk e l u h a na wa l a d a n y ak a k i b e n g k a k( DVT) . KAS US S e o r a n gp e n d e r i t a wa n i t a4 6 t a h u n ,p e g a wa i n e g e r is i p i l ,t i d a k me r o k o k ,d e n g a nr i wa y a tp e n y a k i t s e p e r t i b e r i k u t .S e k i t a r b u l a nd e s e mb e r 20 0 8 , p e n d e r i t a me n g e l u h n y e r ib a h u k a n a n y a n g h i l a n g t i mb u l , t a n p ad i s e r t a ip a n a sd a nk e l u h a nl a i n n y a . P a d as a a t t e r s e b u t d i l a k u k a n e v a l u a s i k l i n i k , l a b o r a t o r i u m d a nr o n t g e n o l o g i s . Da r ip e me r i k s a a nr o n t g e nb a h u d i d a p a t k a nh a s i l y a n gn o r ma l d a nd a r i p e me r i k s a a nf o t o d a d a , t i d a kd i t e mu k a na d a n y ak e l a i n a np a d aj a n t u n gd a n p a r u( Ga mb a r2a ) .T i d a kd i d a p a t k a na d a n y ag a mb a r a n ma s s ap a d ap a r u . Ha s i ld a r il a b o r a t o r i u m:Hb 12, 7 g r / d l ;W BC 5, 8 8 . 10 3/ u l ;p l a t e l e t265.10 3/ u l ;S GOT 10 u / l ; S GP T 9u / l ;GDP 8 4 mg / d l ;GD 2j P P 121 mg / d l ;Li p i dp r o f i l ed a l a mb a t a sn o r ma l . BUN 25 mg / d l ; s e r u mk r e a t i n i n0 , 7 mg / d l . Be b e r a p ab u l a nb e r s e l a n g ,

Ga mb a r1. P e me r i k s a a nDo p p l e rUl t r a s o n o g r a p h yp a d ae k s t r e mi t a sb a wa h .

DeepVein T h romb os iss e b a g a i Ma n i f e s t a s i S i n d r o maP a r a n e o p l a s t i kd a r i Ka n k e rP a r u Ket ut S ueg a

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Me i20 0 9p e n d e r i t a me n g e l u hk a k ik i r it e r a s ab e r a t b e n g k a k ,p a n a sd a n k a d a n g k a d a n g t e r a s a n y e r i . P e n d e r i t ab e r o b a tk ed o k t e rd a nd i d i a g n o s i ss e b a g a i DVT s e r t ad i o b a t id e n g a ne n o x a p a r i n( a n t i k o a g u l a n ) . S e t e l a hs e k i t a r 2b u l a nd e n g a np e n g o b a t a na n t i k o a g u l a n p e n d e r i t ad a t a n gk eRS UPS a n g l a hu n t u kk e l u h a nk a k i b e n g k a k n y ay a n g ma s i hb e l u mb e r k u r a n gs e l u r u h n y a . Di l a k u k a np e me r i k s a a nu l a n gd e n g a n US G Do p p l e r . Ha s i lp e me r i k s a a n US G Do p p l e rt a n g g a l22/ 8 / 20 0 9 p a d ae k s t r e mi t a sb a wa hk i r i( Ga mb a r 1) d i t e mu k a n a d a n y ah a mb a t a na l i r a np a d av e n ap o p l i t e at i b i a l i s a n t e r i o rd a nf i b u l a r i ss i n i s t r a ,c u r i g as u a t ut h r o mb u s p a d av e n ap o p l i t e as i n i s t r a . P e me r i k s a a nD d i me r 4 , 4 8 5 n g / ml( k o n t r o l< 50 0n g / ml ) ,F i b r i n o g e n 367 mg / ml( d a l a mb a t a sn o r ma l ,P P T 20 , 3d e t i k( k o n t r o l 13, 8d e t i k ) , AP P T 28 , 5d e t i k( k o n t r o l 32, 5d e t i k ) , I NR 1, 36 d e t i k( k o n t r o l <0 , 9d e t i k ) .P a d as a a t i n i p e n d e r i t a d i r a wa th a n y ad e n g a n DVT y a n gb e l u m s e mb u h s e h i n g g ao b a t o b a t a nu n t u kDVT n y ad i t e r u s k a n . S e l a n j u t n y ap a d ab u l a nDe s e mb e r 20 0 9p e n d e r i t a d a t a n gl a g i d e n g a nk e l u h a nn y e r i p u n g g u n gk i r i . Ny e r i d i s e r t a id e n g a np e r a s a a no t o ts e k i t a ry a n gt e r t a r i k , s e p a n j a n gh a r id a n me n e t a p . J u g ad i s e r t a id e n g a n b a t u k b a t u ky a n gh i l a n gt i mb u ld e n g a nr i a kk a d a n g d i s e r t a id e n g a nb e r c a kd a r a h . S e s a kn a f a sd i r a s a k a n

