Cancer and coagulation

Clinical guidelines for prevention and treatment of CAT in Japan and other countries

Cancer-associated thrombosis (CAT) is an important prognostic factor for an increasing number of cancer patients. Understanding of CAT among cancer care providers has grown in recent years, and guidelines for the prevention and treatment of CAT have been published in Japan and around the world. In this article, we introduce these major guidelines and discuss differences we identified between the Japanese guidelines and those of other countries, with a focus on problems and issues. Insurance coverage of low-molecular-weight heparin and indications for primary prevention with direct oral anticoagulants in particular require urgent consideration.

Establishment and verification of a prognostic model based on coagulation and fibrinolysis-related genes in hepatocellular carcinoma

BACKGROUND

Studies have shown that coagulation and fibrinolysis (CFR) are correlated with Hepatocellular carcinoma (HCC) progression and prognosis. We aim to build a model based on CFR-correlated genes for risk assessment and prediction of HCC patient.

METHODS

HCC samples were selected from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) databases respectively. The Molecular Signatures Database (MSigDB) was used to select the CFR genes. RiskScore model were established by single sample gene set enrichment analysis (ssGSEA), weighted correlation network analysis (WGCNA), multivariate Cox regression analysis, LASSO regression analysis.

RESULTS

PCDH17, PGF, PDE2A, FAM110D, FSCN1, FBLN5 were selected as the key genes and designed a RiskScore model. Those key genes were Differential expressions in HCC cell and patients. Overexpression PDE2A inhibited HCC cell migration and invasion. The higher the RiskScore, the lower the probability of survival. The model has high AUC values in the first, third and fifth year prediction curves, indicating that the model has strong prediction performance. The difference analysis of clinicopathological features found that a great proportion of high clinicopathological grade samples showed higher RiskScore. RiskScore were positively correlated with immune scores and TIDE scores. High levels of immune checkpoints and immunomodulators were observed in high RiskScore group. High RiskScore groups may benefit greatly from taking traditional chemotherapy drugs.

CONCLUSIONS

We screened CFR related genes to design a RiskScore model, which could accurately evaluate the prognosis and survival status of HCC patients, providing certain value for optimizing the clinical treatment of cancer in the future.

Lung cancer presenting with acute myocardial infarction and pulmonary embolism within 1 month

Acute myocardial infarction and pulmonary embolism can have life-threatening consequences such as congestive heart and respiratory failure, respectively. Cancer patients are at great risk of both acute myocardial infarction and pulmonary embolism complications because the malignancy sparks the patient's blood hypercoagulable state. Nevertheless, the literature currently offers only a few reports on acute myocardial infarction associated with pulmonary embolism, and two of them occurred in the same cancer patient. Here, we present a case of a 60-year-old woman who had been diagnosed with lung cancer. She was admitted to the emergency department twice. She was diagnosed with acute myocardial infarction at her first admission, when she experienced sudden-onset chest pain. Electrocardiography showed ST-segment elevation in leads V1-V3 with inverted T wave and pathological Q wave, suggesting an acute myocardial infarction. Coronary angiography revealed a thrombus in the left anterior descending coronary artery, and thrombus aspiration was performed. After 1 month, she had an attack of pulmonary embolism with syncope upon the second admission. A computed tomographic pulmonary angiography showed branches of right and left pulmonary embolism. Anticoagulation and antiplatelet measures were taken. In this article, we discuss the relationship between cancer and thrombosis with a special focus on the conservative management strategy regarding anticoagulant and antiplatelet therapy in our case.

Smoking and Activated Clotting Time during coronary angiography and angioplasty: protocol for the ACT-Tobacco trial

Background

During percutaneous transluminal coronary angioplasty (PTCA), activated clotting time (ACT) measurements are recommended to attest a correct anticoagulation level and, if needed, to administer further unfractionated heparin (UFH) to obtain a therapeutic ACT value. Our clinical routine led us to observe that smokers had lower ACT values after standardized UFH administration during PTCA. Procoagulant status in smokers is well documented.

Objectives

To determine whether tobacco negatively affects UFH anticoagulation during PTCA when evaluated by ACT.

Methods

The ACT-TOBACCO trial is a single-center, noninterventional, prospective study. The primary end point is the comparison of ACT values after standardized UFH administration between active smokers and nonsmokers (active smoker group vs nonsmoker group) requiring coronary angiography followed by PTCA. The main secondary end points include ACT comparison after the first and second standardized UFH administration according to the patient's smoking status (active, ex-, or nonsmoker) and the clinical presentation of ischemic cardiomyopathy: stable (silent ischemia or stable angina) or unstable (unstable angina or acute coronary syndrome without or with ST-segment elevation).

Conclusions

To the best of our knowledge, ACT values during PTCA between smokers and nonsmokers have not previously been compared. As current PTCA procedures increase in complexity and duration, the understanding of procoagulant risk factors such as smoking and the need for reliable anticoagulation monitoring becomes essential to balance hemorrhagic risk against thrombotic risk.

Venous thromboembolism incidence and risk factors associated with immune checkpoint inhibitors among patients with advanced non-small cell lung cancer

BACKGROUND

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in patients with lung cancer. Systemic therapies, such as chemotherapy (chemo), are associated with increased risk of VTE. Immune checkpoint inhibitors (ICIs) are a new standard of care for the treatment of lung cancer, but their association with VTE is not fully understood. We evaluated the incidence of VTE and risk factors for patients with advanced non-small cell lung cancer (aNSCLC) treated with first-line ICI-based, chemo-based, or ICI+chemo regimens.

METHODS

This retrospective cohort study used HealthCore Integrated Research Environment - Oncology data, an integrated database of administrative claims, coupled with clinical data from a cancer-care quality program. Patients with first-line treatment of stage IV non-small cell lung cancer from July 2014 to August 2020 were grouped based on three treatment types: ICI-based, chemo-based, or ICI+chemo. Patients with VTE before initiation of systemic treatment were excluded. Newly diagnosed VTE events were identified via inpatient and outpatient diagnosis codes. Cox proportional hazards models were used to investigate the factors associated with VTE risk.

RESULTS

Among 2299 eligible patients (ICI-based, n=605; chemo-based, n=1092; ICI+chemo, n=602) with a median follow-up of 9.1 months, the VTE incidence rates (95% CI) per 100 person-years were 17.8 (95% CI 16.0 to 19.5) overall, 13.5 (95% CI 10.6 to 16.5) for ICI-based, 18.0 (95% CI 15.5 to 20.5) for chemo-based, and 22.4 (95% CI 20.2 to 24.5) for ICI+chemo. The 6-month cumulative incidence of VTE was 8.1% for ICI-based, 10.9% for chemo-based, and 12.8% for ICI+chemo. Pulmonary embolism was most common, accounting for 63% of the VTE events. After controlling for baseline patient characteristics, the risk of VTE was 26% lower for ICI-based regimens than for chemo-based regimens (HR 0.74, p=0.03). There was no meaningful difference in the risk between ICI+chemo and chemo-based regimens (HR 1.12, p=0.36). Previous radiation and severe obesity (body mass index ≥40) were associated with VTE.

CONCLUSIONS

VTE incidence rate per 100 person-years was common across regimens in patients with aNSCLC, but numerically lower for patients receiving ICI-based regimens compared with those receiving chemo-based and ICI+chemo regimens. VTE is a common complication of lung cancer, and there is a continued need for awareness of VTE as a comorbidity in this population.

