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Dasgupta P, Ou A, Lin H, Gregory T, Alfaro-Munoz KD, Yuan Y, Afshar-Khargan V, Kamiya-Matsuoka C, Rousseau JF, Majd NK. The risk and burden of thromboembolic and hemorrhagic events in patients with malignant gliomas receiving bevacizumab. J Neurooncol 2024:10.1007/s11060-023-04551-9. [PMID: 38372903 DOI: 10.1007/s11060-023-04551-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/20/2023] [Indexed: 02/20/2024]
Abstract
PURPOSE Bevacizumab has evolved as an integral treatment option for patients with high-grade gliomas. Little is known about clinical risk factors that predispose patients with high-grade gliomas receiving bevacizumab to VTE or ICH. We sought to characterize the clinical risk factors associated with risk of either event. METHODS In this multi-institutional retrospective study, we first evaluated patients with high-grade gliomas who were treated with bevacizumab at University of Texas MD Anderson Cancer Center from 2015-2021. We compared clinical and treatment-related factors among three cohorts: those who developed VTE, ICH, or neither. We further compared survival outcomes of these patients from the time of bevacizumab initiation. Then to further confirm our results in a non-cancer center hospital setting we evaluated patients from two Ascension Seton Hospitals in Austin, Texas which are affiliated with Dell Medical School at the University of Texas at Austin from 2017-2022. RESULTS We found that the presence of cerebral macrobleeding, defined as a magnetic susceptibility of > 1 cm3 on magnetic resonance imaging, was highly associated with risk of developing ICH after initiation of bevacizumab. Development of ICH was significantly associated with poorer survival outcomes. We did not find a statistically significant effect of VTE on survival after bevacizumab initiation. CONCLUSION In order to stratify the risk for developing ICH before the initiation of bevacizumab, we recommend to assess for the presence of cerebral macrobleeding as it is associated with ICH development.
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Affiliation(s)
- Pushan Dasgupta
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexander Ou
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Heather Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Timothy Gregory
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristin D Alfaro-Munoz
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ying Yuan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vahid Afshar-Khargan
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carlos Kamiya-Matsuoka
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Justin F Rousseau
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, 75390, USA.
| | - Nazanin K Majd
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Kacimi SEO, Moeinafshar A, Haghighi SS, Saghazadeh A, Rezaei N. Venous thromboembolism in cancer and cancer immunotherapy. Crit Rev Oncol Hematol 2022; 178:103782. [PMID: 35961476 DOI: 10.1016/j.critrevonc.2022.103782] [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: 04/21/2022] [Revised: 07/22/2022] [Accepted: 08/06/2022] [Indexed: 10/15/2022] Open
Abstract
Venous thromboembolism (VTE) is a clinical disease that includes deep vein thrombosis and pulmonary embolism. Amongst its underlying risk factors, cancer is of great importance. Stasis, endothelial injury, and hypercoagulability result in clot formation and VTE. Cancer can affect coagulability by favoring these three factors, resulting in VTE incidence. Immunotherapy is a novel therapeutic approach, targeting cancer by immune system enhancement. VTE is one of the most important adverse effects of immunotherapy, which complicates the administration of immunotherapy in cancer patients. The current review provides a brief overview of VTE epidemiology, pathophysiology, risk factors, biomarkers, the relationship of cancer and cancer immunotherapy to VTE incidence, and managing cancer-associated VTE.