me n e t a pd a nb e r t a mb a hb e r a t wa l a u p u np e n d e r i t at i d a k me l a k u k a na k t i v i t a sf i s i ky a n gb e r a t . Ba t u kd a ns e s a k d i s e r t a id e n g a nn y e r id a d ay a n g me n u s u kt e r u t a ma p a d ad a d as e b e l a hk a n a nt e mb u sk ep u n g g u n g .P a d a s a a ti n ip e n d e r i t a me r a s al e b i hl e ma h ,n a f s u ma k a n d a n mi n u mj a u hb e r k u r a nd a np e n d e r i t ame r a s al a b i h k u r u s . Mu a l mu a l j u g ad i r a s a k a nn a mu nh a n y ak a d a n g k a d a n gs a j ad i s e r t a id e n g a n mu n t a h . Bu a n ga i rb e s a r d a nb u a n ga i rk e c i lma s i hn o r ma l .P a d ap e me r i k s a a n f i s i kd i t e mu k a np e n d e r i t ad e n g a nk e s a ns a k i tb e r a t , k e s a d a r a n ma s i hc o mp o sme n t i sd a nl e ma h .T e k a n a n d a r a h 110 / 8 2 mmHg ,RR 28 x / mn t ,n a d i9 4x / mn t d a nt e mp e r t a u r37 , 2C. p e me r i k s a a nk e p a l ad a nl e h e r h a n y ad i t e mu k a nk o n y u n g t i v ay a n ga g a ka n e mi s .P a d a p e me r i k s a a nd a d ad i d a p a t k a nv o c a lf r e mi t u sy a n g me n u r u nd ik a n a n , n y e r it e k a np a d ap u n g g u n gk a n a n . J a n t u n gd a l a m b a t a sn o r ma l ,t i d a kd i d a p a t k a ns u a r a mu r mu ra t a ug a l l o p .P a d ae k s t r e mi t a st i d a kd i t e mu k a n a d a n y ap e mb e n g k a k a n p a d ak a k ip e n d e r i t a . Da r i p e me r i k s a a nl a b o r a t o r i u m: b i l i r u b i nt o t a l0 , 63 mg / d l , b i l i r u b i ni n d i r e k0 , 34 mg / d l , AP 61 I U/ l , S GOT 20 I U/ l , S GP T17I U/ l , a l b u mi n3, 2g r / d l , BUN 12, 0mg / d l , s e r u mk r e a t i n i n0 , 65 mg / d l , GDP8 5 mg / d l , HB 0 , 8mg / 3 3 d l , W BC 3, 7 1.10 / u l , p l a t e l e t 215.10 / u l , M CV 7 6, 3f l , M CH 22, 3p g , M CHC 31 g / d l . Di l a k u k a np e me r i k s a a n

mb a r2b . Ma s s ad i p a r uk a n a nd e n g a ne f u s i Ga mb a r2a .F o t ot o r a k sd e n g a nd e n g a nk e s a np a r u Ga d a nj a n t u n gd a l a mb a t a sn o r ma l

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f o t ot o r a k sd e n g a nh a s i lt a mp a ka d a n y ak o n s o l i d a s i r a d i o o p a k sp a d ad a e r a hl o b u sb a wa ha n t e r i o rk a n a n , t e p i mu l u s . S i n u sk o s t o f r e n i k u sk a n a nt u mp u ld a n t e r s e l u b u n g . Ke s a n :t u mo rp a r uk a n a nd e n g a ne f u s i p l e u r ak a n a n DB ( Di a g n o s i s Ba n d i n g ) :p n e u mo n i a l o b u sme d i u s( Ga mb a r2b ) . P a d a s a a t i n i p e n d e r i t a d i r a wa t d e n g a n k e c u r i g a a ns u a t ut u mo rp a r ud e n g a ne f u s ip l e u r a s e h i n g g g ad i u s u l k a np e me r i k s a a nl e b i hl a n j u ts e p e r t i b r o n k o s k o p id a ns c a nd a d a ,d i s a mp i n gp e me r i k s a a n s i t o l o g ic a i r a ne f u s i . P a d ap e me r i k s a a nb r o n k o s k o p i d e n g a nb r o n c h i a l b r u s h i n gd a nd i l a k u k a np e me r i k s a a n h i s t o l o g i sd i t e mu k i a na d a n y ag a mb a r a nb r o n k o g e n i k k a r s i n o ma s e s u a id e n g a na d e n ok a r s i n o ma . Ha li n i d i d u k u n gp u l ao l e hh a s i lF NAB p a d at u mu rd e n g a n t i n d a k a nt r a n s t o r a k a lb i o p s id i ma n ad i t e mu k a nj u g a g a mb a r a n mo r f o l o g is e s u a id e n g a na d e n o k a r s i n o ma . P a d as c a nd a d ad e n g a ni r i s a na x i a lt a n p ad a nd e n g a n k o n t r a sd i t e mu k a na d a n y a ma s s ad ic a r d i o p r e n i k u s k a n a ny a n g me n g i n f i l t r a s ih e mi d i a f r a g ma k a n a nd a n ma s u kk ep a r e n s i m l i v e r ,l o b u l a t e dd e n g a na d a n y a p e n i n g k a t a np a d ap e mb e r i a nk o n t r a s . Uk u r a n ma s a 7 , 6 x6, 7x6 c m, me n d e s a ka t r i u mk a n a nd a nd i s e r t a i d e n g a nl i ma d e n o p a t ip a r aa o r t at o r a k a l i s . Da r ih a s i l e k o c k a r d i o g r a f i d i t e mu k a n k a t u p k a t u p n o r ma l , d i me n s ir u a n gj a n t u n gn o r ma l ,n o r mo k i n e t i kd a nL V s i s t o l i kf u n g s i n o r ma l . Be r d a s a r k a n p e me r i k s a a n US G h e p a rt i d a k d i t e mu k a na d a n y at a n d a t a n d ame t a s t a s e .P e me r i k s a a n t a mb a h a nl a i n y ay a i t uCEA 7 , 8 7mg / ml ( k o n t r o l <5, 0 0 mg / ml , AF P1, 63 UI / ml ( k o n t r o l 8 , 0 0Ui / ml ) .d a r i d a t a y a n ga d ap e n d e r i t ad i d i a g n o s i sd e n g a nk a n k e rp a r u ( a d e n o k a r s i n o ma )s t a d i u m I I I bd e n g a ne f u s ip l e u r a d a nr i wa y a ta d a n y a DVT . P e n d e r i t ad i t e r a p id e n g a n r e g i me n tk e mo t e r a p ik o mb i n a s ig e ms i t a b i nd e n g a n c a r b o p l a t i ns e l a ma6 k a l is i k l u sa k a nt e t a p it i d a ka d a p e r b a i k a ny a n gs i g n i f i k a n . Ko n d i s ip e n d e r i t at e t a p me mb u r u k ma k i nl e ma hd a ns e s a kn a f a sy a n g ma k i n b e r a td a na k h i r n y ap e n d e r i t ame n i n g g a ld e n g a nk a u s a k e ma t i a na k i b a t g a g a l n a f a s .

