Cancer-associated thrombosis: an overview

[Some features controlling the blood D-dimer level after resection of malignant brain glioma]

A high blood D-dimer level is often diagnosed in patients with malignant brain glioma (MBG), with 24% of these patients being detected with deep vein thrombosis of the leg and/or pulmonary embolism (PE). The cause of an elevated blood D-dimer level in most other cases remains unclear. The purpose of this study is to identify the features associated with an increased blood D-dimer level in patients after MBG resection, which may be used to improve the efficacy of adjuvant radiation therapy (ART).

RESULTS

The study included 50 patients. Three to four weeks after resection of malignant brain glioma (MBG), the blood D-dimer level was determined in patients immediately before the onset of ART. An increase in the blood D-dimer level more than by 0.25 μg/mL was detected in 78% of patients. More often, a high D-dimer level was detected in patients aged 60 years or more. In the same age group, an increase in the D-dimer level was significantly larger (p<0.05) than in younger patients (1.2 and 0.6 μg/mL, respectively). The degree of brain tumor malignancy did not affect the rate and value of an increase in the blood D-dimer level.

CONCLUSION

Our findings indicate that an increased blood D-dimer level in patients without symptoms of venous thrombosis after craniotomy for MBG is more pronounced in patients aged 60 years and over. The degree of glioma malignancy has no significant effect on this indicator.

Retrospective analysis of cardiovascular diseases related to chemotherapies for advanced solid tumor patients

Appropriate management of cardiovascular diseases (CVDs) related to chemotherapy for solid tumors is important for safe oncologic treatment. However, prediction of the onset and progression of CVDs has not generally been established in Japan. We carried out a retrospective analysis of advanced or recurrent solid tumor patients who received chemotherapies in a single institution. Patient characteristics, chemotherapy regimens, adverse events, CVDs before chemotherapy, and diagnosis of CVDs in association with chemotherapy were assessed. During the period from April 2006 to March 2012, 394 patients were examined. Cardiac diseases (CDs), hypertension (HT), or arterial thrombosis or venous thromboembolism were prevalent in 37 (9.4%), 22 (5.6%), five (1.3%), and 14 (3.5%) cases, respectively. HT (14.5%) and venous thrombosis (5.8%) were frequent in patients who received bevacizumab-containing chemotherapy. Four cases with left ventricular dysfunction experienced a decrease of ejection fraction and early filling/atrial filling (E/A) and E/A tended to decrease before ejection fraction. Ninety (62.1%) of 145 cases showed an increase in the D-dimer (DD) level before chemotherapy, and a further increase in DD level was found when venous thrombosis occurred. Relative risks of the disease progression of HT, CD, and thromboembolism because of chemotherapy were 1.3, 1.9, and 3.6, respectively. A decrease in E/A and an increase in DD were suggested to be valuable for early diagnosis of the respective onsets of left ventricular dysfunction and venous thrombosis related to chemotherapy. We conclude that patients with previous CD tend to have disease progression of CD during chemotherapy.

Heart and Lung Complications: Assessment and Prevention of Venous Thromboembolism and Cardiovascular Disease in Patients With Multiple Myeloma

BACKGROUND

Venous thromboembolism (VTE) and cardiovascular (CV) disease can occur in patients with multiple myeloma. Although VTE and CV disease are separate medical conditions, they can be serious and even life-threatening.
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OBJECTIVES

The objectives of this article are to describe risk factors for cancer-associated VTE, describe the influence of CV disease on patients with multiple myeloma, and review the approaches to VTE and CV disease identification and treatment.
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METHODS

PubMed and CINAHL® databases were used to identify literature to describe VTE and CV in patients diagnosed with multiple myeloma.
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FINDINGS

When present in patients with multiple myeloma, VTE and CV disease can limit patient tolerance for myeloma treatment and, therefore, decrease therapeutic options.

