ConditionBlood & immune system
Trousseau Syndrome (Cancer-Associated Thrombosis)
Trousseau syndrome is a tendency to form blood clots caused by an underlying cancer. It classically appears as migratory thrombophlebitis, painful clots in surface veins that appear in one place, then another, but it also includes deep vein thrombosis, pulmonary embolism and arterial clots that cause strokes. It is most often linked to adenocarcinomas of the pancreas, lung, stomach and ovary. Unexplained or recurrent clots may be the first sign of a hidden cancer. Treatment is anticoagulation, usually with heparin or newer oral anticoagulants, and treatment of the cancer.
Also called: Cancer-associated thrombosis, Trousseau sign of malignancy, migratory thrombophlebitis, hypercoagulability of malignancy
At a glance
- What it is
- Abnormal blood clotting caused by cancer.
- Classic sign
- Migratory superficial thrombophlebitis, tender cord-like veins appearing in different places.
- Other forms
- Deep vein thrombosis, pulmonary embolism, arterial clots, stroke, nonbacterial thrombotic endocarditis.
- Common cancers
- Pancreatic, lung, stomach, ovarian, brain and blood cancers.
- Diagnosis
- Imaging of clots, then a cancer search when clots are unexplained.
- Treatment
- Low molecular weight heparin or direct oral anticoagulants, plus cancer treatment.
When to get help
Call 911 or go to the ER
- Sudden shortness of breath, chest pain, coughing blood or fainting (possible pulmonary embolism)
- Sudden weakness, numbness, facial drooping, speech trouble or vision loss (possible stroke)
- A cold, pale, painful arm or leg
See a doctor within a day or two
- A swollen, painful, warm calf or arm
- Tender, red, cord-like veins appearing in different places over days or weeks
- A new blood clot in someone with cancer, or a clot while already on anticoagulants
Book a routine appointment
- A history of unexplained clots with weight loss, fatigue, abdominal pain or other new symptoms
- Questions about anticoagulant treatment duration and bleeding risk during cancer therapy
What Trousseau syndrome is
French physician Armand Trousseau described in 1865 that migratory clots in surface veins could signal a hidden stomach cancer. He later developed the same sign himself and died of stomach cancer. Today, the term is used broadly for clotting disorders caused by cancer.
Why cancer causes clots
Cancers make blood more prone to clot through several mechanisms:
- tumor cells release tissue factor, which starts the clotting cascade
- mucins from adenocarcinomas activate platelets and blood vessel lining
- cancer-related inflammation and immobility
- compression of veins by tumors
- cancer treatments: chemotherapy, hormone therapy, some targeted drugs and central venous catheters
Forms of cancer-associated thrombosis
| Form | Features |
|---|---|
| Migratory superficial thrombophlebitis | Tender, red, cord-like veins in unusual places (arms, chest), recurring and moving |
| Deep vein thrombosis | Leg or arm swelling and pain, sometimes in both legs |
| Pulmonary embolism | Breathlessness, chest pain, fast heart rate |
| Arterial thrombosis | Strokes, cold limbs, heart attacks |
| Nonbacterial thrombotic endocarditis | Sterile clots on heart valves that cause multiple strokes |
| Disseminated intravascular coagulation | Widespread clotting and bleeding, especially in advanced cancer |
Cancers most often involved
- pancreatic cancer, with one of the highest clot risks
- lung cancer, especially adenocarcinoma
- stomach, ovarian, uterine and kidney cancers
- brain tumors
- lymphoma, myeloma and leukemia
Symptoms
Symptoms depend on where clots form:
- painful, red, firm streaks along surface veins, appearing in different places
- leg or arm swelling, warmth and pain
- shortness of breath, chest pain and fast heartbeat
- stroke symptoms
- symptoms of the underlying cancer, such as weight loss, fatigue, abdominal or back pain
Diagnosis
- ultrasound of the affected limbs
- CT pulmonary angiography for suspected pulmonary embolism
- brain imaging and echocardiogram for strokes
- blood tests: blood count, clotting tests, D-dimer, fibrinogen
- search for an underlying cancer when clots are unprovoked: guidelines generally recommend a thorough history and examination, routine blood tests, chest X-ray and age-appropriate cancer screening. Extensive CT scanning of everyone with an unprovoked clot has not been shown to improve survival, but more testing is done when symptoms suggest cancer
- testing for thrombophilia in selected cases
Treatment
Anticoagulation
- Direct oral anticoagulants (apixaban, rivaroxaban, edoxaban) or low molecular weight heparin are recommended for cancer-associated venous clots
- warfarin is less effective in Trousseau syndrome and generally not preferred
- treatment usually continues at least 6 months and often as long as the cancer is active
- bleeding risk is weighed carefully, especially with gastrointestinal or genitourinary cancers, where heparin may be preferred
Treating the cancer
Effective cancer treatment reduces the clotting tendency.
Prevention
Some people with cancer at high clot risk, measured by the Khorana score, may be offered preventive anticoagulation during chemotherapy.
Outlook
Cancer-associated clots are a leading cause of death in people with cancer after the cancer itself. Recurrence risk is high, and bleeding on anticoagulation is more common than in people without cancer. Outlook depends mainly on the type and stage of cancer.
Frequently asked questions
What is Trousseau syndrome?
Trousseau syndrome is abnormal blood clotting caused by cancer. It classically shows up as recurring clots in surface veins in different places, but also includes deep vein clots, lung clots and strokes. It is most often linked to pancreatic, lung and stomach cancers.
Can blood clots be a sign of cancer?
Yes. Roughly 1 in 20 to 1 in 10 people with an unprovoked blood clot are diagnosed with cancer within a year, often with the clot being the first sign. Doctors usually do a careful examination, blood tests and age-appropriate cancer screening after an unexplained clot.
Which cancers cause Trousseau syndrome?
It is most commonly associated with mucin-producing adenocarcinomas of the pancreas, lung, stomach and ovary, as well as brain tumors and blood cancers. Any cancer can increase clotting risk.
How is Trousseau syndrome treated?
It is treated with anticoagulants, usually direct oral anticoagulants such as apixaban or low molecular weight heparin, plus treatment of the underlying cancer. Warfarin often fails to prevent new clots in this condition.
What is migratory thrombophlebitis?
It is a pattern of painful, tender clots in superficial veins that appear in one location, resolve, and then appear elsewhere. It is the classic sign of Trousseau syndrome and should prompt a search for an underlying cancer.
Sources
This guide was written from current patient and clinical guidance, including:
- American Society of Clinical Oncology: Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer Guideline (2023)
- American Society of Hematology: 2021 Guidelines for Management of Venous Thromboembolism in Patients With Cancer
- National Cancer Institute: Blood clots and cancer
- Blood (journal): Varki A, Trousseau's syndrome, multiple definitions and multiple mechanisms (2007)
- MedlinePlus: Blood clots