Da r i p e r j a l a n a n p e n y a k i t p e n d e r i t a d i a t a s d i s i mp u l k a nb a h wap e n d e r i t ad i a t a sme n g a l a miDVT y a n g me r u p a k a ns u a t us i n d r o ma p a r a n e o p l a s t i kd a n me r u p a k a nb a g i a nd a r is u a t ut u mo rp a r ud a l a m h a l i n ia d e n o k a r s i n o ma p a r us t a d i u m I I I Bd e n g a ne f u s i p l e u r a . P EM BAHAS AN P a s i e nd e n g a nDVT mu n g k i nh a n y ame mp u n y a i g e j a l ay a n g mi n i ma la t a ua t i p i k a ld a ng e j a l aa t a u t a n d a t a n d a y a n g me n y e r u p a is u a t u DVT s e r i n g d i t e mu k a np a d ak e l a i n a nn o nt r o mb o s i s . Ha n y as e k i t a r 25% p e n d e r i t a DVT mu n c u ld e n g a nk e l a i n a ny a n g s e s u a i . P a s i e nd e n g a n DVT b i a s a n y ad a t a n gd e n g a n k e l u h a nn y e r i ,b e n g k a k ,t e r d e r n e s ss e p a n j a n ga l i r a n v e n ad a l a m,a d a n y ak e me r a h a n ,a d ap e l e b a r a nv e n a . Di a g n o s i s DVTd i t e g a k k a nd e n g a nc omp res s iv ev enous ult ras onog rap h y d a np e me r i k s a a nD d i me r . S t a n d a r 14 , 12, 18 b a k uu n t u kd i a g n o s i sDVT a d a l a hv enog rap h y. P e n d e r i t a i n i d a t a n gd e n g a nk e l u h a nb e n g k a kp a d a k a k i , n y e r i d a nk a k i t e r a s ab e r a t , d a nd a r i p e me r i k s a a n Do o p l e rs o n o g r a p id i t e mu k a na d a n y at a n d as u mb a t a n a l i r a nv e n ap a d av e n ap o p l i t e as e r t ad i d u k u n go l e h Dd i me ry a n gt i n g g i( >4 0 0 0u g / ml )ma k ad i a g n o s i s DVT s a n g a tmu n g k i nd i t e g a k k a n .P a d as a a ti n i ,p a d a p e me r i k s a a nf o t ot o r a kp a r ud a nj a n t u n gd a l a mb a t a s n o r ma l , t i d a kd i t e mu k a nt a n d a t a n d ak e g a n a s a np a r u . Ak a nt e t a p ib e r s e l a n gs e t a h u nk e mu d i a np e n d e r i t a a k h i r n y ad i d i a g n o s i sme n d e r i t ak a n k e r p a r us t a d i u mI I I B ( a d e n o k a r s i n o ma )d e n g a ne f u s ip l e u r a . Di k e t a h u i b a h wak a n k e rp a r ume r u p a k a ns a l a hs a t uj e n i sk a n k e r y a n g s e r i n g d i s e r t a id e n g a n ma n i f e s t a s is i n d r o ma p a r a n e o p l a s t i k . Di s i mp u l k a nb a h wama n i f e s t a s i DVT p a d ak a n k e r p a r ui n i me r u p a k a nma n i f e s t a s i a wa l y a i t u s u a t us i n d r o map a r a n e o p l a t i kd a r i s e b u a hk a n k e rp a r u . Wa l a u p u n t i mb u l n y a k e j a d i a n VTE p a d a p e n d e r i t a k a n k e r me r u p a k a n g e j a l a y a n g u mu m, a k a nt e t a p is e b a l i k n y a DVT/ VTE y a n g me n d a h u l u i d a n me r u p a k a ng e j a l aa wa ld a r is u a t uk a n k e ry a n g

DeepVein T h romb os iss e b a g a i Ma n i f e s t a s i S i n d r o maP a r a n e o p l a s t i kd a r i Ka n k e rP a r u Ket ut S ueg a

