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González Caraballo I, Martín Lozano R, Jiménez Rodríguez R, Soto Alsar J, Ortega Morán L, Martín Jiménez M, Muñoz Martín AJ. Chronological pattern of venous thromboembolism (VTE) occurrence impacts in survival of pancreatic ductal adenocarcinoma (PDAC). Clin Transl Oncol 2024; 26:2388-2392. [PMID: 38558283 DOI: 10.1007/s12094-024-03467-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/13/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Limited data exist on the prognostic significance of the chronology of VTE in patients with PDAC. METHODS Medical data and survival characteristics of patients treated for PDAC from 2019 to 2021 were retrospectively reviewed. Early VTE was defined as occurring within the three months of PDAC diagnosis. RESULTS 197 patients were included, 54 (27.4%) developed a VTE. Early appearance of VTE was associated with worse prognosis: median overall survival (mOS) VTE < 3 months 8.5 months (HR 1.65, 95% CI 1.11-2.46; p = 0.014), mOS VTE > 3 months 12.8 months (HR 0.78, 95% CI 0.39-1.54; p = 0.5) and mOS patients without VTE 11.4 months (95% CI 10.1-15.4). There was no significant association between the patient's VTE risk according to the Khorana risk score (KRS) (chi2 test p-value = 0.9). CONCLUSION Early VTE is a prognostic factor in PDAC, which may identify a more aggressive subtype.
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Affiliation(s)
| | - Rocío Martín Lozano
- Medical Oncology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Javier Soto Alsar
- Medical Oncology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Laura Ortega Morán
- Medical Oncology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Miguel Martín Jiménez
- Medical Oncology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Andrés J Muñoz Martín
- Medical Oncology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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2
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Willems RAL, Biesmans C, Campello E, Simioni P, de Laat B, de Vos-Geelen J, Roest M, Ten Cate H. Cellular Components Contributing to the Development of Venous Thrombosis in Patients with Pancreatic Cancer. Semin Thromb Hemost 2024; 50:429-442. [PMID: 38049115 DOI: 10.1055/s-0043-1777304] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive type of cancer and has a poor prognosis. Patients with PDAC are at high risk of developing thromboembolic events, which is a leading cause of morbidity and mortality following cancer progression. Plasma-derived coagulation is the most studied process in cancer-associated thrombosis. Other blood components, such as platelets, red blood cells, and white blood cells, have been gaining less attention. This narrative review addresses the literature on the role of cellular components in the development of venous thromboembolism (VTE) in patients with PDAC. Blood cells seem to play an important role in the development of VTE. Altered blood cell counts, i.e., leukocytosis, thrombocytosis, and anemia, have been found to associate with VTE risk. Tumor-related activation of leukocytes leads to the release of tissue factor-expressing microvesicles and the formation of neutrophil extracellular traps, initiating coagulation and forming a scaffold for thrombi. Tissue factor-expressing microvesicles are also thought to be released by PDAC cells. PDAC cells have been shown to stimulate platelet activation and aggregation, proposedly via the secretion of podoplanin and mucins. Hypofibrinolysis, partially explained by increased plasminogen activator inhibitor-1 activity, is observed in PDAC. In short, PDAC-associated hypercoagulability is a complex and multifactorial process. A better understanding of cellular contributions to hypercoagulability might lead to the improvement of diagnostic tests to identify PDAC patients at highest risk of VTE.
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Affiliation(s)
- Ruth Anne Laura Willems
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Vascular Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Charlotte Biesmans
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Vascular Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Elena Campello
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Paolo Simioni
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Bas de Laat
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, Maastricht, The Netherlands
- Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, The Netherlands
| | - Judith de Vos-Geelen
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- GROW, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Mark Roest
- Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, The Netherlands
| | - Hugo Ten Cate
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Vascular Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, Maastricht, The Netherlands
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Malte AL, Højbjerg JA, Larsen JB. Platelet Parameters as Biomarkers for Thrombosis Risk in Cancer: A Systematic Review and Meta-analysis. Semin Thromb Hemost 2024; 50:360-383. [PMID: 36921613 DOI: 10.1055/s-0043-1764381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Cancer-associated thrombosis (CAT) is a major cause of both morbidity and mortality in cancer patients. Platelet count has been investigated as a predictor of CAT in various settings while knowledge on platelet activation parameters is sparse. This report provides a systematic review and meta-analysis on available literature on associations between platelet count and/or function and arterial and venous thrombosis in adult cancer patients. The review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. PubMed and Embase were searched up to March 2022. The National Heart, Lung, and Blood Institute's tools were used for quality assessment. In total, 100 studies were included which investigated the association between CAT and platelet count (n = 90), platelet indices (n = 19), and platelet function/activation markers (n = 13) in patients with solid cancers (n = 61), hematological cancers (n = 17), or mixed cancer types (n = 22). Eighty-one studies had venous thrombosis as their outcome measure, while 4 had arterial thrombosis and 15 studies had both. We found significantly elevated odds ratio of 1.50 (95% confidence interval: 1.19-1.88) for thrombosis with higher platelet counts. We saw a tendency toward an association between markers of platelet activation in forms of mean platelet volume and soluble P selectin and both arterial and venous thrombosis. Only one study investigated dynamic platelet function using flow cytometry. In conclusion, platelet count is associated with CAT across different cancer types and settings. Platelet function or activation marker analysis may be valuable in assisting thrombosis risk assessment in cancer patients but is sparsely investigated so far.
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Affiliation(s)
- Anne Lind Malte
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Johanne Andersen Højbjerg
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Julie Brogaard Larsen
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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4
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Willems RAL, Konings J, Huskens D, Middelveld H, Pepels-Aarts N, Verbeet L, de Groot PG, Heemskerk JWM, Ten Cate H, de Vos-Geelen J, de Laat B, Roest M. Altered whole blood thrombin generation and hyperresponsive platelets in patients with pancreatic cancer. J Thromb Haemost 2024; 22:1132-1144. [PMID: 38237861 DOI: 10.1016/j.jtha.2023.12.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/12/2023] [Accepted: 12/29/2023] [Indexed: 02/10/2024]
Abstract
BACKGROUND Thromboembolic disease is a major complication in patients with pancreatic ductal adenocarcinoma (PDAC). Patients with PDAC often have altered blood cell counts, which are associated with venous thromboembolism (VTE) development. The high thrombotic risk in patients with PDAC may be partially caused by procoagulant blood cells. OBJECTIVES The aim of this study was to compare blood cell-dependent coagulation between patients with PDAC (n = 18) and healthy controls matched for age and sex (n = 18). METHODS Thrombin generation (TG) was measured in whole blood (WB) and plasma. The capacity of platelets to release granules (PGRCs) was measured in WB. We explored the occurrence of thromboembolic events in patients with PDAC during a 6-month follow-up. RESULTS Patients showed an increased endogenous thrombin potential in WB compared with controls. This difference was not observed in plasma, indicating a procoagulant effect of blood cells. Both in WB and plasma, the lag time was prolonged in patients compared with controls. Patients had hyperresponsive platelets, with a shorter time to peak granule release. Of the 18 patients with PDAC, 4 developed a venous thromboembolism (22%) and 1 developed an arterial thrombosis (6%). A shorter lag time in WB, but not in plasma, and an increased PGRC were associated with thromboembolic events. CONCLUSION Patients with PDAC have an increased and delayed WB TG coagulation profile compared with controls. A shorter lag time in WB TG and increased PGRC are associated with the incidence of thromboembolic events. Platelets appear to be key players in thrombosis development. Measuring hemostasis in WB could improve thrombosis risk estimation in patients with PDAC.
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Affiliation(s)
- Ruth Anne Laura Willems
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands; Thrombosis Expert Center Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Internal Medicine, Division of Vascular Medicine, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Internal Medicine, Division of Medical Oncology, Maastricht University Medical Center, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht, The Netherlands.
| | - Joke Konings
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands; Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, The Netherlands
| | - Dana Huskens
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands; Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, The Netherlands
| | - Harmen Middelveld
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands; Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, The Netherlands
| | - Nicol Pepels-Aarts
- Department of Internal Medicine, Division of Medical Oncology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lisa Verbeet
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands; Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, The Netherlands
| | - Phillip Gerrit de Groot
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Johan Willem Marie Heemskerk
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht, The Netherlands; Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, The Netherlands
| | - Hugo Ten Cate
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Internal Medicine, Division of Vascular Medicine, Maastricht University Medical Center, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht, The Netherlands; Center of Thrombosis and Haemostasis, Gutenberg University Medical Center, Mainz, Germany
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, Maastricht University Medical Center, Maastricht, The Netherlands; GROW, Research Institute for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bas de Laat
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht, The Netherlands; Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, The Netherlands
| | - Mark Roest
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands; Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, The Netherlands
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5
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Tarasiuk A, Mirocha G, Fichna J. Current status of Complementary and Alternative Medicine Interventions in the Management of Pancreatic Cancer - An Overview. Curr Treat Options Oncol 2023; 24:1852-1869. [PMID: 38079061 PMCID: PMC10781793 DOI: 10.1007/s11864-023-01146-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 01/11/2024]
Abstract
OPINION STATEMENT Pancreatic cancer (PC) remains the deadliest cancer worldwide. Most patients are diagnosed at the advanced or metastatic stage, leading to a poor prognosis. Awareness of the limitations of current therapy and accompanying pain, depression, malnutrition, and side effects of chemoradiotherapy may lead patients and physicians towards complementary and alternative medicine (CAM). CAM refers to a diverse set of medical and healthcare practices, products, and systems that are not part of conventional Western medicine. Despite the low-quality evidence supporting the efficacy of these methods, they remain appealing due to patients' beliefs, fear of death, and the slow development of conventional therapy. Hence, the possibility of using natural products for pancreatic cancer is increasing. CAM options such as: medical cannabis, plants, fungi, herbal formulas, and injections, which originate primarily from traditional Chinese or Japanese medicine i.e. Curcuma longa, Panax ginseng, Poria cocos, Hochuekkito, Juzentaihoto, and Rikkunshito, Shi-quan-da-bu-tang/TJ-48, Huang-qin-tang, Shuangbai San, Wen Jing Zhi Tong Fang, Xiang-Sha-Liu-jun-zi-tang, Aidi injection, Brucea javanica oil emulsion/Yadanziyouru injection, Compound Kushen injection, Huachansu injection, Kangai injection and Kanglaite injections are becoming promising candidates for the management of pancreatic cancer. The abovementioned substances/medications are the most popular or potentially effective in PC treatment and consequently CAM-based adjuvant therapy through improving patients' quality of life, might be a useful addition in the treatment of pancreatic cancer patients.
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Affiliation(s)
- Aleksandra Tarasiuk
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Mazowiecka 5, 92-215, Lodz, Poland.
| | - Grzegorz Mirocha
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Mazowiecka 5, 92-215, Lodz, Poland
| | - Jakub Fichna
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Mazowiecka 5, 92-215, Lodz, Poland
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6
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Franco-Moreno A, Madroñal-Cerezo E, Muñoz-Rivas N, Torres-Macho J, Ruiz-Giardín JM, Ancos-Aracil CL. Prediction of Venous Thromboembolism in Patients With Cancer Using Machine Learning Approaches: A Systematic Review and Meta-Analysis. JCO Clin Cancer Inform 2023; 7:e2300060. [PMID: 37616550 DOI: 10.1200/cci.23.00060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/02/2023] [Accepted: 07/10/2023] [Indexed: 08/26/2023] Open
Abstract
PURPOSE Recent studies have suggested that machine learning (ML) could be used to predict venous thromboembolism (VTE) in cancer patients with high accuracy. METHODS We aimed to evaluate the performance of ML in predicting VTE events in patients with cancer. PubMed, Web of Science, and EMBASE to identify studies were searched. RESULTS Seven studies involving 12,249 patients with cancer were included. The combined results of the different ML models demonstrated good accuracy in the prediction of VTE. In the training set, the global pooled sensitivity was 0.87, the global pooled specificity was 0.87, and the AUC was 0.91, and in the test set 0.65, 0.84, and 0.80, respectively. CONCLUSION The prediction ML models showed good performance to predict VTE. External validation to determine the result's reproducibility is necessary.
