Venous thromboembolism associated with long-term use of central venous catheters in cancer patients

A phase II study of combination therapy with irinotecan and S-1 (IRIS) in patients with advanced colorectal cancer

PURPOSE

A combination of irinotecan with continuous infusional 5-fluorouracil (5-FU) is the standard treatment for advanced colorectal cancer. The aim of this study was to determine the efficacy and safety of combining irinotecan and S-1 (IRIS) in patients with advanced colorectal cancer.

METHODS

Irinotecan was administered as an intravenous infusion at a dose of 120 mg/m(2) on day 1 and 15. And S-1 was administered orally on days 1-14 of a 28-day cycle. S-1 was given orally at a dose that did not exceed 40 mg/m(2) based BSA: BSA < 1.25 m(2), 40 mg twice daily; 1.25-1.5 m(2), 50 mg twice daily, and BSA > 1.5 m(2), 60 mg twice daily, for 14 consecutive days.

RESULTS

A total of 38 patients were enrolled. An intent-to-treat analysis showed a complete response and partial response to occur in 13.2% and 50.0%, respectively. The disease control rate was 84.2%. The median progression-free survival and overall survival were 10.0 months and 29.1 months, respectively. The rates of grade 3/4 toxicity over 4 cycles were the following: neutropenia, 15.8%; leucopenia, 7.9%; anorexia, 15.8%; diarrhea, 10.5%.

CONCLUSION

IRIS is an effective, well tolerated and convenient treatment regimen for patients with advanced colorectal cancer.

Disconnection of chamber and catheter as a complication of central venous catheter type port-a-cath

The use of a central vein catheter (CVC) type port-a-cath (VPS), apart from the comfort it provides to the patient undergoing chemotherapy, also carries certain complications. In this study, our patient was subjected to chemotherapy after a radical breast cancer operation and was given a CVC type VPS. After further care, a rare complication was verified--disconnection of the chamber and catheter, which one was visually identified in the right heart chamber. As the patient was vitally endangered, she was immediately hospitalized and the catheter was removed by catheterization of the right femoral vein, with scopic imaging. Early diagnosis and localization of the problem prevented more severe complications and mortality.

Epidemiology and pathophysiology of cancer-associated thrombosis

Venous thromboembolism (VTE) is a common complication in patients with malignant disease. First recognised by Bouillard in 1823 and later described by Trousseau in 1844, multiple studies have since provided considerable evidence for a clinical association between VTE and cancer. Across all cancers, the risk for VTE is elevated 7-fold; in certain malignancies, the risk for VTE may be increased up to 28-fold. Venous thromboembolism is the second leading cause of death in patients with cancer; among survivors, complications commonly include recurrent VTE and post-thrombotic syndrome, and (more rarely) chronic thromboembolic pulmonary hypertension, which are costly, and have a profound impact on the patient's quality of life. Tumour cells can activate blood coagulation through multiple mechanisms, including production of procoagulant, fibrinolytic, and proaggregating activities, release of proinflammatory and proangiogenic cytokines, and interacting directly with host vascular and blood cells (e.g., endothelial cells, leukocytes, and platelets) through adhesion molecules. Increasing evidence suggests that elements of the haemostatic system also have a direct role in eliciting or enhancing angiogenesis, cell survival, and metastasis. Despite the problem posed by VTE in the setting of cancer, it is evident that a significant number of oncologists do not recognise the link between cancer, its treatment, and thrombogenesis. On 22 May 2009, a group of UK-based physicians met in London, UK, to evaluate recent data on cancer thrombosis. This article (1 of 4) briefly reviews key data on the epidemiology and pathophysiology of VTE as a context for a discussion and consensus statement developed by meeting attendees, on the implications of this information for UK clinical practice.

Upper extremity deep venous thrombosis in the population-based Malmö thrombophilia study (MATS). Epidemiology, risk factors, recurrence risk, and mortality

BACKGROUND

Deep venous thrombosis (DVT) is much less common in the upper than in the lower extremity. Furthermore, there is limited information on risk factors for and the prognosis of upper extremity (UE)DVT in the general population.

AIMS

To estimate incidence, risk factors, and prognosis in UEDVT.

MATERIAL AND METHODS

Among a total of 1203 patients with venous thromboembolism (VTE) diagnosed during 1998-2006 in the prospective population-based Malmö thrombophilia study, 63 (5%, 33 men [52%, age 54+/-17years], and 30 women [48%, age 55+/-22years]) had UEDVT and were evaluated concerning risk factors, treatment, recurrent VTE, and mortality.