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t e r s e mb u n y i ( oc c ult malig nanc y) me r u p a k a nk a s u s y a n g j a r a n g .S u a t us t u d ime l a p o r k a na n g k aa n t a r a7 26% d i t e mu k a na d a n y a oc c ultmalig nanc y p a d ap e n d e r i t a d e n g a nt r o mb o s i s( DVT) . Bu k t il a i nd e n g a ns t u d i k o h o r t d a ns t u d i p a d ap o p u l a s i u mu m me n u n j u k k a n10 15% d a r ip e n d e r i t ay a n gd a t a n gd e n g a n DVT y a n g i d i o p a t i k( unp rov ok ed DVT)a k a n me n d e r i t ak a n k e r 11, 19 d a l a mb e b e r a p at a h u ns e t e l a hk e j a d i a nt h r o mb o s i s . An g k ai n s i s d e na k a n me n i n g k a t2 4 xl i p a tp a d a t a h u np e r t a ma d a nr i s i k oi n i3 4 xl e b i hb e s a rb i l a d i b a n d i n g k a nd e n g a np e n d e r i t a DVT y a n gs e k u n d e r . P r o b a b i l i t a su n t u k me n d e r i t ak a n k e rp a d ap e n d e r i t a DVT i d i o p a t i k 10 xl e b i hb e s a rd i b a n d i n g k a nd e n g a n 14 p e n d e r i t a DVT y a n gf a k t o rr i s i k o n y ad i k e t a h u i .11, Di l a p o r k a nj u g ab a h wa1020 %d a r i s e mu ak e j a d i a n DVT y a n gi d i o p a t i kp a d ap e n d e r i t ay a n gd i k a t a k a n t i d a k me n d e r i t ak a n k e rp a d aa k h i r n y aa k a n me n d e r i t a 14 k a n k e rd a l a m wa k t u3 t a h u n . Me l i h a t a n g k a a n g k a d a n l a p o r a n y a n g me n d a p a t k a n h u b u n g a n y a n g c u k u p k u a ta n t a r a mu n c u l n y a k a n k e rd e n g a n ma n i f e s t a s it r o mb o s i s d a n t e o r it i mb u l n y at r o mb o s i sp a d ap e n d e r i t ay a n g t i d a kj e l a sd i k e t a h u if a k t o rr i s i k o n y a ,t i mb u ls u a t u wa c a n au n t u k me l a k u k a ns e k r i n i n gu n t u k me n d e t e k s i a d a n y as u a t uk a n k e ry a n gt e r s e mb u n y ip a d a me r e k a 5, 20 y a n g mn e d a p a t k a nt h r o mb o s i s . Ad a n y ak e ma j u a n t e k n o l o g id i a g n o s t i kd a np e n e mu a nt e o r i t e o r it e r b a r u l e b i h me n d u k u n ga d a n y ap e n d a p a tu n t u k me l a k u k a n s e k r i n i n g t e r h a d a p k e b e r a d a a n s u a t u k a n k e rp a d a p e n d e r i t a d e n g a nunp rov ok edt h romb os is . Na mu nb u k t i b u k t iy a n gl a n g s u n g me n d u k u n gp e r l u n y as e k r i n i n g i n i ma s i hb e l u mt e r s e d i ac u k u pb a n y a k . Ge e n z e , et al. s e r t aNo r o s t e n ,me l a p o r k a nb a h was k r i n i n gr u t i ns a j a d a p a t me n d e t e k s i a d a n y ak a n k e ry a n gt e r s e mb u n y i .5 S t u d imu t a k h i ry a n g me n g i k u t i8 64 p e n d e r i t a DVT i d i o p a t i ky a n gd i p e r i k s ad e n g a np e me r i k s a a n s e k r i n i n gr u t i nd i s e r t a id e n g a np e me r i k s a a n Xr a y , US G,d a nb e b e r a p ab i o ma r k e rs e p e r t iCA 125,P S A, CA,me n d a p a t k a na d a n y ak a n k e rp a d a34 p a s i e nd a r i 167o r a n gy a n gd i c u r i g a i ( 20 %) . Da l a m1t a h u nf ollowup ,d i t e mu k a nl a g is e k i t a r27 p a s i e nd e n g a nk a n k e r . 130