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Affiliation(s)
- Anabel Franco-Moreno
- Thromboembolism Unit, Internal Medicine Department, Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain
| | - Elena Madroñal-Cerezo
- Thromboembolism Unit, Internal Medicine Department, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Nuria Muñoz-Rivas
- Thromboembolism Unit, Internal Medicine Department, Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain
- Medicine Department, Complutense University, Madrid, Spain
| | - Juan Torres-Macho
- Thromboembolism Unit, Internal Medicine Department, Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain
- Medicine Department, Complutense University, Madrid, Spain
| | - José Manuel Ruiz-Giardín
- Internal Medicine Department, Hospital Universitario de Fuenlabrada, Madrid, Spain
- CIBERINFEC, Madrid, Spain
| | - Cristina L Ancos-Aracil
- Thromboembolism Unit, Internal Medicine Department, Hospital Universitario de Fuenlabrada, Madrid, Spain
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7
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Willems RAL, Michiels N, Lanting VR, Bouwense S, van den Broek BLJ, Graus M, Klok FA, Groot Koerkamp B, de Laat B, Roest M, Wilmink JW, van Es N, Mieog JSD, Ten Cate H, de Vos-Geelen J. Venous Thromboembolism and Primary Thromboprophylaxis in Perioperative Pancreatic Cancer Care. Cancers (Basel) 2023; 15:3546. [PMID: 37509209 PMCID: PMC10376958 DOI: 10.3390/cancers15143546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023] Open
Abstract
Recent studies have shown that patients with pancreatic ductal adenocarcinoma (PDAC) treated with neoadjuvant chemo(radio)therapy followed by surgery have an improved outcome compared to patients treated with upfront surgery. Hence, patients with PDAC are more and more frequently treated with chemotherapy in the neoadjuvant setting. PDAC patients are at a high risk of developing venous thromboembolism (VTE), which is associated with decreased survival rates. As patients with PDAC were historically offered immediate surgical resection, data on VTE incidence and associated preoperative risk factors are scarce. Current guidelines recommend primary prophylactic anticoagulation in selected groups of patients with advanced PDAC. However, recommendations for patients with (borderline) resectable PDAC treated with chemotherapy in the neoadjuvant setting are lacking. Nevertheless, the prevention of complications is crucial to maintain the best possible condition for surgery. This narrative review summarizes current literature on VTE incidence, associated risk factors, risk assessment tools, and primary thromboprophylaxis in PDAC patients treated with neoadjuvant chemo(radio)therapy.
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Affiliation(s)
- R A L Willems
- Department of Functional Coagulation, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
| | - N Michiels
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - V R Lanting
- Department of Internal Medicine, Section Vascular Medicine, University of Amsterdam, Amsterdam UMC Location, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, 1081 HV Amsterdam, The Netherlands
- Tergooi Hospitals, Internal Medicine, 1201 DA Hilversum, The Netherlands
| | - S Bouwense
- Department of Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- NUTRIM, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
| | - B L J van den Broek
- Department of Surgery, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - M Graus
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- GROW, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
| | - F A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - B de Laat
- Department of Functional Coagulation, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
- Department of Platelet Pathophysiology, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
| | - M Roest
- Department of Platelet Pathophysiology, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
| | - J W Wilmink
- Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam University Medical Center, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - N van Es
- Department of Internal Medicine, Section Vascular Medicine, University of Amsterdam, Amsterdam UMC Location, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, 1081 HV Amsterdam, The Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - H Ten Cate
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
| | - J de Vos-Geelen
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- GROW, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
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8
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Muñoz A, Ay C, Grilz E, López S, Font C, Pachón V, Castellón V, Martínez-Marín V, Salgado M, Martínez E, Calzas J, Ortega L, Rupérez A, Salas E, Pabinger I, Soria JM. A Clinical-Genetic Risk Score for Predicting Cancer-Associated Venous Thromboembolism: A Development and Validation Study Involving Two Independent Prospective Cohorts. J Clin Oncol 2023; 41:2911-2925. [PMID: 36730884 PMCID: PMC10414737 DOI: 10.1200/jco.22.00255] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 10/25/2022] [Accepted: 12/01/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Venous thromboembolism (VTE) is a leading cause of death among patients with cancer. The Khorana score was developed for assessing the risk of VTE in outpatients with cancer receiving chemotherapy, but its accuracy in identifying patients at high risk has been questioned. The aim of this study was to develop and validate a clinical-genetic score that improves the assessment of VTE risk in oncology outpatients within 6 months of diagnosis. METHODS The new score was developed using the data of 364 outpatients belonging to the Spanish ONCOTHROMB 12-01 population. In this cohort, clinical data associated with the risk of VTE were collected at the time of diagnosis, including the Khorana score. These patients were also genotyped for the 51 genetic variants known to be associated with VTE. Multivariate logistic regression was performed to determine the weight of each genetic and clinical variable in relation to VTE risk, allowing a clinical-genetic risk score (the ONCOTHROMB score) to be developed. The Khorana and the ONCOTHROMB scores were then compared via the area under the receiver operating characteristic curve (AUC), calibration, and the number of patients needed to treat. The new score was then validated in a study of 263 patients in the Vienna Cancer and Thrombosis Study population. RESULTS Nine genetic variants, tumor site, TNM stage, and a body mass index of > 25 kg/m2 were found to be associated with VTE and were used to build the ONCOTHROMB score, which better predicted the overall risk of VTE than did the Khorana score (AUC, 0.781 v 0.580; P < .001). Similar AUC results were recorded in the validation study the Vienna Cancer and Thrombosis Study cohort involving patients with the same type of tumor (AUC for the ONCOTHROMB score v the Khorana score: 0.686 v 0.577; P < .001) and with all type of tumors (AUC for the ONCOTHROMB score v the Khorana score: 0.720 v 0.561; P < .0001). CONCLUSION The ONCOTHROMB score for VTE risk in outpatients with cancer, which takes into account both clinical and genetic variables, better identifies patients who might benefit from primary thromboprophylaxis than does the Khorana score.
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Affiliation(s)
- Andrés Muñoz
- Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Ella Grilz
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sonia López
- Genomics of Complex Diseases Unit, Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona, Spain
| | - Carme Font
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Clínic, Barcelona, Spain
| | - Vanesa Pachón
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario Ramón y Cajal Madrid, Madrid, Spain
| | - Victoria Castellón
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Complejo Hospitalario de Torrecárdenas, Almería, Spain
| | - Virginia Martínez-Marín
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario La Paz, Madrid, Spain
| | - Mercedes Salgado
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Eva Martínez
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Julia Calzas
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Laura Ortega
- Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
| | - Ana Rupérez
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Fundación Jiménez Díaz, Madrid, Spain
| | - Eduardo Salas
- Scientific Department, Gendiag.exe, Barcelona, Spain
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Jose Manuel Soria
- Genomics of Complex Diseases Unit, Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona, Spain
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9
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Ramos-Esquivel A, Marenco-Flores A, Hernández-Romero G, Umaña-Mora C, Céspedes-Calvo A, Mora-Hidalgo R. Using the Khorana risk score to predict venous thromboembolism and overall survival in a cohort of Hispanic patients with solid malignancies. Ecancermedicalscience 2022; 16:1470. [PMID: 36819798 PMCID: PMC9934874 DOI: 10.3332/ecancer.2022.1470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Indexed: 11/12/2022] Open
Abstract
Background The Khorana risk score (KRS) for prognosis of venous thromboembolism (VTE) has been rarely explored in Hispanic populations. Objective To determine the value of the KRS for prediction of VTE and overall survival (OS) among Hispanic individuals with cancer. Methods We retrospectively evaluated all outpatients with newly diagnosed solid tumours receiving systemic chemotherapy in Hospital San Juan Dios, San José, Costa Rica, from January to December 2021. The 6-month cumulative VTE incidence according to the KRS categories was estimated using the Fine & Gray competing risk model. A Kaplan-Meier analysis was used to compare OS among KRS categories. The Cox regression analysis was performed to calculate the hazard ratio (HR) and its corresponding 95% confidence interval (CI). The receiver operating characteristic (ROC) analysis was performed to identify the optimal cutoff value to predict VTE during follow-up. Results A total of 708 patients were included in the analysis. After a median follow-up of 8.13 months, the cumulative incidence of VTE at 6 months was 1.56% (95% CI: 0.83%-6.82%), 4.83% (95% CI: 2.81%-7.66%) and 8.84% (95% CI: 4.30%-15.42%) for low-, intermediate- and high-risk Khorana score categories, respectively (Gray's p value: 0.0178). The optimal cutoff for the KRS to predict VTE was 2 (area under the ROC curve: 0.65; 95% CI: 0.55-0.756). The KRS was independently associated with overall mortality (HR: 1.83; 95% CI: 1.46-2.29; p < 0.001, for the comparison of 'high-risk' and 'low-risk' KRS). Conclusions The KRS is a valid tool to predict VTE and mortality in a cohort of Hispanic outpatients with newly diagnosed solid tumours.
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Affiliation(s)
- Allan Ramos-Esquivel
- Medical Oncology Service, Hospital San Juan de Dios, Caja Costarricense de Seguro Social, 1001, Costa Rica,Department of Pharmacology, School of Medicine, University of Costa Rica, Sede Rodrigo Facio, 2082 San Pedro, San José, Costa Rica
| | - Ana Marenco-Flores
- Department of Pharmacology, School of Medicine, University of Costa Rica, Sede Rodrigo Facio, 2082 San Pedro, San José, Costa Rica
| | - Gabriel Hernández-Romero
- Department of Medicine, NYC, New York, Jacobi Medical Center/Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Carlos Umaña-Mora
- Medical Oncology Service, Hospital San Juan de Dios, Caja Costarricense de Seguro Social, 1001, Costa Rica
| | - Ana Céspedes-Calvo
- Medical Oncology Service, Hospital San Juan de Dios, Caja Costarricense de Seguro Social, 1001, Costa Rica
| | - Raquel Mora-Hidalgo
- Medical Oncology Service, Hospital San Juan de Dios, Caja Costarricense de Seguro Social, 1001, Costa Rica
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10
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García Adrián S, González AR, de Castro EM, Olmos VP, Morán LO, Del Prado PM, Fernández MS, Burón JDC, Escobar IG, Galán JM, Pérez AIF, Neria F, Lavin DC, Hernández BLDSV, Jiménez-Fonseca P, Muñoz Martín AJ. Incidence, risk factors, and evolution of venous thromboembolic events in patients diagnosed with pancreatic carcinoma and treated with chemotherapy on an outpatient basis. Eur J Intern Med 2022; 105:30-37. [PMID: 35931614 DOI: 10.1016/j.ejim.2022.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/20/2022] [Accepted: 07/26/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pancreatic carcinoma is one of the tumors associated with a higher risk for thromboembolic events, with incidence rates ranging from 5% to 41% in previous retrospective series. PATIENTS AND METHODS We conducted a retrospective study in eleven Spanish hospitals that included 666 patients diagnosed with pancreatic carcinoma (any stage) between 2008 and 2011 and treated with chemotherapy. The main objective was to evaluate the incidence of venous thromboembolic events (VTE) in this population, as well as potential risk factors for thrombosis. The impact of VTE on mortality was also assessed. RESULTS With a median follow-up of 9.3 months, the incidence of VTE was 22.1%; 52% were diagnosed incidentally. Our study was unable to confirm the ability of the Khorana score to discriminate between patients in the intermediate or high risk category for thrombosis. The presence of VTE proved to be an independent prognostic factor associated with increased risk of death (HR 2.39, 95% CI 1.96-2.92). Symptomatic events correlated with higher mortality than asymptomatic events (HR 1.72; 95% CI, 1.21-2.45; p = 0.002), but incidental VTE, including visceral vein thrombosis (VVT), negatively affected survival compared to patients without VTE. Subjects who developed VTE within the first 3 months of diagnosis of pancreatic carcinoma had lower survival rates than those with VTE after 3 months (HR 1.92, 95% CI 1.30-2.84; p<0.001). CONCLUSIONS Pancreatic carcinoma is associated with a high incidence of VTE, which, when present, correlates with worse survival, even when thrombosis is incidental. Early onset VTE has a particularly negative impact.
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Affiliation(s)
- Silvia García Adrián
- Medical Oncology Department, Hospital Universtario de Móstoles, C/ Dr. Luis Montes S/N, Madrid 28935, Spain; Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain.
| | - Adán Rodríguez González
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - Eva Martínez de Castro
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Vanessa Pachón Olmos
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Laura Ortega Morán
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Purificación Martínez Del Prado
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario de Basurto, Bilbao, Spain
| | - Mercedes Salgado Fernández
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Complejo Universitario de Orense, Orense, Spain
| | - José David Cumplido Burón
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital de Torrevieja, Torrevieja, Spain
| | - Ignacio García Escobar
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Joaquina Martínez Galán
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Ana Isabel Ferrer Pérez
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Fernando Neria
- Faculty of Medicine, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - Diego Cacho Lavin
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Borja López de San Vicente Hernández
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario de Basurto, Bilbao, Spain
| | - Paula Jiménez-Fonseca
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - Andrés J Muñoz Martín
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
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11
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Htut TW, Thein KZ, Aung KL, Oo TH. Primary ambulatory thromboprophylaxis in patients with pancreatic cancer receiving chemotherapy: hope or hype? Support Care Cancer 2022; 30:8511-8517. [PMID: 35579754 DOI: 10.1007/s00520-022-07138-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 05/10/2022] [Indexed: 11/29/2022]
Abstract
Thrombosis is the second leading cause of death in cancer patients. Patients with pancreatic cancer (PC) have a very high risk of developing venous thromboembolism (VTE). Even though primary ambulatory thromboprophylaxis (PATP) could decrease this risk, there are uncertain issues with regard to the choice and dose of anticoagulants, duration of anticoagulant therapy, and patient selection criteria. In addition, the current practice guidelines on PATP in PC patients are equivocal. This review critically appraises the evidence on the use of PATP in PC patients receiving chemotherapy.
