Management of venous thromboembolism in cancer patients: Considerations about the clinical practice guideline update of the American society of clinical oncology

Unmet clinical needs in the prevention and treatment of cancer-associated venous thromboembolism

Venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis, is a leading cause of morbidity and mortality in patients with cancer. Based on accumulating evidence, the prophylaxis and treatment of cancer-associated VTE have been changed over the years. Recently, the introduction in clinical practice of the direct oral anticoagulants has radically changed the management of cancer-associated VTE for their easier use and non-inferior efficacy-safety profile compared to low-molecular-weight heparins. However, the heterogeneity of the cancer population in terms of site, type and stage of the malignancy, the presence of comorbidities, and the variability in cancer treatment and prognosis represent major challenges in the management of VTE in patients with cancer. In the present review, we will discuss clinical questions that represent unsolved issues in the setting of cancer-associated VTE and provide an overview on recent evidence on this topic: primary prophylaxis in ambulatory cancer patients treated with chemotherapy and in cancer surgical patients, need of long-term anticoagulation in cancer patients, treatment of VTE in cancer patients at increased bleeding risk and in special categories such as incidental VTE, splanchnic vein thrombosis or catheter-related thrombosis.

Sclerotherapy of lower limb veins: Indications, contraindications and treatment strategies to prevent complications - A consensus document of the International Union of Phlebology-2023

BACKGROUND

Sclerotherapy is a non-invasive procedure commonly used to treat superficial venous disease, vascular malformations and other ectatic vascular lesions. While extremely rare, sclerotherapy may be complicated by serious adverse events.

OBJECTIVES

To categorise contraindications to sclerotherapy based on the available scientific evidence.

METHODS

An international, multi-disciplinary panel of phlebologists reviewed the available scientific evidence and developed consensus where evidence was lacking or limited.

RESULTS

Absolute Contraindications to sclerotherapy where the risk of harm would outweigh any benefits include known hypersensitivity to sclerosing agents; acute venous thromboembolism (VTE); severe neurological or cardiac adverse events complicating a previous sclerotherapy treatment; severe acute systemic illness or infection; and critical limb ischaemia. Relative Contraindications to sclerotherapy where the potential benefits of the proposed treatment would outweigh the risk of harm or the risks may be mitigated by other measures include pregnancy, postpartum and breastfeeding; hypercoagulable states with risk of VTE; risk of neurological adverse events; risk of cardiac adverse events and poorly controlled chronic systemic illness. Conditions and circumstances where Warnings and Precautions should be considered before proceeding with sclerotherapy include risk of cutaneous necrosis or cosmetic complications such as pigmentation and telangiectatic matting; intake of medications such as the oral contraceptive and other exogenous oestrogens, disulfiram and minocycline; and psychosocial factors and psychiatric comorbidities that may increase the risk of adverse events or compromise optimal treatment outcomes.

CONCLUSIONS

Sclerotherapy can achieve safe clinical outcomes provided that (1) patient-related risk factors and in particular all material risks are (1a) adequately identified and the risk benefit ratio is clearly and openly discussed with treatment candidates within a reasonable timeframe prior to the actual procedure; (1b) when an individual is not a suitable candidate for the proposed intervention, conservative treatment options including the option of 'no intervention as a treatment option' are discussed; (1c) complex cases are referred for treatment in controlled and standardised settings and by practitioners with more expertise in the field; (1d) only suitable individuals with no absolute contraindications or those with relative contraindications where the benefits outweigh the risks are offered intervention; (1e) if proceeding with intervention, appropriate prophylactic measures and other risk-mitigating strategies are adopted and appropriate follow-up is organised; and (2) procedure-related risk factors are minimised by ensuring the treating physicians (2a) have adequate training in general phlebology with additional training in duplex ultrasound, procedural phlebology and in particular sclerotherapy; (2b) maintain their knowledge and competency over time and (2c) review and optimise their treatment strategies and techniques on a regular basis to keep up with the ongoing progress in medical technology and contemporary scientific evidence.