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Affiliation(s)
| | - Aysan Moeinafshar
- Cancer Immunology Project Interest Group (CIP), Universal Scientific Education and Research Network (USERN), Tehran, Iran; School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Shirin Shahsavar Haghighi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Systematic Review and Meta-analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Amene Saghazadeh
- Systematic Review and Meta-analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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Orešković D, Kaštelančić A, Raguž M, Almahariq F, Romić D, Dlaka D, Janeš A, Milotić V, Novaković S, Chudy D. Glycemia and venous thromboembolism in patients with primary brain tumors - A speculative review. Med Hypotheses 2021; 157:110719. [PMID: 34717073 DOI: 10.1016/j.mehy.2021.110719] [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: 09/02/2021] [Accepted: 10/19/2021] [Indexed: 02/07/2023]
Abstract
Venous thromboembolism (VTE) is a significant public health issue causing severe morbidity and mortality. One of the most vulnerable populations for VTE development are cancer patients. And among them, patients with brain tumors have arguably the highest risk of developing this often fatal complication. Hyperglycemia is a well-known factor which leads to a wide variety of pro-thrombotic changes. In this article, we review the current literature on the topic of VTE in brain tumor patients. We also discuss the known correlation between VTE and glycemia, as well as the importance and frequency of glycemia dysregulation in brain tumor patients. Based on the already well-known importance of glucose metabolism in cancer patients, as well as the previous research of our group, we hypothesize that there is a significant number of brain tumor patients who have chronically elevated glycemia, a fact that so-far hasn't been reported. We argue that these patients carry a significantly higher risk of VTE development and would benefit greatly from strict glycemic control. We present our hypothesis, the ways in which to test it, as well as the possible counter-arguments against it. Our hope is that other investigators will be inspired by our article to continue this type of research, since we consider the topic of VTE in brain tumor patients highly important and urgent, primarily due to its prevalence and severity.
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Affiliation(s)
- Darko Orešković
- Department of Neurosurgery, Clinical Hospital "Dubrava", Zagreb, Croatia.
| | - Anđelo Kaštelančić
- Department of Neurosurgery, Clinical Hospital "Dubrava", Zagreb, Croatia
| | - Marina Raguž
- Department of Neurosurgery, Clinical Hospital "Dubrava", Zagreb, Croatia
| | - Fadi Almahariq
- Department of Neurosurgery, Clinical Hospital "Dubrava", Zagreb, Croatia
| | - Dominik Romić
- Department of Neurosurgery, Clinical Hospital "Dubrava", Zagreb, Croatia
| | - Domagoj Dlaka
- Department of Neurosurgery, Clinical Hospital "Dubrava", Zagreb, Croatia
| | - Andrea Janeš
- Department of Clinical Microbiology and Hospital Infections, Clinical Hospital "Dubrava", Zagreb, Croatia
| | - Vivian Milotić
- Department of Radiology, General Hospital Pula, Pula, Croatia; Department of Diagnostic and Intervention Radiology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Sabina Novaković
- Depatment of Haematology, University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Darko Chudy
- Department of Neurosurgery, Clinical Hospital "Dubrava", Zagreb, Croatia; Zagreb University School of Medicine, Croatia
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Thirunavu V, Kandula V, Shah P, Yerneni K, Karras CL, Abecassis ZA, Bloch O, Potts M, Jahromi B, Tate MC. Unfractionated Heparin TID Dosing Regimen Is Associated With a Lower Rate of Pulmonary Embolism When Compared With BID Dosing in Patients Undergoing Craniotomy. World Neurosurg 2021; 153:e147-e152. [PMID: 34166830 DOI: 10.1016/j.wneu.2021.06.076] [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: 05/01/2021] [Revised: 06/12/2021] [Accepted: 06/14/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), and intracranial hemorrhage (ICH) may complicate the post-operative course of patients undergoing craniotomy. While prophylaxis with unfractionated heparin (UFH) has been shown to reduce VTE rates, twice-daily (BID) and three-times-daily (TID) UFH dosing regimens have not been compared in neurosurgical procedures. The objective of this study was to explore the association between UFH dosing regimen and rates of VTE and ICH in craniotomy patients. METHODS A retrospective chart review was conducted for 159 patients at Northwestern University receiving 5000 units/0.5 mL UFH injections either BID (n = 132) or TID (n = 27). General linear regression models were run to predict rates of DVT, PE, and reoperation due to bleeding from UFH dosing regimen while controlling for age at surgery, sex, VTE history, craniotomy for tumor resection, surgery duration, length of stay, reoperation, infections, and IDH/MGMT mutations. RESULTS Receiving UFH TID was significantly associated with a lower rate of PE when compared with receiving UFH BID (β = -0.121, P = 0.044; TID rate = 0%, BID rate = 10.6%). UFH TID also showed a trend toward lower rates of DVT (β = -0.0893, P = 0.295; TID rate = 18.5%, BID rate = 21.2%) when compared with UFH BID. UFH TID showed no significant difference in rate of reoperation for bleeding when compared to UFH BID (β = -0.00623, P = 0.725; TID rate = 0%, BID rate = 0.8%). CONCLUSIONS UFH TID dosing is associated with lower rates of PE when compared with BID dosing in patients undergoing craniotomy.