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Affiliation(s)
- Thura Win Htut
- Department of Haematology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK
| | - Kyaw Zin Thein
- Division of Hematology and Medical Oncology, Oregon Health and Science University/Knight Cancer Institute, Portland, OR, USA
| | - Kyaw Lwin Aung
- Department of Oncology and Livestrong Cancer Institutes, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Thein Hlaing Oo
- Section of Thrombosis and Benign Hematology (Unit 1464), The University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA.
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12
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Zaheer A, Naumovski N, Toohey K, Niyonsenga T, Yip D, Brown N, Mortazavi R. Prediction models for venous thromboembolism in ambulatory adults with pancreatic and gastro-oesophageal cancer: protocol for systematic review and meta-analysis. BMJ Open 2022; 12:e056431. [PMID: 35246422 PMCID: PMC8900042 DOI: 10.1136/bmjopen-2021-056431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a common complication of cancer. Pancreatic and gastro-oesophageal cancers are among malignancies that have the highest rates of VTE occurrence. VTE can increase cancer-related morbidity and mortality and disrupt cancer treatment. The risk of VTE can be managed with measures such as using anticoagulant drugs, although the risk of bleeding may be an impeding factor. Therefore, a VTE risk assessment should be performed before the start of anticoagulation in individual patients. Several prediction models have been published, but most of them have low sensitivity and unknown clinical applicability in pancreatic or gastro-oesphageal cancers. We intend to do this systematic review to identify all applicable published predictive models and compare their performance in those types of cancer. METHODS AND ANALYSIS All studies in which a prediction model for VTE have been developed, validated or compared using adult ambulatory patients with pancreatic or gastro-oesphageal cancers will be identified and the reported predictive performance indicators will be extracted. Full text peer-reviewed journal articles of observational or experimental studies published in English will be included. Five databases (Medline, EMBASE, Web of Science, CINAHL and Cochrane) will be searched. Two reviewers will independently undertake each of the phases of screening, data extraction and risk of bias assessment. The quality of the selected studies will be assessed using Prediction model Risk Of Bias Assessment Tool. The results from the review will be used for a narrative information synthesis, and if the same models have been validated in multiple studies, meta-analyses will be done to pool the predictive performance measures. ETHICS AND DISSEMINATION There is no need for ethics approval because the review will use previously peer-reviewed articles. The results will be published. PROSPERO REGISTRATION NUMBER CRD42021253887.
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Affiliation(s)
- Asma Zaheer
- Prehab, Activity, Cancer, Exercise and Survivorship (PACES) research Group, University of Canberra Faculty of Health, Canberra, Australian Capital Territory, Australia
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
| | - Nenad Naumovski
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- Functional Foods and Nutritional Research (FFNR) Laboratory, University of Canberra Faculty of Health Sciences, Canberra, Australian Capital Territory, Australia
| | - Kellie Toohey
- Prehab, Activity, Cancer, Exercise and Survivorship (PACES) research Group, University of Canberra Faculty of Health, Canberra, Australian Capital Territory, Australia
- School of Health Sciences, University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Theophile Niyonsenga
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Desmond Yip
- Department of Medical Oncology, Canberra Hospital, Canberra, Australian Capital Territory, Australia
- ANU Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Nicholas Brown
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- Office of Executive Director of Allied Health,Canberra Health Services, Garran, Canberra, Australian Capital Territory, Australia
| | - Reza Mortazavi
- Prehab, Activity, Cancer, Exercise and Survivorship (PACES) research Group, University of Canberra Faculty of Health, Canberra, Australian Capital Territory, Australia
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
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13
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Ilich A, Kumar V, Henderson M, Mallick R, Wells P, Carrier M, Key NS. Biomarkers in cancer patients at risk for venous thromboembolism: data from the AVERT study. Thromb Res 2021; 191 Suppl 1:S31-S36. [PMID: 32736776 DOI: 10.1016/s0049-3848(20)30394-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 12/02/2019] [Accepted: 12/09/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND The mechanisms surrounding cancer-associated venous thromboembolism (VTE) are not well characterized. AVERT, a randomized placebo controlled thromboprophylaxis study in ambulatory cancer patients, provides a unique opportunity to gain insights into thrombotic mechanism(s). METHODS All available citrated platelet-free plasma samples collected at the point of randomization from individuals enrolled in the AVERT study were evaluated for the expression of D-dimer, soluble P-selectin (sP- selectin), active plasminogen activator inhibitor 1 (aPAI-1), clot lysis time (CLT) and activated factor XIa-C1 inhibitor complex (FXIa-C1). We compared the differential expression of sP-selectin, aPAI-1, CLT and FXIa-C1 among individual tumor types with normal controls. We evaluated the impact of disease type (hematologic versus solid organ malignancy) and stage (metastatic versus non-metastatic) on individual biomarker expression. RESULTS We included 449 AVERT participants in this analysis. Baseline expression of the selected thrombosis biomarkers differed significantly by individual tumor type compared with normal controls. Levels of aPAI-1, CLT, FXIa-C1 and sP-selectin were significantly elevated in individuals with lymphoma compared to individuals with non-metastatic solid organ malignancies (p<0.05). Individuals with metastatic solid organ disease had elevated levels of D-dimer and sP-selectin compared to those with non-metastatic disease (p<0.05). CONCLUSION Among a cohort of ambulatory patients at intermediate to high risk of VTE, these exploratory findings suggest that baseline activation of coagulation and fibrinolysis pathways vary significantly by tumor type and disease stage.
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Affiliation(s)
- Anton Ilich
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA; These authors contributed equally
| | - Vaibhav Kumar
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA; These authors contributed equally
| | - Michael Henderson
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Ranjeeta Mallick
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Philip Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Nigel S Key
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA; Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA.
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14
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Frere C. Burden of venous thromboembolism in patients with pancreatic cancer. World J Gastroenterol 2021; 27:2325-2340. [PMID: 34040325 PMCID: PMC8130043 DOI: 10.3748/wjg.v27.i19.2325] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/28/2021] [Accepted: 04/22/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer (PC) is a devastating malignancy with fewer than 10% of patients being alive at 5 years after diagnosis. Venous thromboembolism (VTE) occurs in approximatively 20% of patients with PC, resulting in increased morbidity, mortality and significant health care costs. The management of VTE is particularly challenging in these frail patients. Adequate selection of the most appropriate anticoagulant for each individual patient according to the current international guidelines is warranted for overcoming treatment challenges. The International Initiative on Thrombosis and Cancer multi-language web-based mobile application (downloadable for free at www.itaccme.com) has been developed to help clinicians in decision making in the most complex situations. In this narrative review, we will discuss the contemporary epidemiology and burden of VTE in PC patients, the performances and limitations of current risk assessment models to predict the risk of VTE, as well as evidence from recent clinical trials for the primary prophylaxis and treatment of cancer-associated VTE that support up-dated clinical practice guidelines.
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Affiliation(s)
- Corinne Frere
- Department of Haematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris F-75013, France
- INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, GRC 27 GRECO, Sorbonne Université, Paris F-75013, France
- Groupe Francophone Thrombose et Cancer, Saint-Louis Hospital, Paris F-75010, France
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15
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Sandow LP, Cannon LA, Weston NR, Aung KL, Oo TH. The Clinical Applicability of Primary Thromboprophylaxis in Ambulatory Patients With Pancreatic Cancer. Pancreas 2021; 50:494-499. [PMID: 33939659 DOI: 10.1097/mpa.0000000000001799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
ABSTRACT Thromboembolism is a leading cause of death in ambulatory patients with cancer. Patients with pancreatic adenocarcinoma have a very high risk of developing venous thromboembolism, especially within the first 6 months of diagnosis. Although primary thromboprophylaxis could reduce this risk, there are unresolved questions concerning choice of agents for anticoagulation, duration of anticoagulation treatment, and criteria for patient selection. Furthermore, the current clinical guidelines on primary thromboprophylaxis in ambulatory patients with pancreatic cancer are ambiguous. This review seeks out to understand and critically appraise the evidence supporting the use of primary thromboprophylaxis in patients with pancreatic cancer and its clinical applicability.
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Affiliation(s)
| | | | | | - Kyaw Lwin Aung
- Department of Oncology, Livestrong Cancer Institutes and Dell Medical School, The University of Texas at Austin, Austin
| | - Thein Hlaing Oo
- Section of Thrombosis and Benign Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX
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16
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Bao Y, Wan X, Fu J, Wu B. The risk of venous thromboembolism in cancer patients receiving chemotherapy: a meta-analysis with systematic review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:277. [PMID: 33708904 PMCID: PMC7944280 DOI: 10.21037/atm-20-3292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
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.
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Affiliation(s)
- Yun Bao
- Institute of Clinical Research and Evidence Based Medicine, Gansu Provincial Hospital, Lanzhou, China.,Department of Pharmacy, Gansu Provincial Hospital, Lanzhou, China
| | - Xu Wan
- Department of Pharmacy, Ren Ji Hospital, South Campus, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jie Fu
- Department of Pharmacy, Ren Ji Hospital, South Campus, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bin Wu
- Department of Pharmacy, Ren Ji Hospital, South Campus, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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17
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van Es N, Ventresca M, Di Nisio M, Zhou Q, Noble S, Crowther M, Briel M, Garcia D, Lyman GH, Macbeth F, Griffiths G, Iorio A, Mbuagbaw L, Neumann I, Brozek J, Guyatt G, Streiff MB, Baldeh T, Florez ID, Gurunlu Alma O, Agnelli G, Ageno W, Marcucci M, Bozas G, Zulian G, Maraveyas A, Lebeau B, Lecumberri R, Sideras K, Loprinzi C, McBane R, Pelzer U, Riess H, Solh Z, Perry J, Kahale LA, Bossuyt PM, Klerk C, Büller HR, Akl EA, Schünemann HJ. The Khorana score for prediction of venous thromboembolism in cancer patients: An individual patient data meta-analysis. J Thromb Haemost 2020; 18:1940-1951. [PMID: 32336010 DOI: 10.1111/jth.14824] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/21/2020] [Accepted: 03/30/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Oncology guidelines suggest using the Khorana score to select ambulatory cancer patients receiving chemotherapy for primary venous thromboembolism (VTE) prevention, but its performance in different cancers remains uncertain. OBJECTIVE To examine the performance of the Khorana score in assessing 6-month VTE risk, and the efficacy and safety of low-molecular-weight heparin (LMWH) among high-risk Khorana score patients. METHODS This individual patient data meta-analysis evaluated (ultra)-LMWH in patients with solid cancer using data from seven randomized controlled trials. RESULTS A total of 3293 patients from the control groups with an available Khorana score had lung (n = 1913; 58%), colorectal (n = 452; 14%), pancreatic (n = 264; 8%), gastric (n = 201; 6%), ovarian (n = 184; 56%), breast (n = 164; 5%), brain (n = 84; 3%), or bladder cancer (n = 31; 1%). The 6-month VTE incidence was 9.8% among high-risk Khorana score patients and 6.4% among low-to-intermediate-risk patients (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.2). The dichotomous Khorana score performed differently in lung cancer patients (OR 1.1; 95% CI, 0.72-1.7) than in the group with other cancer types (OR 3.2; 95% CI, 1.8-5.6; Pinteraction = .002). Among high-risk patients, LMWH decreased the risk of VTE by 64% compared with controls (OR 0.36; 95% CI, 0.22-0.58), without increasing the risk of major bleeding (OR 1.1; 95% CI, 0.59-2.1). CONCLUSION The Khorana score was unable to stratify patients with lung cancer based on their VTE risk. Among those with other cancer types, a high-risk score was associated with a three-fold increased risk of VTE compared with a low-to-intermediate risk score. Thromboprophylaxis was effective and safe in patients with a high-risk Khorana score.