The Significance of the D-Dimer Level as a Prognostic Marker for Survival and Treatment Outcomes in Patients With Stage IV Colorectal Cancer

BACKGROUND/AIM

Predictive markers for survival and therapeutic efficacy in stage IV colorectal cancer have not been established. As described in our previous report, D-dimer levels may have potential utility as an indicator of cancer activity. The present study evaluated the significance of the D-dimer level as a marker for the survival and treatment outcomes in patients with stage IV colorectal cancer.

PATIENTS AND METHODS

A total of 34 patients who underwent surgery for stage IV colorectal cancer between February 2017 and October 2019 were enrolled. The D-dimer level was measured using a blood sample obtained at the first visit to our hospital.

RESULTS

The median preoperative D-dimer level was 1.2 μg/ml (range=0.5-41.0 μg/ml). We divided patients into two groups using a D-dimer level of 2.0 μg/ml as the cut-off value based on receiver operating characteristic curve analysis. The group with a high-D-dimer-level had a significantly shorter overall survival than that with a low D-dimer level. Progression-free survival after first-line chemotherapy tended to be better in those with a low D-dimer level group than in the high-D-dimer-level group.

CONCLUSION

The preoperative D-dimer level may be a useful indicator for survival and chemotherapeutic outcome in patients with stage IV colorectal cancer.

Prognostic Role of Preoperative D-dimer Levels in Patients With Stage I-III Colorectal Cancer

BACKGROUND/AIM

As D-dimer levels have been reported to reflect cancer activity, preoperative D-dimer levels may serve as a prognostic marker in patients with colorectal cancer. The aim of this study was to evaluate the prognostic significance of preoperative D-dimer levels in patients with stage I-III colorectal cancer who underwent curative surgery.

PATIENTS AND METHODS

A total of 264 patients who underwent curative surgery for stage I-III colorectal cancer between January 2015 and December 2019 were enrolled in this study.

RESULTS

The median preoperative D-dimer level was 0.8 μg/ml (range=0.4-42.5 μg/ml). Based on the results of a receiver operating characteristic curve analysis, we set 1.45 as the cut-off value and classified patients into the low (n=215) and high D-dimer (n=49) groups. The high D-dimer group had significantly lower relapse-free and overall survival in comparison to the low D-dimer group (p<0.0001, p<0.0001, respectively).

CONCLUSION

Preoperative D-dimer levels can serve as a prognostic marker for stage I-III colorectal cancer.

Liquid Biopsy as a Prognostic and Theranostic Tool for the Management of Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinomas (PDAC) represent one of the deadliest cancers worldwide. Survival is still low due to diagnosis at an advanced stage and resistance to treatment. Herein, we review the main types of liquid biopsy able to help in both prognosis and adaptation of treatments.

The secret enemy during a flight: Economy class syndrome

Deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE) are the major causes of morbidity and mortality in immobile patients. There is observational evidence that intercontinental air travel is associated with a high incidence of DVT and PTE during or within 48 hours of long-distance flights. This situation is known as the economy class syndrome and can affect both the cabin crew and passengers. The term "economy class syndrome" refers to the occurrence of thrombotic events that mainly occur in passengers in the economy class of the aircraft during long-haul flights. This syndrome results from several factors related to the aircraft cabin and the passenger, acting together to predispose to excessive blood coagulation, which can result in venous thromboembolism. In this review, we have shared the relationship between air travel and the formation of DVT and PTE.

The risk of venous thromboembolism in cancer patients receiving chemotherapy: a meta-analysis with systematic review

Background

The Khorana score was developed to predict the risk of venous thromboembolism (VTE) in cancer patients receiving chemotherapy. However, the utility of the Khorana score remains controversial since different studies report varying results. This meta-analysis aims to analyze the incidence of VTE with different risk stratifications using the Khorana score for overall follow-up time, incidence of deep-vein thrombosis (DVT), incidence of pulmonary embolism (PE) and bleeding in cancer patients receiving chemotherapy.

Methods

A systemic search was performed using PubMed, Embase, Cochrane Library and Web of Science for studies describing VTE incidence in cancer patients undergoing chemotherapy. The incidence of VTE was calculated using R computing software.

Results

We included 13 studies in this meta-analysis, with a total of 5,852 cancer patients and 424 VTE cases. Results revealed that overall incidence of low, intermediate and high-risk groups were 2% (95% CI: 1–6%), 11% (95% CI: 6–18%) and 14% (95% CI: 9–20%), respectively. The overall incidence of DVT and PE were 6% (95% CI: 4–10%) and 4% (95% CI: 2–7%), respectively. Lastly, bleeding rate was 4% (95% CI: 2–8%).

Conclusions

According to this meta-analysis, the Khorana score is suitable for cancer patients receiving chemotherapy in a 3–6-month timeframe rather than “forever”. The incidence of PE in this population was significantly greater than what was observed for non-cancer patients. More than half of VTE events occurred within 6 months of commencing chemotherapy.

Acute Coronary Artery Thrombosis in a Patient With Non-Small Cell Lung Cancer

Patients with cancer are at major risk for both venous and arterial thrombotic complications. Venous involvement of cancer-associated thrombosis encompasses deep vein thrombosis and pulmonary embolism. Arterial manifestations include mainly stroke and myocardial infarction. We present the case of a 59-year-old woman admitted to the hospital for chest pain of five hours duration. She had been diagnosed with advanced lung cancer one month before. Electrocardiogram showed ST-segment elevation in all leads except aVR, suggesting a myocardial infarction. Coronary angiography revealed thrombi in both the right coronary artery and the left anterior descending coronary artery in the absence of any atherosclerotic lesions. Tirofiban infusion was administered; furthermore, a computed tomographic pulmonary angiography showed a distal pulmonary embolism. The patient progressed well and was discharged on anticoagulation with vitamin K antagonist. These findings highly imply that the malignancy altered the patient’s blood coagulability and induced the formation of the thrombi ensuing acute myocardial infarction and pulmonary embolism. We will emphasize the relationship between cancer and thrombosis with a special focus on the conservative management strategy with anticoagulant and antiplatelet therapy in acute coronary syndrome without evidence of atherosclerotic lesions.

Risk factors for venous thromboembolism in endometrial cancer

Background

Venous thromboembolism (vte) in malignancy is associated with poor outcomes. We conducted a retrospective review of vte in patients with endometrial cancer to characterize the vte incidence, identify factors that contribute to vte risk, and compare survival outcomes in patients with and without vte.

Methods

A retrospective chart review identified 422 eligible patients who underwent surgery for endometrial cancer (1 January 2014 to 31 July 2016). The primary outcome was vte. Binary logistic regression identified risk factors for vte; significant risk factors were included in a multivariate analysis. Kaplan-Meier estimates are reported, and log rank tests were used to compare the Kaplan-Meier curves. Risk-adjusted estimates for overall survival based on vte were determined using a multivariate Cox proportional hazards model.

