Stroke as a first manifestation of ovarian cancer

Extracellular vesicles as mediators of cell-cell communication in ovarian cancer and beyond - A lipids focus

Extracellular vesicles (EVs) are messengers that carry information in the form of proteins, lipids, and nucleic acids and are not only essential for intercellular communication but also play a critical role in the progression of various pathologies, including ovarian cancer. There has been recent substantial research characterising EV cargo, specifically, the lipid profile of EVs. Lipids are involved in formation and cargo sorting of EVs, their release and cellular uptake. Numerous lipidomic studies demonstrated the enrichment of specific classes of lipids in EVs derived from cancer cells suggesting that the EV associated lipids can potentially be employed as minimally invasive biomarkers for early diagnosis of various malignancies, including ovarian cancer. In this review, we aim to provide a general overview of the heterogeneity of EV, biogenesis, their lipid content, and function in cancer progression focussing on ovarian cancer.

Stroke as a Paraneoplastic Manifestation of Ovarian Cancer: A Case Report

People with gynecologic neoplasms have the highest risk of having an ischemic stroke. A 76-year-old woman came into the stroke unit of our hospital complaining of anosmia and acutely developing dysarthria. She was ultimately determined to have ovarian cancer after extensive testing. Ovarian carcinoma is one of the neoplasms that cause ischemic stroke and is most commonly documented in case studies. Identifying the underlying neoplastic condition in female ischemic stroke patients who are otherwise "healthy" is crucial as an early surgical intervention on cancer offers therapeutic treatment for both malignancy and thromboembolism.

Non-cancer death causes after ovarian cancer diagnosis: A population-based cohort

BACKGROUND

Research on non-cancer death causes in ovarian cancer (OC) patients remains limited. We aim to focus on and evaluate the non-cancer death causes after OC diagnosis.

METHODS

We studied 82 590 OC patients diagnosed between 2000 and 2016, using the Surveillance, Epidemiology, and End Results (SEER) Program. Risks of death causes were calculated as standardized mortality ratios.

RESULTS

Of included patients, 48 125 (58.3%) died during the follow-up period. The highest number of deaths, 21 722 (45.1%), occurred within 1-5 years after OC diagnosis. On the other hand, 19 992 (41.5%) of deaths occurred within a year from ovary cancer diagnosis, 5255 (10.9%) occurred within 5-10 years, and 1156 (2.4%) deaths occurred after more than 10 years following OC diagnosis. Non-cancer death causes comprise a significant percentage of deaths in OC patients, increasing with time after diagnosis.

CONCLUSIONS

Cardiac diseases, cerebrovascular diseases, and COPD were among the most common non-cancer death causes after OC diagnosis. Other critical non-cancer death causes include septicemia and benign neoplasms. Mortality risk differences based on race and age were also highlighted. These findings provide critical insights into how OC survivors should be followed-up and counseled for relevant future health risks.

A case of multifocal stroke-the first presentation of underlying ovarian malignancy

Ischaemic stroke is a rare manifestation of hypercoagulability induced by underlying malignancy. It is proposed that paraneoplastic non-bacterial thrombotic endocarditis (NBTE) is the most common cause, predisposing to the formation of friable valvular lesions composed of platelets and fibrin that embolize commonly. Pancreas, gallbladder, stomach, colon and gynaecological malignancies have all been associated with NBTE. We describe a female patient who presented to our facility with syncope and limb weakness. Magnetic resonance imaging of the brain revealed ischaemic strokes in both the anterior and posterior circulation. Further investigation revealed a pelvic mass that was biopsy proven to be ovarian malignancy. Prognosis is heavily reliant on disease stage, thus diagnostic clues suggesting the possibility of underlying malignancy in the presentation of stroke should prompt a thorough investigation to exclude malignancy.

Diffusion-weighted imaging-documented bilateral small embolic stroke involving multiple vascular territories may indicate occult cancer: A retrospective case series and a brief review of the literature

Diffusion-weighted imaging (DWI) MRI is very sensitive for detecting small embolic brain infarctions. Stroke as the first manifestation of cancer is extremely rare. We performed a retrospective study to identify the clinical and DWI features of patients with acute ischemic stroke as the first manifestation of occult cancer. A total of five patients in our hospital from January 2017 to May 2019 were analyzed. We also reviewed the literature and seven case series (16 patients) were included. Most of these patients were aged in their sixties and lung cancer was the most common type of occult cancer. Patients showed various presentations of ischemic stroke. All of the patients showed small multiple lesions on DWI that involved mostly the anterior or both anterior and posterior territories. The lesions were mostly in both the supratentorium and infratentorium, with the mechanisms of embolic and watershed infarcts. These features were useful for identifying the causes of embolic stroke. Therefore, patients with small bilateral embolic stroke, especially those involved in multiple vascular territories, should be examined for concealed malignancy.