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Affiliation(s)
- Nick van Es
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Michael G. DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Matthew Ventresca
- Michael G. DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G. D'Annunzio, Chieti-Pescara, Italy
| | - Qi Zhou
- Michael G. DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Wales, UK
| | - Mark Crowther
- Michael G. DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Matthias Briel
- Michael G. DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel and University Hospital Basel, Basel, Switzerland
| | - David Garcia
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Gary H Lyman
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Fergus Macbeth
- Centre for Trials Research, School of Medicine, Cardiff University, Wales, UK
| | - Gareth Griffiths
- Centre for Trials Research, School of Medicine, Cardiff University, Wales, UK
- Faculty of Medicine, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Alfonso Iorio
- Michael G. DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
- Division of Hematology, Department of Medicine, Hamilton, ON, Canada
| | - Lawrence Mbuagbaw
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada
| | - Ignacio Neumann
- Michael G. DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jan Brozek
- Michael G. DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Gordon Guyatt
- Michael G. DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Michael B Streiff
- Division of Hematology, Department of Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tejan Baldeh
- Michael G. DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Ivan D Florez
- Michael G. DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
- Department of Paediatrics, Universidad de Antioquia, Medellin, Colombia
| | | | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine-Stroke Unit, Università di Perugia, Perugia, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Maura Marcucci
- Michael G. DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - George Bozas
- Academic Department of Medical Oncology, Castle Hill Hospital, Cottingham, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
| | - Gilbert Zulian
- Department of Readaptation and Palliative Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Anthony Maraveyas
- Division of Cancer-Hull York Medical School, University of Hull, Hull, UK
| | - Bernard Lebeau
- Service de Pneumologie, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Ramon Lecumberri
- Hematology Service, University Clinic of Navarra, Pamplona, Spain
| | - Kostandinos Sideras
- Divisions of Medical Oncology, Cardiology and Hematology, Mayo Clinic, Rochester, MN, USA
| | - Charles Loprinzi
- Divisions of Medical Oncology, Cardiology and Hematology, Mayo Clinic, Rochester, MN, USA
| | - Robert McBane
- Divisions of Medical Oncology, Cardiology and Hematology, Mayo Clinic, Rochester, MN, USA
| | - Uwe Pelzer
- Division of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin Institute of Health, Freie Universität Berlin, Humboldt Universität-Universität zu Berlin, Berlin, Germany
| | - Hanno Riess
- Department of Hematology, Oncology, and Tumor Immunology, Charité, University Hospital, Berlin, Germany
| | - Ziad Solh
- Transfusion Medicine Section, Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - James Perry
- Division of Neurology, Sunnybrook Health Science Centre, Toronto, ON, Canada
- Ontario Clinical Oncology Group and Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Lara A Kahale
- Michael G. DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Patrick M Bossuyt
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam Public Health Research Institute, Academic Medical Center, Amsterdam, The Netherlands
| | - Clara Klerk
- Department of Internal Medicine, Dijklanderziekenhuis, Hoorn, The Netherlands
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Elie A Akl
- Michael G. DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Holger J Schünemann
- Michael G. DeGroote Cochrane Canada and McGRADE Centres, Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Primary Thromboprophylaxis in Ambulatory Pancreatic Cancer Patients Receiving Chemotherapy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cancers (Basel) 2020; 12:cancers12082028. [PMID: 32722064 PMCID: PMC7464699 DOI: 10.3390/cancers12082028] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/16/2020] [Accepted: 07/22/2020] [Indexed: 02/07/2023] Open
Abstract
Patients with pancreatic cancer (PC) carry the highest risk of venous thromboembolism (VTE) amongst all cancer patients. Appropriate use of primary thromboprophylaxis might significantly and safely reduce its burden. We performed a systematic review of published studies and meeting abstracts using MEDLINE and EMBASE through July 2020 to evaluate the efficacy and safety of primary thromboprophylaxis in ambulatory PC patients receiving chemotherapy. The Mantel–Haenszel random effect model was used to estimate the pooled event-based risk ratio (RR) and the pooled absolute risk difference (RD) with a 95% confidence interval (CI). Five randomized controlled studies with 1003 PC patients were included in this meta-analysis. Compared to placebo, thromboprophylaxis significantly decreased the risk of VTE (pooled RR 0.31, 95% CI 0.19–0.51, p < 0.00001, I2 = 8%; absolute RD −0.08, 95% CI −0.12–−0.05, p < 0.00001, I2 = 0%), with an estimated number needed to treat of 11.9 patients to prevent one VTE event. Similar reductions of VTE were observed in studies with parenteral (RR 0.30, 95% CI 0.17–0.53) versus oral anticoagulants (RR 0.37, 95% CI 0.14–0.99) and in studies using prophylactic doses of anticoagulants (RR 0.34, 95% CI 0.17–0.70) versus supra-prophylactic doses of anticoagulants (RR 0.27, 95% CI 0.08–0.90). The pooled RR for major bleeding was 1.08 (95% CI 0.47–2.52, p = 0.85, I2 = 0%) and the absolute RD was 0.00 (95% CI −0.02–0.03, p = 0.85, I2 = 0%). Evidence supports a net clinical benefit of thromboprophylaxis in ambulatory PC patients receiving chemotherapy. Adequately powered randomized phase III studies assessing the most effective anticoagulant and the optimal dose, schedule and duration of thromboprophylaxis to be used are warranted.
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Kasthuri RS, Hisada Y, Ilich A, Key NS, Mackman N. Effect of chemotherapy and longitudinal analysis of circulating extracellular vesicle tissue factor activity in patients with pancreatic and colorectal cancer. Res Pract Thromb Haemost 2020; 4:636-643. [PMID: 32548563 PMCID: PMC7292676 DOI: 10.1002/rth2.12317] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION We conducted a longitudinal study in patients with pancreatic and colorectal cancer. We determined the effect of chemotherapy on extracellular vesicle tissue factor (EVTF) activity and the association of plasma EVTF activity with venous thromboembolism (VTE) and survival. MATERIAL AND METHODS We enrolled 13 patients with pancreatic and 22 patients with colorectal cancer. Plasma samples were collected during the 85-day study period. Patients were followed for 3 months after the study period. We recorded symptomatic VTE during the study period (3 months) or asymptomatic deep vein thrombosis detected by ultrasound at day 85. We measured EVTF activity before and after chemotherapy. RESULTS AND CONCLUSIONS In the pancreatic cancer group, 2 patients had elevated levels of EVTF activity. One of these patients developed symptomatic VTE and died, and the second patient did not have a VTE but died. Chemotherapy decreased EVTF activity in 2 pancreatic patients with high levels. In the colorectal cancer group, 4 patients developed VTE, but EVTF activity was not elevated in any patient and no patient died. We observed a borderline significant correlation between EVTF activity and D-dimer in the patients with pancreatic but not colorectal cancer. In this small descriptive study, 2 patients with pancreatic cancer had an elevated level of EVTF activity. Both patients died during the study period, and one had a VTE. Chemotherapy decreased EVTF activity in these patients. In contrast, elevated levels of EVTF activity were not observed in patients with colorectal cancer with or without VTE.
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Affiliation(s)
- Raj S. Kasthuri
- Division of Hematology/OncologyDepartment of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
- Blood Research CenterUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
| | - Yohei Hisada
- Division of Hematology/OncologyDepartment of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
- Blood Research CenterUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
| | - Anton Ilich
- Division of Hematology/OncologyDepartment of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
- Blood Research CenterUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
| | - Nigel S. Key
- Division of Hematology/OncologyDepartment of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
- Blood Research CenterUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
| | - Nigel Mackman
- Division of Hematology/OncologyDepartment of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
- Blood Research CenterUniversity of North Carolina at Chapel HillChapel HillNorth Carolina
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20
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Bao Y, Gao B, Yan P, Tian L, Yang K. The effectiveness and safety of thromboprophylaxis in cancer patients based on Khorana score: a meta-analysis and systematic review of randomized controlled trials. Clin Transl Oncol 2020; 22:1992-2001. [PMID: 32246324 DOI: 10.1007/s12094-020-02336-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 03/09/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Cancer patients receiving chemotherapy are a high risk of VTE, yet the importance of thromboprophylaxis for cancer patients that are at high risk of developing VTE is still controversial. AIM To calculate the benefits and harms of thromboprophylaxis, compared to placebo, in ambulatory high-risk cancer patients that are receiving chemotherapy. METHODS We searched PubMed, Embase, Web of Science, the Cochrane Library, Cochrane Central Register of Controlled Trials, Chinese Biomedical Literature Database, WANFANG Data, Chinese National Knowledge Infrastructure and Chinese Scientific Journal Database for randomized controlled trials (RCTs) describing benefits and harms of thromboprophylaxis. Statistical analysis was performed using Stata software (version 15.1). RESULTS We included six studies, which contained a total of 3240 cancer patients with thromboprophylaxis and 2874 cancer patients without thromboprophylaxis. Thromboprophylaxis was effective in high-risk patients with two points or higher (RR 0.51, 95% CI 0.36-0.71, I2 = 0.0%, P = 0.526). It was associated with an increase in bleeding events (RR 1.65, 95% CI 1.14-2.40, I2 = 0.0%, P = 0.498) and was mainly efficient in reducing the risk of pulmonary embolism (RR 0.56, 95% CI 0.33-0.96, I2 = 0.0%, P = 0.263). The risk of major (RR 1.85, 95% CI 0.87-3.94, I2 = 0.0%, P = 0.888) and non-major (RR 1.59, 95% CI 0.96-2.62, I2 = 16.3%, P = 0.303) bleeding showed no significant difference with or without thromboprophylaxis. There was no reduction in all-cause mortality with thromboprophylaxis (RR 0.95, 95% CI 0.78-1.18, I2 = 22.0%, P = 0.277). CONCLUSION Thromoboprophylaxis is effective and safe in cancer patients that are at high risk for developing VTE with chemotherapy.
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Affiliation(s)
- Y Bao
- Institute of Clinical Research and Evidence Based Medicine, Gansu Provincial Hospital, Gansu, China
| | - B Gao
- Department of Pharmacy, Gansu Provincial Hospital, Gansu, China
| | - P Yan
- Institute of Clinical Research and Evidence Based Medicine, Gansu Provincial Hospital, Gansu, China
| | - L Tian
- Department of Endocrinology, Gansu Provincial Hospital, Lanzhou, 730000, China.
| | - K Yang
- Institute of Clinical Research and Evidence Based Medicine, Gansu Provincial Hospital, Gansu, China. .,Evidence-Based Medicine Center, Lanzhou University, No. 199, West Road of Donggang Street, Lanzhou, 730000, China. .,Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China.
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21
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Frere C, Bournet B, Gourgou S, Fraisse J, Canivet C, Connors JM, Buscail L, Farge D. Incidence of Venous Thromboembolism in Patients With Newly Diagnosed Pancreatic Cancer and Factors Associated With Outcomes. Gastroenterology 2020; 158:1346-1358.e4. [PMID: 31843588 DOI: 10.1053/j.gastro.2019.12.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pancreatic ductal adenocarcinoma (PDAC) is associated with the highest incidence of venous thromboembolism (VTE) of any cancer type. However, little is known about risk factors for VTE or its outcomes in patients with PDAC. METHODS We collected data from a prospective, observational study performed at multiple centers in France from May 2014 through November 2018 (the Base Clinico-Biologique de l'Adénocarcinome Pancréatique [BACAP] study) linked to a database of patients with a new diagnosis of PDAC of any stage. Data were collected from 731 patients at baseline and during clinical follow-up or in the event of symptoms. The primary endpoint was the onset of VTE during follow-up. The secondary endpoints were progression-free survival (PFS) and overall survival (OS) times. RESULTS During a median follow-up of 19.3 months, 152 patients (20.79%) developed a VTE. The median time from PDAC diagnosis to the onset of VTE was 4.49 months. Cumulative incidence values of VTE were 8.07% (95% confidence interval [CI], 6.31-10.29) at 3 months and 19.21% (95% CI, 16.27-22.62) at 12 months. In multivariate analysis, PDAC primary tumor location (isthmus vs head: hazard ratio [HR], 2.06; 95% CI, 1.09-3.91; P = .027) and stage (locally advanced vs resectable or borderline: HR, 1.66; 95% CI, 1.10-2.51, P = .016; metastatic vs resectable or borderline: HR, 2.50; 95% CI, 1.64-3.79; P < .001) were independent risk factors for the onset of VTE. Patients who developed VTE during follow-up had shorter times of PFS (HR, 1.74; 95% CI, 1.19-2.54; P = .004) and OS (HR, 2.02; 95% CI, 1.57-2.60; P < .001). CONCLUSION In an analysis of data from the BACAP study, we found that frequent and early onsets of VTE after diagnoses of PDAC are associated with significant decreases in times of PFS and OS. Studies are needed to determine whether primary prophylaxis of VTE in patients with PDAC will improve morbidity and mortality related to VTE. (ClinicalTrials.gov, Number: clinicaltrials.gov as number NCT02818829).
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Affiliation(s)
- Corinne Frere
- Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism and Nutrition, Paris, France; Assistance Publique Hôpitaux de Paris, Department of Haematology, Pitié-Salpêtrière Hospital, Paris, France
| | - Barbara Bournet
- University of Toulouse, Toulouse, France; CHU de Toulouse, Department of Gastroenterology and Pancreatology, Toulouse, France
| | - Sophie Gourgou
- Université de Montpellier, Institut du Cancer de Montpellier-Unité de Biométrie, Montpellier, France
| | - Julien Fraisse
- Université de Montpellier, Institut du Cancer de Montpellier-Unité de Biométrie, Montpellier, France
| | - Cindy Canivet
- University of Toulouse, Toulouse, France; CHU de Toulouse, Department of Gastroenterology and Pancreatology, Toulouse, France
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Louis Buscail
- University of Toulouse, Toulouse, France; CHU de Toulouse, Department of Gastroenterology and Pancreatology, Toulouse, France
| | - Dominique Farge
- Université de Paris, Institut Universitaire d'Hématologie, Paris, France; Assistance Publique Hôpitaux de Paris, Saint-Louis Hospital, Internal Medicine, Autoimmune and Vascular Disease Unit, Paris, France; Department of Medicine, McGill University, Montreal, Québec, Canada.