RESULTS

At diagnosis, 19(30%) patients had known malignancy and 6(10%) had VTE heredity. Among female UEDVT patients 4(13%) used hormone therapy, 1(3%) was pregnant, while none was in the postpartum period. Of all 63 UEDVT patients, 12(19%) were heterozygous, and 3(5%) homozygous for the Factor V Leiden (FVL)-mutation. Two (3%) patients were heterozygous for the prothrombin mutation, and 1 patient (1.6%) showed both heterozygous FVL-mutation and lupus anticoagulant antibodies. Phlebography had been used for diagnosis in 48(76%), ultrasonography in 16(25%), and computer tomography (CT) in 9(14%) patients. Twenty-two patients (35%) were treated in hospital, and the remaining 41(65%) as out-patients. Sixty-two (98%) was treated with low molecular weight heparin (LMH), 60(95%) with oral anticoagulants (OAC), 3(5%) with unfractionated heparin, and 3(5%) with thrombolysis. VTE recurrence rate during median 62 (range 31-117) month of follow-up was 8/63(13%). Fifteen (24%) UEDVT patients died during follow-up; 9(47%) of the 19 patients with known malignancy at diagnosis and 6(14%) of the other patients. Yearly incidence of UEDVT was 3.6/100.000 (95% confidence interval [CI], 3.3 - 4.03).

CONCLUSION

Malignancies and the FVL mutation were common among patients with UEDVT. Mortality during follow-up vas high.

Management of venous thromboembolism and the potential to impact overall survival in patients with cancer

The risk of venous thromboembolism (VTE) in patients with cancer is 6-12-fold higher than in the general population, and VTE is the second leading cause of death in this population, after cancer itself. The etiology underlying the increased risk of VTE is multifactorial and complex, involving patient-, tumor-, and treatment-related factors. In patients with cancer, cumulative results from studies in those with VTE versus without VTE suggest that anticoagulation therapy, particularly with low-molecular-weight heparins, prevents morbidity and may reduce mortality. Despite the availability of effective and safe therapeutic options, VTE is often underrecognized and suboptimally managed. Interventions such as assessing individual patient risk of VTE, providing VTE prophylaxis and/or prompt treatment, and adopting VTE guidelines are essential aspects of cancer-related care. Aggressive VTE management and strategies are critical to improving survival in patients with cancer and VTE.

Erythropoiesis stimulating agents, thrombosis and cancer

Venous thromboembolism (VTE) is common in cancer and is associated with both morbidity and mortality. Erythropoiesis stimulating agents (ESAs) were originally developed to correct anemia. Recent trials in cancer patients however, raise concerns over both increased VTE rates and the possibility of worse tumour outcomes and increased mortality with ESA use. The most common reason offered for explaining the possible negative impact of ESAs on cancer outcomes has been the stimulation of erythropoietin receptors on tumour cells. Despite an extensive literature, it is unlikely that most practicing appreciate the intricate relationship and interaction between the coagulation pathways, angiogenesis and tumour progression and ESA effects. This paper will review these connections and interactions and examine the hypothesis that other mechanisms may underlie the possible negative impact of ESAs on cancer outcomes.

Acquired thrombotic risk factors in the critical care setting

Acquired thrombotic risk factors include a variety of noninherited clinical conditions that can predispose an individual to an increased risk for venous thromboembolism. For patients in a critical care setting, certain acquired risk factors represent chronic conditions that the patients may have had before the current acute illness (e.g., malignancy, various cardiovascular risk factors, certain medications), whereas others may be directly related to the reason the patient is in an intensive care unit or the patient's management there (e.g., postoperative state, trauma, indwelling vascular access, certain medications). Optimal thromboprophylactic strategies depend on individual patient risk profiles including an assessment of the specific clinical setting. Treatment for patients with acquired thrombotic risk factors includes anticoagulant therapy and, if possible, resolution of the acquired risk factor(s). Heparin-induced thrombocytopenia represents a unique clinical situation in which all sources of heparin must be discontinued and the patient started on an alternative anticoagulant (e.g., a direct thrombin inhibitor) in the acute setting. The duration of anticoagulant therapy would vary depending on the specific clinical setting.

Malignancy and venous thrombosis in the critical care patient

Venous thromboembolic disease has significant clinical consequences. There are few data available to guide its management in the critically ill cancer patient, perhaps the most complex and challenging patient population encountered. Multiple interacting and often unique factors contribute to both the thrombotic and bleeding risk in such patients. Anticoagulants are effective for prophylaxis and treatment; heparins are the best-studied agents in this setting. Whether unfractionated or low-molecular-weight heparin is the most appropriate agent depends on the exact clinical situation. Prevention of venous thrombosis is a well-recognized health priority, but thromboprophylaxis remains underused, especially in some high-risk populations such as cancer patients. Enhanced recognition of the thrombotic risk factors and a better understanding of the risks and benefits of anticoagulant therapy are necessary to improve utilization, and much research is needed to address how to implement effective thromboprophylaxis strategies. Careful consideration of the patient's overall prognosis is necessary to develop safe, effective, and individualized approaches to treating thrombosis.

Metastatic carcinoma of unknown primary presenting as jugular venous thrombosis

Jugular venous thrombosis is unusual and is associated with central venous catheterisation, intravenous drug abuse and head and neck sepsis. It is rarely associated with malignancy. We report a case of metastatic carcinoma of unknown primary in a forty year old female which presented with jugular venous thrombosis. The discussion includes investigation and treatment options for this condition.

Upper extremity compartment syndrome in the setting of deep venous thrombosis and phlegmasia cerulea dolens: case report

Forearm compartment syndrome is an uncommon but emergent condition that can threaten limb and life. An uncommon cause of compartment syndrome is deep venous thrombosis, usually in the setting of phlegmasia cerulea dolens of the lower extremity. We present a case of compartment syndrome secondary to venous occlusion of the upper extremity due to phlegmasia cerulea dolens in a patient with metastatic lung cancer.