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Affiliation(s)
- Vineeth Thirunavu
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Viswajit Kandula
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Parth Shah
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ketan Yerneni
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Constantine L Karras
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Zachary A Abecassis
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Orin Bloch
- Department of Neurological Surgery, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Matthew Potts
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Babak Jahromi
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew C Tate
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Lu G, Rao M, Zhu P, Liang B, El-Nazer RT, Fonkem E, Bhattacharjee MB, Zhu JJ. Triple-drug Therapy With Bevacizumab, Irinotecan, and Temozolomide Plus Tumor Treating Fields for Recurrent Glioblastoma: A Retrospective Study. Front Neurol 2019; 10:42. [PMID: 30766509 PMCID: PMC6366009 DOI: 10.3389/fneur.2019.00042] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 01/14/2019] [Indexed: 12/11/2022] Open
Abstract
Clinical studies treating pediatric and adult solid tumors, such as glioblastoma (GBM), with a triple-drug regimen of temozolomide (TMZ), bevacizumab (BEV), and irinotecan (IRI) [TBI] have demonstrated various efficacies, but with no unexpected toxicities. The TBI regimen has never been studied in recurrent GBM (rGBM) patients. In this retrospective study, we investigated the outcomes and side effects of rGBM patients who had received the TBI regimen. We identified 48 adult rGBM patients with a median age of 56 years (range: 26-76), who received Tumor Treating Fields (TTFields) treatment for 30 days or longer, and concurrent salvage chemotherapies. The patients were classified into two groups based on chemotherapies received: TBI with TTFields (TBI+T, N = 18) vs. bevacizumab (BEV)-based chemotherapies with TTFields (BBC+T, N = 30). BBC regimens were either BEV monotherapy, BEV+IRI or BEV+CCNU. Patients in TBI+T group received on average 19 cycles of TMZ, 26 and 21 times infusions with BEV and IRI, respectively. Median overall survival (OS) and progression-free survival (PFS) for rGBM (OS-R and PFS-R) patients who received TBI+T were 18.9 and 10.7 months, respectively. In comparison, patients who received BBC+T treatment had OS-R and PFS-R of 11.8 (P > 0.05) and 4.7 (P < 0.05) months, respectively. Although the median PFS results were significantly different by 1.5 months (6.6 vs. 5.1) between TBI+T and BBC+T groups, the median OS difference of 14.7 months (32.5 vs. 17.8) was more pronounced, P < 0.05. Patients tolerated TBI+T or BBC+T treatments well and there were no unexpected toxicities. The most common side effects from TBI+T treatment included grade III hypertension (38.9%) and leukopenia (22.2%). In conclusion, the TBI regimen might play a role in the improvement of PFS-R and OS-R among rGBM patients. Prospective studies with a larger sample size are warranted to study the efficacy and toxicity of TBI+T regimen for rGBM.
