The Optimal Cutoff Level of D-Dimer during Pregnancy to Exclude Deep Vein Thrombosis, and the Association between D-Dimer and Postpartum Hemorrhage in Cesarean Section Patients.

OBJECTIVE: The main purpose was to clarify the optimal D-dimer cutoff level during pregnancy to exclude deep vein thrombosis (DVT) prior to Cesarean section. The secondary purpose was to determine whether D-dimer can predict severe postpartum hemorrhage (PPH) in Cesarean section patients. METHODS: Two hundred and seventy eight elective Cesarean section cases were enrolled. Clinical factors and blood parameters at 34-37 weeks of gestation were analyzed. To detect DVT, lower extremities veins were examined using color Doppler ultrasonography in cases with D-dimer level ≥ 1.5 µg/mL. In addition, postpartum blood loss amounts during Cesarean section were recorded. RESULTS: Five DVT cases occurred in 250 singleton pregnancies, and 2 DVT cases occurred in 28 twin pregnancies. The overall incidence of DVT was 2.5%. The D-dimer level was higher in DVT cases than in non-DVT cases (3.84±1.97 vs. 2.31±1.48 µg/mL, P<0.01). The optimal D-dimer cutoff level was 2.6 µg/mL with a negative predic tive value of 99.5%, and sensitivity of 85.7%. PPH during Cesarean section was positively correlated with D-dimer level in all pregnancies. However, this relationship disappeared after excluding twin pregnancies. CONCLUSION: A D-dimer level < 2.6 µg/mL at 34-37 weeks of gestation has the potential to exclude DVT. D-dimer can be an independent predictor for severe PPH for all Cesarean section cases, including twin pregnancies.

Predicting postpartum depression by evaluating temperament during pregnancy.

AIM: The purpose of this study was to investigate premorbid temperaments to predict postpartum depression in pregnant women with no previous psychiatric history and to clarify the correlation between postpartum depression and the factors included in the Postpartum Depression Predictors Inventory-Revised (PDPI-R) and the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Auto questionnaire (TEMPS-A)/Munich Personality Test (MPT). METHODS: A total of 170 eligible pregnant women filled out both questionnaires, the first between the 8th and 23rd week of gestation, and the latter between the 34th and 38th week of gestation. Participants filled out The Edinburgh Postnatal Depression Scale (EPDS) one month postpartum to measure for postpartum depression symptoms. All participants delivered full-term healthy babies. RESULTS: Seventeen (10%) women met the criteria for postpartum depression with a score of 9 or higher on the EDPS. The factors significantly related to developing postpartum depression were schizoid and melancholic temperament on the TEMPS-A/MPT and marital dissatisfaction on the PDPI-R. The total score on the PDPI-R was significantly correlated with depressive, cyclothymic, irritable, and anxious temperaments on the TEMPS-A/MPT. A lack of social support on the PDPI-R was significantly correlated with depressive, irritable, and anxious temperaments on the TEMPS-A/MPT. CONCLUSION: The findings suggest that postpartum depression may be related to schizoid and melancholic temperaments and marital dissatisfaction. The hyperthymic temperament was identified as a significant predictor in preventing PPD. Careful observation during puerperium is recommended if a pregnant woman is likely to have these temperaments or psychological conditions. Temperament evaluation should be done during pregnancy as a form of postpartum depression screening.

Weight reduction using a formula diet recovers menstruation in obese patients with an ovulatory disorder.

Aim: To determine the effectiveness of a formula diet in weight reduction and the recovery of menstruation in obese patients with ovulatory disorders. Methods: After the enrollment of 39 obese women with ovulatory disorders, they replaced one or two of their three normal meals with a microdiet (MD) (240 kcal/meal) for 24 weeks. Physical, endocrinological, and biochemical tests were conducted before and at 12 and 24 weeks of the study. Of the 39 women enrolled, 26 were not taking clomiphene. They were divided into three groups according to their body weight outcomes and then analyzed for menstruation recovery. Results: A weight reduction of ≥5% was observed in 31 (81.5%) of the 39 women. There were significant decreases in the body weight and Body Mass Index during the study. Menstruation returned in 18 (69%) of the 26 patients without clomiphene treatment, with the recovery being significantly more prevalent in the groups (totally 81.0%) that exhibited a 5%-10% weight reduction and ≥10% weight reduction, compared to the group with a <5% weight reduction. Conclusion: The use of a formula diet effectively reduced the patients' body weight and led to the recovery of menstruation in these obese patients with ovulatory disorders.