A prospective 7-year survey on central venous catheter-related complications at a single pediatric hospital

The aims of this study were to assess the incidence and risk factors of major central venous catheter (CVC)-related complications in a large cohort of children affected by oncological, hematological, or immunological diseases in a 7-year prospective observational study at a single center. Nine hundred fifteen CVCs were inserted in 748 children for a total period of 307,846 CVC-days. Overall, 298 complications were documented with a complication rate of 0.97/1,000 CVC-days: 105 mechanical complications (dislocations 0.30/1,000 CVC-days, ruptures 0.04/1,000 CVC-days), 174 infections (bloodstream infections 0.46/1,000 CVC-days, tunnel infections 0.10/1,000 CVC-days), and 19 thrombosis (0.06/1,000 CVC-days). Significant risk factors were: diagnosis of acute lymphoblastic leukemia (ALL) and age <or=3 years for dislocations; nonmalignant disease for ruptures; ALL for thrombosis; double-lumen and partially implanted CVCs for bloodstream infections; age <or=3 years for tunnel infections. In conclusion, the rate of CVC-related complications in children was lower than that usually reported.

Phase I/II study of sequential therapy with irinotecan and S-1 for metastatic colorectal cancer

Background:

Both irinotecan (CPT-11) and S-1 are active against colorectal cancer; however, as S-1 is a prodrug of 5-fluorouracil (5-FU), 5-FU and its metabolites might inhibit the antitumour effect of CPT-11. Therefore, we designed a sequential combination, in which CPT-11 infusion was given on day 1 and S-1 was given orally at 80 mg m⁻² per day on days 3–16 every 3 weeks.

Methods:

Twelve patients entered the phase I study, and the recommended doses were determined as a CPT-11 dose of 150 mg m⁻² and an S-1 dose of 80 mg m⁻².

Results:

In all, 36 patients entered the phase II study, of whom 4 and 16 had complete and partial responses. The overall response rate was 55.6% (95% confidence interval, 38.1–72.1%), and median progression-free survival was 7.7 months (95% confidence interval, 4.8–12.6 months). Grade 3 neutropenia was the most common haematological toxicity and occurred in 6.5% of 215 treatment courses. Grade 3 non-haematological toxicities included anorexia (1.4%) and diarrhoea (0.9%). There was no grade 4 toxicity of any kind.

Conclusion:

Our results suggest that this regimen is convenient, safe and promising, compared with conventional regimens for patients with metastatic colorectal cancer.

Venous thromboembolism prophylaxis and treatment in cancer: a consensus statement of major guidelines panels and call to action

PURPOSE

Venous thromboembolism (VTE) is an increasingly frequent complication of cancer and its treatments, and is associated with worsened mortality and morbidity in patients with cancer.

DESIGN

The Italian Association of Medical Oncology, the National Comprehensive Cancer Network, the American Society of Clinical Oncology, the French National Federation of the League of Centers Against Cancer, and the European Society of Medical Oncology have recently published guidelines regarding VTE in patients with cancer. This review, authored by a working group of members from these panels, focuses on the methodology and areas of consensus and disagreement in the various clinical guidelines as well as directions for future research.

RESULTS

There is broad consensus regarding the importance of thromboprophylaxis in hospitalized patients with cancer, including prolonged prophylaxis in high-risk surgical patients. Prophylaxis is not currently recommended for ambulatory patients with cancer (with exceptions) or for central venous catheters. All of the panels agree that low molecular weight heparins are preferred for the long-term treatment of VTE in cancer. Areas that warrant further research include the benefit of prophylaxis in the ambulatory setting, the risk/benefit ratio of prophylaxis for hospitalized patients with cancer, an understanding of incidental VTE, and the impact of anticoagulation on survival.

CONCLUSION

We call for a sustained research effort to investigate the clinical issues identified here to reduce the burden of VTE and its consequences in patients with cancer.

Assessing risk of venous thromboembolism in the patient with cancer

PURPOSE

Patients with cancer are increasingly at risk for venous thromboembolism (VTE). Rates of VTE, however, vary markedly among patients with cancer.

DESIGN

This review focuses on recent data derived from population-based, hospital-based, and outpatient cohort studies of patients with cancer that have identified multiple clinical risk factors as well as candidate laboratory biomarkers predictive of VTE.

RESULTS

Clinical risk factors for cancer-associated VTE include primary tumor site, stage, initial period after diagnosis, presence and number of comorbidities, and treatment modalities including systemic chemotherapy, antiangiogenic therapy, and hospitalization. Candidate predictive biomarkers include elevated platelet or leukocyte counts, tissue factor, soluble P-selectin, and D-dimer. A recently validated risk model, incorporating some of these factors, can help differentiate patients at high or low risk for developing VTE while receiving chemotherapy.

CONCLUSION

Identifying patients with cancer who are most at risk for VTE is essential to better target thromboprophylaxis, with the eventual goal of reducing the burden as well as the consequences of VTE for patients with cancer.

