Implementation of NICE recommendations on abdomino-pelvic CT, following unprovoked venous thromboembolism, in a UK teaching hospital: no additional detection of occult malignancy and high numbers of incidental findings.
BACKGROUND
NICE Clinical Guideline 144 recommends that patients with an unprovoked VTE, who do not have signs or symptoms of cancer on initial investigation, be considered for further investigation with an abdomino-pelvic CT to exclude occult malignancy. This study aimed to evaluate numbers of scans performed in a UK teaching hospital and outcomes, following this recommendation.


METHODS
Retrospective review of CT scans performed before and after publication of the NICE guidance in 2012. CT reports and case notes were analysed. Type and stage of malignancy, treatment and other relevant findings were documented. For the 2014 data set, all incidental radiological findings and follow-up recommendations were reviewed.


RESULTS
The annual number of CT scans requested for "unprovoked VTE", rose by 142% following publication of NICE Clinical Guideline 144. In the 2011 - 2012 data set, 21 patients were included, one of which was found to have a malignancy, which was clinically overt at the time of diagnosis i.e. not occult. Five patients (23.8%) had incidental findings requiring further investigation. In the 2014 - 2015 data set, 51 patients were included, five (9.8%) of which were found to have malignancy. In retrospect, all showed signs/symptoms of potential malignancy on initial investigation. No occult malignancies were detected in the patients correctly referred. Incidental findings warranting further investigation were reported in ten cases (19.6%). On review, follow-up advice was deemed incorrect in four of these.


CONCLUSIONS
Addition of an abdomino-pelvic CT scan in patients with a first unprovoked VTE and no signs or symptoms of cancer on initial investigation, significantly increased the number of scans and incidental findings, but did not pick up any additional occult malignancies.
Foundation Year 1 Doctor, Royal Liverpool University Hospital, UK.
David
D
Garwood
Consultant in Acute Medicine, Royal Liverpool University Hospital, UK.
Bryan J
BJ
Renton
Consultant Radiologist, Royal Liverpool University Hospital, UK.
Elizabeth
E
Joekes
D000005:Abdomen / Q000000981:diagnostic imaging; D000328:Adult; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006784:Hospitals, Teaching / Q000592:standards; D006801:Humans; D033162:Incidental Findings; D008297:Male; D008875:Middle Aged; D009382:Neoplasms, Unknown Primary / Q000150:complications / Q000000981:diagnostic imaging*; D017063:Outcome Assessment, Health Care; D010388:Pelvis / Q000000981:diagnostic imaging; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D018570:Risk Assessment; D014057:Tomography, X-Ray Computed / Q000379:methods*; D006113:United Kingdom; D054556:Venous Thromboembolism / Q000000981:diagnostic imaging* / Q000503:physiopathology