Results

The incidence of vte was 6.16% overall and 0.7% within 60 days postoperatively. Non-endometrioid histology, stages 3 and 4 disease, laparotomy, and age (p < 0.1) were identified as factors associated with vte and were included in a multivariate analysis. The overall death rate in patients with vte was 42% (9% without vte): hazard ratio, 5.63; 95% confidence interval, 2.86 to 11.08; p < 0.0001. Adjusting for age, stage of disease, and histology, risk of death remained significant for patients with a vte: hazard ratio, 2.20; 95% confidence interval, 1.09 to 4.42; p = 0.0271.

Conclusions

A method to identify patients with endometrial cancer who are at high risk for vte is important, given the implications of vte for patient outcomes and the frequency of endometrial cancer diagnoses. Factors identified in our study might assist in the recognition of such patients.

Dynamic assessment of venous thromboembolism risk in patients with cancer by longitudinal D-Dimer analysis: A prospective study

BACKGROUND

Venous thromboembolism (VTE) is a frequent complication of cancer. Elevated D-dimer is associated with an increased risk of cancer-associated VTE. Whether changes in D-dimer over time harbor additional prognostic information that may be exploited clinically for dynamic prediction of VTE is unclear.

OBJECTIVES

To explore the potential role of longitudinal D-dimer trajectories for personalized prediction of cancer-associated VTE.

PATIENTS/METHODS

A total of 167 patients with active malignancy were prospectively enrolled (gastrointestinal: n = 59 [35%], lung: n = 56 [34%], brain: n = 50 [30%], others: n = 2 [1%]; metastatic disease: n = 74 [44%]). D-dimer (median = 0.8 µg/mL [25th-75th percentile: 0.4-2.0]) was measured at baseline and during 602 monthly follow-up visits. Joint models of longitudinal and time-to-event data were implemented to quantify the association between D-dimer trajectories and prospective risk of VTE.

RESULTS

VTE occurred in 20 patients (250-day VTE risk = 12.1%, 95% confidence interval [CI], 7.8-18.5). D-dimer increased by 34%/month (0.47 µg/mL/month, 95% CI, 0.22-0.72, P < .0001) in patients who developed VTE, but remained constant in patients who did not develop VTE (change/month = -0.06 µg/mL, 95% CI, -0.15 to 0.02, P = .121). In joint modeling, a doubling of the D-dimer trajectory was associated with a 2.8-fold increase in the risk of VTE (hazard ratio = 2.78, 95% CI, 1.69-4.58, P < .0001). This finding was independent of established VTE risk factors. Highly personalized, dynamic predictions of VTE conditional on individual patients' D-dimer trajectories could be obtained.

CONCLUSIONS

D-dimer increases before the onset of cancer-associated VTE, but remains constant over time in patients without VTE. This study represents proof-of-concept that longitudinal trajectories of D-Dimer may advance the personalized assessment of VTE risk in the oncologic setting.

Pancreatic ductal adenocarcinoma: Treatment hurdles, tumor microenvironment and immunotherapy

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal diseases, with an average 5-year survival rate of less than 10%. Unfortunately, the majority of patients have unresectable, locally advanced, or metastatic disease at the time of diagnosis. Moreover, traditional treatments such as chemotherapy, surgery, and radiation have not been shown to significantly improve survival. Recently, there has been a swift increase in cancer treatments that incorporate immunotherapy-based strategies to target all the stepwise events required for tumor initiation and progression. The results in melanoma, non-small-cell lung cancer and renal cell carcinoma are very encouraging. Unfortunately, the application of checkpoint inhibitors, including anti-CTLA4, anti-PD-1, and anti-PD-L1 antibodies, in pancreatic cancer has been disappointing. Many studies have revealed that the PDAC microenvironment supports tumor growth, promotes metastasis and consists of a physical barrier to drug delivery. Combination therapies hold great promise for enhancing immune responses to achieve a better therapeutic effect. In this review, we provide an outline of why pancreatic cancer is so lethal and of the treatment hurdles that exist. Particular emphasis is given to the role of the tumor microenvironment, and some of the latest and most promising studies on immunotherapy in PDAC are also presented.

Mechanisms of the Antitumor Activity of Low Molecular Weight Heparins in Pancreatic Adenocarcinomas

Immune checkpoint inhibitors have revolutionized cancer treatment in the last decade. Despite the progress in immunotherapy, most pancreatic cancer patients still do not derive benefit when receiving immune-based therapies. Recently, resistance mechanisms to immune therapies have been mainly focused on tumor microenvironment properties. Pancreatic cancer is considered one of the most lethal and difficult to treat tumors due to its highly immunosuppressive and desmoplastic microenvironment. Low molecular weight heparins (LMWHs) have been used for the treatment and prevention of thromboembolic disease in these patients. However, many nonanticoagulant properties attributed to LMWHs have been described. Exploiting LMWH properties in a combined treatment modality with immune checkpoint inhibition and chemotherapy could provide a new approach in the management of pancreatic adenocarcinoma patients. The ability of LMWH to interfere with various aspects of the tumor microenvironment could result in both the alleviation of immunosuppression and improvement in drug delivery within the tumor, leading to higher cancer cell destruction rates and more potent immune system activity that would, ultimately, lead to better patient outcomes.

Ex vivo properties of plasma clot formation and lysis in patients with cancer at risk for venous thromboembolism, arterial thrombosis, and death

A prothrombotic state is frequently observed in patients with cancer and contributes to the risks of venous thromboembolism (VTE), arterial thromboembolism (ATE), tumor progression, and death. Altered ex vivo properties of plasma clot formation and lysis have been observed in patients with cancer. The aim of this prospective study was to comprehensively characterize the relationship between plasma clot properties, inflammation, hypercoagulability, thrombotic complications, and mortality in patients with cancer using a tissue-factor-based turbidimetric assay of clot formation and lysis. Turbidity parameters were determined in 815 patients with newly-diagnosed or recurrent cancer and 97 healthy controls. Patients were followed-up for 2 years and rates of VTE (n = 72 events), ATE (n = 21 events), and death (n = 304 events) were assessed. Compared to controls, cancer patients' turbidity profiles showed an increased clot formation potential and higher resistance toward fibrinolysis. Elevated biomarkers of inflammation and hemostasis, such as C-reactive protein, FVIII, and thrombin generation explained substantial amounts of variation in turbidity parameters. In a prospective analysis, altered parameters of clot formation identified cancer patients at high risk of ATE (Hazard ratio [HR] per doubling of peak absorbance: 4.43, 95% CI: 1.50-13.07, P = 0.007) and death (HR per doubling of peak absorbance: 2.73, 2.00-3.72, P< 0.0001); these findings were independent of other prognostic covariates. Contrarily, turbidity parameters were not associated with risk of VTE (HR per doubling of peak absorbance: 1.15, 0.66-2.01, P = 0.62). We conclude that patients with cancer have altered ex vivo properties of clot formation which predict risks of ATE and mortality but not VTE.

Prognostic Value of Neutrophil-Lymphocyte Ratio and Platelet-Lymphocyte Ratio in Head and Neck Malignancies

To study the prognostic significance of neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) in head and neck cancers. The study included 170 cases of histopathologically diagnosed head and neck cancer patients and 80 control subjects. NLR and PLR of patients with head and neck cancers were compared to the control group. The correlation between NLR and PLR values and factors such as age, gender, duration of symptoms, site of tumour, histological type, histological grading, T-category, N-category and TNM stages in cancer patients were analysed. NLR and PLR were statistically higher in cancer patients compared to control. There was a non-significant increase in both NLR and PLR with advancing degree of differentiation and TNM Stages of the cancer patients. A significant increase in NLR and PLR with increasing T Categories and increasing N Categories of head and neck cancer patients was obtained. NLR and PLR can be used to estimate tumour prognosis in head and neck cancers. Increased NLR and PLR values can be used as a marker for poor prognosis. However further studies with larger study groups including treatment response and surveillance should be carried out to corroborate these results.

