Symptoms of shortness of breath with a proven DVT

Dear Ask The Doctor:  I'm a 48 year male. I am married with 4 kids. I'm 6'2" and 215 lbs. In April I began having chest pains and shortness of breath when exercising. My doctor ordered a stress test which was normal. In August I developed DVT in my left leg. Multiple clots in multiple veins. I have been tested for every clotting problem all of which have proven negative. My doctors have labeled this as idiopathic DVT. Also in August the chest pains and the feeling of palpitations have become constant as well as the shortness of breath. I get out of breath tying my shoes. I was tested again for heart problems with an echocardiogram and a heart monitor. All proved negative. I went to a hematologist oncologist who ordered a CT scan of the chest looking for a possible silent PE. No PE but they did find 3 nodules in one lung and 1 in another. The largest nodule being .5cm. I was then sent to a pulmonologist who said the nodules are too small to biopsy and to rescan in 3 months. He did not believe it was cancer. I have been told by all doctors that idiopathic DVT is a marker for cancer, expecially lung cancer. I should also say that I smoked 2 packs a day for 10 years. I quit 20 years ago. I also worked in ashphalt construction for 4 years. Can you provide me your professional thought and opinion? The chest pain, back pain (between my shoulder blades) and now lower rib pain along with my continued shortness of breath is getting worse. Thanks Dan
 

Dear Patient:  Idiopathic DVT can be a manifestation of malignant disease in the body; however this is not always the case. The pulmonary nodules identified may just be an incidental finding on CT scan, particularly if the largest nodule is 0.5cm. If these nodules are not amenable to biopsy, it would be best to monitor them with serial CT scans to detect any change, enlargement, or adjacent enlargement of lymph nodes. By CT criteria lymph nodes of greater than 1cm are considered malignant until proven otherwise, but at present there is no evidence of nodal enlargement. It is difficult to determine the cause of your symptoms, if cardiac investigations are normal and CT Pulmonary angiogram revealed no evidence of pulmonary embolus. If not already completed I would advise pulmonary function testing, arterial blood gas measurement, auto immune screen, peak flow measurement and possible bronchoscopy or high resolution CT scan of the chest, with referral to a Respiratory Consultant for a specialized opinion.

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