Predictive Factors for Efficacy and Safety of Prophylactic Theophylline for Extubation in Infants with Apnea of Prematurity.

PURPOSE: This study aimed to evaluate predictive factors involved in efficacy and safety in Japanese infants who received theophylline therapy to prevent apnea of prematurity (AOP) after weaning from mechanical ventilation. METHODS: We retrospectively reviewed the medical records of infants who were administered intravenous aminophylline (theophylline ethylenediamine) for AOP at the neonatal intensive care unit, Kagoshima University Hospital, Japan, between January 2009 and June 2013. RESULTS: A total of 100 infants were evaluated as two separate groups in terms of efficacy and safety of theophylline. Sixty-seven (67.0%) infants had effective theophylline therapy. Multivariate logistic regression analysis showed that gestational age at birth was significant, with an odds ratio of 0.59 (p < 0.001). Receiver operating characteristic analysis showed that the cut-off value was 31.1 weeks old for predicting the efficacy of theophylline (specificity, 66.7%; sensitivity, 86.6%; p < 0.001; area under the curve, 0.750; 95% confidence interval, 0.45-0.74). Adverse reactions were identified in 21 (21.0%) infants. Multivariate logistic regression analysis showed that the number of days of theophylline administration from birth was associated with an increased risk of adverse reactions after theophylline administration (p = 0.01). CONCLUSIONS: Physicians need to be aware of the possibility that theophylline fails to produce therapeutic effects for extubation in infants aged less than 31.1 weeks old, and adverse reactions can easily develop when theophylline is administered soon after birth.

Clinical Usefulness of Bakri Balloon Tamponade in the Treatment of Massive Postpartum Uterine Hemorrhage.

Intrauterine globe-shaped metreurynter tamponade has been used for some time to treat massive postpartum hemorrhage (PPH). More recently, the Bakri balloon has come into use to treat PPH. It is made of silicon, possesses a drainage lumen, and has a sausage-like spindle shape. The aim of the present study was to investigate the clinical usefulness of Bakri balloon tamponade for massive PPH. Subjects in the present study comprised 5 patients with uterine atony, 3 with placenta previa, and 2 with low-lying placenta. All patients exhibited massive PPH and resistance to conventional hemostatic managements. Bakri balloon tamponade was appliedto these 10 patients. The mean amounts of uterine bleeding (average ± SD) before and after Bakri insertion were2,732 ± 1,397 mL and 380 ± 376 mL, respectively. The median (third-first quartile ranges) volume of salineinflating the balloon was 200 mL (300-150 mL). The median (third-first quartile ranges) indwelling duration of Bakri balloon was 24 hours (24-11 hrs). The overall success rate of Bakri balloon tamponade was 90% (9/10).There were no cases of slipping out or complications regarding balloon placement. Our findings suggest that Bakri balloon tamponade may be applied to the treatment of massive PPH in uterine atony and placenta previa.The Bakri balloon appears to have the following merits: (1) easy insertion into the uterine cavity and low rate of slipping out, (2) proper conformability to the hemorrhagic area due to its spindle shape, (3) ability to monitor blood loss through the drainage lumen even after insertion.

HPMA Copolymer-Conjugated Pirarubicin in Multimodal Treatment of a Patient with Stage IV Prostate Cancer and Extensive Lung and Bone Metastases.