Characterization of Risk Factors and Timing of Venous Thromboembolism in Patients With Uterine Serous Carcinoma

OBJECTIVE

To characterize risk factors and timing of venous thromboembolism in women with uterine serous carcinoma.

METHODS

A retrospective cohort study was performed including all women diagnosed with uterine serous carcinoma from 1999 to 2016 at our institution. Clinicopathologic data and information regarding timing of venous thromboembolism were abstracted from the medical record. Logistic regression and Cox proportional hazards modeling were used to examine the association between covariates and risk and timing of venous thromboembolism.

RESULTS

Seventy of the 413 included patients (17%) developed venous thromboembolism, with a median time from presentation to venous thromboembolism of 7.2 months (interquartile range 1.0-24.8) and from surgery to venous thromboembolism of 13.2 months (interquartile range 3.5-33.6). Fifty-nine of the 70 patients (84%) who developed venous thromboembolism were diagnosed either before surgery or greater than 6 weeks postoperatively. Twenty-two of the 70 patients (31%) who developed clots were on chemotherapy at the time of diagnosis. Venous thromboembolism was highly associated with cancer stage and presence of hypertension (P<.01). Cox proportional hazards modeling revealed that only cancer stages III and IV (hazard ratio [HR] 3.20, 95% CI 1.54-6.64 and HR 8.68, 95% CI 4.50-16.73, respectively) and hypertensive or cardiovascular diseases (HR 2.29, 95% CI 1.08-4.85 and HR 1.82, 95% CI 1.05-3.13) were associated with time to venous thromboembolism.

CONCLUSION

Patients with uterine serous carcinoma are at high risk of developing venous thromboembolism even many months after their cancer diagnosis. This study generates the hypothesis that venous thromboembolism prophylaxis may be beneficial in patients with uterine serous carcinoma during other time points along the continuum of disease rather than only in the postoperative period, especially for those with advanced cancer.

Apixaban for the prevention of venous thromboembolism in high-risk ambulatory cancer patients receiving chemotherapy: Rational and design of the AVERT trial

Patients with active cancer have a heightened risk of venous thromboembolism (VTE). This risk is further increased by the initiation of chemotherapy. Although previous studies have suggested that the use of parenteral thromboprophylaxis in all ambulatory cancer patients receiving chemotherapy significantly decreases the rate of VTE, current clinical practice guidelines do not recommend routine use of thromboprophylaxis in this patient population. A major criticism of these studies has been the inclusion of patients at lower risk for VTE, which may have diluted the potential beneficial effect of the parenteral thromboprophylaxis. It is therefore imperative to appropriately risk stratify ambulatory cancer patients using a validated scoring system (e.g. Khorana risk score) in order to identify those most likely to benefit from thromboprophylaxis. Direct oral anticoagulants, such as apixaban, may offer a convenient and safe option for thromboprophylaxis. As such, AVERT will randomize 574 ambulatory cancer patients receiving chemotherapy who are at high-risk for VTE (as defined by a Khorana score of ≥2) to Apixaban 2.5 mg BID versus placebo. The primary study outcome will be the first episode of objectively documented symptomatic or incidental VTE (deep vein thrombosis and/or pulmonary embolism) within the first 6 months (180 days ± 3) following initiation of the blinded study drug for both intervention and placebo groups. The secondary safety outcomes include major bleeding, clinically relevant non-major bleeding, and overall survival rates. This study will hopefully offer evidence regarding the benefit of apixaban in ambulatory patients at high risk for VTE receiving chemotherapy.

Economy class syndrome: what is it and who are the individuals at risk?

The term ‘economy class syndrome’ refers to the occurrence of thrombotic events during long-haul flights that mainly occur in passengers in the economy class of the aircraft. This syndrome results from several factors related to the aircraft cabin (immobilization, hypobaric hypoxia and low humidity) and the passenger (body mass index, thrombophilia, oral contraceptives or hormone replacement therapy, cancer), acting together to predispose to excessive blood coagulation, which can result in venous thromboembolism. Several risk factors, both genetic and acquired, are associated with venous thromboembolism. The most important genetic risk factors are natural anticoagulant deficiencies (antithrombin, protein C and protein S), factor V Leiden, prothrombin and fibrinogen gene mutations and non-O blood group individuals. Acquired risk factors include age, pregnancy, surgery, obesity, cancer, hormonal contraceptives and hormone replacement therapy, antiphospholipid syndrome, infections, immobilization and smoking. People who have these risk factors are predisposed to hypercoagulability and are more susceptible to suffer venous thromboembolism during air travel. For these individuals, a suitable outfit for the trip, frequent walks, calf muscle exercises, elastic compression stockings and hydration are important preventive measures. Hence, it is essential to inform about economic class syndrome in an attempt to encourage Brazilian health and transport authorities to adopt measures, in partnership with the pharmaceutical industry, to prevent venous thromboembolism.

High pretreatment plasma D-dimer predicts poor survival of colorectal cancer: insight from a meta-analysis of observational studies

D-dimer, one of the canonical markers of hypercoagulability, was reported to be a potential prognostic marker of colorectal cancer. However, an inconsistent conclusion existed in several published studies. Thus, we performed this meta-analysis to provide a comprehensive insight into the prognostic role for pretreatment D-dimer in colorectal cancer. Six databases (English: Pubmed, Embase and Web of Science; Chinese: CNKI, Wangfang and VIP) were utilized for the literature retrieval. Hazard ratio (HR) was pooled by Stata 12.0. A total of fifteen studies (2283 cases) corresponded to this meta-analysis and provided available data to evaluate the prognostic role of D-dimer for colorectal cancer. The pooled HR reached 2.167 (95%. CI (confidence interval): 1.672-2.809, P < 0.001) utilizing random effect model due to obvious heterogeneity among the included studies (I²: 73.3%; P < 0.001). To explore the heterogeneity among the studies, we conducted a sensitivity analysis and found a heterogeneous study. After removing it, the heterogeneity reduced substantially (I²: 0%; P = 0.549) and we obtained a more convincing result by fixed effect model (HR = 2.143, 95% CI = 1.922-2.390, P < 0.001, 14 studies with 2179 cases). In summary, high pretreatment plasma D-dimer predicts poor survival of colorectal cancer based on the current evidence. Further prospective researches are necessary to confirm the role of D-dimer in colorectal cancer.

Prognostic Significance of Venous Thromboembolic Events in Disseminated Germ Cell Cancer Patients

Background

Disseminated germ cell cancers are at high risk of developing thromboembolic complications. We evaluated the prognostic value of venous thromboembolic events (VTE) in disseminated germ cell cancer.