Low-molecular-weight heparins for the prevention of recurrent venous thromboembolism in patients with cancer: A systematic literature review of efficacy and cost-effectiveness

Background

Patients with cancer have an elevated risk of venous thromboembolism. Importantly, patients with cancer, who have metastatic disease, renal insufficiency, or are receiving anticancer therapy, have an even higher risk of a recurrent event. Similarly, the risk of recurrent venous thromboembolism is higher than the risk of an initial event. To reduce the risk, extended duration of prophylaxis for up to six months with low-molecular-weight heparins such as dalteparin, enoxaparin, nadroparin, and tinzaparin is recommended by international guidelines. In this paper, the clinical and economic literature is reviewed to provide evidenced based recommendations based on clinical benefit and economic value.

Methods

A systematic review of major databases was conducted from January 1996 to October 2016 for randomized controlled trials evaluating the four distinct low-molecular-weight heparins against a vitamin K antagonists control group for the prevention of recurrent venous thromboembolism in patients with active cancer. This was then followed by the application of the National Institute of Health and Clinical Excellence guidance to assess the quality of all trials that met the inclusion criteria. Finally, the cost-effectiveness literature supporting the value proposition of each product was reviewed.

Results

Six randomized trials met the inclusion criteria. There were one, two, and three trials that compared dalteparin, tinzaparin, and enoxaparin to a vitamin K antagonists control group. However, there were no trials for nadroparin in the setting of secondary venous thromboembolism prevention. In addition, only the dalteparin and one of the tinzaparin trials were of high quality and adequately powered. Of the two studies, only the dalteparin trial reported a statistically significant benefit in terms of venous thromboembolism absolute risk reduction when compared to a vitamin K antagonists control group (HR = 0.48; p = 0.002). In addition, there was robust pharmacoeconomic data from Canada, the Netherlands, France, and Austria supporting the cost-effectiveness of dalteparin for this indication. There were no such studies for any of the other agents.

Conclusions

The totality of high-quality clinical and cost-effectiveness data supports the use of dalteparin over other low-molecular-weight heparins for preventing recurrent venous thromboembolism in patients with cancer.

Dysfunctional Natural Killer Cells in the Aftermath of Cancer Surgery

The physiological changes that occur immediately following cancer surgeries initiate a chain of events that ultimately result in a short pro-, followed by a prolonged anti-, inflammatory period. Natural Killer (NK) cells are severely affected during this period in the recovering cancer patient. NK cells play a crucial role in anti-tumour immunity because of their innate ability to differentiate between malignant versus normal cells. Therefore, an opportunity arises in the aftermath of cancer surgery for residual cancer cells, including distant metastases, to gain a foothold in the absence of NK cell surveillance. Here, we describe the post-operative environment and how the release of sympathetic stress-related factors (e.g., cortisol, prostaglandins, catecholamines), anti-inflammatory cytokines (e.g., IL-6, TGF-β), and myeloid derived suppressor cells, mediate NK cell dysfunction. A snapshot of current and recently completed clinical trials specifically addressing NK cell dysfunction post-surgery is also discussed. In collecting and summarizing results from these different aspects of the surgical stress response, a comprehensive view of the NK cell suppressive effects of surgery is presented. Peri-operative therapies to mitigate NK cell suppression in the post-operative period could improve curative outcomes following cancer surgery.

Epidemiological and outcome data in Japanese patients with deep vein thrombosis with and without malignancy

There are very few epidemiological studies on Japanese patients with deep vein thrombosis (DVT). In particular, mortality rate differences in Japanese DVT patients with and without malignancy have rarely been evaluated. To elucidate these differences, we enrolled 211 patients who had been diagnosed with de-novo acute DVT of the pelvis or lower extremities between January 2012 and December 2015. The clinical characteristics, treatment information, and follow-up data were retrospectively assessed. We compared these variables in patients with (n = 120) and without (n = 91) concomitant malignancies. The median age of patients was 67 years, 33.7% were male, and 82.9% patients were treated with oral anticoagulants including direct oral anticoagulants. The clinical characteristics and treatment provided were almost identical in the two groups with some exceptions. Three-year survival rates of the total population, patients with malignancy, and patients without malignancy were 80.6, 67.6, and 97.6%, respectively (log-rank p < 0.001). Multivariable Cox regression analysis demonstrated that malignancy was independently associated with high risk of 3-year all-cause mortality with an adjusted hazard ratio of 9.1 (95% confidence interval; 2.1-39.0, p = 0.003). Bootstrap validation demonstrated an acceptable index corrected slope of 0.766 without significant overfitting in a multivariable model. In conclusion, we analyzed epidemiological data on Japanese patients with DVT. Malignancy was independently associated with increased 3-year all-cause mortality.