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22
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Farge D, Bournet B, Conroy T, Vicaut E, Rak J, Zogoulous G, Barkun J, Ouaissi M, Buscail L, Frere C. Primary Thromboprophylaxis in Pancreatic Cancer Patients: Why Clinical Practice Guidelines Should Be Implemented. Cancers (Basel) 2020; 12:E618. [PMID: 32155940 PMCID: PMC7139861 DOI: 10.3390/cancers12030618] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 02/27/2020] [Accepted: 03/04/2020] [Indexed: 12/13/2022] Open
Abstract
Exocrine pancreatic ductal adenocarcinoma, simply referred to as pancreatic cancer (PC) has the worst prognosis of any malignancy. Despite recent advances in the use of adjuvant chemotherapy in PC, the prognosis remains poor, with fewer than 8% of patients being alive at 5 years after diagnosis. The prevalence of PC has steadily increased over the past decades, and it is projected to become the second-leading cause of cancer-related death by 2030. In this context, optimizing and integrating supportive care is important to improve quality of life and survival. Venous thromboembolism (VTE) is a common but preventable complication in PC patients. VTE occurs in one out of five PC patients and is associated with significantly reduced progression-free survival and overall survival. The appropriate use of primary thromboprophylaxis can drastically and safely reduce the rates of VTE in PC patients as shown from subgroup analysis of non-PC targeted placebo-controlled randomized trials of cancer patients and from two dedicated controlled randomized trials in locally advanced PC patients receiving chemotherapy. Therefore, primary thromboprophylaxis with a Grade 1B evidence level is recommended in locally advanced PC patients receiving chemotherapy by the International Initiative on Cancer and Thrombosis clinical practice guidelines since 2013. However, its use and potential significant clinical benefit continues to be underrecognized worldwide. This narrative review aims to summarize the main recent advances in the field including on the use of individualized risk assessment models to stratify the risk of VTE in each patient with individual available treatment options.
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Affiliation(s)
- Dominique Farge
- Institut Universitaire d’Hématologie, Université de Paris, EA 3518, F-75010 Paris, France
- Assistance Publique Hôpitaux de Paris, Saint-Louis Hospital, Internal Medicine, Autoimmune and Vascular Disease Unit, F-75010 Paris, France
- Department of Medicine, McGill University, Montreal, Québec, QC H4A 3J1, Canada
| | - Barbara Bournet
- University of Toulouse, F-31059 Toulouse, France; (B.B.); (L.B.)
- CHU de Toulouse, Department of Gastroenterology and Pancreatology, F-31059 Toulouse, France
| | - Thierry Conroy
- Institut de Cancérologie de Lorraine, Department of Medical Oncology, Université de Lorraine, APEMAC, EA4360, F-54519 Vandoeuvre-lès-Nancy, France;
| | - Eric Vicaut
- Department of Biostatistics, Université de Paris, F-75010 Paris, France;
- Assistance Publique Hôpitaux de Paris, Department of Biostatistics, Fernand Widal Hospital, F-75010 Paris, France
| | - Janusz Rak
- McGill University and the Research Institute of the McGill University Health Centre, Montreal, Québec, QC H4A 3J1, Canada; (J.R.)
| | - George Zogoulous
- McGill University and the Research Institute of the McGill University Health Centre, Montreal, Québec, QC H4A 3J1, Canada; (J.R.)
| | - Jefferey Barkun
- McGill University and the Research Institute of the McGill University Health Centre, Montreal, Québec, QC H4A 3J1, Canada; (J.R.)
| | - Mehdi Ouaissi
- Department of Digestive, Oncological, Endocrine, and Hepatic Surgery, and Hepatic Transplantation, Trousseau Hospital, CHRU Trousseau, F-37170 Chambray-les-Tours, France;
| | - Louis Buscail
- University of Toulouse, F-31059 Toulouse, France; (B.B.); (L.B.)
- CHU de Toulouse, Department of Gastroenterology and Pancreatology, F-31059 Toulouse, France
| | - Corinne Frere
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM UMRS_1166, GRC 27 GRECO, F-75013 Paris, France;
- Assistance Publique Hôpitaux de Paris, Department of Haematology, Pitié-Salpêtrière Hospital, F-75013 Paris, France
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Muñoz Martín AJ, Gallardo Díaz E, García Escobar I, Macías Montero R, Martínez-Marín V, Pachón Olmos V, Pérez Segura P, Quintanar Verdúguez T, Salgado Fernández M. SEOM clinical guideline of venous thromboembolism (VTE) and cancer (2019). Clin Transl Oncol 2020; 22:171-186. [PMID: 31981080 DOI: 10.1007/s12094-019-02263-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 12/05/2019] [Indexed: 12/12/2022]
Abstract
In 2011, the Spanish Society of Medical Oncology (SEOM) first published a clinical guideline of venous thromboembolism (VTE) and cancer. This guideline was updated in 2014, and since then, multiple studies and clinical trials have changed the landscape of the treatment and prophylaxis of VTE in cancer patients. To incorporate the most recent evidence, including data from direct oral anticoagulants (DOACs) randomized clinical trials, SEOM presents a new update of the guideline.
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Affiliation(s)
- A J Muñoz Martín
- Medical Oncology Department, Instituto de Investigación Sanitaria Gregorio Marañón, C/ Dr. Esquerdo, 46, 28007, Madrid, Spain.
| | - E Gallardo Díaz
- Medical Oncology Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - I García Escobar
- Medical Oncology Department, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - R Macías Montero
- Medical Oncology Department, Complejo H. Universitario, Badajoz, Spain
| | - V Martínez-Marín
- Medical Oncology Department, Hospital Universitario la Paz, Madrid, Spain
| | - V Pachón Olmos
- Medical Oncology Department, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERONC, Madrid, Spain
| | - P Pérez Segura
- Medical Oncology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | - M Salgado Fernández
- Medical Oncology Department, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
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Hisada Y, Mackman N. Update from the laboratory: mechanistic studies of pathways of cancer-associated venous thrombosis using mouse models. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:182-186. [PMID: 31808871 PMCID: PMC6913477 DOI: 10.1182/hematology.2019000025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Cancer patients have an increased risk of venous thromboembolism (VTE). The rate of VTE varies with cancer type, with pancreatic cancer having one of the highest rates, suggesting that there are cancer type-specific mechanisms of VTE. Risk assessment scores, such as the Khorana score, have been developed to identify ambulatory cancer patients at high risk of VTE. However, the Khorana score performed poorly in discriminating pancreatic cancer patients at risk of VTE. Currently, thromboprophylaxis is not recommended for cancer outpatients. Recent clinical trials showed that factor Xa (FXa) inhibitors reduced VTE in high-risk cancer patients but also increased major bleeding. Understanding the mechanisms of cancer-associated thrombosis should lead to the development of safer antithrombotic drugs. Mouse models can be used to study the role of different prothrombotic pathways in cancer-associated thrombosis. Human and mouse studies support the notion that 2 prothrombotic pathways contribute to VTE in pancreatic cancer patients: tumor-derived, tissue factor-positive (TF+) extracellular vesicles (EVs), and neutrophils and neutrophil extracellular traps (NETs). In pancreatic cancer patients, elevated levels of plasma EVTF activity and citrullinated histone H3 (H3Cit), a NET biomarker, are independently associated with VTE. We observed increased levels of circulating tumor-derived TF+ EVs, neutrophils, cell-free DNA, and H3Cit in nude mice bearing human pancreatic tumors. Importantly, inhibition of tumor-derived human TF, depletion of neutrophils, or administration of DNAse I to degrade cell-free DNA (including NETs) reduced venous thrombosis in tumor-bearing mice. These studies demonstrate that tumor-derived TF+ EVs, neutrophils, and cell-free DNA contribute to venous thrombosis in a mouse model of pancreatic cancer.
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Affiliation(s)
- Yohei Hisada
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Nigel Mackman
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC
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25
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Key NS, Khorana AA, Kuderer NM, Bohlke K, Lee AYY, Arcelus JI, Wong SL, Balaban EP, Flowers CR, Francis CW, Gates LE, Kakkar AK, Levine MN, Liebman HA, Tempero MA, Lyman GH, Falanga A. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol 2019; 38:496-520. [PMID: 31381464 DOI: 10.1200/jco.19.01461] [Citation(s) in RCA: 859] [Impact Index Per Article: 171.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To provide updated recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. METHODS PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs published from August 1, 2014, through December 4, 2018. ASCO convened an Expert Panel to review the evidence and revise previous recommendations as needed. RESULTS The systematic review included 35 publications on VTE prophylaxis and treatment and 18 publications on VTE risk assessment. Two RCTs of direct oral anticoagulants (DOACs) for the treatment of VTE in patients with cancer reported that edoxaban and rivaroxaban are effective but are linked with a higher risk of bleeding compared with low-molecular-weight heparin (LMWH) in patients with GI and potentially genitourinary cancers. Two additional RCTs reported on DOACs for thromboprophylaxis in ambulatory patients with cancer at increased risk of VTE. RECOMMENDATIONS Changes to previous recommendations: Clinicians may offer thromboprophylaxis with apixaban, rivaroxaban, or LMWH to selected high-risk outpatients with cancer; rivaroxaban and edoxaban have been added as options for VTE treatment; patients with brain metastases are now addressed in the VTE treatment section; and the recommendation regarding long-term postoperative LMWH has been expanded. Re-affirmed recommendations: Most hospitalized patients with cancer and an acute medical condition require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for all outpatients with cancer. Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days. Patients with cancer should be periodically assessed for VTE risk, and oncology professionals should provide patient education about the signs and symptoms of VTE.Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
- Nigel S Key
- University of North Carolina, Chapel Hill, NC
| | | | - Nicole M Kuderer
- Advanced Cancer Research Group and University of Washington, Seattle, WA
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Agnes Y Y Lee
- BC Cancer Agency, Vancouver, British Columbia, Canada
| | | | | | | | | | - Charles W Francis
- James P Wilmot Cancer Center and University of Rochester, Rochester, NY
| | | | - Ajay K Kakkar
- Thrombosis Research Institute and University College, London, United Kingdom
| | | | - Howard A Liebman
- University of Southern California and Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA
| | - Anna Falanga
- Hospital Papa Giovanni XXIII, Bergamo; and University of Milan Bicocca, Milan, Italy
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Boone BA, Zenati MS, Rieser C, Hamad A, Al-Abbas A, Zureikat AH, Hogg ME, Neal MD, Zeh HJ. Risk of Venous Thromboembolism for Patients with Pancreatic Ductal Adenocarcinoma Undergoing Preoperative Chemotherapy Followed by Surgical Resection. Ann Surg Oncol 2019; 26:1503-1511. [PMID: 30652227 DOI: 10.1245/s10434-018-07148-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDA) is associated with a hypercoagulable state, resulting in a high risk of venous thromboembolism (VTE). Risk of VTE is well established for patients receiving chemotherapy for advanced disease and during the perioperative period for patients undergoing surgical resection. However, data are lacking for patients undergoing neoadjuvant treatment followed by resection, who may have a unique risk of VTE because of exposure to both chemotherapy and surgery. METHODS The study included patients with PDA who underwent neoadjuvant therapy followed by surgery from 2007 to June 2017. Development of VTE was evaluated from the start of treatment through the 90-day postoperative period. Risk factors including demographic, treatment, and laboratory variables were evaluated. RESULTS The study investigated 426 patients receiving neoadjuvant therapy before surgical resection. Of these patients, 20% had a VTE within 90 days postoperatively (n = 87), and 70% of the VTE occurred during the postoperative period. The VTE included pulmonary embolism (30%), deep vein thrombosis (33%), and thrombosis of the portal vein (PV)/superior mesenteric vein (SMV) (40%). A pretreatment hemoglobin level lower than 10 g/dL and a platelet count higher than 443 were independently associated with VTE during neoadjuvant treatment. The independent predictors of postoperative VTE were a body mass index higher than 35 kg/m2, a preoperative platelet-to-lymphocyte ratio higher than 260, resection with distal pancreatectomy with celiac axis resection/total pancreatectomy, PV/SMV resection, and longer operative times. Development of VTE was associated with worse overall and disease-free survival and an independent predictor of survival and decreased likelihood of receiving adjuvant chemotherapy. CONCLUSIONS Venous thromboembolism during neoadjuvant therapy and the subsequent perioperative period is common and has a significant impact on outcome. Further study into novel thromboprophylaxis measures or protocols during neoadjuvant treatment and the perioperative period is warranted.