Nanomedicine allows achievement of tumor-selective drug delivery because of the enhanced permeability and retention (EPR) effect of solid tumors. We report here the first clinical application of a new agent-HPMA copolymer-conjugated pirarubicin (P-THP)-with a molecular size of about 8 nm, or 38.5 kDa. A patient had advanced prostate cancer with multiple metastases in the lung, pelvis, femur, and perhaps the sacrum. In April 2013, this 60-year-old patient started treatment with leuprorelin and estradiol, which continued until July 2014, but the patient became refractory to this treatment. So the patient underwent proton beam radiotherapy targeted to the primary prostate cancer, and P-THP was administered for numerous metastatic tumor nodules concomitantly with radiotherapy. This combination therapy had remarkable results, with complete remission of multiple metastases in the lung and bone. The prostate-specific antigen (PSA) value was decreased from about 1000 ng/mL on April 30, 2013, to about 100 ng/mL on June 24, 2013, with hormone therapy, but rose again to 964.2 ng/mL and then to 1472 ng/mL in July 2013, during leuprorelin administration. P-THP treatment administered concomitantly with proton beam irradiation was started in August 2013. The PSA value was decreased to 102 ng/mL on August 26, 2013, and then to 0.971 ng/mL on October 8, 2013, and 0.277 ng/mL on January 15, 2015. The P-THP doses ranged from 30 to 75 mg of free THP equivalent/patient every 2-3 weeks without signs of serious toxicity, such as cardiovascular side effects or a reduction in quality of life. No evidence of relapse was found more than 20 months after P-THP administration. This case demonstrates the value of hydrazone-bonded polymeric drugs in multimodal therapy.

Is It Possible to Perform Less Radical Surgery for Invasive Uterine Cervical Cancer?

BACKGROUND/AIMS: A retrospective analysis was performed to evaluate the possibility of less radical surgery for early-stage invasive uterine cervical cancer without compromising the oncological outcome. METHODS: The analysis was performed on 175 patients with invasive uterine cervical cancer in FIGO stage IA2-IIB, all of whom underwent primary radical hysterectomy. Relationship of tumor size with the incidence of pathologic parametrial involvement and the pelvic lymph node metastasis were investigated. RESULTS: Fifty-one patients had tumor size ≤2 cm and 124 had tumor size >2 cm. Patients with tumor size ≤2 cm had a significantly lower incidence of parametrial invasion (p < 0.0001), lymph node metastasis (p < 0.0001), lymph vascular space involvement (p < 0.0001) and recurrence (p = 0.0002) than patients with tumor size >2 cm. Five-year relapse-free survival rate was 98 and 73%, respectively (p = 0.0004). CONCLUSION: It is suggested that less radical surgery may be appropriate for some cases with tumor size <2 cm.

A very rare case of endometriosis presenting with massive hemoperitoneum.

Endometriosis is a cause of acute abdomen because of the leakage or rupture of endometriotic cyst and tubo-ovarian abscess. However, massive hemoperitoneum as a cause of acute abdomen with endometriosis is very rare. We herein present a case of a 48-year-old woman who was urgently referred to our clinic with colic, abdominal distension, and hypovolemic shock during menstruation. Ultrasonography revealed massive hemorrhagic ascites. Exploratory laparoscopy was urgently performed to achieve hemostasis. The volume of hemoperitoneum evacuated from the pelvis was 1,890 mL. Although the uterus and bilateral ovaries were normal, fresh bleeding was observed from endometriosis on the left cul-de-sac peritoneum, and hemostasis was successfully performed. The potential occurrence of hemorrhagic shock associated with endometriosis, depending on the implantation site, needs to be recognized.

Identification of new risk factors for wound separation in gynecologic malignancy surgery.

AIM: The purpose of this study was to compare prophylactic subcutaneous drainage plus subcuticular sutures versus staples for the risk of wound separation after skin closure following gynecologic malignancy surgery, and to investigate the risk factors of this procedure. MATERIAL AND METHODS: Patients were divided into two groups: 120 patients who were treated with subcutaneous drainage plus subcuticular sutures (Suture group) and 201 patients with staples plus subcutaneous sutures (Staples group). In the Suture group, subcuticular tissue was approximated with interrupted 4-0 polydioxanone sutures, and adhesive closure strips were used on the skin surface. A 3.3-mm closed drainage was implicated in subcutaneous tissue. In the Staples group, subcutaneous tissue was approximated with interrupted polyglactin (Vicryl, Ethicon) sutures. RESULTS: Baseline characteristics were not significantly different between the two groups. Mean operation times were compatible (201 vs 196 min, P = 0.16). The incidence of wound separation was less in the Suture group than in the Staples group (3/120 vs 17/201, P = 0.033). Multiple logistic regression analysis revealed that the Staples group was an independent risk factor for wound separation (odds ratio 7.34, 95% confidence interval: 1.59-33.91, P = 0.011), independent of obesity, International Federation of Gynecology and Obstetrics stages, and operation time. None of the 14 obese patients in the Suture group showed surgical wound separation. CONCLUSIONS: The combination of a prophylactic subcutaneous drain and subcuticular sutures reduced wound separation after skin closure following gynecologic malignancy surgery. With the information regarding risk factors established in this study, the above method provides the best results to minimize the risk, particularly in obese patients.