Enhanced procoagulant activity of platelets after chemotherapy in non-small cell lung cancer

The procoagulant status of patients with non-small cell lung cancer (NSCLC) after chemotherapy is poorly characterized and the role of platelets in hypercoagulative state of NSCLC is unknown. The aim of this study was to evaluate the procoagulant activity (PCA) of platelets in NSCLC before and after chemotherapy. The subjects were 52 patients newly diagnosed with NSCLC. The patients had decreased clotting time compared with healthy subjects, and the thrombin-antithrombin complex increased 2.5-fold after chemotherapy. Platelets in the patients after chemotherapy had enhanced phosphatidylserine (PS) exposure, and shortened coagulation time as well as increased thrombin and fibrin formation of platelets compared with those before chemotherapy. Platelet-derived microparticles increased 2-fold at day 1 and peaked at day 2 post-chemotherapy. Treatment of cisplatin in vitro also resulted in upregulated intrinsic FXa and thrombin formation on platelets with a dose-dependent manner. Platelets treated with aspirin significantly decreased PCA. However, lactadherin blocked PS and inhibited the PCA approximately by 70%. Seven days after chemotherapy, PCA of platelets restored to the baseline as that before chemotherapy, indicating that within a week of chemotherapy patient platelets are highly procoagulant and effective intervention should be taken in case of thrombosis. Our results suggested that platelets after chemotherapy had elevated PCA and may contribute to the hypercoagulative state of NSCLC. Prophylactic anti-coagulant combined with anti-platelet therapy may play an inhibitory role in thrombotic complications in NSCLC.

Clinical and Prognostic Significance of Lupus Anticoagulant Measurement in Patients With Lung Cancer

Lupus anticoagulants is related to both recurrent thrombosis and cancer. Thrombotic complications occur more frequently in patients with lung cancer. The aim of this study is to investigate the association of lupus anticoagulants with hypercoagulability and thrombotic complications, as well as prognostic significance of lupus anticoagulants for patients with lung cancer. The study comprised 205 patients with non–small cell lung cancer. Plasma normalized LAC ratio, D-dimer, fibrinogen, activities of antithrombin, and FVIII before treatment were analyzed by coagulation analyzer, and routine hematologic and biochemical parameters were also evaluated. In patients, normalized LAC ratio, D-dimer, fibrinogen, and procoagulant activity of coagulating factor VIII levels significantly increased, whereas antithrombin activity significantly decreased compared with healthy controls (P < .001). Normalized LAC ratio was positively correlated with D-dimer, fibrinogen, and procoagulant activity of coagulating factor VIII, and negatively correlated with antithrombin activity, respectively (P < .01). D-dimer, procoagulant activity of coagulating factor VIII, and antithrombin levels revealed statistical difference in non–deep venous thrombosis patients with elevated or normal normalized LA ratio (P < .05). The incidence of deep venous thrombosis and tumor metastasis was higher, and 1-year survival rate was lower in elevated normalized LAC ratio patients than in normal ones, respectively (P < .01). There was higher normalized LAC ratio level in patients with deep venous thrombosis and/or metastasis (P < .05). In 1-year deceased patients, normalized LAC ratio level and the incidence of deep venous thrombosis and metastasis were higher than those in survivors, respectively (P < .05). Hazard regression analysis demonstrated normalized LAC ratio was independently associated with short survival time in patients with non–small cell lung cancer (hazard regression: 2.871, 95%confidence interval: 1.704-4.835; χ²: 19.130; P < .01). Our study suggests that lupus anticoagulants is a useful marker to predict thrombotic complications and prognosis in patient with lung cancer.

Occult cancer in patients with deep-vein thrombosis in a general hospital at Mexico City: A pilot study

Background:

We aimed to explore the frequency of occult cancer in patients with deep-vein thrombosis (DVT) at a general hospital in Mexico City.