Methods

Patients with germ cell cancer receiving upfront platinum-containing chemotherapy between 2004 and 2014 were pooled from the Spanish Germ Cell Cancer Group (SGCCG) registry and reviewed for the presence of VTE. Results were validated in an independent international group of patients. We used a penalized Cox proportional hazards model including VTE as a time-varying covariate to identify and validate prognostic factors. All statistical tests were two-sided.

Results

The SGCCG registry identified 416 patients from 14 referral institutions. With a median follow-up of 49 months, VTEs were observed in 9% of patients (n = 38). Events occurred at diagnosis, during chemotherapy, and after chemotherapy in 2.6%, 5.0%, and 1.4% of patients, respectively. VTE was associated with shorter progression-free survival (PFS; hazard ratio [HR] = 2.29, 95% confidence interval [CI] = 1.18 to 4.47, P = .02) and overall survival (OS; HR = 5.14, 95% CI = 2.22 to 11.88, P < .001). In multivariable analysis, the effect was consistent in the intermediate-risk group, both for PFS (HR = 9.52 95% CI = 2.48 to 36.58, P < .001) and OS (HR = 12.84, 95% CI = 2.01 to 82.02, P = .007). VTE at diagnosis is also an adverse prognostic variable for progression-free survival (HR = 4.64, 95% CI = 2.04 to 10.54, P < .001) and for overall survival (HR = 6.28, 95% CI = 1.68 to 17.10, P = .01). These results were validated in an independent international cohort that included 241 patients from four hospitals.

Conclusions

VTE is an independent adverse prognostic factor in disseminated germ cell cancers, in particular for the intermediate prognostic group of the International Germ Cell Cancer Collaborative Group classification. The presence of VTE at diagnosis has also prognostic significance and should be further explored in future prognostic classifications.

The Antithrombotic Potential of Tinzaparin and Enoxaparin Upon Thrombin Generation Triggered In Vitro by Human Ovarian Cancer Cells IGROV1

BACKGROUND

A documented relationship between ovarian cancer and thrombosis does exist. Low-molecular-weight heparins (LMWHs) are cornerstone drugs in the primary prevention and treatment of venous thromboembolic events in patients with cancer. However, cancer cells may alter the efficiency of these antithrombotic agents.

OBJECTIVE

We aimed to characterize the procoagulant phenotype of human epithelial ovarian adenocarcinoma cells, IGROV1, and to compare the capacity of tinzaparin and enoxaparin to inhibit thrombin generation triggered by these cells.

METHODS

Thrombin generation induced by different concentrations of IGROV1 cells on platelet poor plasma (PPP) was assessed by the calibrated automated thrombogram assay. Tissue factor (TF) expression was studied using Western blot analysis. Then, the experimental model of thrombin generation was used to compare the inhibitory effect of clinically relevant concentrations of both tinzaparin and enoxaparin. The inhibitory concentration 50 (IC50) of the mean rate index and the endogenous thrombin potential and the 2-fold increase in lag time were analyzed on the basis of the anti-Xa and anti-IIa activities of the LMWHs.

RESULTS

IGROV1 cells suspended into PPP resulted in a significant increase in thrombin generation in the absence of any exogenous source of TF and phospholipids. Tissue factor was expressed by IGROV1 cells. Tinzaparin was a more potent inhibitor of thrombin generation than enoxaparin. The inhibition of thrombin generation induced by IGROV1 cancer cells depended mainly on the anti-Xa activity of the LMWHs.

CONCLUSION

This experimental study in ovarian cancer cells demonstrates that the antithrombotic activity of LMWHs is not completely predicted by the anti-Xa or anti-IIa activities measured in PPP.

Low rates of symptomatic venous thromboembolism in patients with gastrointestinal cancer: an Iranian study

: Venous thromboembolism (VTE), which mostly includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is associated with considerable morbidity and mortality in patients with cancer. As little is known about VTE associated with gastrointestinal cancers among the populations in the Middle East. This study aimed to determine the relative frequency of symptomatic VTE in patients with gastrointestinal malignancies in Iran. The charts of patients with gastrointestinal cancers in our institute from April 2010 to March 2015 were investigated for symptomatic VTE in a retrospective study. In this study, all of the patients received chemotherapy. The data included the site of cancer, time of therapies initiation, patient's characteristics, type of VTE, the time of developing symptomatic VTE of patients with gastrointestinal cancer and the stage which VTE occurred. All of DVTs and pulmonary embolism were confirmed by Doppler ultrasonography and computed tomography angiography. A total of 614 consecutive patients with gastrointestinal cancer were included in study. In total, 22 patients (3.6%) were found to have experienced symptomatic VTE (confidence interval 95%: 2.1-5.1%) which included: 19 patients who suffered from DVT and three of them detected pulmonary embolism, and other types of VTE were not reported. Out of 22 patients with VTE, 17 of them have been occurred after chemotherapy (77%) within 6.17 ± 5.17 (range, 1-19) month after starting chemotherapy. The distribution of frequency of stage in which the VTE occurred, was more in stage III and IV. The rate of symptomatic VTE in patients with gastrointestinal cancer in Iran is relatively lower than other studies done in the west. Therefore, it seems the rate of VTE differs in different ethnic groups.

Signs and Symptoms of Venous Thromboembolism and Survival Outcome of Endometrial Cancer

Objective

This study aimed to evaluate if the presence of venous thromboembolism (VTE) diagnosed with subjective and objective measurements correlates with the survival outcome in patients with endometrial cancer.

Methods

A retrospective study was conducted on patients with endometrial cancer who developed VTE between cancer diagnosis and follow-up from 1999 to 2013. Disease-specific survival after VTE diagnosis was evaluated according to VTE symptoms and vital signs.

Results

Among 827 endometrial cancer cases during the study period, there were 72 (8.7%) patients with VTE identified (pulmonary embolism [PE] with or without deep vein thrombosis [DVT], n = 34; and DVT alone n = 38). In the PE group, decreased disease-specific survival after the diagnosis of VTE was associated with fatigue, systolic blood pressure (BP) less than 120 mm Hg, diastolic BP less than 70 mm Hg, and a heart rate 90 beats per minute or greater (all,P< 0.05) in a univariate analysis. Symptomatic PE was associated with decreased survival as compared to asymptomatic PE (2-year rate; 23.1% vs 77.8%,P< 0.01). In a multivariate analysis controlling for symptoms of VTE, signs, and tumor factors, a diastolic BP less than 70 mm Hg (adjusted-hazard ratio [HR], 10.0; 95% confidence interval, 2.70–37.1;P< 0.01) and HR greater than 90 beats per minute (adjusted-HR, 8.06; 95% confidence interval, 2.36–27.5;P< 0.01) remained as independent prognostic factors for decreased disease-specific survival after PE diagnosis. Patients with PE presenting with low diastolic BP and high heart rate resulted in a dismal survival outcome (diastolic BP < 70 mm Hg/heart rate ≥ 90 beats per minute vs diastolic BP ≥ 70 mm Hg/heart rate < 90 beats per minute; 0% vs 85.7%,P< 0.01). In the group of patients with DVT alone, no signs or symptoms correlated with survival outcome (all,P> 0.05).

Conclusions

Our results suggested that both signs and symptoms of PE are important consideration in the management of patients with endometrial cancer with PE.

A Validated Risk Score for Venous Thromboembolism Is Predictive of Cancer Progression and Mortality

BACKGROUND

Retrospective studies have suggested an association between cancer-associated venous thromboembolism (VTE) and patient survival. We evaluated a previously validated VTE Clinical Risk Score in also predicting early mortality and cancer progression.

