Coagulation disorders in cancer. 3. Fibrinolysis and inhibitors

Thromboembolic Events in the Cancer Patient

Thromboembolic events are a major cause of morbidity in cancer patients and may be harbingers of occult malignancy. Trousseau's syndrome (TS) is probably the best known thromboembolic syndrome in the cancer patient, encompassing a variety of paraneoplastic thromboembolic disorders. These include spontaneous recurrent or migratory venous thromboses and arterial emboli caused by nonbacterial thrombotic endocarditis in a patient with malignancy. Although linked to almost all cancers, venous thromboembolism (VTE) is a terminal event in many cancers occurring in women, such as breast, uterine, and lung cancers (Monreal et al. Thrombosis and Haemostasis 1997;78:1316). Appropriate recognition of the syndrome is paramount because TS often requires careful medical surveillance and management. Significant complications of thromboembolic events in the cancer patient include limb ischemia and deep venous thrombosis/pulmonary embolism, which can cause devastating and permanent consequences. The rehabilitation management of these complications is reviewed, with an emphasis on diagnostic and therapeutic approaches in this patient population.

Hemostatic Changes in Patients with Malignancy

Alterations of hemostasis commonly accompany the progression of malignant disease and every known component of the hemostatic mechanism may be affected by this disease process. Nearly all patients with an active neoplasm will exhibit at least subtle biochemical changes in hemostasis, and a minority of these patients will also develop clinical thrombosis or hemorrhage. In this paper, we will review intravascular coagulation and fibrinolysis, thrombocytopenia, and thrombocytosis, as well as more rare thrombotic and hemorrhagic events resulting from the direct interactions of neoplasms, or of their products, with the individual elements of hemostatic mechanisms. Thrombotic and hemorrhagic events resulting from the induction of autoimmune or thrombotic microangiopathic syndromes are also discussed. This review focuses on the clinical thrombotic and bleeding syndromes that may occur as a result of this interaction between neoplasia and hemostasis.

Rates of initial and recurrent thromboembolic disease among patients with malignancy versus those without malignancy. Risk analysis using Medicare claims data

Although the association between malignancy and thromboembolic disease is well established, the relative risk of developing initial and recurrent deep vein thrombosis (DVT) or pulmonary embolism (PE) among patients with malignancy versus those without malignancy has not been clearly defined. The Medicare Provider Analysis and Review Record (MEDPAR) database was used for this analysis. Patients hospitalized during 1988-1990 with DVT/PE alone, DVT/PE and malignancy, malignancy alone, or 1 of several nonmalignant diseases (other than DVT/PE) were studied. The association of malignancy and nonmalignant disease with an initial episode of DVT/PE, recurrent DVT/PE, and mortality were analyzed. The percentage of patients with DVT/PE at the initial hospitalization was higher for those with malignancy compared with those with nonmalignant disease (0.6% versus 0.57%, p = 0.001). The probability of readmission within 183 days of initial hospitalization with recurrent thromboembolic disease was 0.22 for patients with prior DVT/PE and malignancy compared with 0.065 for patients with prior DVT/PE and no malignancy (p = 0.001). Among those patients with DVT/PE and malignant disease, the probability of death within 183 days of initial hospitalization was 0.94 versus 0.29 among those with DVT/PE and no malignancy (p = 0.001). The relative risk of DVT/PE among patients with specific types of malignancy is described. This study demonstrates that patients with concurrent DVT/PE and malignancy have a more than threefold higher risk of recurrent thromboembolic disease and death (from and cause) than patients with DVT/PE without malignancy. An alternative management strategy may be indicated for such patients.