Analysis of risk factors for central venous port failure in cancer patients

AIM: To analyze the risk factors for central port failure in cancer patients administered chemotherapy, using univariate and multivariate analyses.

METHODS: A total of 1348 totally implantable venous access devices (TIVADs) were implanted into 1280 cancer patients in this cohort study. A Cox proportional hazard model was applied to analyze risk factors for failure of TIVADs. Log-rank test was used to compare actuarial survival rates. Infection, thrombosis, and surgical complication rates (χ² test or Fisher’s exact test) were compared in relation to the risk factors.

RESULTS: Increasing age, male gender and open-ended catheter use were significant risk factors reducing survival of TIVADs as determined by univariate and multivariate analyses. Hematogenous malignancy decreased the survival time of TIVADs; this reduction was not statistically significant by univariate analysis [hazard ratio (HR) = 1.336, 95% CI: 0.966-1.849, P = 0.080)]. However, it became a significant risk factor by multivariate analysis (HR = 1.499, 95% CI: 1.079-2.083, P = 0.016) when correlated with variables of age, sex and catheter type. Close-ended (Groshong) catheters had a lower thrombosis rate than open-ended catheters (2.5% vs 5%, P = 0.015). Hematogenous malignancy had higher infection rates than solid malignancy (10.5% vs 2.5%, P < 0.001).

CONCLUSION: Increasing age, male gender, open-ended catheters and hematogenous malignancy were risk factors for TIVAD failure. Close-ended catheters had lower thrombosis rates and hematogenous malignancy had higher infection rates.

Prolonged interval in prophylactic heparin flushing for maintenance of subcutaneous implanted port care in patients with cancer

The long-term use of subcutaneous implanted ports for chemotherapy in cancer patients has been associated with the occurrence of thrombosis and infection. In this study, we compared the safety and efficacy of administration of 1000 U of heparin flushes in prolonged interval (every 6 weeks) with standard dose and schedule (500 U every 4 weeks) for port-related infections and thrombosis during periods of non-use. Data were collected retrospectively from patients treated for various cancer types (matched as 2:1 for age, gender, stage of the disease). Patients who had diseases that could cause thrombosis or bleeding in their past medical history, or were taking oral anticoagulants, or had contraindications for heparin usage were excluded. After completing their chemotherapy, 59 patients received prolonged interval, while 30 patients received standard schedule. All patients were followed for at least 1 year. No clinically documented port-related infection or thrombosis has been found in both groups. Also, none of the devices was removed during this time. Prophylactic flushing of central venous ports with 1000 U of heparin in every 6 weeks might be a safe, easy, cheaper, comfortable and effective alternative to standard dose and schedule for preventing thrombosis and infections.

Treatment of venous thromboembolism in patients with cancer: Guidelines of the Italian Society for Haemostasis and Thrombosis (SISET)

BACKGROUND

The treatment of venous thromboembolism (VTE) in cancer patients remains controversial.

PURPOSE

The Italian Society for Thrombosis and Haemostasis (SISET) commissioned a project to develop clinical practice guidelines for the therapy of VTE in patients with malignancies.

METHODS

Key questions about the treatment of VTE in patients with malignancies were formulated by a multidisciplinary working group consisting of experts in clinical medicine and research. After a systematic review and discussion of the literature, recommendations were formulated and graded according to the supporting evidence. For those questions for which the literature search did not yield any definitive answer (absence of evidence evidence of low quality, and contradictory evidence), a formal consensus method was used to issue clinical recommendations.

RESULTS

The results of the available literature on VTE treatment in cancer patients were reviewed and clinical recommendations were drafted.

CONCLUSION

We describe the results of a systematic literature review and an explicit approach to consensus techniques which resulted in recommendations for the key therapeutic issues in cancer patients with VTE.

Catheter-associated thrombosis in patients with malignancy

Central venous catheters are widely used in the care of patients with cancer. Indwelling catheters are associated with upper extremity deep venous thrombosis in some patients, and recognition of this entity is an important aspect of treating patients with malignancies. This article will review the incidence, pathogenesis, clinical presentation, diagnosis, treatment, and prophylaxis of catheter-associated thrombosis in patients with malignancy. The care of pediatric patients with malignancy and catheter-associated thrombosis will also be addressed.

Capecitabine in combination with oxaliplatin or irinotecan in elderly patients with advanced colorectal cancer: results of a randomized phase II study

BACKGROUND

To determine the efficacy and tolerability of capecitabine combined with oxaliplatin (CAPOX) or irinotecan (CAPIRI) as first-line treatment in patients with advanced/metastatic colorectal cancer aged > or =70 years.

PATIENTS AND METHODS

Patients aged > or =70 years were randomly assigned to receive CAPOX [oxaliplatin 65 mg/m(2) intravenously (i.v.) days 1 and 8 and capecitabine 1000 mg/m(2) orally b.i.d. days 1-14; q21d] or CAPIRI (irinotecan 80 mg/m(2) i.v. days 1 and 8 and capecitabine 1000 mg/m(2) orally b.i.d. days 1-14; q21d). The primary study end point was overall response rate (ORR).