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Affiliation(s)
- Guangrong Lu
- The Vivian L. Smith Department of Neurosurgery, The University of Texas Health Science Center at Houston (UTHealth), McGovern Medical School, Houston, TX, United States
| | - Mayank Rao
- The Vivian L. Smith Department of Neurosurgery, The University of Texas Health Science Center at Houston (UTHealth), McGovern Medical School, Houston, TX, United States
| | - Ping Zhu
- The Vivian L. Smith Department of Neurosurgery, The University of Texas Health Science Center at Houston (UTHealth), McGovern Medical School, Houston, TX, United States
- Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, UTHealth School of Public Health, Houston, TX, United States
| | - Buqing Liang
- Baylor Scott and White Health, Temple, TX, United States
| | | | - Ekokobe Fonkem
- Baylor Scott and White Health, Temple, TX, United States
| | - Meenakshi B. Bhattacharjee
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston (UTHealth), McGovern Medical School, Houston, TX, United States
| | - Jay-Jiguang Zhu
- The Vivian L. Smith Department of Neurosurgery, The University of Texas Health Science Center at Houston (UTHealth), McGovern Medical School, Houston, TX, United States
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Length of Thromboprophylaxis in Patients Operated on for a High-Grade Glioma: A Retrospective Study. World Neurosurg 2018; 115:e723-e730. [PMID: 29715571 DOI: 10.1016/j.wneu.2018.04.151] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE High-grade gliomas are associated with venous thromboembolism (VTE). This retrospective study with a parallel cohort design investigated influence of continuing prophylactic anticoagulation after discharge on rate of VTE and intracranial hemorrhage (ICH) in patients operated on for high-grade glioma. METHODS Consecutive adult patients who underwent subtotal or gross total resection for high-grade glioma at a single institution were included. Multivariable logistic regression analysis was used to investigate the association between duration of thromboprophylaxis (dalteparin administered 21 days vs. 0-7 days) and occurrence of VTE and ICH within 21 or 90 days after surgery, corrected for known risk factors. RESULTS Of 301 included patients, 166 received short-term thromboprophylaxis, and 135 received prolonged thromboprophylaxis. In multivariable analysis, prolonged thromboprophylaxis was not significantly associated with occurrence of VTE within 21 days (3.0% vs. 1.2%; P = 0.24) or 90 days (8.9% vs. 4.8%; P = 0.09) after surgery; however, prolonged prophylaxis was associated with occurrence of ICH (5.9% vs. 0.6%; P = 0.03). Additionally, immobility (P = 0.03) and high body mass index (P = 0.02) were associated with occurrence of VTE. CONCLUSIONS Prophylactic anticoagulation for 21 days postoperatively was not associated with a decreased rate of VTE compared with thromboprophylaxis until discharge. ICH was more common with prolonged thromboprophylaxis. These results provide insufficient evidence to extend duration of prophylaxis beyond hospitalization. Large-scale randomized prospective studies are needed to clarify safety, efficacy, and optimal timing of postoperative thromboprophylaxis in patients with high-grade glioma.
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Senders JT, Goldhaber NH, Cote DJ, Muskens IS, Dawood HY, De Vos FYFL, Gormley WB, Smith TR, Broekman MLD. Venous thromboembolism and intracranial hemorrhage after craniotomy for primary malignant brain tumors: a National Surgical Quality Improvement Program analysis. J Neurooncol 2018; 136:135-145. [PMID: 29039075 PMCID: PMC5754452 DOI: 10.1007/s11060-017-2631-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/29/2017] [Indexed: 12/21/2022]
Abstract
Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), frequently complicates the postoperative course of primary malignant brain tumor patients. Thromboprophylactic anticoagulation is commonly used to prevent VTE at the risk of intracranial hemorrhage (ICH). We extracted all patients who underwent craniotomy for a primary malignant brain tumor from the National Surgical Quality Improvement Program (NSQIP) registry (2005-2015) to perform a time-to-event analysis and identify relevant predictors of DVT, PE, and ICH within 30 days after surgery. Among the 7376 identified patients, the complication rates were 2.6, 1.5, and 1.3% for DVT, PE, and ICH, respectively. VTE was the second-most common major complication and third-most common reason for readmission. ICH was the most common reason for reoperation. The increased risk of VTE extends beyond the period of hospitalization, especially for PE, whereas ICH occurred predominantly within the first days after surgery. Older age and higher BMI were overall predictors of VTE. Dependent functional status and longer operative times were predictive for VTE during hospitalization, but not for post-discharge events. Admission two or more days before surgery was predictive for DVT, but not for PE. Preoperative steroid usage and male gender were predictive for post-discharge DVT and PE, respectively. ICH was associated with various comorbidities and longer operative times. This multicenter study demonstrates distinct critical time periods for the development of thrombotic and hemorrhagic events after craniotomy. Furthermore, the VTE risk profile depends on the type of VTE (DVT vs. PE) and clinical setting (hospitalized vs. post-discharge patients).
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Affiliation(s)
- Joeky T Senders
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
- Department of Neurosurgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Nicole H Goldhaber
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - David J Cote
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Ivo S Muskens
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
- Department of Neurosurgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Hassan Y Dawood
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Filip Y F L De Vos
- Department of Medical Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - William B Gormley
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Timothy R Smith
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Marike L D Broekman
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA.
- Department of Neurosurgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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