Thrombosis and hemorrhage in oncology patients

As outlined in this review, patients with cancer may harbor many alterations of hemostasis. These are multifaceted and must be considered when trying to control hemorrhage or thrombosis in cancer patients. Also, hemorrhage or thrombosis is often the final fatal event in many patients with metastatic solid tumor or hematologic malignancies. Patients with malignancy present a major clinical challenge in this new era of oncologic awareness and more aggressive care, which has led to prolonged survival for patients and a longer time frame during which these complications may develop. Therefore, these complications are occurring more commonly. It is important to realize that these alterations of hemostasis exist and must be approached in a sequential and logical manner with respect to diagnosis; only in this way can responsible, efficacious, and rational therapy be delivered to patients. By far the most common alteration of hemostasis in malignancy is that of hemorrhage associated with thrombocytopenia, either drug-induced, or radiation-induced, or from bone marrow invasion. Hemorrhage resulting from DIC, however, is also quite common and may present as hemorrhage, thrombosis, thromboembolus, or any combination thereof. Many antineoplastic drugs and radiation therapy may lead to or significantly enhance hemorrhage in patients with malignancy. Thrombosis, also commonly seen in patients with malignancy, is often a manifestation of low-grade DIC. When approaching the patient with malignancy and either hemorrhage or thrombosis, all the potential defects in hemostasis must be considered, defined from the laboratory standpoint, and treated in as precise and logical manner as possible.

Trousseau's syndrome in association with ovarian carcinoma

BACKGROUND

The association of neoplastic disease and thromboembolic disorders was first recognized by Trousseau in 1865. Abnormalities of blood coagulation tests have been reported in the majority of patients with cancer, including ovarian carcinoma. However, Trousseau's syndrome has rarely been reported in women with ovarian carcinoma.

METHODS

A literature search for cases of Trousseau's syndrome in association with ovarian carcinoma was performed using the MEDLINE database. Case notes of patients with ovarian carcinoma treated at St. George's Hospital were reviewed and cases of Trousseau's syndrome identified.

RESULTS

We report a series of 4 cases of Trousseau's syndrome in association with ovarian carcinoma occurring over a 3- to 4-year period, and highlight the particular difficulties associated with the management of these thromboembolic effects.

CONCLUSIONS

Trousseau's syndrome can impair quality of life in patients with advanced ovarian carcinoma and enhanced anticoagulation regimens may be required for effective palliation.

Coagulation disorders in cancer

Coagulation disorders are common in cancer patients. This article reviews the coagulation laboratory findings in these patients and the thromboembolic and hemorrhagic manifestations of malignancy. Among the many topics addressed are Trousseau's syndrome, disseminated intravascular coagulation, and acquired von Willebrand disease. Pathogenesis of the coagulation disorders and recommendations for treatment of various syndromes are discussed.

Thromboembolic complications associated with brain tumors

Thromboembolic complications are the second most common cause of death in hospitalized cancer patients; they are caused by alterations of hemostasis and include hypercoagulable states, acute and chronic disseminated intravascular coagulation, and primary fibrinolysis. The fibrinolytic system is comprised of several serine protease enzymes and their inhibitors and is associated in various biological systems with physiological and pathological events such as tissue development, remodeling, invasiveness, and migratory potentials of both normal and malignant cells. It also plays a key role in the dissolution of fibrin strands. Defective fibrinolysis, which is often associated with the pathogenesis of venous thrombosis and other thromboembolic complications, occurs when the balance is disrupted, resulting in either inhibition or enhancement of fibrinolysis. The association between thromboembolic complications and neoplastic disease has been well-established since Trousseau in 1865 first reported a high incidence of venous thrombosis in a series of patients with gastric carcinoma. In this article, we discuss the factors that have been shown to be associated with thromboembolic complications in patients who harbor brain tumors, namely, hemostatic alterations caused by the tumors themselves or through interactions with neural tissue around the tumors, pre-operative hemostatic alterations in certain patients, and defective fibrinolysis associated with specific tumor types and/or tumor locations.

Perioperative coagulopathy in patients undergoing primary cytoreduction

BACKGROUND

This study was performed to determine the frequency of a perioperative coagulopathy in patients undergoing primary cytoreduction for ovarian cancer or carcinoma of the peritoneum and to identify variables that might predict this phenomenon.

METHODS

A retrospective review of 90 patients undergoing primary cytoreduction for ovarian cancer or carcinoma of the peritoneum was performed at Cedars Sinai Medical Center. Univariate analysis was performed to test the relationship between 15 variables and coagulopathy status.