Materials and Methods:

From March 2012 to February 2015, all patients with primary DVT of lower extremities attended in the emergency department of our hospital were studied. Initially, all patients were evaluated with clinical history, physical examination, basic laboratories, abdominal ultrasound, chest X-ray, and duplex venous ultrasonography. In a case-by-case approach, if necessary, computed tomography, endoscopy, colonoscopy, and tumor markers were done.

Results:

From 182 patients with primary DVT, 30 (16.5%) presented occult cancer: Thirteen males and 17 females, with an average age of 61 years. In males, prostate cancer prevailed (6/13, 46%); meanwhile, in females, pelvic gynecologic cancers predominated (7/17, 41%).

Conclusion:

Our results suggest that in Mexican patients with primary DVT, occult cancer is frequent.

Highlights from the first ecancer-Liga Colombiana contra el Cancer conference, 17-18 November 2016, Bogota, Colombia

The first oncology conference organised by ecancer and the Liga Colombiana contra el Cancer took place on 17-18 November 2016 in Bogota. It was a highly successful event owing to the number of participants, the quality of the speakers, and the academic programme. Around 48 professors from 8 different countries came and shared their knowledge and experience of cancer management. They also talked about the most recent developments noted or achieved in this area. The keynote speech from Dr Nubia Muñoz was of great interest which was related to the safety of a HPV vaccine and the implications of a mass vaccination programme in developing countries. Geriatric oncology and palliative care were also topics that sparked great interest during the event.

Much More than Trousseau Syndrome. The Broad Spectrum of the Pancreatic Paraneoplastic Syndromes

When 150 years ago Armand Trousseau proposed that some thrombotic events might be the first sign of concealed visceral malignancies, these findings seemed to be just of anecdotal interest. Since then, however, we have learned that adenocarcinomas, including pancreatic cancers could be associated with a wide spectrum of paraneoplastic syndromes. They may precede the detection of the tumor, may occur simultaneously or may develop during its progression. Due to various hematologic, endocrine, cutaneous, articular, neuromuscular, renal or even psychiatric syndromes, their correct interpretation is intriguing, and because their early signs are not necessarily recognized first by oncologists, the paraneoplastic syndromes pose a diagnostic challenge. Unfortunately, we cannot generalize about their mechanisms, because the molecular backgrounds are far-reaching. In most of the cases, the pancreatic cancer cells release various factors into the bloodstream triggering the coagulation cascade. These patients frequently present with venous thromboembolism, and sometimes they are resistant to anticoagulation. The simultaneous thrombotic and bleeding evens do reflect the abnormal hemostasis. In other instances autoantibodies are formed against cutaneous, renal, neuromuscular or nervous tissues, but the mechanism of some syndromes remains unclear. Clinicians should be aware that pancreatic carcinoma may be associated with not just the Trousseau-syndrome.

Tissue Factor Pathway Inhibitor-1 Is a Valuable Marker for the Prediction of Deep Venous Thrombosis and Tumor Metastasis in Patients with Lung Cancer

Activation of blood coagulation contributes to cancer progression. Tissue factor pathway inhibitor-1 (TFPI-1) is the main inhibitor of extrinsic coagulation pathway. The aim of this study is to assess the predicting significance of TFPI-1 for thrombotic complication and metastasis in lung cancer patients. Total of 188 non-small cell lung cancer (NSCLC) patients were included in this study. Plasma TFPI-1, D-dimer (D-D), antithrombin (AT), Fibrinogen (Fbg), and coagulating factor VIII activity (FVIII:C) were measured. In NSCLC patients, significantly decreased TFPI-1 and AT and increased D-D, Fbg, and FVIII:C levels were observed, and there was a significant correlation between TFPI-1 and other hemostatic parameters (P < 0.001, resp.). NSCLC patients with deep venous thrombosis (DVT) or metastasis had significantly lower TFPI-1 levels than those without DVT or metastasis (P < 0.01, resp.). Multivariate regression revealed that TFPI-1 acted as a predictor for DVT or tumor metastasis in NSCLC patients [OR: 4.15 or 3.28, P < 0.05, resp.]. The area under ROC curve of TFPI-1 was 0.905 (95% CI, 0.842~0.967) or 0.828 (95% CI, 0.742~0.915) for predicting DVT or metastasis (P < 0.001, resp.). The optimal point of TFPI-1 was 57.7 or 54.3 ng/mL for predicting DVT or metastasis, respectively. Combination of TFPI-1 and D-D measurements can improve the predicting power for DVT or metastasis in NSCLC patients. Our findings suggested that TFPI-1 was a valuable predictor of DVT and tumor metastasis in NSCLC patients.