Mitigating acute chemotherapy-associated adverse events in patients with cancer

Despite the enthusiasm surrounding novel targeted agents and immunotherapies, chemotherapy remains the mainstay treatment for most human malignancies, either alone or in combination. Yet, the burden of chemotherapy-associated adverse events (CAAEs) remains high and, importantly, is associated with considerable morbidity, mortality and costs that affect patients across multiple dimensions, including physical, emotional and social functioning. CAAEs can directly affect patient outcomes and indirectly increase the risk of cancer recurrence by compromising treatment intensity and continuity. Systematic efforts to identify and critically summarize the evidence on management approaches for CAAEs remain limited. Herein, we review the most common acute CAAEs having a major effect on survival, quality of life, function and/or continuation of optimal therapy. We focus on selected acute toxicities that occur during treatment, summarizing their underlying pathophysiology, multifactorial aetiologies, evidenced-based treatments, prevention strategies and management recommendations. We also summarize the available evidence on risk factors, validated risk assessment tools and other efforts to optimize symptom control in patients most likely to benefit in order to personalize the prevention and treatment of acute CAAEs. Finally, we discuss innovative symptom monitoring and supportive care interventions that are under development to further improve the outcomes of patients with cancer.

Advanced lung cancer patient with isolated heparin-induced thrombocytopenia: A case report

RATIONALE

Heparin-induced thrombocytopenia (HIT), a potentially devastating form of drug-induced thrombocytopenia, occurs in patients receiving heparin for thrombosis prevention or treatment. An isolated HIT is characterized by decreased platelet counts without thrombosis, which are atypical and difficult to clinically find.

SYMPTOMS AND CLINICAL FINDINGS

A 33-year-old female patient's admission examination revealed elevated D-dimer levels. After prophylactic anticoagulation using low-molecular weight heparin, her blood platelet counts were rapidly decreased, whereas her D-dimer levels increased, followed by presentations of chest tightness, abdominal pain, and skin itching without thrombosis. After excluding all the other causes of thrombocytopenia, HIT was suspected. Her 4Ts score was 5 points, and enzyme-linked immunoassay for platelet factor 4 (PF4)/heparin antibodies was positive, indicating isolated HIT.

DIAGNOSES, INTERVENTIONS, AND OUTCOMES

The patient was diagnosed with advanced lung cancer presenting with isolated HIT. We immediately stopped low-molecular weight heparin and initiated rivaroxaban for anticoagulation. We administered thrombopoietin (TPO) and avatripopal maleate tablets to increase blood platelet counts, whereas intravenous immunoglobulin (IVIG) was administered to stimulate her immune system. The patient's thrombocytopenia was successfully treated without thrombosis and bleeding complications.

LESSONS

Rivaroxaban is a potential option for tumor preventive anticoagulation and HIT treatment. Early HIT identification is necessary. After identification, the 4Ts score as well as PF4/heparin antibodies should be assessed and appropriate anticoagulants selected based on patients' conditions.

Arguments for Using Direct Oral Anticoagulants in Cancer-Related Venous Thromboembolism

(1) Background: Patients with cancer with a hypercoagulable state present an increased incidence of venous thromboembolism (VTE). Neoplastic patients with concurrent VTE undergoing anticoagulant treatment face a series of issues. (2) The aim of the present paper is to systematically summarize current VTE management in patients with neoplasia and to review the current clinical evidence from meta-analyses of randomized controlled trials and guidelines regarding the administration of direct oral anticoagulants (DOACs) for cancer-associated VTE. (3) Search Strategy: We performed a review on meta-analyses of randomized controlled trials and guidelines in favor of the administration of DOACs in patients with cancer-associated VTE published in the last 6 years in the Medline (PubMed) and Embase databases. (4) Results: 21 meta-analyses, 14 randomized controlled studies comparing DOACs to VKAs and LMWH, and 7 national and international guidelines were identified. We identified five studies that show the antineoplastic effect of DOAC on experimental models. (5) Conclusions: DOACs can be seen as the first choice for VTE treatment in neoplastic patients who have a low risk of bleeding, who do not have severe renal impairment, and who are not undergoing treatments that could interact with DOAC's mechanism of action.