RESULTS

Six patients (6.7%) developed a perioperative coagulopathy that was unrelated to preoperative subcutaneous heparin or dilution. Coagulation disturbances developed intraoperatively before packed erythrocyte replacement equivalent to one blood volume. Four patients (4.4%) required a repeat laparotomy due to continued postoperative bleeding unresponsive to blood component replacement. Vascular pedicles were not the cause of bleeding in any patient. Univariate analysis demonstrated a significant association between perioperative coagulopathy and the following variables: ascites volume (P = 0.009), estimated blood loss (P = 0.002), preoperative serum albumin less than 3.5 g/dl (P < 0.0001), and metastasis greater than 10 cm (P = 0.033).

CONCLUSIONS

Patients undergoing primary cytoreduction who have ascites, preoperative serum albumin less than 3.5 g/dl, or metastases greater than 10 cm may be at increased risk for development of a perioperative coagulopathy.

Pulmonary embolism as the initial manifestation of large cell lung cancer--a case report with review

Lung cancer is known as a risk factor of pulmonary embolism. We experienced a case of pulmonary embolism combined with pleural effusion and pleuritic chest pain as the initial manifestation of large cell lung cancer, which is a relatively rare cell type of lung cancer in Korea. We report it with a review of the literature.

Plasma thrombin-antithrombin III complexes in the diagnosis of primary hepatocellular carcinoma complicating liver cirrhosis

Detection of hypercoagulable state might be helpful in the diagnosis of primary hepatocellular carcinoma (HCC) complicating liver cirrhosis (LC). Plasma levels of thrombin-antithrombin III complex (TAT) were determined in 50 patients of LC with or without HCC. The levels were above 2 ng/ml in 80% of 25 HCC patients, but only in 12% of 25 non-HCC patients (P less than 0.01). The levels over 2 ng/ml occurred even in five of six HCC patients whose serum alpha-fetoprotein levels were below 20 ng/ml as well as in two of three patients with HCC less than 2 cm in diameter. Those levels in HCC patients were significantly decreased within 8 days after treatment with transcatheter arterial embolization or infusion of antitumor agents, without affecting plasma antithrombin III levels. These results suggest that plasma TAT levels may be useful in the diagnosis of HCC complicating LC.

Hematologic manifestations of malignancy

Hematologic dysfunction occurs commonly in patients with malignancy. Over half are anemic, often because of acute or chronic blood loss, marrow involvement by the malignancy, marrow suppressive effects of chemotherapy or radiation therapy, or because of the anemia of chronic disease. Less frequently, anemia may result from red cell aplasia, folate or B12 deficiency, hemolytic processes, or hypersplenism. Occasional patients may become polycythemic because of erythropoietin-producing tumors such as renal adenocarcinomas or cerebellar hemangiomas. Elevation of the white cell count is commonly seen, especially in patients with lung cancer. Monocytosis and thrombocytosis, which may be early signs of an underlying malignancy, are also very common and occur in up to half of patients. Thrombocytopenia is commonly a result of therapy or marrow replacement; a few patients may have a syndrome resembling immune thrombocytopenic purpura. Abnormalities of coagulation are present in many patients, and may lead to superficial or deep venous thromboses, pulmonary emboli, nonbacterial thrombotic endocarditis with arterial emboli, bleeding, or acute disseminated intravascular coagulation. A sound understanding of the potential hematologic complications that can result from the malignant process is essential to the clinician caring for cancer patients.

The influence of chemotherapy on plasma coagulation and fibrinolytic systems in lung cancer patients

After the administration of cytostatic drugs, an increase in thromboembolic phenomena has been described in cancer patients. The authors studied the changes in plasmatic coagulation and fibrinolysis in 40 patients with nonoperable Stage III and IV lung cancer after cytostatic chemotherapy. The results show significant postchemotherapy increases in fibrinopeptide A levels, as well as a decrease in fibrinolytic activity reflected by a drop in functional tissue activator. Also the authors studied the potential accumulative effect of three chemotherapy cycles. A significant increase in functional plasminogen activator inhibitor has been noted. Chemotherapy is apparently capable of conditioning a decrease in fibrinolytic activity in these cancer patients that could be related to the enhanced tendency to developing thromboembolic phenomena after cytostatic chemotherapy.