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Affiliation(s)
- Brian A Boone
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Division of Surgical Oncology, Department of Surgery, West Virginia University, Morgantown, WV, USA.
| | - Mazen S Zenati
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Caroline Rieser
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ahmad Hamad
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amr Al-Abbas
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melissa E Hogg
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Herbert J Zeh
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Surgery, UT Southwestern, Dallas, TX, USA
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Mulder FI, Candeloro M, Kamphuisen PW, Di Nisio M, Bossuyt PM, Guman N, Smit K, Büller HR, van Es N. The Khorana score for prediction of venous thromboembolism in cancer patients: a systematic review and meta-analysis. Haematologica 2019; 104:1277-1287. [PMID: 30606788 PMCID: PMC6545838 DOI: 10.3324/haematol.2018.209114] [Citation(s) in RCA: 178] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/02/2019] [Indexed: 12/13/2022] Open
Abstract
We aimed to evaluate the performance of the Khorana score in predicting venous thromboembolic events in ambulatory cancer patients. Embase and MEDLINE were searched from January 2008 to June 2018 for studies which evaluated the Khorana score. Two authors independently screened studies for eligibility, extracted data, and assessed risk of bias. Additional data on the 6-month incidence of venous thromboembolism were sought by contacting corresponding authors. The incidence in each Khorana score risk group was estimated with random effects meta-analysis. A total of 45 articles and eight abstracts were included, comprising 55 cohorts enrolling 34,555 ambulatory cancer patients. For 27,849 patients (81%), 6-month follow-up data were obtained. Overall, 19% of patients had a Khorana score of 0 points, 64% a score of 1 or 2 points, and 17% a score of 3 or more points. The incidence of venous thromboembolism in the first six months was 5.0% (95%CI: 3.9-6.5) in patients with a low-risk Khorana score (0 points), 6.6% (95%CI: 5.6-7.7) in those with an intermediate-risk Khorana score (1 or 2 points), and 11.0% (95%CI: 8.8-13.8) in those with a high-risk Khorana score (3 points or higher). Of the patients with venous thromboembolism in the first six months, 23.4% (95%CI: 18.4-29.4) had been classified as high risk according to the Khorana score. In conclusion, the Khorana score can be used to select ambulatory cancer patients at high risk of venous thromboembolism for thromboprophylaxis; however, most events occur outside this high-risk group.
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Affiliation(s)
- Frits I Mulder
- Tergooi Hospitals, Department of Internal Medicine, Hilversum, the Netherlands .,Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam, the Netherlands
| | - Matteo Candeloro
- University G. D'Annunzio, Department of Medicine and Ageing Sciences, Chieti, Italy
| | - Pieter W Kamphuisen
- Tergooi Hospitals, Department of Internal Medicine, Hilversum, the Netherlands
| | - Marcello Di Nisio
- University G. D'Annunzio, Department of Medicine and Ageing Sciences, Chieti, Italy
| | - Patrick M Bossuyt
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam, the Netherlands
| | - Noori Guman
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam, the Netherlands
| | - Kirsten Smit
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam, the Netherlands
| | - Harry R Büller
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam, the Netherlands
| | - Nick van Es
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam, the Netherlands
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Kim JS, Kang EJ, Kim DS, Choi YJ, Lee SY, Kim HJ, Seo HY, Kim JS. Early venous thromboembolism at the beginning of palliative chemotherapy is a poor prognostic factor in patients with metastatic pancreatic cancer: a retrospective study. BMC Cancer 2018; 18:1260. [PMID: 30558603 PMCID: PMC6296039 DOI: 10.1186/s12885-018-5154-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 11/29/2018] [Indexed: 02/07/2023] Open
Abstract
Background This study investigated the prognostic effects of venous thromboembolism (VTE)-related factors in patients with metastatic pancreatic cancer receiving palliative chemotherapy. Predictive factors for VTE were also investigated. Methods A total of 216 patients diagnosed with metastatic pancreatic cancer who received gemcitabine-based palliative chemotherapy at our institution were retrospectively evaluated. Results VTE occurred in 51 (23.6%) patients during treatment and did not affect survival. However, patients who were diagnosed with VTE at the beginning of chemotherapy showed poor prognosis compared with patients diagnosed with VTE during chemotherapy: all patients (hazard ratio [HR] 1.897, p = 0.008); patients diagnosed with VTE (HR = 3.768, p = 0.001). Low serum sodium (Na) (< 135 mmol/L) and high Khorana score (≥3) were strong predictive factors of early VTE (odds ratio [OR] 5.109; 95% confidence interval [95% CI] = 1.010–25.845; p = 0.049 for Khorana score, OR 10.304; 95% CI = 1.036–102.466; p = 0.047) for hyponatremia). Conclusions Our study demonstrated that occurrence and detection of VTE in the early period of chemotherapy was the most significant VTE-related prognostic factor in patients with metastatic pancreatic cancer receiving chemotherapy. Prediction using the Khorana score and serum Na levels would be helpful in early diagnosis of VTE.
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Affiliation(s)
- Jung Sun Kim
- Division of Hematology/Oncology, Department of Internal Medicine, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Eun Joo Kang
- Division of Hematology/Oncology, Department of Internal Medicine, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea.
| | - Dae Sik Kim
- Division of Hematology/Oncology, Department of Internal Medicine, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Yoon Ji Choi
- Division of Hematology/Oncology, Department of Internal Medicine, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Suk Young Lee
- Division of Hematology/Oncology, Department of Internal Medicine, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Hong Jun Kim
- Division of Hematology/Oncology, Department of Internal Medicine, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Hee Yeon Seo
- Division of Hematology/Oncology, Department of Internal Medicine, Konkuk University School of Medicine, Chungchungbukdo, Chungju, South Korea
| | - Jun Suk Kim
- Division of Hematology/Oncology, Department of Internal Medicine, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
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Hung YS, Chen JS, Chen YY, Lu CH, Chang PH, Chou WC. Incidence, Risk Factors, and Outcomes of Arterial Thromboembolism in Patients with Pancreatic Cancer Following Palliative Chemotherapy. Cancers (Basel) 2018; 10:cancers10110432. [PMID: 30424491 PMCID: PMC6267556 DOI: 10.3390/cancers10110432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Few studies have explored the association between pancreatic cancer and arterial thromboembolism (aTE). METHODS A total of 838 consecutive patients receiving palliative chemotherapy for pancreatic cancer between 2010 and 2016 were retrospectively enrolled. The clinical characteristics of patients were analyzed to determine the incidence, risk factors, and survival outcome of aTE in patients with pancreatic cancer. RESULTS aTE occurred in 42 (5.0%) of 838 patients. Patients with aTE had a worse survival outcome than those without (5.1 months versus 7.8 months, hazard ratio 1.53, 95% confidence interval [CI]: 1.12⁻2.09). Stage IV disease, high aspartate transaminase level, and comorbidity with hypertension or atrial fibrillation were four independent predictors of aTE. A concise predictive model stratified patients into low (0⁻1 predictor), intermediate (2 predictors), and high (3⁻4 predictors) risk groups. The hazard ratios for the comparison of patients in intermediate and high risk groups with those in low risk group were 4.55 (95% CI: 2.31⁻8.98), and 13.3 (95% CI: 5.63⁻31.6), respectively. CONCLUSION Patients with pancreatic cancer undergoing palliative chemotherapy have an increased risk of aTE. A predictive model showed that patients presented with 3 or 4 predictors had the highest risk for developing aTE.
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Affiliation(s)
- Yu-Shin Hung
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan 333, Taiwan.
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan 333, Taiwan.
| | - Yen-Yang Chen
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung 833, Taiwan.
| | - Chang-Hsien Lu
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Chiayi, Chiayi 612, Taiwan.
| | - Pei-Hung Chang
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Keelung, Keelung 204, Taiwan.
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan 333, Taiwan.
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Frère C, Bournet B, Benzidia I, Jamelot M, Debourdeau P, Hij A, Rafii-Elayoubi H, Buscail L, Farge D. [Venous thromboembolism and pancreatic cancer]. JOURNAL DE MEDECINE VASCULAIRE 2018; 43:246-254. [PMID: 29981733 DOI: 10.1016/j.jdmv.2018.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/22/2018] [Indexed: 06/08/2023]
Abstract
Pancreatic cancer (PC) is a devastating malignancy with an overall 5-year survival of 8% for all stages combined. Most of the PC patients diagnosed have an advanced disease (40%) or metastatic stage (40%), which eliminates surgery as a potentially curative treatment. The disease course is often complicated by venous thromboembolism (VTE) events, which per se account for significant morbidity and mortality, with significantly worsen survival. PC is associated with the highest risk of VTE among all cancer patients. We review the literature data to address the incidence and clinical outcomes of VTE in PC patients. VTE incidence varies from 5 to 41% according to epidemiological studies and is as high as 57% in postmortem series. Since 2013, international clinical practice guidelines recommend primary thromboprophylaxis with a grade 1B level of evidence as an adjuvant therapy in advanced PC. A recent meta-analysis of randomized controlled trials investigating the benefit and risk of low-molecular-weight heparins (LMWH) in ambulatory advanced PC patients under chemotherapy showed that the incidence of VTE was 2.1% in patients treated with LMWH and 11.2% in controls (risk ratio, 0.18; 95% CI, 0.083-0.39; P<0.0001). In conclusion, improved earlier diagnosis and effective management of VTE, a frequent and life-threatening complication in PC, is warranted to improve PC patient outcomes.
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Affiliation(s)
- C Frère
- Service d'hématologie biologique, hôpital Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - B Bournet
- Pôle digestif, service de gastro-entérologie et de nutrition, hôpital Rangueil, CHU de Toulouse, 31059 Toulouse cedex 9, France
| | - I Benzidia
- Service de médecine interne, UF04 maladies auto-immunes et pathologie vasculaire, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 75475 Paris cedex 10, France
| | - M Jamelot
- Service d'oncologie médicale, centre Henri-Becquerel, 76038 Rouen, France
| | - P Debourdeau
- Service oncologie, institut Sainte-Catherine, 84918 Avignon, France
| | - A Hij
- Service de médecine interne, UF04 maladies auto-immunes et pathologie vasculaire, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 75475 Paris cedex 10, France
| | - H Rafii-Elayoubi
- Service de médecine interne, UF04 maladies auto-immunes et pathologie vasculaire, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 75475 Paris cedex 10, France
| | - L Buscail
- Pôle digestif, service de gastro-entérologie et de nutrition, hôpital Rangueil, CHU de Toulouse, 31059 Toulouse cedex 9, France
| | - D Farge
- Service de médecine interne, UF04 maladies auto-immunes et pathologie vasculaire, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 75475 Paris cedex 10, France
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Biomarkers for the risk of thrombosis in pancreatic adenocarcinoma are related to cancer process. Oncotarget 2018; 9:26453-26465. [PMID: 29899870 PMCID: PMC5995170 DOI: 10.18632/oncotarget.25458] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 05/07/2018] [Indexed: 12/18/2022] Open
Abstract
Background Venous thrombo-embolic events (VTE) frequently occur in patients with pancreatic ductal adenocarcinoma (PDAC) and contribute to high morbidity and mortality. Objectives To determine whether VTE biomarkers are related to cancer, inflammation or precancerous states and to assess their relevance to predict VTE in PDAC. Patients and Methods We compared VTE biomarkers in patients with PDAC (n = 42), intraductal papillary mucinous neoplasm of the pancreas (IPMN, n = 48) or chronic pancreatitis (n = 50). PDAC patients were followed-up for 6 months. Results Factor VIII, D-dimers, von Willebrand factor, free tissue factor pathway inhibitor and microvesicle-tissue factor (MV-TF) activity were higher in PDAC patients compared to patients with IPMN or chronic pancreatitis. PDAC patients with metastasis presented higher D-dimers and MV-TF activity compared to patients with localized lesions, but elevation of D-dimers was dependent on tumor size. In multivariate analysis, elevated D-dimers (≥2.16 µg/mL) or MV-TF activity (≥2.37 pg/mL) were significant risk factors for VTE in PDAC patients, after adjustment for age and sex (HR 4.9 [1.0-23.1] or HR 10.5 [1.5-72.4], mean [interquartile range], respectively). Cumulative probability of VTE at 6 months was higher in patients with elevated D-dimers (56.3% vs 15.6%, p = 0.009) and in patients with high MV-TF activity (74.3% vs 21.7%, p = 0.01). Conclusions VTE biomarkers including D-dimers and MV-TF activity are not related to inflammation but rather to cancer process and dissemination. D-dimers and MV-TF activity are associated to future VTE in PDAC patients and could help identify patients who could benefit from thromboprophylaxis.