Di l a p o r k a nd a r is t u d ii n ib a h wa d e n g a np e n i l a i a n a wa ly a n gb a i kd i s e r t a id e n g a na n a mn e s i sl e n g k a p , p e me r i k s a a nf i s i kd a nl a b o r a t o r i u md a s a ra k a nd a p a t me n d e t e k s i p r o p o r s i y a n gc u k u pb e s a rd a r i k a n k e r p a d a 21 p e n d e r i t ad e n g a nunp rov ok edDVT . Na mu nd e mi k i a n s t u d i i n i t i d a kme n y e b u t k a na p a k a ht i n d a k a ns e k r i n i n g a k a n me mp e r b a i k i a t a u me n i n g k a t k a n s urv iv al p e n d e r i t a p e n d e r i t ay a n ga k h i r n y ad i k e t a h u id e n g a n k a n k e rt e r s e b u t . S u a t us t u d ir a n d o mi s a s it e r k o n t r o l me n c o b a me mb a n d i n g k a na p a k a ht i n d a k a ns k r i n i n g a k a nd a p a tme n u r u n k a n mo r t a l i t a sp e n d e r i t ak a n k e r d e n g a n DVT i d i o p a t i k . T e r n y a t at i n d a k a ns e k r i n i n g d e n g a np e me r i k s a a nd a nt i n d a k a ny a n gc u k u pi n t e n s i f t i d a k ma mp u me mb e r i k a nk e u n t u n g a np a d ap a s i e n 22 p a s i e nt e r s e b u t . P a d ap a s i e ni n it i d a kd i l a k u k a np e me r i k s a a n k h u s u s u n t u k me n d e t e k s i a d a n y a k a n k e r y a n g t e r s e mb u n y iwa l a u p u n DVT y a n gd i d e r i t ap a s i e ni n i a d a l a hj e n i si d i o p a t i kk a r e n at i d a kd i t e mu k a na d a n y a f a k t o rr i s i k oy a n gu mu m s e p e r t id i a b e t e s ,k o l e s t e r o l y a n gt i n g g i , h i p e r t e n s i , me r o k o k .F o t ot o r a kp e n d e r i t a i n ip a d a s a a ta wa l n y a t i d a k d i d a p a t k a n a d a n y a k e c u r i g a a na d a n y a ma s s ap a d ap a r u . Ha n y a s e t a h u n k e mu d i a np e n d e r i t a me n g e l u hb a t u kd i s e r t a is e s a k n a f a sd a np a d ag a mb a r a nf o t ot o r a kd i t e mu k a na d a n y a t u mo rp a r ud e n g a ne f u s i p l e u r ak a n a n . Da r i d a t al a i nd i k a t a k a nb a h wap e n d e r i t ak a n k e r d e n g a n VTE me mp u n y a ip r o g n o s i sy n a gl e b i hj e l e k b i l ad i b a n d i n g k a nd e n g a np e n d e r i t ak a n k e ry a n gt i d a k d i s e r t a id e n g a n VTE. An g k as u r v i v a l1 t a h u np a d a k a n k e rd e n g a nVTE h a n y a12% d i b a n d i n g k a nd e n g a n 36% p a d ap e n d e r i t ak a n k e rt a n p a VTE.23 S t u d il a i n me l a p o r k a na d a n y af a k t o rl a i ns e l a i n DVT s e b a g a i p r e d i k t o r p r o b a b i l i t a sk e mu n g k i n a nmu n c u l n y as e b u a h k a n k e r , y a i t ut i n g g i n y ak a d a r Dd i me r p a d ap e me r i k s a a n a wa l .P a d as t u d i i n i d i l a p o r k a na n g k aD d i me r> 4 0 0 0 n g / mlp a d as a a ta wa la k a n me n i n g k a t k a np r o b a b i l i t a s u n t u k mu n c u l n y ak a n k e r ,k h u s u s n y ap a d ap e n d e r i t a y a n gb e r u mu r< 60 t a h u nd e n g a n RR 3, 4p a d ap = 13 0 , 0 2. P a d ak a s u si n ij u g ad i d a p a t k a nk a d a rD d i me r
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y a n gt i n g g i> 4 0 0 0n g / mls e b e l u mk e b e r a d a a nk a n k e r p a r u n y ab i s ad i d e t e k s is e t a h u n k e mu d i a n d e n g a n p r o g n o s i s y a n gl e b i hj e l e ky a i t up e n d e r i t ai n i me n i n g g a l wa l a u p u ns u d a hs e mp a t me n d a p a t k e mo t e r a p i s e b a n y a k 6s i k l u st a n p ap e r b a i k a nk l i n i ky a n gn y a t a. Ka i t a n a n t a r a k a n k e rd a n t r o mb o s i ss u d a h s e j a k 150 t a h u ny a n gl a l ud i k e t a h u i ,n a mu na s p e k b i o mo l e k u l e r n y ab a r u mu l a il e b u hj e l a sd i k e t a h u i . S a mp a is a a ti n is u b s t a n s iy a n gp e n t i n gp a d ak a n k e r y a n ge r a tk a i t a nd e n g a nt r o mb o s i sa d a l a hp r o t e i n f a k t o rj a r i n g a n y a n g d i s e b u ts e b a g a ic anc er c ell 9 , 24 p roc oag ulant .7, P r o t e i ni n ia k a nb e r i t e r a k s id e n g a n p r o t e i nk o a g u l a s i d a np r o t e i nf i b r i n i l i t i ks e r t a k o mp o n e n s e l u l e rd a r is i s t e m h e mo s t a s i sy a i t up l a t e l e t ,e n d o t e l d a n ma k r o f a gs e h i n g g aa k a nt e r b e n t u kt r o mb o s i s . Di s a mp i n gi t ua d a n y as i t o k i n ,p r o t e i nf a s ea k u td a n mo l e k u la d e s ij u g ab e r p e r a na k t i fs e b a g a ib a g i a n d a r ir e s p o na k t i ft u b u ht e r h a d a ps e lk a n k e rt e r s e b u t . Ke s e mu ap r o s e si n ia k a nb e r p e r a np u l ap a d ap r o s e s p e r t u mb u h a n k a n k e rk h u s u s n y a p a d a me k a n i s me t e r j a d i n y ame t a s t a s e . Ha s i la k h i rd a r ii n t e r a k s is e mu a s e n y a wat a d i j u g ad i t e n t u k a no l e hb e b e r a p ah a l s e p e r t i 5, 8 j e n i sk a n k e r , r e s p o nt u b u h , d e r a j a t d a r i p e n y a k i t n y a . S e b a g a i mi s a l ,a d e n o k a r s i n o ma y a n g me mp r o d u k s i mu c i n u t a ma n y a k a n k e rp a n k r e a s ,a v a r i u m, p a r u me mp u n y a ih u b u n g a n y a n g t e r k u a td e n g a n DVT d i b a n d i n g k a n d e n g a n k a n k e rl a i n n y a ,d a n k a n k e r d e n g a ns t a d i u m me t a s t a s e me mp u n y a ii n s i d e n VTE y a n gl e b i ht i n g g ib i l ad i b a n d i n g k a nd e n g a nk a n k e r 13 p a d as t a d i u ma wa l .8, S i n d r o ma p a r a n e o p l a t i k me r u p a k a nh a ly a n g p e n t i n gd i k e t a h u io l e hk a r e n as i n d r o ma i n imu n g k i n s e b a g a it a n d a a wa ld a r is u a t u k a n k e r ,s e h i n g g a me mu n g k i n k a nu n t u k me n d e t e k s ik a n k e rp a d af a s e 25 a wa l d a nme n a n g a n i n y ad e n g a nl e b i hb a i k .17, S a mp a i s a a t i n i b a g a i ma n as e b u a hk a n k e r d a p a t me mp e n g a r u h i j a r i n g a ny a n gj a u hd a r i n y ab e l u m d i k e t a h u id e n g a n p a s t i . P e n e mu a n a n t ib o d ia n t i n e u r a lp a d ak a s u s s i n d r o map a r a n e o p l a s t i k , me mb e r i k e s a nb a h wah a l i n i t i mb u l o l e ha d a n y ar e s p o ni mu ny a n gb e r p e r a n , wa l a u t i d a ks e t i a ps i n d r o ma i n ia k a nd i i k u t io l e ht e mu a n
DeepVein T h romb os iss e b a g a i Ma n i f e s t a s i S i n d r o maP a r a n e o p l a s t i kd a r i Ka n k e rP a r u Ket ut S ueg a