An assessment of monocyte procoagulant activity in patients with solid tumors

Generation of thromboplastin by monocytes has been shown to play a vital role in hypercoagulable states seen in malignancy. The purpose of this study was to compare the procoagulant activity in cancer patients and controls. Recalcification times (RT) of whole blood from 19 normal volunteers, 8 patients with benign polyps, 12 patients previously treated by surgery for head and neck (H&N) or colon cancer, and 13 untreated patients with various stages of H&N or colon cancer were determined. Tests were performed with and without stimulation with Escherichia coli endotoxin. The mean RT in saline (RTS) of untreated patients with early cancer (4.58 +/- 0.83 min) and that of patients with advanced cancer (5.23 +/- 1.16 min) were lower than that of controls (6.55 +/- 0.82 min), P less than 0.01 and P less than 0.05, respectively. The RTS of patients previously treated and of those with benign polyps were no different from those of controls. Activation with endotoxin significantly lowered the recalcification times (RTE) in the early (3.90 +/- 0.58 min) and advanced cancer patients (4.23 +/- 0.66 min) compared to the RTE of controls (5.69 +/- 0.75 min, P less than 0.01 for both groups) as well as compared to those with benign tumors, P less than 0.05. The mean RTE of previously treated patients (4.72 +/- 0.58 min) was also lower than that of controls, P less than 0.05. Our results suggest that RT is significantly reduced in cancer patients compared to that of controls. Furthermore, monocyte activation with endotoxin may enable us to distinguish cancer patients from controls as well as from those with benign tumors.

Nonbacterial thrombotic endocarditis: a review

The entity of NBTE is reviewed in this article. Historic aspects, epidemiology, and pathogenesis are discussed. The clinicopathologic findings are emphasized as well as the potential for antemortem diagnosis and therapy. NBTE is diagnosed infrequently before death. Clinical suspicion is aroused in patients with an underlying process such as malignancy, DIC, or a spectrum of other diseases and evidence of pulmonary and/or systemic embolization. Systemic infection must be excluded. Two-dimensional echocardiography can be utilized to confirm the diagnosis. Anticoagulation therapy with heparin may prevent embolization.

Isolation and partial characterization of a proteinase inhibitor from human colorectal adenocarcinoma

A proteinase inhibitor has been isolated from human colorectal adenocarcinomas by extraction with a low-ionic-strength buffer and a combination of Con A-Sepharose, Sephadex G-200, DEAE-cellulose and chromatofocusing steps. The preparation appeared to be homogeneous upon gel exclusion chromatography and SDS-polyacrylamide gel electrophoresis and had an estimated molecular weight of 66,000. The inhibitor was able to bind and inhibit urokinase, plasmin, trypsin, tissue plasminogen activator and thrombin. The binding appeared to be stoichiometric and relatively fast. The isoelectric point of the protein was 4.6-4.7. The inhibitor did not crossreact with antisera elicited against alpha 2-macroglobulin, alpha 2-antiplasmin, antithrombin III or C1-inhibitor, but it did crossreact with an antiserum against alpha 1-antitrypsin in double immunodiffusion. The antiserum only partially attenuated the activity of the inhibitor. Whereas alpha 1-antitrypsin completely inhibited the amidolytic activity of elastase, the tumor inhibitor had no effect on elastase under the same conditions.

Trousseau's syndrome. Devastating coagulopathy in the absence of heparin

Two patients with Trousseau's syndrome experienced frequently recurring concomitant arterial and venous thrombotic events that resulted in sequential amputation and loss of the lower extremities. Serial examination of the blood in the patients demonstrated that these devastating thrombotic events were preceded by severe disseminated intravascular coagulopathy that occurred within an interval of a few hours. Warfarin therapy was without effect in preventing the occurrence of these events. Both patients demonstrated the absolute need for intravenous heparin, which effectively prevented the thrombotic events; when it was discontinued, the immediate consequences were disastrous and resulted in death. Techniques for long-term outpatient heparin therapy are discussed.