RESULTS

Ninety-four patients were enrolled. In an intent-to-treat analysis, 2 complete responses (CRs) and 16 partial responses (PRs) were reported with CAPOX (ORR 38%), and 2 CRs and 15 PRs with CAPIRI (ORR 36%; P = 0.831). Median time to progression was 8 months for CAPOX and 7 months for CAPIRI (P = 0.195), with median survival times of 19.3 months and 14.0 months (P = 0.165), respectively. Global health status was improved in 45% and in 21% of patients in the CAPOX and CAPIRI arms, respectively. The most common treatment-related grade 3-4 adverse events in CAPIRI versus CAPOX patients were diarrhea (32% versus 15%; P = 0.052) and neutropenia (23% versus 6%; P = 0.021).

CONCLUSION

CAPOX and CAPIRI had similar efficacy in elderly patients, although CAPOX seemed to be better tolerated.

Thromboembolism in Adults with Acute Lymphoblastic Leukemia During Induction with L-Asparaginase-containing Multi-agent Regimens: Incidence, Risk Factors, and Possible Role of Antithrombin

Thromboembolism (TE) is a known complication of L-asparaginase (ASP) therapy of acute lymphoblastic leukemia (ALL), possibly attributable to reduced synthesis of natural anticoagulants, in particular antithrombin (AT). This retrospective single institution study was performed to determine the TE incidence among adults undergoing induction with contemporary, ASP-containing regimens. Ten of 54 (18.5%) consecutive adults developed symptomatic, objectively confirmed TE, at a median of 5.5 days after the first ASP dose. These were notable for CNS and upper extremity localization, varied significantly according to ALL immunophenotype (precursor B: 11% vs. T cell: 33%), without apparent effect of schedule or total dose of ASP. Median baseline AT level was 94% and fell to a nadir of 47% (P < 0.0001) during ASP therapy. Prophylactic AT had been given to 17 during ASP therapy. None of these developed TE vs. 10/37 (27%) without replacement (P = 0.021). These observations merit further study to gain insight into disease and/or therapy-specific pathogenesis of TE in this population and call for the prospective evaluation of appropriate prophylactic interventions.

Management of venous thromboembolism in colorectal cancer patients treated with bevacizumab

Venous thromboembolism associated with use of a central venous access system is an urgent problem in patients treated with bevacizumab (bev). We investigated the effectiveness of Doppler ultrasound imaging (DUS) in the early detection of catheter-related thrombosis for avoidance of severe venous thromboembolism. Patients with metastatic colorectal cancer received either FOLFOX-4 + bev or FOLFIRI + bev. DUS was performed on the deep venous system for detection of thrombus formation during the initial cycle of treatment, followed by re-evaluation after the third cycle in patients with asymptomatic thrombus formation. All patients were followed up until treatment was interrupted. Median duration of follow-up was 484 days (range 72-574). Among 41 enrolled patients, curable symptomatic thrombosis occurred in one, and asymptomatic thrombosis in 21 (51.2%). Of 21 patients undergoing re-evaluation, thrombi remained without progression in 17 patients, and enlargement in 4 patients. In two of the patients in whom there was progression, pulmonary embolism occurred after the sixth cycle. In the asymptomatic group, no thrombi developed as far as the superior vena cava in any patient. In the cases of progression, thrombotic enlargement was observed in all the 4 patients, with decreased vascular flow in 2. Using DUS, we were able to detect asymptomatic thrombosis in the early cycles of treatment, indicating its potential in the monitoring of venous thrombi. In the event of an enlarging asymptomatic thrombosis developing into the superior vena cava along with decreased vascular flow, careful follow-up and appropriate anticoagulant therapy may be recommended without increased risk of bleeding.

Epidemiology of cancer-related venous thromboembolism

Recent studies have better defined the epidemiology of venous thromboembolism (VTE) in cancer patients. The incidence is highest in patients who have metastatic disease at the time of presentation and who have fast growing, biologically aggressive cancers associated with a poor prognosis. The incidence is also high in patients with haematological cancers. Other specific risk factors that affect the incidence of VTE include undergoing invasive neurosurgery, the number of underlying chronic co-morbid conditions, and being of Asian/Pacific Islander decent (lower incidence). The incidence is highest in the first few months after diagnosis, which may reflect the biology of the cancer or medical interventions such as major surgery or start of chemotherapy. The development of VTE is clearly associated with decreased survival, and this effect is greater among patients initially diagnosed with local- or regional-stage cancer compared with patients with metastatic cancer, probably because VTE reflects the presence of a biologically aggressive cancer. Finally, a small percentage of patients with idiopathic VTE and no clinical or laboratory evidence of cancer may harbour an aggressive but 'occult' malignancy likely causally linked to the development of VTE.