Enhanced Recovery in a Minimally Invasive Thoracic Surgery Program

Enhanced Recovery After Surgery (ERAS®) is a strategy that seeks to reduce patients' perioperative stress response, thereby reducing potential complications, decreasing hospital length of stay, and enabling patients to return more quickly to their baseline functional status. The concept was introduced in the late 1990s and was first adopted for use with patients undergoing open colorectal surgery. Since that time, the concept of ERAS has spread to multiple surgical specialties. This article explores the changes in patient care using an ERAS framework in a minimally invasive thoracic surgery program, barriers to implementation, and patient outcomes.

Clinical features and biological markers of lung cancer-associated stroke

Objective

To identify the unique clinical features and biological markers of lung cancer-associated stroke.

Methods

We recruited 102 patients with lung cancer plus stroke, 102 with lung cancer, and 102 with stroke. Detailed information was analysed and compared among groups.

Results

The groups were age-matched. Patients with lung cancer plus stroke showed multiple lesions involving multiple cerebral artery territories on magnetic resonance imaging, compared with stroke-alone patients. These patients also had a poorer modified Rankin Scale score at 30 days, and high mortality (18.6%). Patients with lung cancer plus stroke had a higher incidence of metastasis, and higher blood levels of D-dimer, CA125 and CA199 compared with patients with lung cancer alone. Multivariate logistic regression analysis showed that levels of D-dimer, CA125 and CA199 were independently related to lung cancer-associated stroke.

Conclusion

Elevated plasma D-dimer, CA125 and CA199 may be independent risk factors for and biomarkers of lung cancer-associated stroke.

Venous Access Devices: Clinical Rounds

Nursing management of venous access devices (VADs) requires knowledge of current evidence, as well as knowledge of when evidence is limited. Do you know which practices we do based on evidence and those that we do based on institutional history or preference? This article will present complex VAD infection and occlusion complications and some of the controversies associated with them. Important strategies for identifying these complications, troubleshooting, and evaluating the evidence related to lack of blood return, malposition, infection, access and maintenance protocols, and scope of practice issues are presented.

Pharmacology of Heparin and Related Drugs

Heparin has been recognized as a valuable anticoagulant and antithrombotic for several decades and is still widely used in clinical practice for a variety of indications. The anticoagulant activity of heparin is mainly attributable to the action of a specific pentasaccharide sequence that acts in concert with antithrombin, a plasma coagulation factor inhibitor. This observation has led to the development of synthetic heparin mimetics for clinical use. However, it is increasingly recognized that heparin has many other pharmacological properties, including but not limited to antiviral, anti-inflammatory, and antimetastatic actions. Many of these activities are independent of its anticoagulant activity, although the mechanisms of these other activities are currently less well defined. Nonetheless, heparin is being exploited for clinical uses beyond anticoagulation and developed for a wide range of clinical disorders. This article provides a "state of the art" review of our current understanding of the pharmacology of heparin and related drugs and an overview of the status of development of such drugs.

Systematic review and meta-analysis of the risk of severe and life-threatening thromboembolism in cancer patients receiving anti-EGFR monoclonal antibodies (cetuximab or panitumumab)