High-grade ovarian serous carcinoma patients exhibit profound alterations in lipid metabolism

Ovarian cancer is a very severe type of disease with poor prognosis. Treatment of ovarian cancer is challenging because of the lack of tests for early detection and effective therapeutic targets. Thus, new biomarkers are needed for both diagnostics and better understanding of the cellular processes of the disease. Small molecules, consisting of metabolites or lipids, have shown emerging potential for ovarian cancer diagnostics. Here we performed comprehensive lipidomic profiling of serum and tumor tissue samples from high-grade serous ovarian cancer patients to find lipids that were altered due to cancer and also associated with progression of the disease. Ovarian cancer patients exhibited an overall reduction of most lipid classes in their serum as compared to a control group. Despite the overall reduction, there were also specific lipids showing elevation, and especially alterations in ceramide and triacylglycerol lipid species were dependent on their fatty acyl side chain composition. Several lipids showed progressive alterations in patients with more advanced disease and poorer overall survival, and outperformed CA-125 as prognostic markers. The abundance of many serum lipids correlated with their abundance in tumor tissue samples. Furthermore, we found a negative correlation of serum lipids with 3-hydroxybutyric acid, suggesting an association between decreased lipid levels and fatty acid oxidation. In conclusion, here we present a comprehensive analysis of lipid metabolism alterations in ovarian cancer patients, with clinical implications.

Clinical features and biological markers of lung cancer-associated stroke

Objective

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

Methods

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

Results

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

Conclusion

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

Cancer-Associated Stroke: The Bergen NORSTROKE Study

Background

Underlying malignancy can cause ischemic stroke in some patients. Mechanisms include the affection of the coagulation cascade, tumor mucin secretion, infections and nonbacterial endocarditis. The release of necrotizing factor and interleukins may cause inflammation of the endothelial lining, creating a prothrombotic surface that triggers thromboembolic events, including stroke. The aims of this study were to assess the occurrence of cancer in patients who had recently suffered an ischemic stroke and to detect possible associations between stroke and cancer subtypes.

Methods

All ischemic stroke patients registered in the Norwegian Stroke Research Registry (NORSTROKE) as part of the ongoing Bergen NORSTROKE study were included. Blood samples were obtained on admission. Stroke etiology was determined by the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria, and the severity of stroke was defined according to the National Institute of Health Stroke Scale score. Information about cancer disease after stroke was obtained from patient medical records and The Cancer Registry of Norway.

Results

From a total of 1,282 ischemic stroke patients with no history of cancer, 55 (4.3%) patients were diagnosed with cancer after stroke. The median time from stroke onset to cancer diagnosis was 14.0 months (interquartile range 6.2-24.5). Twenty-three (41.8%) patients were diagnosed with cancer within 1 year and 13 (23.6%) within 6 months. The most common cancer type was lung cancer (19.0%). By Cox regression analysis, cancer after stroke was associated with elevated D-dimer levels on admittance (p < 0.001), age (p = 0.01) and smoking (p = 0.04).

Conclusions

Cancer-associated stroke is rare, and routine investigation for cancer seems unwarranted in acute ischemic stroke. However, in stroke patients with elevated levels of blood coagulation factors, C-reactive protein, higher age and a history of smoking, underlying malignancy should be considered. Our study suggests that an unknown stroke etiology does not predict malignancy.

Multiple embolic cerebral infarcts as the first manifestation of metastatic ovarian cancer

A 36-year-old woman presented to the emergency department with a 3-day history of an occipital headache associated with transient visual impairment and short-term memory loss. MRI of the brain showed innumerable focal embolic infarcts of differing ages, for which a cause could not be determined. The patient was discharged and readmitted 7 weeks later with acute aphasia and a right-sided hemiplegia. CT of the abdomen revealed a right-sided ovarian mass and prominent retroperitoneal nodes, which cytology confirmed to be metastatic ovarian cancer.

Risk of ischemic stroke in patients with ovarian cancer: a nationwide population-based study

BACKGROUND

Cancer patients are at risk of thromboembolism. However, studies investigating the relationship between ovarian cancer and ischemic stroke are lacking. The objectives of this study were to assess the association between ovarian cancer and ischemic stroke, and to determine the predictive risk factors.

METHODS

Ovarian cancer patients aged 20 years and older without antecedent cerebrovascular events and who were followed up for more than 1 year between 1 January 2003 and 31 December 2011 were recruited from the Taiwan National Health Insurance database. Hazard ratios (HRs) of stroke risk for ovarian cancer patients compared with an age- and comorbidity-matched cohort were calculated by Cox proportional regression analysis. The difference in cumulative ischemic stroke incidence between ovarian cancer patients and the matched cohort was analyzed with the Kaplan-Meier method and tested with the log-rank test.