Potential proton beam therapy for recurrent endometrial cancer in the vagina.

Proton beam radiotherapy mainly has been used in the gynecological field in patients with cervical cancer. The efficacy of proton beam therapy in patients with recurrent endometrial cancer has not yet been determined. A 77-year-old endometrial cancer patient presented with recurrence in the vagina without distant metastasis following hysterectomy. A hard mass measuring 6 cm originated from the apex of the vagina, surrounded the vaginal cavity, and infiltrated the proximal and distal vagina. The patient received proton beam radiotherapy using a less invasive particle treatment system while minimizing the dose to the surrounding normal tissues. The dose to the planning target volume was 74 Gy (relative biological effectiveness) with 37 fractions. The patient was treated with 150-210-MeV proton beams for 53 days. Proton beam therapy led to the disappearance of tumors without any complications except for grade 1 cystitis although evidence of further complications is not available past our 6-month follow-up period. Proton beam therapy may become a useful treatment modality for recurrent endometrial cancer as well as cervical uterine cancer.

Menstrual restoration in severe panhypopituitarism many years after cranial irradiation for suprasellar germinoma.

Purpose: We report a very rare case showing menstrual restoration in severe pan-hypopituitarism many years after cranial irradiation for suprasellar germinoma. Case: A 30-year-old, almost primarily amenorrheic woman with severe panhypopituitarism presented with cyclic genital bleeding for the previous five months. She had menstruated once, when she was 13 years old. When she was 14 years old, she was diagnosed with a suprasellar germinoma measuring 10 mm in diameter, which led to diabetes insipidus. Cranial irradiation with a total dose of 24 Gy and chemotherapy resulted in complete tumor remission. She developed severe hypopituitarism [luteinizing hormone (LH) = 0.4 mIU/mL, follicle-stimulating hormone (FSH) = 1.7 mIU/mL, and serum estradiol (E2) level < 10 pg/mL]. She had received multiple hormone replacement therapies for many years. When she was 29 years old, she expressed a desire to become pregnant. Serum gonadotropin and E2 levels increased (LH = 5.8 mIU/mL, FSH = 5.9 mIU/mL, and E2 = 58 pg/mL). She conceived with clomiphene therapy, and then delivered a healthy baby. Eight months after parturition, her basal body temperature and serum progesterone levels indicated recovery of ovulatory cycles. Ten months after parturition, she also spontaneously conceived. Conclusion: Menstrual restoration is very rare in severe panhypopituitarism after cranial irradiation. A relatively low dose of irradiation and small tumor size may have contributed to the recovery of menstruation in our patient.

Current human T-cell lymphotropic virus type 1 mother-to-child transmission prevention status in Kagoshima.

The aim of this study was to assess the current human T-cell lymphotropic virus type 1 (HTLV-I) mother-to-child transmission (MTCT) prevention system in Kagoshima Prefecture. We investigated the rate of carrier pregnant women from obstetrics facilities in Kagoshima by mail in 2012 and compared our results with previous study results. We interviewed carrier pregnant women about their choices for infant nutrition, and we interviewed midwives about the follow-up system. In 2012, 8719 screening tests were performed, covering 58.1% of all pregnant women in Kagoshima; the rate of carrier pregnant women was 1.3%. Of 59 carriers, 39 chose short-term breast-feeding. The HTLV-I carrier rate among pregnant women in Kagoshima has declined. The current HTLV-I MTCT prevention system in Kagoshima is effective, but not sufficient. To bring the nutrition methods to completion, various types of support are needed. Further studies will elucidate many unsolved problems concerning MTCT.

Cryotherapy for massive vulvar lymphatic leakage complicated with lymphangiomas following gynecological cancer treatment.