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Muñoz Martín AJ, Ortega I, Font C, Pachón V, Castellón V, Martínez-Marín V, Salgado M, Martínez E, Calzas J, Rupérez A, Souto JC, Martín M, Salas E, Soria JM. Multivariable clinical-genetic risk model for predicting venous thromboembolic events in patients with cancer. Br J Cancer 2018; 118:1056-1061. [PMID: 29588512 PMCID: PMC5931103 DOI: 10.1038/s41416-018-0027-8] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 01/17/2018] [Accepted: 01/22/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a leading cause of death among patients with cancer. Outpatients with cancer should be periodically assessed for VTE risk, for which the Khorana score is commonly recommended. However, it has been questioned whether this tool is sufficiently accurate at identifying patients who should receive thromboprophylaxis. The present work proposes a new index, TiC-Onco risk score to be calculated at the time of diagnosis of cancer, that examines patients' clinical and genetic risk factors for thrombosis. METHODS We included 391 outpatients with a recent diagnosis of cancer and candidates for systemic outpatient chemotherapy. All were treated according to standard guidelines. The study population was monitored for 6 months, and VTEs were recorded. The Khorana and the TiC-Onco scores were calculated for each patient and their VTE predictive accuracy VTEs was compared. RESULTS We recorded 71 VTEs. The TiC-Onco risk score was significantly better at predicting VTE than the Khorana score (AUC 0.73 vs. 0.58, sensitivity 49 vs. 22%, specificity 81 vs. 82%, PPV 37 vs. 22%, and NPV 88 vs. 82%). CONCLUSIONS TiC-Onco risk score performed significantly better than Khorana score at identifying cancer patients at high risk of VTE who would benefit from personalised thromboprophylaxis.
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Affiliation(s)
- Andrés J Muñoz Martín
- Medical Oncology Service, Hospital General Universitario Gregorio Marañón, C/ Doctor Esquerdo, 46, 28007, Madrid, Spain.
- Cancer & Thrombosis Working Group, Spanish Society of Medical Oncology (SEOM), C/ de Velázquez, 7, 28001, Madrid, Spain.
| | - Israel Ortega
- Scientific Department, Gendiag, Joan XXIII, 10, 08950, Esplugues de Llobregat, Spain
| | - Carme Font
- Cancer & Thrombosis Working Group, Spanish Society of Medical Oncology (SEOM), C/ de Velázquez, 7, 28001, Madrid, Spain
- Medical Oncology, Hospital Clínic, c/ Villarroel, 170, 08036, Barcelona, Spain
| | - Vanesa Pachón
- Cancer & Thrombosis Working Group, Spanish Society of Medical Oncology (SEOM), C/ de Velázquez, 7, 28001, Madrid, Spain
- Medical Oncology, Hospital Universitario Ramón y Cajal Madrid, Ctra. Colmenar Viejo, Km. 9,100, 28034, Madrid, Spain
| | - Victoria Castellón
- Cancer & Thrombosis Working Group, Spanish Society of Medical Oncology (SEOM), C/ de Velázquez, 7, 28001, Madrid, Spain
- Medical Oncology, Complejo Hospitalario de Torrecárdenas, c/ Hermandad de Donantes de Sangre, 04009, Almería, Spain
| | - Virginia Martínez-Marín
- Cancer & Thrombosis Working Group, Spanish Society of Medical Oncology (SEOM), C/ de Velázquez, 7, 28001, Madrid, Spain
- Medical Oncology, Hospital Universitario la Paz, Paseo de la Castellana, 261, 28046, Madrid, Spain
| | - Mercedes Salgado
- Cancer & Thrombosis Working Group, Spanish Society of Medical Oncology (SEOM), C/ de Velázquez, 7, 28001, Madrid, Spain
- Medical Oncology, Complejo Hospitalario Universitario de Ourense, c/ Ramon Puga Noguerol, 54, 32005, Ourense, Spain
| | - Eva Martínez
- Cancer & Thrombosis Working Group, Spanish Society of Medical Oncology (SEOM), C/ de Velázquez, 7, 28001, Madrid, Spain
- Medical Oncology, Hospital Universitario Marqués de Valdecilla, Av. Valdecilla, 25, 39008, Santander, Spain
| | - Julia Calzas
- Cancer & Thrombosis Working Group, Spanish Society of Medical Oncology (SEOM), C/ de Velázquez, 7, 28001, Madrid, Spain
- Medical Oncology, Hospital Universitario de Fuenlabrada, Camino del Molino, 2, 28942, Madrid, Spain
| | - Ana Rupérez
- Cancer & Thrombosis Working Group, Spanish Society of Medical Oncology (SEOM), C/ de Velázquez, 7, 28001, Madrid, Spain
- Medical Oncology, Fundación Jiménez Díaz, Av. Reyes Católicos, 2, 28040, Madrid, Spain
| | - Juan C Souto
- Thrombosis and Haemostasia, Hospital de la Santa Creu i Sant Pau, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
| | - Miguel Martín
- Medical Oncology Service, Hospital General Universitario Gregorio Marañón, C/ Doctor Esquerdo, 46, 28007, Madrid, Spain
- Cancer & Thrombosis Working Group, Spanish Society of Medical Oncology (SEOM), C/ de Velázquez, 7, 28001, Madrid, Spain
| | - Eduardo Salas
- Scientific Department, Gendiag, Joan XXIII, 10, 08950, Esplugues de Llobregat, Spain
| | - Jose M Soria
- Genomic of complex diseases, Institut d'Investigació Sant Pau (IIB-Sant Pau), Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
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Abstract
OBJECTIVES Pancreatic cancer is reported to be highly associated with thromboembolism (TE). The aim of this analysis is to clarify risk factors for TE and its clinical impact in Japanese patients with pancreatic cancer. METHODS Data on consecutive pancreatic cancer patients receiving systemic chemotherapy between August 1999 and July 2015 were retrospectively studied. Both symptomatic and asymptomatic, arterial and venous TEs were included in the analysis. Risk factors for TE development were analyzed using a proportional hazards model with death without TE as a competing risk. The impact of TE on survival was also evaluated using a time-dependent covariate multiple Cox model. RESULTS A total of 475 patients were included in the analysis, and 57 TEs (12%) were identified: 45 venous TEs and 12 arterial TEs. The median time to TE was 169 days and the median survival from TE was 65 days. Liver metastasis was the only significant risk factor for TE (subdistribution hazards ratio, 2.15; P = 0.01), and TE was significantly associated with poor prognosis (hazards ratio, 3.31; P < 0.01). CONCLUSIONS Thromboembolism was not uncommon in Japanese patients receiving chemotherapy for advanced pancreatic cancer and was associated with poor prognosis. Liver metastasis was the risk factor for TE.
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van Es N, Di Nisio M, Cesarman G, Kleinjan A, Otten HM, Mahé I, Wilts IT, Twint DC, Porreca E, Arrieta O, Stépanian A, Smit K, De Tursi M, Bleker SM, Bossuyt PM, Nieuwland R, Kamphuisen PW, Büller HR. Comparison of risk prediction scores for venous thromboembolism in cancer patients: a prospective cohort study. Haematologica 2017; 102:1494-1501. [PMID: 28550192 PMCID: PMC5685240 DOI: 10.3324/haematol.2017.169060] [Citation(s) in RCA: 147] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 05/25/2017] [Indexed: 12/21/2022] Open
Abstract
In ambulatory patients with solid cancer, routine thromboprophylaxis to prevent venous thromboembolism is not recommended. Several risk prediction scores to identify cancer patients at high risk of venous thromboembolism have been proposed, but their clinical usefulness remains a matter of debate. We evaluated and directly compared the performance of the Khorana, Vienna, PROTECHT, and CONKO scores in a multinational, prospective cohort study. Patients with advanced cancer were eligible if they were due to undergo chemotherapy or had started chemotherapy in the previous three months. The primary outcome was objectively confirmed symptomatic or incidental deep vein thrombosis or pulmonary embolism during a 6-month follow-up period. A total of 876 patients were enrolled, of whom 260 (30%) had not yet received chemotherapy. Fifty-three patients (6.1%) developed venous thromboembolism. The c-statistics of the scores ranged from 0.50 to 0.57. At the conventional positivity threshold of 3 points, the scores classified 13-34% of patients as high-risk; the 6-month incidence of venous thromboembolism in these patients ranged from 6.5% (95%CI: 2.8-12) for the Khorana score to 9.6% (95%CI: 6.6-13) for the PROTECHT score. High-risk patients had a significantly increased risk of venous thromboembolism when using the Vienna (subhazard ratio 1.7; 95%CI: 1.0-3.1) or PROTECHT (subhazard ratio 2.1; 95%CI: 1.2-3.6) scores. In conclusion, the prediction scores performed poorly in predicting venous thromboembolism in cancer patients. The Vienna CATS and PROTECHT scores appear to discriminate better between low- and high-risk patients, but further improvements are needed before they can be considered for introduction into clinical practice.
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Affiliation(s)
- Nick van Es
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, G. D'Annunzio University, Chieti, Italy
| | - Gabriela Cesarman
- Department of Hematology, National Cancer Institute Mexico, Mexico City, Mexico
| | - Ankie Kleinjan
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Hans-Martin Otten
- Department of Internal Medicine, Slotervaart hospital, Amsterdam, the Netherlands
| | - Isabelle Mahé
- Department of Internal Medicine, Hôpital Louis Mourier, Paris, France
| | - Ineke T Wilts
- Department of Internal Medicine, University Medical Center Groningen, the Netherlands
| | - Desirée C Twint
- Department of Internal Medicine, VU Medical Center, Amsterdam, the Netherlands
| | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University, Chieti, Italy
| | - Oscar Arrieta
- Department of Hematology, National Cancer Institute Mexico, Mexico City, Mexico
| | - Alain Stépanian
- Department of Hematology, Hôpital Lariboisière, Paris, France
| | - Kirsten Smit
- Department of Internal Medicine, VU Medical Center, Amsterdam, the Netherlands
| | - Michele De Tursi
- Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University, Chieti, Italy
| | - Suzanne M Bleker
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Patrick M Bossuyt
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Academic Medical Center, Amsterdam, the Netherlands
| | - Rienk Nieuwland
- Department of Experimental Clinical Chemistry, Academic Medical Center, Amsterdam, the Netherlands
| | - Pieter W Kamphuisen
- Department of Internal Medicine, University Medical Center Groningen, the Netherlands
- Department of Internal Medicine, Tergooi Hospital, Hilversum, the Netherlands
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
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Kruger S, Haas M, Burkl C, Goehring P, Kleespies A, Roeder F, Gallmeier E, Ormanns S, Westphalen CB, Heinemann V, Rank A, Boeck S. Incidence, outcome and risk stratification tools for venous thromboembolism in advanced pancreatic cancer - A retrospective cohort study. Thromb Res 2017; 157:9-15. [PMID: 28675831 DOI: 10.1016/j.thromres.2017.06.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/12/2017] [Accepted: 06/20/2017] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is frequent in advanced pancreatic cancer (APC). Recent studies demonstrated that the Khorana score - an established risk stratification tool for VTE in cancer - performs poorly in identifying pancreatic cancer patients at high risk for VTE. MATERIALS AND METHODS We performed a retrospective cohort study in order to define incidence, treatment and outcome of VTE as well as the performance of VTE risk stratification tools (Khorana score, CONKO score and aPTT ratio) in a "real life" clinical cohort of APC patients undergoing palliative chemotherapy. RESULTS AND CONCLUSIONS One hundred and seventy-two eligible APC patients from our comprehensive cancer center were identified. VTE after start of palliative chemotherapy was diagnosed in 71 patients (41.3%). Most VTE events were asymptomatic (n=50, 29.1%) with only 21 symptomatic events (12.2%). On multivariate analysis - including age, performance status and carbohydrate antigen 19-9 (CA 19-9) - symptomatic VTE was an independent risk factor for death (hazard ratio [HR]: 2.22, 95% CI: 1.05-2.60, p<0.05). Khorana score, CONKO score and aPTT ratio alone were not able to predict the risk for symptomatic VTE. High risk patients could only be identified by using a combination of either Khorana or CONKO score with aPTT ratio (30% vs. 10% symptomatic VTE events in high vs. low risk patients, p<0.05). The combination of Khorana or CONKO score with aPTT thus may represent a novel risk stratification tool for symptomatic VTE in APC and should further be validated within prospective clinical trials.
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Affiliation(s)
- Stephan Kruger
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Michael Haas
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Carolin Burkl
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Peter Goehring
- Institute of Laboratory Medicine, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Axel Kleespies
- Department of General, Visceral, Transplantation, Vascular, and Thoracic Surgery, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Falk Roeder
- Department of Radiation Oncology, Ludwig-Maximilians-University of Munich, Munich, Germany; Department of Molecular Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Eike Gallmeier
- Department of Gastroenterology, Endocrinology and Metabolism, University Hospital of Marburg, Philipps-University of Marburg, Marburg, Germany
| | - Steffen Ormanns
- Institute of Pathology, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Christoph Benedikt Westphalen
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Volker Heinemann
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Andreas Rank
- Department of Hematology and Oncology, Klinikum Augsburg, Augsburg, Germany
| | - Stefan Boeck
- Department of Internal Medicine III and Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany.