Management of occlusion and thrombosis associated with long-term indwelling central venous catheters

Long-term central venous catheters (CVCs) are important instruments in the care of patients with chronic illnesses, but catheter occlusions and catheter-related thromboses are common complications that can result from their use. In this Review, we summarise management of these complications. Mechanical CVC occlusions need cause-specific treatment, whereas thrombotic occlusions usually resolve with thrombolytic treatment, such as alteplase. Prophylaxis with thrombolytic flushes might prevent CVC infections and catheter-related thromboses, but confirmatory studies and cost-effectiveness analysis of this approach are needed. Risk factors for catheter-related thromboses include previous catheter infections, malposition of the catheter tip, and prothrombotic states. Catheter-related thromboses can lead to catheter infection, pulmonary embolism, and post-thrombotic syndrome. Catheter-related thromboses are usually diagnosed by Doppler ultrasonography or venography and treated with anticoagulation therapy for 6 weeks to a year, dependent on the extent of the thrombus, response to initial therapy, and whether thrombophilic factors persist. Prevention of catheter-related thromboses includes proper positioning of the CVC and prevention of infections; anticoagulation prophylaxis is not currently recommended.

Children with acute lymphoblastic leukaemia have high plasma levels of total homocysteine at time of diagnosis

OBJECTIVE

Cancer can induce venous thromboembolic complications for various reasons. As part of a greater study, acquired and congenital prothrombotic risk factors were investigated in children with leukaemia or non-Hodgkin's lymphoma and compared with similar investigations in children with congenital heart defects.

MATERIAL AND METHODS

Blood samples were taken from 60 children with newly diagnosed leukaemia or lymphoma and 133 children with congenital heart defects in the course of a scheduled cardiac catheterization. When children with cancer were in remission, analyses of acquired prothrombotic risk factors were repeated. Children with cancer were observed for symptoms of thromboembolism throughout their treatment period.

RESULTS

Total homocysteine levels were significantly raised in children with cancer (median value 10.0 micromol/L) as compared with the levels in children with congenital heart diseases (5.0 micromol/L) (p<0.001), while children with acute lymphoblastic leukaemia had the highest values. The median level of lipoprotein(a) was slightly increased in children with newly diagnosed leukaemia or lymphoma (105 mg/L versus 100 mg/L, p<0.001), and levels of coagulation inhibitors were higher (p<0.001). Total homocysteine levels normalized when children attained remission of cancer disease. Two children had symptoms of acute thrombosis.

CONCLUSIONS

Raised concentrations of total homocysteine were frequent in children with newly diagnosed cancer, but this normalized when the children were in remission. The clinical significance of our observations and the impact on venous thromboembolism have yet to be defined.

Clinical outcomes and factors predicting development of venous thromboembolic complications in patients with advanced refractory cancer in a Phase I Clinic: the M. D. Anderson Cancer Center experience

Venous thromboembolism (VTE) is common in patients with advanced cancer and may influence patient eligibility for clinical studies, quality of life, and survival. We reviewed the medical records of 220 consecutive patients seen in the Phase I Clinical Trials Program at M. D. Anderson Cancer Center to determine the frequency of VTE, associated characteristics, and clinical outcomes. Twenty-three (10.5%) patients presenting to the Phase I Clinic had a history of VTE; 26 (11.8%) patients subsequently developed VTE, with a median follow-up of 8.4 months. These included nine (39%) patients with and 17 (8.6%) without a history of VTE (P < 0.0001). The most common events were deep venous thromboses of the extremities and pulmonary emboli. The median survival of patients with and without a history of VTE was 4.7 and 10.9 months, respectively (P = 0.0002). Multivariate analysis demonstrated that a history of VTE (P < 0.0001), pancreatic cancer (P = 0.007), and platelet count >440 x 10(9)/L (P = 0.026) predicted new VTE episodes. In conclusion, this retrospective analysis demonstrated that a history or new development of VTE was noted in 40 (18%) of 220 patients seen in our Phase I Clinic. A prognostic score that can be used to predict time to development of and frequency of VTE is proposed. Am. J. Hematol. 2009. (c) 2009 Wiley-Liss, Inc.

Early and short-term acenocumarine or dalteparin for the prevention of central vein catheter-related thrombosis in cancer patients: a randomized controlled study based on serial venographies

BACKGROUND

We evaluated efficacy and safety of early and short-term prophylaxis with acenocumarine or dalteparin in the prevention of non-occlusive or occlusive central vein catheter-related thrombosis (CVCrT).

PATIENTS AND METHODS

Consecutive cancer patients scheduled for chemotherapy randomly received: acenocumarine 1 mg/day for 3 days before and 8 days after central vein catheter (CVC) insertion; dalteparin 5000 IU 2 h before and daily for 8 days after CVC insertion; no anticoagulant treatment (NT). All patients underwent venography on days 8 and 30, some of them on days 90, 150 and 210 after CVC.

RESULTS

A total of 450 patients were randomized, 348 underwent at least two venography. Both acenocumarine and dalteparin reduced venography-detected CVCrT rate [21.9% acenocumarine versus 52.6% NT, odds ratio (OR) 0.3, P < 0.01; 40% dalteparin versus 52.6% NT, OR 0.6, P = 0.05]. Acenocumarine was more effective than dalteparin (OR 0.4, P = 0.01). The rate of occlusive CVCrT was not different in the three groups (0.9% acenocumarine, 3.3% dalteparin, 1.8% NT; P = 0.40). Most CVCrTs (95.6%) were observed on day 8 after CVC insertion and were non-occlusive.

CONCLUSIONS

In this study of early and short-term prophylaxis, acenocumarine was more effective than dalteparin on non-occlusive and asymptomatic CVCrT events. The first days following CVC insertion represent the highest risk for CVCrT.

