Arterial and Venous Thrombotic Complications with Thalidomide in Multiple Myeloma

A Comprehensive Review of Risk Factors for Venous Thromboembolism: From Epidemiology to Pathophysiology

Venous thromboembolism (VTE) is the third most common cause of death worldwide. The incidence of VTE varies according to different countries, ranging from 1-2 per 1000 person-years in Western Countries, while it is lower in Eastern Countries (<1 per 1000 person-years). Many risk factors have been identified in patients developing VTE, but the relative contribution of each risk factor to thrombotic risk, as well as pathogenetic mechanisms, have not been fully described. Herewith, we provide a comprehensive review of the most common risk factors for VTE, including male sex, diabetes, obesity, smoking, Factor V Leiden, Prothrombin G20210A Gene Mutation, Plasminogen Activator Inhibitor-1, oral contraceptives and hormonal replacement, long-haul flight, residual venous thrombosis, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, trauma and fractures, pregnancy, immobilization, antiphospholipid syndrome, surgery and cancer. Regarding the latter, the incidence of VTE seems highest in pancreatic, liver and non-small cells lung cancer (>70 per 1000 person-years) and lowest in breast, melanoma and prostate cancer (<20 per 1000 person-years). In this comprehensive review, we summarized the prevalence of different risk factors for VTE and the potential molecular mechanisms/pathogenetic mediators leading to VTE.

Arterial Thrombosis in Patients with Cancer

PURPOSE OF REVIEW

Cancer is a common cause of morbidity and mortality in the USA. While the association between venous thrombosis and malignancy is well established, arterial thrombosis has more recently been recognized as a serious complication of cancer and certain chemotherapeutic agents. This review aims to summarize the most recent literature regarding the incidence and risk factors for cancer-related arterial thrombosis, understand the pathophysiologic mechanisms of thrombosis, and highlight the specific diagnostic and treatment considerations relevant to cancer patients.

RECENT FINDINGS

Based on a recent study looking at the Surveillance, Epidemiology, and End Results (SEER) database, the incidence of arterial thromboembolic events (ATEs) in patients with cancer at 6 months is 4.7%; the presence of an ATE is predictive of worse outcomes. Certain drugs such as platinum-based agents, vascular endothelial growth factor inhibitors, tyrosine kinase inhibitors, and taxanes have been associated with high rates of ATEs. Increased platelet reactivity appears crucial to development of arterial thrombosis in cancer patients. Cancer patients have an increased risk of arterial thrombosis that is likely due to both a cancer-associated procoagulant state as well as the adverse effects of certain chemotherapeutic agents. Treatment of arterial thromboembolism in cancer patients typically requires a multidisciplinary approach in part due to high rates of thrombocytopenia and stent thrombosis in the setting of percutaneous interventions. More studies are needed to investigate optimal prophylaxis, surveillance strategies, and treatments of cancer-related arterial thromboembolic disease.

Increased risk of arterial thromboembolic events with combination lenalidomide/dexamethasone therapy for multiple myeloma

INTRODUCTION

Cancer associated thrombosis is a leading cause of morbidity and mortality. Research and guidelines have focused on venous thromboembolic events (VTE). Within the past decade, combination lenalidomide and dexamethasone has become a standard of therapy for multiple myeloma and is now widely used. In these patients, the risk of arterial thromboembolic events (ATE) has not been addressed to the same extent as VTE. Areas discussed: Presented is a targeted review of published data on ATE in MM patients on combination lenalidomide/dexamethasone therapy. Incidence, clinical presentations, prognosis, mechanisms and thromboprophylaxis are discussed. A framework for approaching ATE/VTE in these patients is suggested. Expert commentary: There is an increased incidence of ATE in this population, primarily cerebrovascular and cardiovascular events. ATE is associated with poorer prognosis and its prevention must be an important goal of management. It is suggested that on initiating treatment, a combined VTE/ATE risk assessment should be performed and thromboprophylaxis initiated for a minimum of 6 months. As newer immunomodulatory therapies are developed, thromboembolic risk must be assessed early on. Further studies are needed to determine the optimal strategy to reducing both VTE and ATE in this population.

A Case of Internal Carotid Artery Thrombosis associated with Thalidomide Administration in Multiple Myeloma

Thalidomide is an effective chemotherapeutic agent used to achieve remission in multiple myeloma. However, its administration is associated with several adverse effects including venous thromboembolism, while arterial thrombosis has also, although rarely, been described in the literature. We report a case of internal carotid artery occlusion within 1 week of starting thalidomide with prophylactic low molecular weight heparin in a patient who had no other prothrombotic risk factors. It is not known why this complication occurs despite the administration of anticoagulant prophylaxis. The role of factor VIII, von Willebrand factor antigen levels and fibrinogen in multiple myeloma patients should be studied in order to determine if these factors should be targeted in future prophylactic treatment.