a d a n y aa u t oa n t i b o d i . Bu k t i t e r a k h i r me n g a t a k a nb a h wa s i n d r o mai n ime r u p a k a na k i b a td a r ir e s p o ni mu nk i t a t e r h a d a ps e lk a n k e r . Ol e hk a r e n a n y aa p a b i l ar e s p o n i mu ni n is e d e mi k i a nh e b a t n y a ,ma k ah a li n na k a n d a p a t me mp e r l a mb a t p e r t u mb u h a ns e l k a n k e r t e r s e b u t . Ha l i n i me n j e l a s k a nk e n a p ap a d as i n d r o mai n i k a d a n g k a n k e rp r i me r n y at i d a ka t a ub e l u md i k e t a h u i p a d as a a t p r e s e n t a s ia wa ld a r is i n d r o mai n i . Ak a nt e t a p ik a n k e r y a n gt e r s e mb u n y ii n ia p a b i l ap a d aa k h i r n y a mu n c u l b i a s a n y a me mp u n y a ip r o g n o s i sy a n g l e b i h j e l e k o l e hk a r e n ab i a s a n y ad i j u mp a is u d a hp a d as t a d i u m l a n j u ta k i b a td a r ig e j a l aa wa lt u mo ri n id i t u t u p io l e h 16, 17 k e b e r a d a a ns i n d r o map a r a n e o p l a s t i ki n i . Be b e r a p a t u mo rs o l i dy a n gs e r i n gd i t e mu k a nd e n g a ns i n d r o ma p a r a n e o p l a s t i ka d a l a ht u mo rp a n k r e a s ,p a r u ,o v a r i u m d a ns a l u r a nc e r n a . Da l a ms a l a hs a t ul a p o r a n10d i a n t a r a 11 p e n d e r i t ak a n k e rd e n g a ns i n d r o mai n i a d a l a ht u mo r p a r ud a na n t i Hua n t i b o d i me r u p a k a ns a l a hs a t uma r k a p e n t i n gu n t u kk e b e r a d a a nt u mo rp a r u .25 P a d ak a s u si n i , k e b e r a d a a nDVT s e b a g a i b a g i a n d a r i s i n d r o map a r a n e o p l a s t i kd i d u g ak a r e n ame r u p a k a n t a n d aa wa ld a r is u a t uk a n k e rp a r uy a n gd i k e t a h u i s e k i t a rs e t a h u nk e mu d i a ns e t e l a hp e n d e r i t ame n g e l u h b a t u k b a t u kl a ma d i s e r t a id e n g a ns e s a kn a f a s . P a d a s a a ta wa l DVT d i k e l u h k a nk e b e r a d a a nt u mo rp a r u b e l u m b i s ad i b u k t i k a n wa l a u p u np a d as a a tt e r s e b u t s u d a hd i l a k u k a nb e b e r a p ap e me r i k s a a nt e r ma s u kf o t o t o r a k s . De mi k i a np u l ah a ln y ak e b e r a d a a n DVT p a d a k a n k e r i n i a k a nme mb e r i k a np r o g n o s i sy a n gl e b i hj e l e k d a ni n i t e r b u k t i d e n g a nme n i n g g a l n y ap a s i e ni n i d a l a m wa k t uc u k u ps i n g k a t wa l a u p u nt e l a hs e mp a t d i b e r i k a n t e r a p i k o mb i n a s i k a r b o p l a t i nd a ng e ms i t a b i n . Ka r e n at a n d ad a ng e j a l ad a r is u a t us i n d r o ma p a r a n e o p l a s t i ks a n g a tb e r v a r i a s id a nt i d a ks p e s i f i k ma k ad i p e r l u k a ns u a t up e ma h a ma ny a n gk o mp r e n s i f u n t u k me n g e n a ld a n me mb e d a k a na p a k a hy a n gk i t a h a d a p is u a t us i n d r o map a r a n e o p l a s t i ka t a u k a hk o n d i s i k l i n i ka k i b a tp e n y a k i tl a i n n y a . Ha li n ime n j a d is a n g a t p e n t i n go l e hk a r e n as i n d r o ma i n id a p a tme r u p a k a n s a t u s a t u n y ag e j a l aa wa l s u a t uk a n k e r , d a np e n g e n a l a n i n it e n t u n y aa k a nme n u n t u nk i t au n t u kme n c a r it u mo r 131