2008 SOR guidelines for the prevention and treatment of thrombosis associated with central venous catheters in patients with cancer: report from the working group

BACKGROUND

In view of the lack of recommendations on central venous catheter (CVC)-associated thrombosis in cancer patients, we established guidelines according to the well-standardized Standards, Options and Recommendations methodology.

MATERIAL AND METHODS

A literature review (1990-2007) on CVC-associated thrombosis was carried out. The guidelines were developed on the basis of the corresponding levels of evidence derived from analysis of the 36 of 175 publications selected. They were then peer reviewed by 65 independent experts.

RESULTS

For the prevention of CVC-associated thrombosis, the distal tip of the CVC should be placed at the junction between the superior cava vein and right atrium; anticoagulants are not recommended. Treatment of CVC-associated thrombosis should be based on the prolonged use of low-molecular weight heparins. Maintenance of the catheter is justified if it is mandatory, functional, in the right position, and not infected, with a favorable clinical evolution under close monitoring; anticoagulant treatment should then be continued as long as the catheter is present.

CONCLUSIONS

Several rigorous studies do not support the use of anticoagulants for the prevention of CVC-associated thrombosis. Treatment of CVC-associated thrombosis relies on the same principles as those applied in the treatment of established thrombosis in cancer patients.

Venous thromboembolism (VTE) in patients with cancer: epidemiology and risk factors

Although cancer is recognized as a major risk factor for venous thromboembolism, the exact magnitude of the problem and specific risk factors most strongly associated with the development of VTE is not well defined. Several recent studies have shown that the incidence of VTE is highest in patients who present with metastatic cancer, particularly cancers associated with a high one-year mortality rate, such as pancreatic cancer. The incidence rate of VTE is highest in the first few months after the diagnosis of cancer, and it decreases over time thereafter. For most cancers, it is not clear to what extent undergoing major surgery adds to the already high risk of VTE associated with the presence of the cancer. However, patients with glioma clearly have a very high incidence of VTE soon after they undergo any invasive neurosurgical procedure. Active chemotherapy, the use of erythropoetin agents, and the use of certain anti-cancer therapies such as thalidomide, high-dose steroids, and anti-angiogenic therapy also increase the risk of thrombosis. Similar to patients without cancer, the risk of VTE is higher in patients with coexisting chronic medical illnesses. Development of VTE is clearly associated with decreased survival and this effect is greater among patients initially diagnosed with local or regional stage cancer compared to patients with metastatic cancer.

Thromboembolism in patients with advanced gastroesophageal cancer treated with anthracycline, platinum, and fluoropyrimidine combination chemotherapy: a report from the UK National Cancer Research Institute Upper Gastrointestinal Clinical Studies Group

PURPOSE

Data concerning the prevalence of and outcomes related to thromboembolic events (TEs) in patients with advanced gastroesophageal cancer who are undergoing chemotherapy are limited.

PATIENTS AND METHODS

This was a prospective, exploratory analysis of TEs in a randomized, controlled trial of 964 patients recruited between 2000 and 2005 and treated with epirubicin/platinum/fluoropyrimidine combination chemotherapy for advanced/locally advanced gastroesophageal cancer. Regimens were epirubicin (E), cisplatin (C), fluorouracil (F; ECF); E, C, capecitabine (X; ECX); E, F, oxaliplatin (O; EOF); and EOX. Continuously infused F was administered via a central venous access device (CVAD) with 1 mg of warfarin for thromboprophylaxis. The principal outcome was the incidence of TEs (venous and arterial) in the whole treated patient cohort, according to chemotherapy, associated with CVADs and TE-related prognoses.

RESULTS

The incidences of any, of venous, and of arterial TEs among 964 treated patients were 12.1% (95% CI, 10.7 to 14.3), 10.1% (95% CI, 8.3 to 12.3), and 2.2% (95% CI, 1.4 to 3.4) respectively. There were fewer TEs in the O compared with the cisplatin groups (EOF/EOX v ECF/ECX: 7.6% v 15.1%; P = .0003). C was identified as a risk factor for TE in multivariate analysis (hazard ratio [HR], 0.51; 95% CI, 0.34 to 0.76; P = .001). There was no difference in the incidence of TEs for the F group compared with the capecitabine groups. The incidence of CVAD-related thrombosis was 7.0% (ECF/EOF arms). Overall survival was worse for patients who experienced TEs versus no TEs (median survival, 7.4 v 10.5 months; HR, 0.8; 95% CI, 0.64 to 0.99; P = .043).

CONCLUSION

This analysis has prospectively quantified the incidence/pattern of TEs among patients with advanced gastroesophageal cancer who were treated with four triplet regimens, has demonstrated a differential thrombogenic effect according to platinum use, and has noted a poorer outcome associated with TE during treatment. Chemotherapy-related TE should contribute to the risk/benefit assessment of treatment.

Warfarin thromboprophylaxis in cancer patients with central venous catheters (WARP): an open-label randomised trial

BACKGROUND

The role and dose of anticoagulants in thromboprophylaxis for patients with cancer receiving chemotherapy through central venous catheters (CVCs) is controversial. We therefore assessed whether warfarin reduces catheter-related thrombosis compared with no warfarin and whether the dose of warfarin determines the thromboprophylactic effect.