Vulvar lymphatic leakage is a severe complication associated with gynecological cancer treatments. However, standard treatment strategies have not yet been determined. We encountered a rare case of a 76-year-old multiparous woman suffering from massive lymphatic fluid leakage from the entire vulva, and papules developed and were identified as lymphangiomas. A large amount of straw-colored discharge continued from all vulvar papules, which extended over the mons pubis. Nine years ago, the patient had undergone a radical hysterectomy with concurrent chemoradiation for uterine cervical cancer treatment. Her serum albumin level was 1.9 mg/dl, which was attributed to the loss of a large amount of lymph fluid due to leakage from the vulva. Her quality of life gradually decreased because of general fatigue and the need for frequent diaper exchanges every 2 h. The patient received a less-invasive treatment with cryotherapy using liquid nitrogen. She also received a multimodality treatment consisting of the intravenous administration of albumin, massage of the lower limbs and intensive rehabilitation. Cryotherapy was administered once a week for 3 months. Her discharge almost stopped and vulvar lymphangiomas decreased without any major complications. To the best of our knowledge, this is the first case report of massive lymphatic leakage complicated with vulvar lymphangiomas. Additionally, this case may represent the first successful treatment of vulva lymph leakage by cryotherapy without recurrence. Cryotherapy may have the potential to improve the quality of life as a less-invasive treatment for gynecological cancer survivors without serious complications.

Concentrated ascites re-infusion therapy for pseudo-Meigs' syndrome complicated by massive ascites in large pedunculated uterine leiomyoma.

Pseudo-Meigs' syndrome accompanied by massive ascites in uterine leiomyoma is rare. We encountered a rare case of a 37-year-old, nulliparous woman with a lower abdominal tumor and severe abdominal distention due to massive ascites. Serum cancer antigen 125 and vascular endothelial growth factor levels were elevated to 1007.9 U/mL and 103 pg/mL, respectively. She was tentatively diagnosed with ovarian cancer. Emergency concentrated ascites re-infusion therapy was performed to improve dyspnea, abdominal pain, and her preoperative respiratory condition. Concentrated ascites re-infusion therapy eliminated dyspnea and abdominal discomfort without decreasing serum albumin levels. The patient underwent laparotomy, which revealed a fist-sized pedunculated uterine leiomyoma arising from the right uterine fundus. Myomectomy was performed. Pseudo-Meigs' syndrome mimics advanced ovarian cancer due to massive ascites and markedly elevated serum cancer antigen 125 and vascular endothelial growth factor levels. Concentrated ascites re-infusion therapy was effective in improving the subjective symptoms of pseudo-Meigs' syndrome and the patient's preoperative condition.

Can pelvic lymphadenectomy be omitted in stage IA2 to IIB uterine cervical cancer?

OBJECTIVES: The aims of this study were to predict pelvic lymph node metastasis in uterine cervical cancer before surgery and to evaluate the potential efficacy of omitting pelvic lymphadenectomy. MATERIALS AND METHODS: A total of 163 patients with invasive uterine cervical cancer in FIGO stage IA2 to IIB, all of whom underwent primary radical hysterectomy with pelvic lymphadenectomy, participated in this study. RESULTS: The incidences of pelvic lymph node metastasis in stage IA2, stage IB1, stage IB2, stage IIA, and stage IIB cervical cancer were 0% (0/12), 17% (13/76), 22% (6/27), 33% (8/24), and 63% (15/24), respectively. A significant difference was observed in overall survival with nodal metastasis status (P < 0.0001). Univariate analysis revealed that parametrial invasion (P < 0.0001), tumor markers (P = 0.0006), tumor size greater than 2 cm (P < 0.0001), tumor size less than 3 cm (P = 0.0009), and tumor size greater than 4 cm (P = 0.0024) were correlated with pelvic lymph node metastasis. However, multivariate analysis revealed that parametrial invasion (P = 0.01; odds ratio, 3.37; 95% confidence interval, 1.31-9.0) and tumor size greater than 2 cm (P = 0.005; odds ratio, 4.93; 95% confidence interval, 1.54-22.01) were independently associated with nodal metastasis. CONCLUSIONS: Pelvic lymphadenectomy may be avoided in patients with negative parametrial invasion and a tumor size less than 2 cm, thereby minimizing postoperative complications.

Major causes of impractical brachytherapy in elderly patients with uterine cervical cancer.