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37
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Supportive care in pancreatic ductal adenocarcinoma. Clin Transl Oncol 2017; 19:1293-1302. [PMID: 28612201 DOI: 10.1007/s12094-017-1682-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 05/15/2017] [Indexed: 12/27/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the cancers with poorest prognosis and represents the third leading cause of cancer-related deaths in Western countries. Despite advances in diagnostic procedures and treatment, diagnosis is made in most cases when the disease is locally advanced or metastatic. Supportive care aims to improve symptoms, reduce hospital admission rates, and preserve quality of life. Proper symptomatic management is critical to allow administration of chemotherapy and radiotherapy. Symptomatic management should be accomplished in a multidisciplinary fashion. Its primary aims include relief of biliary or duodenal obstruction, prevention and/or treatment of thromboembolic disease, and control cancer-related pain. Nutritional support and optimal replacement therapy in patients with endocrine and/or exocrine insufficiency, is mandatory. This manuscript highlights the most significant problems faced when caring for patients with advanced PDAC and provides an evidence-based approach to symptomatic management.
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Hashimoto D, Nakagawa S, Umezaki N, Yamao T, Kitano Y, Yamamura K, Kaida T, Arima K, Imai K, Yamashita YI, Chikamoto A, Baba H. Efficacy and safety of postoperative anticoagulation prophylaxis with enoxaparin in patients undergoing pancreatic surgery: A prospective trial and literature review. Pancreatology 2017; 17:464-470. [PMID: 28366422 DOI: 10.1016/j.pan.2017.03.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/26/2017] [Accepted: 03/28/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND /Objectives: Enoxaparin is low-molecular-weight heparin that is used for postoperative thromboprophylaxis. The purpose of this study was to evaluate the efficacy and safety of enoxaparin after pancreatic resection. We additionally carried out a literature review regarding venous thromboembolism (VTE) and postoperative bleeding mainly after hepatobiliary-pancreatic surgery. METHODS This was a prospective, single-arm study. Patients aged 20-79 years who planned to undergo pancreatic resection followed by postoperative anticoagulation therapy with enoxaparin were enrolled from 2013 to 2016. The exclusion criteria were low renal function, active bleeding, clinical signs of VTE at screening, or evidence of thromboembolic disease before surgery. The primary endpoint was the incidence of postoperative VTE. The secondary endpoint was the incidence of postoperative complications. For the literature review, PubMed was searched for relevant articles and the PRISMA guidelines were used. RESULTS In total, 103 patients were analyzed. Two patients (1.9%) developed asymptomatic VTE, and no patients developed symptomatic VTE. No in-hospital mortality occurred. Morbidities (Clavien-Dindo grade ≥ IIIa) occurred in 29 patients (28.1%). Three patients (2.9%) developed intra-abdominal hemorrhage due to pseudoaneurysm formation after pancreaticoduodenectomy or distal pancreatectomy. The literature review included nine articles, and all indicated that the results of this study were feasible. CONCLUSION This is the first prospective trial to focus on pharmacologic prophylaxis with enoxaparin after pancreatic surgery. Postoperative anticoagulant therapy with enoxaparin was used in patients who underwent pancreatic surgery with a low incidence of VTE and no increase in postoperative bleeding events compared with existing evidence.
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Affiliation(s)
- Daisuke Hashimoto
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Shigeki Nakagawa
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Naoki Umezaki
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Takanobu Yamao
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Yuki Kitano
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Kensuke Yamamura
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Takayoshi Kaida
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Kota Arima
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Katsunori Imai
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Yo-Ichi Yamashita
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Akira Chikamoto
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan.
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Wang Y, Attar BM, Fuentes HE, Yu J, Zhang H, Tafur AJ. Performance of Khorana Risk Score for Prediction of Venous Thromboembolism in Patients With Hepatocellular Carcinoma. Clin Appl Thromb Hemost 2017; 24:471-476. [PMID: 28288526 DOI: 10.1177/1076029617699088] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Cancer-associated venous thromboembolism (VTE) is one of the leading causes of mortality and morbidity among patients with malignancy. The Khorana risk score (KRS) is currently the best validated risk assessment model to stratify risks of VTE development in ambulatory patients with cancer. In the current study, we assessed the performance of KRS in patients with hepatocellular carcinoma (HCC). We retrospectively analyzed patients with diagnosis of HCC (screened by International Classification of Diseases [ ICD-9] and ICD-10 code, confirmed with radiographic examination and/or histopathology) at a large public hospital over 15 years (January 2000 through July 2015). Cases with VTE were identified through radiographic examination and blindly adjudicated. Khorana risk score was calculated for each patient, and its association with VTE development and mortality was assessed. Among 270 patients with HCC, 16 (5.9%) cases of VTE were identified, including 7 (43.8%) pulmonary embolism, 4 (25%) peripheral deep vein thrombosis, and 6 (37.5%) intra-abdominal thrombosis. One hundred eighty-four (68.1%) patients had a KRS of 0 and 86 (31.9%) patients had a KRS >0. Most of the thrombotic (n = 9, 56%) events occurred in the low-risk group. In univariate analysis, only prechemotherapy leukocyte count equal to or greater than 11 000/μL was statistically significant in the prediction of VTE incidence. After adjusting for confounding factors in multivariate analysis, KRS >0 was not predictive of VTE (hazard ratio [HR] = 1.83, 95% confidence interval [CI] = 0.81-4.15, P = .15) or mortality (HR = 1.61, 95% CI = 0.92-2.81, P = .09). Khorana risk score did not predict VTE development or mortality in patients with HCC. Design of HCC-specific risk assessment model for VTE development is necessary.
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Affiliation(s)
- Y Wang
- 1 Department of Internal Medicine, John Stroger Jr. Hospital, Chicago, IL, USA
| | - B M Attar
- 2 Division of Gastroenterology and Hepatology, John Stroger Jr. Hospital, Chicago, IL, USA
| | - H E Fuentes
- 1 Department of Internal Medicine, John Stroger Jr. Hospital, Chicago, IL, USA
| | - J Yu
- 1 Department of Internal Medicine, John Stroger Jr. Hospital, Chicago, IL, USA
| | - Huiyuan Zhang
- 3 Collaborative Research Unit, John Stroger Jr. Hospital, Chicago, IL, USA
| | - A J Tafur
- 4 Cardiology-Vascular Medicine, Northshore University Healthsystem, Evanston, IL, USA
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40
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The Khorana score for the prediction of venous thromboembolism in patients with pancreatic cancer. Thromb Res 2017; 150:30-32. [DOI: 10.1016/j.thromres.2016.12.013] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 11/30/2016] [Accepted: 12/14/2016] [Indexed: 02/07/2023]
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41
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Krepline AN, Christians KK, George B, Ritch PS, Erickson BA, Tolat P, Evans DB, Tsai S. Venous thromboembolism prophylaxis during neoadjuvant therapy for resectable and borderline resectable pancreatic cancer-Is it indicated? J Surg Oncol 2016; 114:581-586. [PMID: 27760280 DOI: 10.1002/jso.24361] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 06/23/2016] [Indexed: 12/19/2022]
Abstract
PURPOSE To describe venous thromboembolism (VTE) rates in patients with pancreatic cancer (PC) during neoadjuvant therapy. METHODS Factors associated with VTE were evaluated using multivariable logistic regression modeling in patients with resectable and BLR PC treated with neoadjuvant therapy between 2009 and 2014. RESULTS Prevalent VTEs were detected in 13 (5%) of the 260 patients. Incident VTEs were detected in 26 patients (10%); 9 (8%) of the 109 resectable and 17 (11%) of the 151 BLR patients (P = 0.53). Of the 26 incident events, 9 (35%) were PEs, 9 (35%) were extremity DVTs, and 8 (31%) involved the SMV/PV. VTEs were catheter-related in 7 (27%) of the 26 patients. Rh(D) antigen positivity was associated with a decreased risk of incident VTE (OR:0.32, 95%CI:0.11-0.85, P = 0.02). Completion of neoadjuvant therapy to include surgery occurred in 176 (75%) of the 234 patients without incident VTE as compared to 14 (54%) of the 26 patients with incident VTE (P = 0.02). The median survival for all 260 patients was 24.3 months: 17.0 months versus 24.6 months for patients who did and did not develop incident VTE during neoadjuvant therapy (P = 0.11). CONCLUSIONS Patients with localized PC who receive neoadjuvant therapy are at significant risk of VTE and thromboprophylaxis may be warranted. J. Surg. Oncol. 2016;114:581-586. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ashley N Krepline
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kathleen K Christians
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ben George
- Department of Medicine, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Paul S Ritch
- Department of Medicine, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Beth A Erickson
- Department of Radiation Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Parag Tolat
- Department of Radiology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Douglas B Evans
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Susan Tsai
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, Wisconsin.
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42
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Lee JC, Ro YS, Cho J, Park Y, Lee JH, Hwang JH, Choi HJ, Lee S. Characteristics of Venous Thromboembolism in Pancreatic Adenocarcinoma in East Asian Ethnics: A Large Population-Based Observational Study. Medicine (Baltimore) 2016; 95:e3472. [PMID: 27124043 PMCID: PMC4998706 DOI: 10.1097/md.0000000000003472] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Pancreatic cancer (PC) is known to be frequently associated with venous thromboembolism (VTE). Although treatment and prophylaxis strategies for VTE in PC patients were updated recently, these were mainly based on data from Western populations and were not verified in East Asian ethnic populations.We investigated the clinical characteristics of VTE in East Asian PC patients. We reviewed electronic medical records (EMR) of 1334 patients diagnosed with pancreatic adenocarcinoma from 2005 to 2010 at single tertiary hospital in Korea. All the patients with newly diagnosed VTE were classified by anatomical site and manifestation of symptoms. The primary outcomes of interest were 2-year cumulative incidence of VTE events. Cox proportional hazards models were used to analyze associations between risk factors and clinical outcomes.A total of 1115 patients were eligible for enrollment. The 2-year cumulative VTE incidence was 9.2%. Major risk factors associated with VTE event were advanced cancer stage, major surgery, and poor performance status. Risk factors associated with mortality after PC diagnosis included advanced cancer stage, poor performance score, leukocytosis, and lower albumin level. The overall VTE did not affected mortality. However in subgroup analysis, symptomatic VTE and deep vein thrombosis/pulmonary thromboembolism (DVT/PTE) showed worse prognosis than incidental or intra-abdominal VTE.The overall incidence of VTE events in Korean PC patients was lower than previous studies. Advanced cancer stage was the most important factor for VTE event and mortality. Unlike Western population group, VTE event did not affect overall prognosis after PC diagnosis. However, symptomatic VTE and DVT/PTE showed higher mortality after VTE event.
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Affiliation(s)
- Jong-Chan Lee
- From the Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam (J-CL, JC, YP, J-HH); Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute (YSR); Department of Radiology (JHL); and Division of Medical Oncology, Department of Internal Medicine (HJC, SL), Yonsei University College of Medicine, Seoul, Korea
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43
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Boone BA, Orlichenko L, Schapiro NE, Loughran P, Gianfrate GC, Ellis JT, Singhi AD, Kang R, Tang D, Lotze MT, Zeh HJ. The receptor for advanced glycation end products (RAGE) enhances autophagy and neutrophil extracellular traps in pancreatic cancer. Cancer Gene Ther 2015; 22:326-34. [PMID: 25908451 PMCID: PMC4470814 DOI: 10.1038/cgt.2015.21] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 12/30/2014] [Accepted: 01/06/2015] [Indexed: 12/12/2022]
Abstract
Neutrophil extracellular traps (NETs) are formed when neutrophils expel their DNA, histones and intracellular proteins into the extracellular space or circulation. NET formation is dependent on autophagy and is mediated by citrullination of histones to allow for unwinding and subsequent expulsion of DNA. NETs play an important role in the pathogenesis of several sterile inflammatory diseases, including malignancy, therefore we investigated the role of NETs in the setting of pancreatic ductal adenocarcinoma (PDA). Neutrophils isolated from two distinct animal models of PDA had an increased propensity to form NETs following stimulation with platelet activating factor (PAF). Serum DNA, a marker of circulating NET formation, was elevated in tumor bearing animals as well as in patients with PDA. Citrullinated histone H3 expression, a marker of NET formation, was observed in pancreatic tumors obtained from murine models and patients with PDA. Inhibition of autophagy with chloroquine or genetic ablation of RAGE resulted in decreased propensity for NET formation, decreased serum DNA, and decreased citrullinated histone H3 expression in the pancreatic tumor microenvironment. We conclude that NETs are upregulated in pancreatic cancer through RAGE dependent/autophagy pathways.
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Affiliation(s)
- B A Boone
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - L Orlichenko
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - N E Schapiro
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - P Loughran
- 1] Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA [2] Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA, USA
| | - G C Gianfrate
- Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA, USA
| | - J T Ellis
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - A D Singhi
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - R Kang
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - D Tang
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - M T Lotze
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - H J Zeh
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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