Cancer-associated thromboembolism is a substantial problem in clinical practice. An increase in the level of fibrinopeptide A (a substance associated with hypercoagulable states) has been observed in humans exposed to fluorouracil. Anti-EGFR monoclonal antibodies cetuximab and panitumumab, which are now widely used in patients with metastatic colorectal cancer, could prolong the uncovering of endothelial structures resulting from flouorouracil or other co-administered agents, thus favouring several factors leading to thromboembolism. We performed a systematic review and meta-analysis of randomised, controlled trials assessing whether cancer patients receiving anti-EGFR monoclonal antibodies cetuximab and panitumumab are at increased risk of thromboembolic events. We searched electronic databases (Medline, Embase, Web of Science, Central) and reference lists. Phase II/III randomised, controlled trials comparing standard anti-cancer regimens with or without anti-EGFR monoclonal antibodies and reporting serious venous thromboembolic events were included in the analysis. Seventeen studies (12,870 patients) were considered for quantitative analysis. The relative risk (RR) for venous thromboembolism (18 comparisons) was 1.46 (95% CI 1.26 to 1.69); the RR of pulmonary embolism, on the basis of eight studies providing nine comparisons, was 1.55 (1.20 to 2.00). Cancer patients receiving anti-EGFR monoclonal antibodies-containing regimens are approximately 1.5 times more likely to experience venous or pulmonary embolism, compared to those treated with the same regimens without anti-EGFR monoclonal antibodies. Clinicians should consider patient's baseline thromboembolic risk when selecting regimens that include cetuximab or panitumumab. Potential non-reporting of these important adverse events remains a concern. PROSPERO registration number is CRD42014009165.

The Role of Inferior Vena Cava Filters in Cancer Patients

Cancer induces a hypercoagulable state and renders patients susceptible to venous thromboembolism. While anticoagulation remains the mainstay of treatment, many of these patients require placement of an inferior vena cava (IVC) filter, often due to a contraindication to or failure of anticoagulation. In this article, the available data on IVC filter usage in cancer patients will be reviewed.

Platelet-cytokine Complex Suppresses Tumour Growth by Exploiting Intratumoural Thrombin-dependent Platelet Aggregation

Tumours constitute unique microenvironments where various blood cells and factors are exposed as a result of leaky vasculature. In the present study, we report that thrombin enrichment in B16F10 melanoma led to platelet aggregation, and this property was exploited to administer an anticancer cytokine, interferon-gamma induced protein 10 (IP10), through the formation of a platelet-IP10 complex. When intravenously infused, the complex reached platelet microaggregates in the tumour. The responses induced by the complex were solely immune-mediated, and tumour cytotoxicity was not observed. The complex suppressed the growth of mouse melanoma in vivo, while both platelets and the complex suppressed the accumulation of FoxP3⁺ regulatory T cells in the tumour. These results demonstrated that thrombin-dependent platelet aggregation in B16F10 tumours defines platelets as a vector to deliver anticancer cytokines and provide specific treatment benefits.

Postoperative Massive Pulmonary Embolism Due to Superficial Vein Thrombosis of the Upper Limb

It is well known that deep vein thrombosis of the upper extremities is linked to high morbidity/mortality, resulting in 12-20% of all documented pulmonary embolism; however, there are few data about thromboembolism originating from a vein and/or a branch of a superficial vein of the upper extremities. Pulmonary embolism secondary to upper limb superficial vein thrombosis (not combined with upper extremities deep vein thrombosis) is a very rare clinical manifestation with few cases reported in the literature. We report a rare case of thrombophlebitis in departure from a superficial branch of the cephalic vein of the right arm, complicated by cardiac arrest secondary to a massive pulmonary embolism in a patient who underwent major surgery for ovarian cancer. We discuss on the numerous thrombotic risk factors, triggering a cascade of reactions and resulting in a potential fatal clinical manifestation.

Primary prevention and treatment of venous thromboembolic events in patients with gastrointestinal cancers - Review

Venous thromboembolism event (VTE) is a common and morbid complication in cancer patients. Patients with gastrointestinal cancers often suffer from symptomatic or incidental splanchnic vein thrombosis, impaired liver function and/or thrombocytopenia. These characteristics require a thorough risk/benefit evaluation for individual patients. Considering the risk factors for the development of VTE and bleeding events in addition to recent study results may be helpful for correct initiation of primary pharmacological prevention and treatment of cancer-associated thrombosis (CAT), preferably with low molecular weight heparins (LMWH). Whereas thromboprophylaxis is most often recommended in hospitalized surgical and non-surgical patients with malignancy, there is less agreement as to its duration. With regard to ambulatory cancer patients, the lack of robust data results in low grade recommendations against routine use of anticoagulant drugs. Anticoagulation with LMWH for the first months is the evidence-based treatment for acute CAT, but duration of secondary prevention and the drug of choice are unclear. Based on published guidelines and literature, this review will focus on prevention and treatment strategies of VTE in patients with gastrointestinal cancers.