p r i me r n y as e h i n g g ad e t e k s i d i n i i n i a k a nme n i n g k a t k a n 15 a n g k ak e s e mb u h a n n y a . S u a t uk u mp u l a nd a r ig e j a l a d a p a td i a n g g a p s e b a g a is i n d r o ma p a r a n e o p l a s t i k a p a b i l ag e j a l a g e j a l at e r s e b u tb e r h u b u n g a nd e n g a n b a h a na k t i fy a n gd i k e l u a r k k a no l e hs e lt u mo r n y ad a n b e r e d a rd a l a m d a r a h ,y a n ga p a b i l ad i l a k u k a nr e s e k s i d a r it u mo r n y aa k a nd i i k u t id e n g a n me n g h i l a n g n y a g e j a l a g e j a l ak l i n i kt a d i d a nb a h a nt e r s e b u t h a r u sd a p a t d i b u k t i k a ns e c a r ain v iv o ma u p u nin v it ro.17 RI NGKAS AN Di l a p o r k a n s e b u a h k a s u s s e o r a n g p e n d e r i t a wa n i t a 4 6t a h u n , t i d a kme r o k o k , me n d e r i t ak a n k e r p a r us t a d i u m l a n j u ty a n gk e l u h a na wa l n y as e t a h u ns e b e l u mn y a h a n y ab e r u p ap e mb e n g k a k a nk a k i k a n a n( DVT)t a n p a d i s e r t a i d e n g a nk e l a i n a nl a i n n y a . Da l a mp e r j a l a n a n n y a p e n d e r i t a me n g e l u hb a t u ky a n gb e r l a n g s u n gc u k u p l a ma , h i l a n gt i mb u l d a nma k i nme mb e r a t y a n gd i s e r t a i d e n g a ns e s a kn a f a sd a np e n u r u n a nb e r a tb a d a n .P a d a a k h i r n y a p e n d e r i t a d i d i a g n o s i s me n d e r i t a k a n k e r p a r us t a d i u m l a n j u t . S e mp a t me n j a l a n ip e n g o b a t a n d e n g a nr e g i me nk e mo t e r a p i k o mb i n a s i k a r b o p l a t i nd a n g e ms i t a b i ns e l a ma 6s i k l u s a k a nt e t a p i p e n y a k i t p e n d e r i t a ma k i nb e r t a mb a hb e r a td a n me n i n g g a la k i b a tg a g a l n a f a sk a r e n at u mo r y a n gp r o g r e s i f . Di s i mp u l k a nb a h wa b e n g k a kk a k i( DVT) p a d ap e n d e r i t ai n ime r u p a k a n s i n d r o ma p a r a n e o p l a t i ky a i t u ma n i f e s t a s ia wa ld a r i s u a t uk a n k e r d a l a mh a l i n i a d a l a hk a n k e r p a r u . DAF T AR RUJ UKAN

4 .

5.

6.

7 .

8 . 9 .

10 .

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12. 1. Do n a l d S . De e p v e i n t h r o mb o s i s a n d t h r o mb o p h l e b i t i s . Av a i l a b l e f r o m: www.e t h Me d i c i n e .c o m/ f o r We b M D. Ac e s s e do n : 10 S e p 20 0 7 . Ke l l y J , Ru d d A, Le wi s RR, Hu n t BJ . P l a s ma Dd i me r s i n t h e d i a g n o s i s o f v e n o u st h r o mb o e mb o l i s m. Ar c h I n t e r n Me d 20 0 2; 162: 7 4 7 56. Qa s e e m A,S n o w V,Ba r r yP ,Ho r n b a k e ER,

13.

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3. 132

Ro d n i c kJ E, T o b o l i cT ,e ta l . Cu r r e n td i a g n o s i s o fv e n o u st h r o mb o e mb o l i s mi np r i ma r yc a r e :a c l i n i c a lp r a c t i c eg u i d e l i n ef r o m t h e Ame r i c a n Ac a d e myo f F a mi l yP h y s i c i a na n dt h eAme r i c a n Co l l e g eo fP h y s i c i a n s . An nF a m Me d 20 0 7 ; 5( 1) : 57 62. S c a r v e l i sD, We l l sP . Di a g n o s i sa n dT r e a t me n t o f d e e p v e i nt h r o mb o s i s . CM AJ 20 0 6; 17 5( 9 ) : 10 8 7 10 9 2. Le e AYY. Th r o mb o s i sa n dc a n c e r :t h er o l eo f s c r e e n i n gf o ro c c u l tc a n c e ra n dr e c o g n i z i n gt h e u n d e r l y i n gb i o l o g i c a l me c h a n i s ms . He ma t o l o g y 20 0 6; 66: 11258 . Ka k k a rAK,Le v i n e M ,P i n e d o HM ,Wo l f fR, Wa yJ . Ve n o u st h r o mb o s i si nc a n c e rp a t i e n t : i n s i g h tf r o m t h eF r o n t l i n es u r v e y . On c o l o g i s t 20 0 3, 8 : 38 58 . S o u s o uT , Kh o r a n a AA. Ne wi n s i g h t s i n t oc a n c e r a s s o c i a t e dt h r o mb o s i s . Ar t e r i o s c l e r Th r o mbVa s c Bi o l 20 0 9 ; 29 : 31620 . Hi l l e n HF . Th r o mb o s i si nc a n c e rp a t i e n t s . An n On c o l 20 0 0 ; 11( S 3) : 27 36. Bo c c a c c i o C,Co mo g l i oP M. A f u n c t i o n a lr o l e f o rh e mo s t a s i si ne a r l yc a n c e rd e v e l o p me n t . Ca n c e rRe s20 0 5; 65( 19 ) : 8 57 9 8 2. Kr o g e r K,We i l a n d D, Os e C, Ne u ma n n N, We i s sS , Hi r s c hC, e t a l . Ri s kf a c t o r sf o rv e n o u s t h r o mb o e mb o l i ce v e n t si nc a n c e rp a t i e n t s . An n On c o l 20 0 6; 17 : 29 7 30 3. P a n d o n n iP ,P i c c i o l i A, Gi r o l a mi A. Ca n c e r a n dv e n o u st h r o mb o e mb o l i s m: a no v e r v i e w. Ha e ma t o l o g i c a19 9 9 ; 8 4 : 4 37 4 5. P r a n d o n i P . Ho wI t r e a t v e n o u s t h r o mb o e mb o l i s m i n p a t i e n t s wi t h c a n c e r . Bl o o d 20 0 5; 10 6: 4 0 27 33. S c h u t g e n s R,Be c k e r s M ,Ha a sF ,Bi e s ma D. Th ep r e d i c t i v ev a l u eo fDd i me rme a s u r e me n t f o r c a n c e r i np a t i e n t swi t hd e e pv e i nt h r o mb o s i s . Ha e ma t o l o g i c a20 0 5; 9 0 : 214 9 . Ro b e r t F . Th e p o t e n t i a l b e n e f i t s o f l o wmo l e c u l a r we i g h th e p a r i n si nc a n c e rp a t i e n t s . J o u r n a lo f He ma t o l o g ya n dOn c o l o g y20 10 ; 3: 36.
J Peny Dalam, Volume 12 Nomor 2 Mei 2011

