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Massive PE — SCE Medical Oncology MCQ

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HardOncological EmergenciesMassive PESCE Medical Oncology

A 65-year-old man presents to A&E with acute left leg swelling and sudden breathlessness. He was diagnosed with pancreatic cancer 2 weeks ago and has not yet started chemotherapy. CT confirms extensive ileofemoral DVT and bilateral PE with right heart strain. What initial management is required?

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Correct answer: D — IV unfractionated heparin with monitoring, consider thrombolysis given massive PE with RV strain

Massive PE with right ventricular strain/haemodynamic compromise requires urgent IV unfractionated heparin (bolus + infusion) due to its short half-life, titrability and reversibility. Thrombolysis (systemic alteplase) or catheter-directed therapy should be considered for massive PE with haemodynamic instability. While DOACs and LMWH are appropriate for haemodynamically stable cancer-associated VTE, massive PE requires more aggressive intervention. UFH also allows for perioperative bridging if surgery is imminent.

Reference: NICE NG158 VTE diseases; ESMO 2024 Oncological Emergencies; ESC 2019 PE Guidelines