RESULTS

Each cohort (ovarian cancer and matched cohort) consisted of 8,810 individuals, with a median age of 49 years. After a median follow-up of 2.68 and 3.85 years, respectively, the ischemic stroke incidence was 1.38-fold higher in the ovarian cancer cohort than in the comparison cohort (9.4 versus 6.8 per 1,000 person-years), with an age- and comorbidity-adjusted HR of 1.49 (P <0.001). The ischemic stroke risk imposed by ovarian cancer was more prominent in patients under 50 years old (HR 2.28; P <0.001) compared with patients 50 years and older (HR 1.33; P = 0.005). Significant risk factors predicting stroke development were age 50 years and older (HR 2.21; P <0.001), hypertension (HR 1.84; P <0.001), diabetes mellitus (HR 1.71; P <0.001), and treatment with chemotherapy (HR 1.45; P = 0.017), especially platinum-based regimens.

CONCLUSIONS

Ovarian cancer patients were at an increased risk of developing ischemic stroke. Age, hypertension, diabetes, and chemotherapy treatment were independent risk factors.

Ischaemic stroke as initial presentation of systemic malignancy

Ischaemic stroke as the initial presentation of systemic malignancy is reported infrequently and is characterised by ischaemic lesions that exceed the vascular territory of a single vessel. There is also a high rate of early stroke recurrence. Several pathophysiological mechanisms are known to cause cerebrovascular complications in malignancies, as a direct effect of the tumour, paraneoplastic or even of the tumour treatment itself. Prognosis is reportedly poor, treatment is symptomatic and at best anecdotal. We present a case report and available literature.

Predictive value of plasma (D)-dimer levels for cancer-related stroke: a 3-year retrospective study

BACKGROUND

Cerebrovascular disease is the second leading cause of central nervous system pathology in cancer patients. Cancer-associated hypercoagulation plays an important role in cancer-related stroke. The present study aims to test whether plasma d-dimer levels could predict comorbid malignancy in patients with ischemic stroke.

METHODS

Five hundred sixteen stroke patients with measured d-dimer levels and who were consecutively admitted to our stroke center from 2009 to 2012 were included. Cancer status was determined by medical chart, and 59 patients were identified to have active cancer. An additional 48 cancer patients with stroke were identified from the hospital database. Several d-dimer cutoff levels were used to predict cancer-related stroke.

RESULTS

Stroke patients with active cancer had significantly higher d-dimer levels than those without cancer (P < .001). The average d-dimer level in stroke patients without cancer was .66 ± 1.83 mg/L, whereas the levels for active cancer patients from the stroke center and hospital database were 5.70 ± 9.63 mg/L and 10.47 ± 12.31 mg/L, respectively. When using d-dimer of .55 mg/L or more and multiple territory infarctions as criteria, the specificity and positive predictive value (PPV) for cancer-related stroke were 99.7% and 92.9%, respectively. When using d-dimer of 5.5 mg/L or more as the cutoff value, the test had a high specificity and PPV regardless the brain magnetic resonance imaging (MRI) findings. Six stroke patients fitting our criteria were confirmed to have occult malignancy after comprehensive cancer survey.

CONCLUSIONS

Extraordinary high d-dimer levels or combining d-dimer and MRI findings may be used as a screening tool to detect malignancy in stroke patients.

Ischemic stroke in patients with solid gynecologic tract tumors and coagulopathy

AIM

Patients with gynecological neoplasms often suffer ischemic stroke. This study aimed to clarify the underlying mechanisms of ischemic stroke in patients with gynecological tract tumors.

METHODS

We retrospectively reviewed 6 patients with gynecologic tumors and hypercoagulability who were being treated for acute ischemic stroke between 2006 and 2012. Diffusion-weighted magnetic resonance imaging (DW-MRI), cardiovascular risk factors including plasma D-dimer levels, and histologic examination of the patients' solid tumors were performed. All 6 patients underwent transesophageal echocardiography (TEE) for nonbacterial thrombotic endocarditis (NBTE) and paradoxical embolism.

RESULTS

All 6 patients showed elevated plasma D-dimer levels. In 1 patient, paradoxical embolism was diagnosed. In the remaining 5 patients, DW-MRI scans showed numerous lesions in multiple vascular territories, and in 4 of these 5 patients, TEE demonstrated vegetations on the mitral valve, leading to the diagnosis of NBTE. Interestingly, 2 of these 4 patients had benign uterine tumors, whereas the other 2 had ovarian cancer.

CONCLUSIONS

NBTE was the main etiology for ischemic stroke in patients with gynecologic tract tumors and coagulopathy. Both malignant and benign tumors of the gynecologic tract can cause NBTE.