METHODS

In 68 clinical centres in the UK, we randomly assigned 1590 patients aged at least 16 years with cancer who were receiving chemotherapy through CVCs to no warfarin, fixed-dose warfarin 1 mg per day, or dose-adjusted warfarin per day to maintain an international normalised ratio between 1.5 and 2.0. Clinicians who were certain of the benefit of warfarin randomly assigned patients to fixed-dose or dose-adjusted warfarin groups. The primary outcome was the rate of radiologically proven, symptomatic catheter-related thrombosis. Analysis was by intention to treat. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN 50312145.

FINDINGS

Compared with no warfarin (n=404), warfarin (n=408; 324 [79%] on fixed-dose and 84 [21%] on dose-adjusted) did not reduce the rate of catheter-related thromboses (24 [6%] vs 24 [6%]; relative risk 0.99, 95% CI 0.57-1.72, p=0.98). However, compared with fixed-dose warfarin (n=471), dose-adjusted warfarin (n=473) was superior in the prevention of catheter-related thromboses (13 [3%] vs 34 [7%]; 0.38, 0.20-0.71, p=0.002). Major bleeding events were rare; an excess was noted with warfarin compared with no warfarin (7 vs 1, p=0.07) and with dose-adjusted warfarin compared with fixed-dose warfarin (16 vs 7, p=0.09). A combined endpoint of thromboses and major bleeding showed no difference between comparisons. We did not note a survival benefit in either comparison.

INTERPRETATION

The findings show that prophylactic warfarin compared with no warfarin is not associated with a reduction in symptomatic catheter-related or other thromboses in patients with cancer and therefore we should consider newer treatments.

FUNDING

Medical Research Council and Cancer Research UK.

Best choice of central venous insertion site for the prevention of catheter-related complications in adult patients who need cancer therapy: a randomized trial

BACKGROUND

Central venous access is extensively used in oncology, though practical information from randomized trials on the most convenient insertion modality and site is unavailable.

METHODS

Four hundred and three patients eligible for receiving i.v. chemotherapy for solid tumors were randomly assigned to implantation of a single type of port (Bard Port, Bard Inc., Salt Lake City, UT), through a percutaneous landmark access to the internal jugular, a ultrasound (US)-guided access to the subclavian or a surgical cut-down access through the cephalic vein at the deltoid-pectoralis groove. Early and late complications were prospectively recorded until removal of the device, patient's death or ending of the study.

RESULTS

Four hundred and one patients (99.9%) were assessable: 132 with the internal jugular, 136 with the subclavian and 133 with the cephalic vein access. The median follow-up was 356.5 days (range 0-1087). No differences were found for early complication rate in the three groups {internal jugular: 0% [95% confidence interval (CI) 0.0% to 2.7%], subclavian: 0% (95% CI 0.0% to 2.7%), cephalic: 1.5% (95% CI 0.1% to 5.3%)}. US-guided subclavian insertion site had significantly lower failures (e.g. failed attempts to place the catheter in agreement with the original arm of randomization, P = 0.001). Infections occurred in one, three and one patients (internal jugular, subclavian and cephalic access, respectively, P = 0.464), whereas venous thrombosis was observed in 15, 8 and 11 patients (P = 0.272).

CONCLUSIONS

Central venous insertion modality and sites had no impact on either early or late complication rates, but US-guided subclavian insertion showed the lowest proportion of failures.

Two cases of central venous catheter-related thrombosis in living liver donors: how can the risk be minimized?

A central venous catheter (CVC) is commonly used for intraoperative management by anesthetists and surgeons during major operations, including donor operations for living donor liver transplantation (LDLT), in which donor safety is of utmost importance. Reasons for use of CVC for donors include measurement of central venous pressure and drug infusion when necessary. A potentially serious complication of a major operation is pulmonary thromboembolism. We report two cases of LDLT donors complicated by catheter related thrombosis (CRT) of the jugular vein, who were eventually discharged without long-term complications. To the best of our knowledge, there has been no report of CRT among LDLT donor population. In this report, in order to minimize the risks related to CRT in LDLT donors, we propose thorough screening for thrombophilic disorders, use of a silicone or polyurethane double-lumen CVC as thin as possible, placement of the tip of the CVC at the superior vena cava via the right jugular vein using ultrasonography as a guide for puncture, and removal of the catheter at the end of the operation based on our experience of CRT among LDLT donors.

Central venous access ports in children treated for hematopoietic malignancies

During past 10 years 234 central venous access ports (CVAP) were implanted in 225 patients at the Department of Pediatric Hematology and Oncology in Zabrze. Mean exposure time was 745 days and total implantation time reached 173,768 days. Complications were encountered in 17 patients (7.6%). This mainly concerned central venous line infection, which led to removal of 10 CVAP (4.4%). The remaining complications necessitating removal of the CVAP consisted mainly of mechanical problems (catheter fracture, occlusion, and erroneous implantation to artery). In the opinion of the authors, subcutaneously implanted CVAP are a safe and effective option for high-dose chemotherapy deliverance in childhood cancer patients.