METHODS

A large, nationwide, prospective cohort study of adults with solid tumors or lymphoma initiating chemotherapy was conducted from 2002 to 2006 at 115 U.S. practice sites. Survival and cancer progression were estimated by the method of Kaplan and Meier. Multivariate analysis was based on Cox regression analysis adjusted for major prognostic factors including VTE itself.

RESULTS

Of 4,405 patients, 134 (3.0%) died and 330 (7.5%) experienced disease progression during the first 4 months of therapy (median follow-up 75 days). Patients deemed high risk (n = 540, 12.3%) by the Clinical Risk Score had a 120-day mortality rate of 12.7% (adjusted hazard ratio [aHR] 3.00, 95% confidence interval [CI] 1.4-6.3), and intermediate-risk patients (n = 2,665, 60.5%) had a mortality rate of 5.9% (aHR 2.3, 95% CI 1.2-4.4) compared with only 1.4% for low-risk patients (n = 1,200, 27.2%). At 120 days of follow-up, cancer progression occurred in 27.2% of high-risk patients (aHR 2.2, 95% CI 1.4-3.5) and 16.4% of intermediate-risk patients (aHR 1.9, 95% CI 1.3-2.7) compared with only 8.5% of low-risk patients (p < .0001).

CONCLUSION

The Clinical Risk Score, originally developed to predict the occurrence of VTE, is also predictive of early mortality and cancer progression during the first four cycles of outpatient chemotherapy, independent from other major prognostic factors including VTE itself. Ongoing and future studies will help determine the impact of VTE prophylaxis on survival.

IMPLICATIONS FOR PRACTICE

The risk of venous thromboembolism (VTE) is increased in patients receiving cancer chemotherapy. In this article, the authors demonstrate that a popular risk score for VTE in patients with cancer is also associated with the risk of early mortality in this setting. It is important that clinicians evaluate the risk of VTE in patients receiving cancer treatment and discuss the risk and associated symptoms of VTE with patients. Individuals at increased risk should be advised that VTE is a medical emergency and should be urgently diagnosed and appropriately treated to reduce the risk of serious and life-threatening complications.

Thymoquinone Modulates Blood Coagulation in Vitro via Its Effects on Inflammatory and Coagulation Pathways

Thymoquinone (THQ) is a major component of black seeds. Given that both THQ and black seeds exhibit anti-cancer and anti-inflammatory activities, we hypothesized that THQ will affect cancer-associated thrombosis (CAT), which is primarily triggered by tissue factor (TF) and inflammation. The effect of both black seed-extracted and purchased (“pure”) THQ on normal blood coagulation was tested with in vitro thromboelastography (TEG) and activated partial thromboplastin time (aPTT) coagulation assays. The effect of pure THQ on CAT was tested with aPTT assay using pancreatic cancer cell lines that are either positive or negative for TF, and with TEG assay using lipopolysaccharide as an inflammatory trigger. Additionally, the direct effect of THQ on the inactivation of factors IIa and Xa was assessed. Since TNF-α facilitates crosstalk between inflammation and thrombosis by triggering the NF-κB pathway, we tested THQ’s ability to interfere with this communication with a luciferase assay. Both extracted and pure THQ had minimal effects on normal blood coagulation. Pure THQ reversed CAT initiated by both TF and inflammation to basal levels (p < 0.001). Mechanistically, while THQ had minimal to no effect on factor IIa and Xa inactivation, it strongly reduced the effects of TNF-α on NF-κB elements (p < 0.001). THQ has a minimal effect on basal coagulation and can reverse CAT in vitro, possibly by interfering with the crosstalk between inflammation and coagulation. This study suggests the utility of THQ as a preventative anticoagulant and/or as a supplement to existing chemotherapies and anticoagulant therapies.

Procoagulant activity in gynaecological cancer patients; the effect of surgery and chemotherapy

BACKGROUND

Gynaecological cancers are associated with high rates of venous thromboembolism (VTE). Studies on ambulatory cancer patients do not support thromboprophylaxis during chemotherapy. Approximately 6-7% of gynaecological cancer patients suffer a postoperative VTE despite Low Molecular Weight Heparin prophylaxis (LMWH). Large cancer studies have shown that Calibrated Automated Thrombogram (CAT) and Microparticles (MP) assays may be useful in predicting VTE but data on gynaecological cancer patients is scarce.

OBJECTIVE

Our objective was to identify whether the CAT assay and MP functional assays have potential as biomarkers predictive of VTE in gynaecological cancer patients.

PATIENTS AND METHODS

Gynaecological cancer patients were investigated before surgery (n=146) and at 5, 14 and 42days post-surgery (n=78). Fourteen additional patients were investigated before chemotherapy and after 3 and 6 cycles of therapy. Thrombin generation was measured before and after addition of thrombomodulin.

RESULTS

Patients with clear cell cancer (CCC) of the ovary and patients with endometrial cancer had higher ETP and peak thrombin compared with patients with benign disease. Patients who developed VTE (n=8) following surgery had enhanced thrombin generation prior to surgery which persisted during the post-operative period despite LMWH prophylaxis. Both neoadjuvant and adjuvant chemotherapy showed increased thrombin generation following addition of thrombomodulin. There were no differences in MP levels during the study.

CONCLUSIONS

CAT assay shows potential as a promising biomarker for the prediction of VTE in gynaecological cancer patients. The identification of high risk patients combined with individualised LMWH prophylaxis might reduce VTE in this high risk group.

Intracranial hemorrhage in setting of glioblastoma with venous thromboembolism

Background

Venous thromboembolism (VTE) is a complication of glioblastoma. Anticoagulating patients with glioblastoma carries a theoretical risk of intracranial hemorrhage (ICH).

Methods

We performed a retrospective cohort study of consecutive glioblastoma patients (2007-2013) diagnosed with VTE.

Results

The study population comprised of 523 glioblastoma patients of whom 173 (33%) had VTE events. Seventeen (10%) had ICH: 6 (35%) subdural hematomas and 11 (65%) intratumoral hemorrhages. In total, 4 patients with ICH required neurosurgical intervention. Enhancement in the area of subsequent intratumoral hemorrhage was noted in 9 of 10 with available pre-ICH scans. Multivariable regression did not show associations between ICH and tumor enhancement diameter or use of vascular-endothelial-growth-factor inhibitor. Fifteen (16%) patients receiving anticoagulation had ICH compared with 2 (2.6%) not receiving anticoagulation (P = .005). The method of anticoagulation was not associated with development of ICH. Median survival times from nondistal VTE diagnosis to death were 8.0 and 3.5 months (P = .05) in patients receiving anticoagulation and those not on anticoagulation, respectively.

Conclusion

Patients with glioblastoma and VTE on anticoagulation have increased incidence of ICH. However, development of ICH was not associated with lower median survival from time of VTE. Intratumoral hemorrhage occurred within the enhancing portion of tumor; however, no relationship was identified between the development of ICH and (i) the median diameter of enhancement or (ii) type of anticoagulant used. However, patients with absence of enhancing tumor did not have intratumoral bleed, suggesting gross total resection may limit this adverse outcome. It is appropriate to initiate anticoagulation in glioblastoma patients with VTEs.