Activation of platelets in cancer, especially with reference to genesis of disseminated intravascular coagulation

Seventy-five cancer patients were evaluated on a scale of coagulation abnormalities related to DIC, one point given for each of the following criteria fulfilled and the score (0 to 4) being used. 1. Platelet count less than 150 x 10(3)/mu 1. 2. PT prolonged more than 1 sec over control or APTT prolonged more than 10 sec over control. 3. Fibrinogen less than 250 mg/dl (mean fibrinogen value of the cancer patients minus 1SD). 4. FDP greater than or equal to 20 micrograms/ml. The patients were distributed with 27% for score 0, 38% for 1, 20% for 2, 7% for 3 and 8% for 4. Platelet mode volume in score 4 was smaller than that of the other groups. Platelet aggregation by epinephrine was decreased in score 3 and 4 (P less than 0.01), while it was increased in score 0 (P less than 0.05). ADP-induced aggregation was increased in score 0 and 1 (P less than 0.01 - 0.05). The mean value of beta-thromboglobulin in cancer patients (44 +/- 24 ng/ml) was significantly higher than that of control (22 +/- 13 ng/ml) (P less than 0.01). These results suggest the existence of hyperfunction of platelets in cancer patients and possibility of a triggering mechanism of such activated platelets in the genesis of DIC in cancer.

Primary cerebral venous thrombosis in patients with cancer--a rarely diagnosed paraneoplastic syndrome. Report of three cases and review of the literature

Idiopathic thrombosis of the cerebral venous structures is a rare complication of malignancy. The clinical, radiologic, pathologic, and laboratory findings in the 15 previously reported cases are reviewed, and three additional cases are reported. The clinical syndrome that develops in such patients is similar to that seen in other patients with cerebral venous or sinus thrombosis. However, the diagnosis is often not made clinically because cerebral involvement by neoplastic disease provides a more common and readily acceptable explantation of the observed phenomena. If venous thrombosis involving the brain is suspected, angiography provides the only certain method of diagnosis. The relationship of this thrombotic process to a cancer-associated hypercoagulable state is discussed.

Thrombophlebitis in cancer patients

Five cancer patients (three with lesions in the lung and one each with breast and head and neck cancer) with multiple metastases developed "migratory thrombophlebitis." These patients were not ambulatory. None of the patients showed a picture of "consumptive coagulopathy," although a "hypercoagulable state" was observed. Fibrinogen levels were normal or increased, FDP were slightly increased, and AT-III was decreased. Prior to heparin therapy, values for PT and PTT were within normal range. Sodium heparin, 30,000 to 36,000 units per day, was administered by continuous intravenous infusion. Despite prolongation of the PTT to twice the baseline levels, signs and symptoms of thrombophlebitis persisted for several days. When thrombophlebitis was controlled with heparin, Coumadin therapy was instituted, but thrombophlebitis recurred at the original site and at new sites, even though the prothrombin time was in the therapeutic range (2 to 2 1/2 times the normal value). The antithrombotic action of heparin depends on a normal quantity of plasma AT-III. Long-term use of heparin is feasible, but the optimal time for discontinuation of heparin treatment has not been established. Heparin is superior to oral anticoagulation therapy to control thrombophlebitis associated with advanced cancer.

Hemostatic function in cancer patients

We performed coagulation profiles including a complete blood count (CBC), prothrombin time (PT), activated partial thromboplastin time (aPTT), and quantitation of fibrinogen, antithrombin III (AT III), plasminogen, and fibrin/fibrinogen degradation products (FDP) on 73 cancer patients. All had solid tumors with clinically documented metastases. Eleven patients had strong clinical and laboratory evidence of disseminated intravascular coagulation (DIC). Fifty-five of the remaining 62 patients had no clinical evidence of serious hemorrhage or thrombosis at the time of testing. Thirty-one (50%) non-DIC patients had no abnormal clotting tests. Our data indicate that a majority of cancer patients, with or without hepatic involvement, are able to maintain normal or near normal hemostatic function in vitro until advanced stage of disease. Deviation from normal for PT, aPTT, or TT, depressed AT III activity, or increased FDP signal the presence of complicating pathophysiologic events such as DIC or cirrhosis. Diminution of fibrinogen level or AT III activity and elevation of FDP are more sensitive indicators of DIC than prolongation of PT, aPTT, or TT.