[Use of heparin and its derivatives in nursing care]

Heparin is an injectable anti-coagulant indicated in the treatment of venous thromboembolic diseases. In the case of major kidney failure, unfractionated heparins (UFHs) can be administered while low molecular weight heparins (LMWHs) are contraindicated at a curative dose. Platelet count must be monitored in patients treated with UFHs and when an LMWH is prescribed in a surgical context.

The Role of New Oral Anticoagulants (NOACs) in Cancer Patients

New oral anticoagulants (NOACs) are likely to have a major impact in the next few years, changing clinical practice of anticoagulation therapy. Evidence on its efficacy and superiority to vitamin K antagonists (VKAs) in treating non-cancer patients have been reported in a few clinical trials. However, patients with cancer are complicated by the prothrombotic nature of the disease, need for potentially invasive surgery and interventions, and altered drug handling. This chapter examines the available evidence and guidelines on the use of NOAC in patients with cancer.

Trousseau's syndrome: cancer-associated thrombosis

Trousseau's syndrome (cancer-associated thrombosis) is the second leading cause of death in cancer patients, after death from cancer itself. The risk of a venous thromboembolism is 4- to 7-fold higher in patients with cancer than in those without cancer. The causes of this impaired coagulation are associated with general patient-related risk factors, and other factors that are specific to the particular cancer or treatment. It is important to assess the risk of thrombotic events in cancer patients and administer effective prophylaxis and treatment. Effective prophylaxis and treatment of venous thromboembolism reduces morbidity and mortality, and improves patients' quality of life. Low molecular weight heparin is the first-line treatment for venous thromboembolism, as an effective and safe means for prophylaxis and treatment, according to guidelines released by international scientific societies. Oral anticoagulation therapy with warfarin is preferable to no therapy. However, warfarin has low efficacy and is associated with high rates of recurrence. If low molecular weight heparin is unavailable, some guidelines recommend the use of vitamin K antagonists that have a target international normalized ratio in the range of 2-3, as acceptable alternatives. Novel oral anticoagulants that directly inhibit factor Xa or thrombin are promising for the prophylaxis of high-risk cancer patients and in the long-term treatment of venous thromboembolism. However, to date, there is insufficient evidence to support the use of these new anticoagulants.

Beyond Thrombus Detection: The Role of Multimodality Imaging Approach

We present a very rare case of paraneoplastic syndrome characterized by the unusual coexistence of a left ventricular apical thrombus and pulmonary embolism as the first manifestation of an unrecognized lung adenocarcinoma.

Impact of thrombosis on standard treatment in solid tumors

INTRODUCTION

Malignancy leading to a hypercoagulable state is a well established concept. The reported frequency of venous thrombotic events in cancer patients is 5-8%. There is limited data on the influence of thrombosis on treatment decisions in solid tumors.

METHODS

A retrospective audit of all cases of thrombosis developing in newly diagnosed solid tumors from 1st January 2011 to 31st December 2014 was performed. Changes in treatment decisions for malignancy (deferral of surgery/chemotherapy, changes in the planned course of chemotherapy or changes in the planned dates of chemotherapy) after the documentation of thrombosis were noted.

RESULTS

A total of 11,796 solid tumor cases were registered. 61 patients with thrombosis (0.52%) were identified. In 14 patients(23%), treatment decisions for malignancy had to be changed after the occurrence of thrombosis. 2 patients were deferred surgery, 9 could not undergo chemotherapy according to planned schedules, and 3 were deferred chemotherapy. In survival analysis by multivariate model, stage (p=0.01) and ECOG performance status (p=0.01) significantly predicted survival whereas thrombus location (p=0.09), symptomatic thrombosis (p=0.06), and age (p=0.19) did not.

CONCLUSIONS

Frequency of thrombosis in solid tumors in our centre was less compared to previous reports. There was a significant deviation (nearly one fourth patients) from standard of treatment for malignancy after the development of thrombosis. Survival of patients who developed thrombosis did not significantly vary depending on location of thrombosis or whether it is symptomatic or not.