High incidence of arterial thrombosis in young patients treated for multiple myeloma: results of a prospective cohort study

This prospective study evaluated the risk of arterial thrombosis in 195 consecutive patients aged 18 to 65 years with newly diagnosed multiple myeloma (MM). All patients were treated with 3 cycles of VAD (vincristine, doxorubicin, and dexamethasone) or TAD (thalidomide-AD) or PAD (bortezomib-AD) in national trials, followed by high-dose melphalan and autologous stem cell transplantation. For a period of 522 patient-years, 11 of the 195 patients (5.6%) developed arterial thrombosis. The highest incidence was seen during induction chemotherapy courses. Median age at onset of arterial thrombosis was 59 years (range, 43-65 years). Hypertension and smoking were significantly associated with arterial thrombosis with a relative risk of 11.7 (2.23-61.2) and 15.2 (1.78-130), respectively. Factor VIII levels (FVIII:C) correlated significantly with age (P = .02) and higher International Scoring System (ISS) stage (P = .001). A higher FVIII:C was associated with arterial thrombosis (hazard ratio [HR] = 1.85; 95% confidence interval [CI] = 0.99-3.47) after adjustment for age, ISS score, and assigned treatment arm. MM patients have an increased risk for arterial thrombotic events during and after induction chemotherapy. Hypertension, smoking, and high factor VIII levels, possibly reflecting disease activity, contribute to the risk of arterial thrombosis.

Risk of cardiac ischemia and arterial thromboembolic events with the angiogenesis inhibitor bevacizumab in cancer patients: a meta-analysis of randomized controlled trials

BACKGROUND

The risk of cardiovascular toxicities is a serious concern with the increased application of angiogenesis inhibitors in current cancer therapy. Arterial thromboembolic events (ATE) were associated with bevacizumab, an antibody against vascular endothelial growth factor. To determine the risk of ATE including cardiac ischemia and stroke, a systematic review and meta-analysis of published randomized controlled trials (RCTs) was performed.

METHODS

We searched the databases of PubMed, Web of Science, and American Society of Clinical Oncology conferences to identify relevant clinical trials up to May, 2009. Eligible studies included prospective RCTs in which bevacizumab was compared to a control concurrently in combination with standard anti-neoplastic therapy. Summary incidence rates, relative risks (RRs), and 95% confidence intervals (CIs) were calculated using random-effects or fixed-effects models.

RESULTS

A total of 12 617 patients with a variety of advanced solid tumors from 20 RCTs were included for analysis. The incidences of all-grade and high-grade ATE in patients receiving bevacizumab were 3.3% (95% CI, 2.0-5.6%) and 2.0% (95% CI, 1.7-2.5) respectively. Patients treated with bevacizumab had a significantly increased risk of ATE with an RR of 1.44 (95% CI, 1.08-1.91; p=0.013) compared with controls. The risk similarly increased for bevacizumab at 2.5 and 5 mg/kg/week; in addition, significantly increased risks were observed in patients with renal cell cancer (RR, 3.72, 95% CI, 1.15-12.04; p=0.029) and colorectal cancer (RR, 1.89, 95% CI, 1.28-2.80, p=0.001). Notably, the risk of high-grade cardiac ischemia with bevacizumab was significantly higher than controls with an RR of 2.14 (95% CI, 1.12-4.08, p=0.021); however, the risk of ischemic stroke with bevacizumab was not significantly different from controls (RR, 1.37, 95% CI, 0.67-2.79, p=0.39).

DISCUSSION

Treatment with bevacizumab may significantly increase the risk of cardiac ischemic events in cancer patients.