Platelets in cancer. From basic research to therapeutic implications

Platelets are well-known for their major role in primary hemostasis and thrombosis. Cancer patients frequently manifest thrombotic events and present abnormalities in blood coagulation which appear to be linked to altered platelet function and turnover. Moreover, numerous studies indicate an intimate cross-talk between platelets and tumor growth, angiogenesis and metastatic dissemination. Finally, several experimental data and clinical trials suggest possible benefits of anti-platelet drugs on some cancers. Here, we will review the current state of basic biological research regarding the role of platelets in cancer progression. We also critically review the possible clinical applicability of some anti-platelet therapies to limit tumor growth and prevent metastatic dissemination.

Evasion and interactions of the humoral innate immune response in pathogen invasion, autoimmune disease, and cancer

The humoral innate immune system is composed of three major branches, complement, coagulation, and natural antibodies. To persist in the host, pathogens, such as bacteria, viruses, and cancers must evade parts of the innate humoral immune system. Disruptions in the humoral innate immune system also play a role in the development of autoimmune diseases. This review will examine how Gram positive bacteria, viruses, cancer, and the autoimmune conditions systemic lupus erythematosus and anti-phospholipid syndrome, interact with these immune system components. Through examining evasion techniques it becomes clear that an interplay between these three systems exists. By exploring the interplay and the evasion/disruption of the humoral innate immune system, we can develop a better understanding of pathogenic infections, cancer, and autoimmune disease development.

Venous thromboembolism in cancer patients: an underestimated major health problem

Venous thromboembolism (VTE) is a major health problem among patients with cancer, its incidence in this particular population is widely increasing. Although VTE is associated with high rates of mortality and morbidity in cancer patients, its severity is still underestimated by many oncologists. Thromboprophylaxis of VTE now considered as a standard of care is still not prescribed in many institutions; the appropriate treatment of an established VTE is not yet well known by many physicians and nurses in the cancer field. Patients are also not well informed about VTE and its consequences. Many studies and meta-analyses have addressed this question so have many guidelines that dedicated a whole chapter to clarify and expose different treatment strategies adapted to this particular population. There is a general belief that the prevention and treatment of VTE cannot be optimized without a complete awareness by oncologists and patients. The aim of this article is to make VTE a more clear and understood subject.

Estimating risk of venous thromboembolism in patients with cancer in the presence of competing mortality

BACKGROUND

In studies on cancer-associated venous thromboembolism (VTE), patients not only are at risk for VTE but also may die from their underlying malignancy.

OBJECTIVES

In this competing-risk (CR) scenario, we systematically compared the performance of standard (Kaplan-Meier estimator [1-KM]), log-rank test, and Cox model) and specific CR methods for time-to-VTE analysis.

PATIENTS AND METHODS

Cancer patients (1542) were prospectively followed for a median of 24 months. VTE occurred in 112 (7.3%) patients, and 572 (37.1%) patients died.

RESULTS

In comparison with the CR method, 1-KM slightly overestimated the cumulative incidence of VTE (cumulative VTE incidence at 12 and 24 months [1-KM vs. CR]: 7.22% vs. 6.74%, and 8.40% vs. 7.54%, respectively). Greater bias was revealed in tumor entities with high early mortality (e.g., pancreatic cancer, n = 99, 24-month cumulative VTE incidence: 28.37% vs. 19.30%). Comparing the (subdistribution) hazard of VTE between patients with low and high baseline D-dimer, the Cox model yielded a higher estimate than the corresponding CR model (hazard vs. subdistribution hazard ratio [95% CI] 2.85 [1.92-4.21] vs. 2.47 [1.67-3.65]). For this comparison, the log-rank test yielded a higher test statistic and smaller P-value than Gray's test (χ(2) on 1 degree of freedom: 29.88 vs. 21.34).

CONCLUSION

In patients with cancer who are at risk for VTE and death, standard and CR methods for time-to-VTE analysis can generate differing results. For 1-KM, the magnitude of bias is a direct function of competing mortality. Consequently, bias tends to be negligible in cancer patient populations with low mortality but can be considerable in populations at high risk of death.

Risk stratification strategies for cancer-associated thrombosis: an update

Rates of venous thromboembolism (VTE) vary substantially between cancer patients. Multiple clinical risk factors including primary site of cancer and systemic therapy, and biomarkers including leukocyte and platelet counts and tissue factor are associated with increased risk of VTE. However, risk cannot be reliably predicted based on single risk factors or biomarkers. New American Society of Clinical Guidelines recommend that patients with cancer be assessed for VTE risk at the time of chemotherapy initiation and periodically thereafter. This narrative review provides an update on risk stratification approaches including a validated Risk Score. Potential applications of risk assessment including targeted thromboprophylaxis are outlined. © 2014 Elsevier Ltd. All rights reserved.

Prevention and treatment of venous thromboembolism in patients with cancer

Robust evidence remains scarce in guiding best practice in the prevention and treatment of venous thromboembolism in patients living with cancer. Recommendations from major consensus guidelines are largely based on extrapolated data from trials performed mostly in noncancer patients, observational studies and registries, studies using surrogate outcomes, and underpowered randomized controlled trials. Nonetheless, a personalized approach based on individual risk assessment is uniformly recommended for inpatient and outpatient thromboprophylaxis and there is consensus that anticoagulant prophylaxis is warranted in selected patients with a high risk of thrombosis. Prediction tools for estimating the risk of thrombosis in the hospital setting have not been validated, but the use of prophylaxis in the ambulatory setting in those with a high Khorana score is under active investigation. Symptomatic and incidental thrombosis should be treated with anticoagulant therapy, but little is known about the optimal duration. Pharmacologic options for prophylaxis and treatment are still restricted to unfractionated heparin, low molecular weight heparin, and vitamin K antagonists because there is currently insufficient evidence to support the use of target-specific, non-vitamin K-antagonist oral anticoagulants. Although these agents offer practical advantages over traditional anticoagulants, potential drug interaction with chemotherapeutic agents, gastrointestinal problems, hepatic and renal impairment, and the lack of rapid reversal agents are important limitations that may reduce the efficacy and safety of these drugs in patients with active cancer. Clinicians and patients are encouraged to participate in clinical trials to advance the care of patients with cancer-associated thrombosis.

Coagulation and angiogenic gene expression profiles are defined by molecular subgroups of medulloblastoma: evidence for growth factor-thrombin cross-talk

BACKGROUND

The coagulation system becomes activated during progression and therapy of high-grade brain tumors. Triggering tissue factor (F3/TF) and thrombin receptors (F2R/PAR-1) may influence the vascular tumor microenvironment and angiogenesis irrespective of clinically apparent thrombosis. These processes are poorly understood in medulloblastoma (MB), in which diverse oncogenic pathways define at least four molecular disease subtypes (WNT, SHH, Group 3 and Group 4). We asked whether there is a link between molecular subtype and the network of vascular regulators expressed in MB.

METHODS

Using R2 microarray analysis and visualization platform, we mined MB datasets for differential expression of vascular (coagulation and angiogenesis)-related genes, and explored their link to known oncogenic drivers. We evaluated the functional significance of this link in DAOY cells in vitro following growth factor and thrombin stimulation.

