Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
Department of Oncology, McMaster University, Hamilton, Canada.
J Thromb Haemost. 2020 Sep;18(9):2245-2252. doi: 10.1111/jth.14900. Epub 2020 Jul 8.
A previous individual participant data (IPD) meta-analysis showed that the Wells rule and D-dimer testing cannot exclude suspected deep vein thrombosis (DVT) in cancer patients.
To explore reasons for this reduced diagnostic accuracy and to optimize the diagnostic pathway for cancer patients suspected of DVT.
Using IPD from 13 studies in patients with suspected DVT, DVT prevalence and the predictive value of the Wells rule items and D-dimer testing were compared between patients with and without cancer. Next, we developed a prediction model with five variables selected from all available diagnostic predictors.
Among the 10 002 suspected DVT patients, there were 834 patients with cancer. The median prevalence of DVT in these patients with cancer was 37.5% (interquartile range [IQR], 30.8-45.5), whereas it was 15.1% (IQR, 11.5-16.7) in patients without cancer. Diagnostic performance of individual Wells rule items and D-dimer testing was similar across patients with and without cancer, except "immobility" and "history of DVT." The newly developed rule showed a pooled c-statistic 0.80 (95% confidence interval [CI], 0.75-0.83) and good calibration. However, using this model, still only 4.3% (95% CI, 3.0-5.7) of the suspected patients with cancer could be identified with a predicted DVT posttest probability of <2%.
Likely because of the high prevalence of DVT, clinical models followed by D-dimer testing fail to rule out DVT efficiently in cancer patients suspected of DVT. Direct referral for compression ultrasonography appears to be the preferred approach for diagnosis of suspected DVT in cancer patients.
先前的一项个体参与者数据（IPD）荟萃分析表明，Wells 评分和 D-二聚体检测不能排除癌症患者疑似深静脉血栓形成（DVT）的可能性。
探究导致这一诊断准确性降低的原因，并优化疑似 DVT 的癌症患者的诊断途径。
利用来自 13 项疑似 DVT 患者研究的 IPD，比较了有和无癌症患者的 DVT 患病率，以及 Wells 评分项目和 D-二聚体检测的预测价值。然后，我们从所有可用的诊断预测因素中选择五个变量，建立了一个预测模型。
在 10 002 例疑似 DVT 患者中，有 834 例为癌症患者。这些癌症患者的 DVT 患病率中位数为 37.5%（四分位距 [IQR]，30.8-45.5），而无癌症患者的患病率中位数为 15.1%（IQR，11.5-16.7）。除了“活动受限”和“DVT 病史”外，个体 Wells 评分项目和 D-二聚体检测的诊断性能在有和无癌症患者中相似。新开发的规则显示出汇总的 c 统计量为 0.80（95%置信区间 [CI]，0.75-0.83）和良好的校准度。然而，使用该模型，仍只有 4.3%（95% CI，3.0-5.7）的疑似癌症患者可以被识别，其预测的 DVT 后验概率<2%。
可能由于 DVT 患病率较高，在疑似 DVT 的癌症患者中，临床模型联合 D-二聚体检测不能有效地排除 DVT。对于疑似 DVT 的癌症患者，直接进行压迫超声检查似乎是首选的诊断方法。