Arterial and venous thrombosis in monoclonal gammopathy of undetermined significance and multiple myeloma: a population-based study

Patients with multiple myeloma (MM) have an increased risk of venous thrombosis. Interestingly, excess risk of venous thromboembolism has been observed among patients with monoclonal gammopathy of undetermined significance (MGUS). Using population-based data from Sweden, we assessed the risks of venous and arterial thrombosis in 18,627 MM and 5326 MGUS patients diagnosed from 1958 to 2006, compared with 70,991 and 20,161 matched controls, respectively. At 1, 5, and 10 years after MM diagnosis, there was an increased risk of venous thrombosis: hazard ratios (95% confidence intervals) were 7.5 (6.4-8.9), 4.6 (4.1-5.1), and 4.1 (3.8-4.5), respectively. The corresponding results for arterial thrombosis were 1.9 (1.8-2.1), 1.5 (1.4-1.6), and 1.5 (1.4-1.5). At 1, 5, and 10 years after MGUS diagnosis, hazard ratios were 3.4 (2.5-4.6), 2.1 (1.7-2.5), and 2.1 (1.8-2.4) for venous thrombosis. The corresponding risks for arterial thrombosis were 1.7 (1.5-1.9), 1.3 (1.2-1.4), and 1.3 (1.3-1.4). IgG/IgA (but not IgM) MGUS patients had increased risks for venous and arterial thrombosis. Risks for thrombosis did not vary by M-protein concentration (> 10.0 g/L or < 10.0 g/L) at diagnosis. MGUS patients with (vs without) thrombosis had no excess risk of MM or Waldenström macroglobulinemia. Our findings are of relevance for future studies and for improvement of thrombosis prophylaxis strategies.

Arterial thrombosis with immunomodulatory derivatives in the treatment of multiple myeloma: a single-center case series and review of the literature

Although the increased risk of venous thrombotic events with thalidomide in multiple myeloma (MM) has been well described, an association with an increased risk of arterial events is less well appreciated. We describe 5 unusual arterial thromboses in patients with MM shortly after beginning thalidomide-based therapies. The cases are remarkable for a paucity of risk factors and short latency. We also review the literature on arterial thromboembolic events in patients taking thalidomide. Care should be taken in future trials to document arterial events with both thalidomide and lenalidomide.

Epidemiology of cancer-related venous thromboembolism

Recent studies have better defined the epidemiology of venous thromboembolism (VTE) in cancer patients. The incidence is highest in patients who have metastatic disease at the time of presentation and who have fast growing, biologically aggressive cancers associated with a poor prognosis. The incidence is also high in patients with haematological cancers. Other specific risk factors that affect the incidence of VTE include undergoing invasive neurosurgery, the number of underlying chronic co-morbid conditions, and being of Asian/Pacific Islander decent (lower incidence). The incidence is highest in the first few months after diagnosis, which may reflect the biology of the cancer or medical interventions such as major surgery or start of chemotherapy. The development of VTE is clearly associated with decreased survival, and this effect is greater among patients initially diagnosed with local- or regional-stage cancer compared with patients with metastatic cancer, probably because VTE reflects the presence of a biologically aggressive cancer. Finally, a small percentage of patients with idiopathic VTE and no clinical or laboratory evidence of cancer may harbour an aggressive but 'occult' malignancy likely causally linked to the development of VTE.

Venous thromboembolism (VTE) in patients with cancer: epidemiology and risk factors

Although cancer is recognized as a major risk factor for venous thromboembolism, the exact magnitude of the problem and specific risk factors most strongly associated with the development of VTE is not well defined. Several recent studies have shown that the incidence of VTE is highest in patients who present with metastatic cancer, particularly cancers associated with a high one-year mortality rate, such as pancreatic cancer. The incidence rate of VTE is highest in the first few months after the diagnosis of cancer, and it decreases over time thereafter. For most cancers, it is not clear to what extent undergoing major surgery adds to the already high risk of VTE associated with the presence of the cancer. However, patients with glioma clearly have a very high incidence of VTE soon after they undergo any invasive neurosurgical procedure. Active chemotherapy, the use of erythropoetin agents, and the use of certain anti-cancer therapies such as thalidomide, high-dose steroids, and anti-angiogenic therapy also increase the risk of thrombosis. Similar to patients without cancer, the risk of VTE is higher in patients with coexisting chronic medical illnesses. Development of VTE is clearly associated with decreased survival and this effect is greater among patients initially diagnosed with local or regional stage cancer compared to patients with metastatic cancer.

Thalidomide-Related Eosinophilic Pneumonia: A case report and brief literature review

Thalidomide has regained value in the multimodality treatment of leprosy, multiple myeloma, prostate, ovarian and renal cancer. Complications related to arterial and venous complications are well described. However, pulmonary complications remain relatively uncommon. The most common pulmonary side-effect reported is non-specific dyspnea. We report a patient with multiple myeloma, who developed an eosinophilic pneumonia, shortly after starting thalidomide. She had complete resolution of her symptoms and pulmonary infiltrates on discontinuation of the drug and treatment with corticosteroids. Physicians should be cognizant of this potential complication in patients receiving thalidomide who present with dyspnea and pulmonary infiltrates.