Thrombophlebitis migrans: a further systemic complication of ulcerative colitis

Thrombophlebitis migrans complicating ulcerative colitis has been reported only once previously when it occurred in a patient with chronic and extensive bowel disease. This report describes the occurrence of thrombophlebitis before any bowel upset in a patient who proved to have only a mild colitis, and no laboratory evidence of hypercoagulability. It seems that thrombophlebitis migrans is a further systemic complication of ulcerative colitis, and that its occurrence may precede overt bowel disease.

Disorders of hemostasis in malignancy

Disorders of hemostasis are frequent in malignant disease and their cause is often multifactorial and complex. Both primary (platelets and vessel walls) and secondary (coagulation factors) hemostasis are impaired, often concurrently. Therapy is most often directed toward the underlying disease; however, a knowledge of the complications and treatment of each malignancy will often prevent a number of the problems cited in this chapter. The hypercoagulable states are still poorly understood and need better definition, but their recognition, treatment and prevention may decrease morbidity significantly.

Recurrent venous thrombosis (thrombophlebitis migrans) and carcinoma of the lung

A case of thrombopheblitis migrans associated with a poorly differentiated adenocarcinoma of the lung is presented. The patient died of a massive pulmonary embolus despite anticoagulant therapy. Disordered fibrinolysis may be the cause of the clotting tendency in this condition.

Fibrinolytic activator in the endothelium of the veins of the lower limb

The local fibrinolytic acitivity of the femoral, popliteal and soleal veins has been studied using a histochemical technique. The results suggest that the fibrinolytic activity in the soleal veins may be low when compared with that in the femoral and popliteal veins. This may be an aetiological factor responsible for the high incidence of thrombi occurring in the soleal veins.

[Observations on tumor-associated fibrinolysis in human breast-cancer (author's transl)]

In 30 cases of breast-cancer, including 24 primary cases, the tumor-associted fibrinolysis was investigated using agar plate method. In 60% of the tissue sample fibrinolytic activity was found. No activity could be detected in the remaining 40%. There was evidence of a positive correlation between tumor-associated fibrinolysis and tumor size as well as the rate of axilla metastases. Among the fibrinolytic active cases there was a disproporionate number of adenocarcinoma, whereas in the inactive collective the solid and scirrhous carcinoma prevailed. There was no relation between the tumor-associated fibrinolysis and the percentage of tumor cells in the tissue. The firbinolytic inactive tumors showed a better histopathological adaptation to the surrounding tissue than the active ones. There was less small-cell infiltrate in the stroma of the fibrinolytic active tumors than in the inactive cases. No significant difference was found in the form of growth and the occurence of fibre structure. For clinical assessment a longer period of observation and a larger study are necessary.

Fibrinolytic activity in malignant disease

Resting fibrinolytic activity and fibrinolytic capacity were compared in 31 patients with malignant disease and in 24 control subjects without malignant disease. Patients with malignant disease had a lower mean fibrinolytic activity: this was particularly marked in those with disseminated disease. In contrast, patients with malignant disease had a fibrinolytic capacity which did not differ from that of the control subjects.

Incidence of paramalignant disorders in bronchogenic carcinoma

The incidence of paramalignant disorders was studied in 280 consecutive patients with early lung cancer confirmed histologically. The commonest disorders were weight loss exceeding 6.4 kg (30.7 percent of the series), finger clubbing (29 percent), fever (21.1 percent), and endocrinopathies (12.1 percent). Paramalignant diseases are common even in early lung cancer and all patients should have investigations for their detection.