RESULTS

The coagulome and angiome differ across MB subtypes. F3/TF and F2R/PAR-1 mRNA expression are upregulated in SHH tumors and correlate with higher levels of hepatocyte growth factor receptor (MET). Cultured DAOY (MB) cells exhibit an up-regulation of F3/TF and F2R/PAR-1 following combined SHH and MET ligand (HGF) treatment. These factors cooperate with thrombin, impacting the profile of vascular regulators, including interleukin 1β (IL1B) and chondromodulin 1 (LECT1).

CONCLUSIONS

Coagulation pathway sensors (F3/TF, F2R/PAR-1) are expressed in MB in a subtype-specific manner, and may be functionally linked to SHH and MET circuitry. Thus coagulation system perturbations may elicit subtype/context-specific changes in vascular and cellular responses in MB.

Antithrombotic Therapy in Patients With Thrombocytopenic Cancer

Background:

Guidelines are discordant concerning management of patients having thrombocytopenia with cancer-associated thrombosis (CAT).

Methods:

Hospitalized adults with CAT and platelets ≤50 × 109 cells/L were managed with dalteparin 100 units/kg subcutaneously once daily. Comparator patients with CAT and platelets >50 × 109 cells/L were managed with dalteparin 200 units/kg/d.

Results:

Outcomes of 35 patients with thrombocytopenia (mean platelet count 26 ± 8.3 × 109 cells/L) and 58 comparator patients (mean platelet count 155 ± 75 × 109 cells/L) were evaluated. In all, 2 (5.7%) patients in the thrombocytopenia group and 1 patient (1.9%) in the comparator group experienced new-onset venous thromboembolism (odds ratio 3.31, 95% confidence interval [CI] 0.29-37.90, P = .556). The incidence of bleeding in patients with thrombocytopenia (8.6%) was similar to that in comparator patients (9.4%; risk ratio 0.94, 95% CI 0.37-2.39, P = .607).

Conclusion:

In hospitalized patients having thrombocytopenia with CAT, reduced-dose low-molecular-weight heparin was generally efficacious.

Review of the American College of Chest Physicians 2012 Guidelines for Anticoagulation Therapy and Prevention of Thrombosis

The eighth edition (AT8) of the American College of Chest Physicians (ACCP) Antithrombotic Therapy and Prevention of Thrombosis Guideline, published in June 2008, was a comprehensive presentation of primary studies and detailed discussions of rationale for recommendations. This resulted in an approximately 900-page Chest Supplement publication. Updating the guidelines in a succinct fashion posed a formidable challenge for the ninth edition (AT9), published in February 2012. The strategy adopted for AT9 was to publish an Executive Summary of the recommendations in a 50-page document in the Chest supplement highlighting the changes, with online publication of the full version. Major innovative changes include a recognition of the value of estimating the risk reductions in symptomatic, as opposed to asymptomatic (venographically), detected venous thrombosis, using nonconflicted methodologists as topic editors, new insights into evidence, and increasing emphasis on what is known about patients' values and preferences that have served to improve this edition of the guidelines. This review provides a summary of the updates of the guidelines for anticoagulation therapy and prevention of thrombosis. The AT9 recommendations are presented with, if included, the AT8 recommendations in parenthesis for comparison purposes.

Assessing the risk and prognosis of thrombotic complications in cancer patients

CONTEXT

Cancer is characterized by the development of a prothrombotic state. Approximately 15% to 20% and 1.5% to 3.1% of cancer patients develop venous and arterial thrombosis, respectively, whereas 18% to 20% of idiopathic venous events are caused by an occult neoplasia. The highest risk is observed in hematologic, gastrointestinal, and lung malignancies, as well as in patients with active disease, especially in the first 3 months after cancer diagnosis. Hospitalization, surgical interventions, and implanted venous devices increase the thrombotic risk. Patients with metastatic disease, febrile neutropenia, infections, and severe comorbidities experience more frequently a thrombotic event. A contemporary prechemotherapy predictive model incorporates both clinical and biologic parameters, such as the primary cancer site, platelet count, white blood cell count, hemoglobin, use of erythropoietic agents, and body mass index. Several studies aim to clarify the prognostic value of tissue factor, P-selectin, thrombin generation, microparticles, and D-dimers.

OBJECTIVES

To summarize current views on epidemiology, risk factors, and predictive variables, discussing the future perspectives and existing limitations in clinical practice.

DATA SOURCES

Review of published literature, including review papers, epidemiologic studies, and clinical trials, in online medical databases.

CONCLUSIONS

The thrombogenic properties of tumor cells affect the prognosis and quality of life for the cancer population. Despite the improved awareness and prompt use of thromboprophylaxis, recent studies reported increased rates of thrombotic events, whereas the annual risks for thrombosis recurrence and bleeding are 21% and 12%, respectively. The clinical use of risk factors and prognostic parameters could allow for patient risk stratification and individualization of anticoagulant treatment.

Expression of tissue factor and tissue factor pathway inhibitor in microparticles and subcellular fractions of normal and malignant prostate cell lines

The association between cancer and thrombogenesis has been recognized since 1865, and tissue factor (TF) is important at various stages in the natural history of the disease. It is involved in cancer angiogenesis, growth and metastasis. TF pathway inhibitor (TFPI), being the major physiological regulator of the TF-dependent coagulation pathway, is also important in establishing net procoagulant potential. In this study, we determine TF and TFPI levels in three prostate epithelial cell lines, one of normal and two of malignant origin. Cells were grown in standard maintenance conditions and harvested at more than 90% confluence. These were fractionated into cytosol, membrane and nuclei for analysis. Microparticles secreted into the culture medium were also analysed. TF and TFPI levels were determined using an ELISA. TF expression in these cells was also visualized using immunocytochemistry. There was absence of TF and TFPI in nuclei of all cell lines. TF expression was higher in subcellular fractions and microparticles of normal prostate cells than cancer cells. In contrast, levels of TFPI (structurally resembling a secreted, rather than transmembrane protein) in microparticles of normal prostate cells were much lower than tumour cells. In conclusion, the activity of prostate cancer cells themselves is unlikely to be the source of hypercoagulability in patients, but might precipitate chains of events that would produce such an effect.

Diagnosis and treatment of coagulopathy following percutaneous cryoablation of liver tumors: experience in 372 patients

Coagulopathy after liver cryoablation was first reported many years ago; the cause is local platelet trapping and destruction within the margin of the cryolesion. However, the prognosis and therapeutic effects of coagulopathy remain unclear. This study retrospectively reviewed clinical data from 372 patients (525 sessions) who underwent liver cryoablation in our hospital during the past 4.5 years. Small tumors (major diameter < 6 cm) were treated with a single complete ablation; massive tumors (major diameter 6-10 cm or >10 cm) were divided into two or three parts that were dealt with in turn. Platelet counts decreased to an average of (46.12 ± 68.13) × 10(9)/L after each session of cryoablation. The decline was most evident in patients with high pretreatment platelet counts, while those with low pretreatment counts had the highest risk of coagulopathy. Change in platelet count was not correlated with the diameter of the tumor. Slight coagulopathy (platelet count (70-100) × 10(9)/L) can resolve without treatment within 1 week and administration of recombinant human interleukin-11 can assist recovery from severe coagulopathy (platelet count < 70 × 10(9)/L).