Activity profile of the CA125 antigen towards human red blood cells

Starting from the mucin nature of the CA125 antigen and conditions associated with high serum concentrations, this study is an attempt to gain insight into its activity profile towards human erythrocytes. Carcinomaassociated and pregnancy-associated CA125 antigens were tested in agglutination/aggregation, adhesion and hemolysis assays. The results obtained indicated that CA125 antigens increased agglutination/aggregation and inhibited erythrocyte adhesion, but differed in their effective concentrations. Galectin-1 slightly modulated the effects observed. CA125 antigens had no effect on hemolysis. The activity profile of the CA125 antigen towards erythrocytes may have biomedical consequences in different microenvironments in relevant physiological and pathophysiological conditions.

Marantic Endocarditis Associated with Pancreatic Cancer: A Case Series

Marantic endocarditis, otherwise known as nonbacterial thrombotic endocarditis (NBTE), is a well-documented phenomenon due to hypercoagulability from an underlying cause. It has been associated with a variety of inflammatory states including malignancy. Surprisingly, although hypercoagulability is often seen in patients with pancreatic cancer, marantic endocarditis has rarely been reported antemortem in this population. We report three cases of marantic endocarditis in patients with advanced pancreatic cancer. In two instances, the patients' neurological symptoms preceded the diagnosis of advanced pancreatic cancer. Health care professionals should be alert to the possibility of marantic endocarditis in any patient with cancer, especially pancreatic cancer, who presents with symptoms of neurological dysfunction or an arterial thrombotic event. Prompt diagnosis and treatment with heparin, unfractionated or low molecular weight, may prevent catastrophic CNS events and decrease morbidity in patients with pancreatic cancer and other malignancies.

First-ever stroke as initial presentation of systemic cancer

BACKGROUND

Stroke is a frequent complication in patients with cancer, occurring in nearly 15% of patients with cancer. However, cerebrovascular disease as the first manifestation of cancer has rarely been reported.

METHODS

We retrospectively reviewed all 5106 patients admitted for ischemic stroke to our stroke department between 1991 to 2004, and identified a group of 24 patients (0.4%) who had an underlying malignancy.

RESULTS

The mean age of the 24 patients was 52 +/- 4.1 years and 62.5% were women. Vascular risk factors were found in only 41% of patients. The principal mechanisms of stroke pathogenesis were nonbacterial thrombotic endocarditis (8/24), diffuse intravascular coagulation (6/24), and atherosclerosis (5/24). The most frequent neoplasms were lung and breast cancer. All patients but 4 were diagnosed with an underlying malignancy at the second ischemic event. Mean follow-up of surviving patients was 29 months (3-60). Nineteen patients died (79%), with a median survival of 58 days after cerebral infarction.

CONCLUSIONS

A systemic cancer workup should be considered in patients in whom stroke origin is unclear or who have an early vascular recurrence. Stroke as the first manifestation of an underlying malignancy is mostly secondary to specific cancer-related causes. Outcome is poor and correlates with both severity of neurologic disability and the stage of tumor.

Multifocal strokes as the presentation of occult lung cancer

Cancer patients are hypercoagulable through a variety of mechanisms and are at significant risk for ischemic stroke. Though usually occurring in the later stages of neoplastic disease, stroke can rarely be the first manifestation of an occult malignancy. We report a 46-year-old woman who presented with multiple cerebral infarctions in numerous vascular distributions, refractory to anticoagulation, and associated with systemic thromboses. These atypical features prompted a malignancy evaluation which revealed an occult lung adenocarcinoma. Our patient had a rapidly deteriorating course with recurrent strokes despite numerous anti-platelet and anti-coagulant agents, and was only responsive to chemotherapy aimed at the underlying cancer.

Stroke as the first manifestation of concealed cancer

BACKGROUND AND PURPOSE

Trousseau's syndrome (TS) is defined as a malignancy-related thromboembolism occurring in patients with an underlying or undiagnosed malignancy. Stroke seldom occurs as the first manifestation of a cancer. We investigated the clinical and radiological features of patients with TS.

METHODS

We reviewed the clinical, pathologic, and radiological records of consecutive stroke patients, whose cancers were diagnosed at stroke presentation. Cancer-related stroke was defined if no definite cause was confirmed and malignancy was detected within 6 months of first stroke onset without cancer-related treatment. All patients underwent brain diffusion-weighted MRI (DWI), MR angiography, and echocardiography. The sizes, numbers, and locations of all hyperintense lesions in the DWI were noted.

RESULTS

Ten patients were finally analyzed. Histologically, cancers were often proven to adenocarcinomas (50%, 5/10) of advanced stage. Six of 10 patients tested (60%) had elevated D-dimer. Seven of the 10 patients (70%) showed bihemispheric anterior and posterior involvement. DWI features showed numerous small and medium or large lesions in multiple territories in 9 patients (90%).

CONCLUSIONS

The authors emphasize that when presented with multiple bihemispheric infarctions on DWI and an unknown etiology, the neurologist must consider the existence of a concealed cancer.