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20 .

Da r n e l l RB, P o s n e r J B. P a r a n e o p l a s t i c s y n d r o me si n v o l v i n gt h en e r v u ss y s t e m. N En gJ Me d20 0 3; 34 9 : 154 354 . Bl o o m F E. P a r a n e o p l a s t i c s y n d r o me s . Th e c o mp l e t ed a n ag u i d et ob r a i nh e a l t h . Av a i l a b l e t h f r o m: www.d a n a p r e s s .c o m. Ac e s s e do n : 10 Ma r c h20 0 7 . Wo n g AK,Al f e r tM ,Ca s t r i l l o n DH,S h e n Q, Ho l a s hJ ,Ya n c o p o u l u s GD. Ex c e s s i v et u mo r e l a b o r a t e d VEGF a n di t sn e u t r a l i z a t i o nd e f i n e a l e t h a l p a r a n e o p l a s t i c s y n d r o me . P NAS 20 0 1; 9 8 : 7 4 8 16. Hi r s hJ , Le eA. Ho w wed i a g n o s ea n dt r e a t d e e p v e i nt h r o mb o s i s . Bl o o d20 0 2; 9 9 ( 9 ) : 310 210 . Mu r c h i s o nJ T ,W y k e L,S t o c k t o n DL. Ex c e s s r i s ko fc a n c e ri np a t i e n t swi t hp r i ma r yv e n o u s t h r o mb o e mb o l i s m: a n a t i o n a l ,p o p p u l a t i o n b a s e dc o h o r t s t u d y . BrJCa n c e r20 0 4 ; 9 1: 9 25. Ca r r i e rM ,Le Ga lG,W i l l sP S ,F e r g u s s o n D, r a ms a yT ,Ro d g e rM A. S y s t e ma t i cr e v i e w:t h e T r o u s s e us y n d r o mer e v i s i t e d :s h o u l d wes e c r e n e x t e n s i v e l yf o rc a n c e ri np a t i e n t swi t hv e n o u s t h r o mb o e mb o l i s m? An nI n t e rM e d 20 0 8 ; 14 9 : 32333.

21.

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Mo n r e a l M , Le n s i n g AN, P r i ms M H, Bo n e t M ,f e r n a n d e z Li a mz a r e sJ ,M u c h a r tJ ,e ta l . S c r e e n i n gf o r o c c u l t c a n c e r i np a t i e n t swi t ha c u t e d e e pv e i nt h r o mb o s i so rp u l mo n a r ye mb o l i s m. J Th r o mbHa e mo s t 20 0 4 ; 6: 8 7 68 1. P i c c i o l iA,Le n s i n g AW,P r i n s M H. Ex t e n s i v e s c r e e n i n g f o ro c c u l t ma l i g n a n td i s e a s e i n i d i o p a t h i c v e n o u s t h r o mb o e mb o l i s m: a p r o s p e c t i v er a n d o mi z e dc l i n i c a lt r i a l . JTh r o mb Ha e mo s t 20 0 4 ; 2: 8 8 4 9 . S o r e n s e n HT , Me l l e mk j a e rL, Ol s e nJ H, Ba r o n J H. P r o g n o s i so fc a n c e ra s s o c i a t e d wi t hv e n o u s t h r o mb o e mb o l i s m. N En g lJ M e d 20 0 0 ; 34 3: 18 4 650 . Wa j t u c k e wi t c z M Z,S i e r k o E,Ll e me n tP ,Ra k J . Th eh e mo s t a t i cs y s t e m a n da n g i o g e n e s i si n l a i g n a n c y . Ne o p l a s i a20 0 1; 3: 37 18 . Le f e b v r e CC,Ho wa r t h N,Gr e n i e rP ,Ke i me F ,Or c e lB,Be i g e l ma n C. As s o c i a t i o no fs ma l l c e l ll u n gc a n c e ra n dt h ea n t i h up a r a n e o p l a s t i c s y n d r o me :r a d i o g r a p h i ca n d CT f i n d i n g s . AJ R. 19 9 8 ; 17 0 : 15137 .

DeepVein T h romb os iss e b a g a i Ma n i f e s t a s i S i n d r o maP a r a n e o p l a s t i kd a r i Ka n k e rP a r u Ket ut S ueg a

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