Clinical factors and outcomes of subsegmental pulmonary embolism in cancer patients

In the cancer population, patients diagnosed with venous thromboembolism (VTE) are considered to have a threefold increased risk of mortality compared with those without VTE. With the advent of modern computed tomography (CT), the rate of diagnosis of subsegmental pulmonary embolism (SSPE) has increased, likely as a result of improved visualization of the peripheral pulmonary arteries. The clinical significance of SSPE remains unclear because of the lack of randomized controlled clinical trials. The aim of this study was to identify the incidence and risk factors of recurrent proximal PE within 12 months of diagnosis of SSPE in cancer. We performed a retrospective analysis of 206 adult cancer patients who were diagnosed with SSPE from 2014 to 2016 at the University of Texas MD Anderson Cancer Center. At the time of SSPE diagnosis, the majority had metastatic cancer, 108 patients (53.2%) were undergoing chemotherapy, and 23 patients (11.2%) had a history of VTE. Most patients had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 2. Sixty-seven percent of SSPE was discovered incidentally on restaging CT scans, with the majority being a single and isolated event (70.9%). Within 12 months of SSPE diagnosis, 18 patients (8.7%) were found to have a recurrent PE. The patients treated with anticoagulation had a lower rate of PE recurrence (8% vs 13% in those not treated with anticoagulation). Treatment with anticoagulation did not appear to have a significant impact on overall survival (P = .48) when adjusted for ECOG performance status and cancer stage.

Risk Prediction and New Prophylaxis Strategies for Thromboembolism in Cancer

In the general population, the incidence of thromboembolic events is 117 cases/100,000 inhabitants/year, while in cancer patient incidence, it is four-fold higher, especially in patients who receive chemotherapy and who are affected by pancreatic, lung or gastric cancer. At the basis of venous thromboembolism (VTE) there is the so-called Virchow triad, but tumor cells can activate coagulation pathway by various direct and indirect mechanisms, and chemotherapy can contribute to VTE onset. For these reasons, several studies were conducted in order to assess efficacy and safety of the use of anticoagulant therapy in cancer patients, both in prophylaxis setting and in therapy setting. With this review, we aim to record principal findings and current guidelines about thromboprophylaxis in cancer patients, with particular attention to subjects with additional risk factors such as patients receiving chemotherapy or undergoing surgery, hospitalized patients for acute medical intercurrent event and patients with central venous catheters. Nonetheless we added a brief insight about acute and maintenance therapy of manifested venous thromboembolism in cancer patients.

Venous Thromboembolism in Cancer Patients on Simultaneous and Palliative Care

Simultaneous care represents the ideal integration between early supportive and palliative care in cancer patients under active antineoplastic treatment. Cancer patients require a composite clinical, social and psychological management that can be effective only if care continuity from hospital to home is guaranteed and if such a care takes place early in the course of the disease, combining standard oncology care and palliative care. In these settings, venous thromboembolism (VTE) represents a difficult medical challenge, for the requirement of acute treatments and for the strong impact on anticancer therapies that might be delayed or, even, totally discontinued. Moreover, cancer patients not only display high rates of VTE occurrence/recurrence but are also more prone to bleeding and this forces clinicians to optimize treatment strategies, balancing between hemorrhages and thrombus formation. VTE prevention is, therefore, regarded as a double-edged sword. Indeed, while on one hand the appropriate use of antithrombotic agents can reduce VTE occurrence, on the other it significantly increases the bleeding risk, especially in the frail patients who present with multiple co-morbidities and poly-therapy that can interact with anticoagulant drugs. For these reasons, thromboprophylaxis should start while active cancer treatment is ongoing, according to a simultaneous care model in a patient-centered perspective.