AIM: Incomplete brachytherapy is a major risk factor for recurrence. However, high-dose-rate intracavitary brachytherapy has not been assessed adequately in elderly patients with invasive cervical cancer. The present study investigated the clinical importance of intracavitary brachytherapy and risk factors of incomplete intracavitary brachytherapy in elderly patients with cervical cancer. MATERIAL AND METHODS: Subjects were 76 patients aged 70-89 years old with invasive cervical cancer. All subjects were recruited between January 1997 and September 2010, and were planning to receive external beam radiation therapy followed by high-dose-rate intracavitary brachytherapy. Survival rates and the incidence of complications were compared between the 70s and 80s age groups. Risk factors for recurrence in elderly patients were evaluated using multivariate analysis, and risk factors for impractical intracavitary brachytherapy were also estimated. RESULTS: No significant differences were observed in 3-year progression-free survival rates or the incidence of complications in the two age groups. Cox multivariate analysis showed that histology (non-squamous cell carcinoma), incomplete intracavitary brachytherapy, and lymph node swelling were significant prognostic factors for recurrence. Impractical application was the major reason for incomplete treatment. Multiple logistic regression analysis revealed that a previous history without vaginal births (P = 0.016) was an independent risk factor for the impractical application, independent of tumor diameter ≥ 4 cm (P = 0.007). CONCLUSIONS: Incomplete intracavitary brachytherapy decreased the survival rates of elderly patients. Larger tumors and patients without a history of vaginal births were the two major causes of impractical intracavitary brachytherapy, which may be fatal, especially in elderly patients with bulky tumors.

Annual report of Women's Health Care Committee, Japan Society of Obstetrics and Gynecology, 2013.

The activity of the Women's Health Care Committee for 1 year up to June 2013 includes: (i) guides for the management of health care in middle-aged women; (ii) postoperative women's health care; (iii) survey on the treatment of pelvic organ prolapse; and (iv) survey of postoperative infection in gynecologic surgery. The detailed activity of the four subcommittees is described in the text.

New hemostatic method using Mohs' paste for fatal genital bleeding in advanced cervical cancer.

► Mohs' paste is made of a mixture of zinc chloride paste. ► Recent reports show that hemostasis could be achieved in various kinds of cancer. ► Mohs' paste can save a patient's life from fatal genital bleeding.

Decreasing full-term neonatal birthweight over the past 2 decades in a single institute in Japan.

AIM: The aim of this study was to investigate whether full-term neonatal birthweight is decreasing or not. MATERIAL AND METHODS: Subjects were selected from the registration database of full-term singletons from a single local practitioner at two time-points, 1991 (n = 750) and 2011 (n = 442). Maternal age, parity, and smoking habits were recorded. Baseline characteristics included pre-pregnancy bodyweight (BW), body mass index (BMI), bodyweight before parturition, and weight gain during pregnancy. Neonatal birthweight and height were recorded. Variables correlated with neonatal size were investigated. RESULTS: Male birthweight decreased from 3248 ± 409 (n = 373) to 3149 ± 430 g (n = 230) (P < 0.001). Female birthweight also decreased from 3148 ± 378 (n = 377) to 3063 ± 343 g (n = 212) (P < 0.01). Gestational age was shorter (40.1 ± 1.1 to 39.6 ± 1.1 weeks, P < 0.001). Pre-pregnancy maternal BMI did not change (20.7 ± 2.6, n = 750 to 20.5 ± 2.7, n = 442). Weight gain during pregnancy decreased (11.3 ± 3.8 to 10.8 ± 3.4 kg, P < 0.05) and was positively correlated with birthweight (P < 0.001). On multiple regression analysis, time was inversely correlated with birthweight, while it was positively correlated with pre-pregnancy BMI, weight gain during pregnancy, and gestational age. CONCLUSIONS: In addition to maternal slenderness, increasing lower weight gain during pregnancy and medical intervention by physicians may in part contribute to the decrease in full-term birthweight over the past 2 decades.

Systemic thromboembolism after anti-cancer chemotherapy in a woman with ovarian germ cell tumor.

A high cure rate of ovarian germ cell tumors was achieved by establishment of a cisplatin-containing regimen. We encountered a rare case of a 33-year-old, nulligravida Japanese woman with systemic thromboembolism following anti-cancer chemotherapy with cisplatin, etoposide, and bleomycin in ovarian germ cell tumor. She suffered from brain infarction, multiple embolisms in the bilateral pulmonary artery and pelvic vein, and a broad range of deep vein thromboses in the right extremities vein. When thrombosis is detected during anti-cancer chemotherapy, we must investigate whether the presence of thrombosis is systemic or local.