Incidence of venous thromboembolism in patients with non-Hodgkin lymphoma

Evaluation of the incidence, predictors, risk assessment scores and outcomes of thromboembolism in a cohort of Egyptian NHL patients - Real World Experience

Non-Hodgkin's Lymphoma (NHL) is the most common subtype of lymphoma. The incidence of venous thromboembolism (VTE) in aggressive NHL was estimated recently to be 11%. Several risk assessment scores and factors are available to help identify cancer patients at risk for developing VTE. Patients with a pathologically confirmed diagnosis of NHL were identified at the Oncology Center of Mansoura University. The study included 777 patients: 719 with DLBCL-NOS, 26 with Anaplastic-B-cell, and 32 with T-cell-rich-NHL. Data were retrospectively collected from electronic medical records, including clinical, radiological, and laboratory information related to VTE and NHL. The median age at NHL diagnosis was 53 years, (range: 18-98). There was a male predominance, 51.4% of the cases. At initial lymphoma diagnosis, VTE was identified in 46 (5.9%) patients, and 61 (7.9%) patients experienced VTE while undergoing chemotherapy. According to logistic regression analysis, a PS (performance status) ≥ 2, bulky lesions, and mediastinal masses were significant predictors of VTE at presentation, with P-values of 0.022, 0.002, and < 0.001, respectively. Meanwhile, NHL patients who developed VTE during chemotherapy had significantly poorer PS, higher absolute neutrophilic counts (ANC), neutrophil/lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and lactate dehydrogenase (LDH) levels than lymphoma patients without VTE, with P-values of 0.003,  0.034, 0.049, 0.01 and 0.007, respectively, as determined by multivariate analysis. The ROC curve identified the cut-off values of 4.875 × 109/L for ANC, 2.985 for NLR, 144.85 for PLR, and 417.5 U/L for LDH as potential markers for predicting VTE in NHL patients. Patients with a PS ≥ 2 and values exceeding these cut-offs for ANC, NLR, and PLR experienced significantly higher incidences of VTE than other groups, with P-values of 0.003, < 0.001, < 0.001, and < 0.001, respectively. At the end of the follow-up, the overall survival was significantly shortened by VTE occurring during chemotherapy, hypoalbuminemia,  intermediate-high and high international prognostic index (IPI) scores (intermediate-high and high), responses other than CR and relapse, all with P-values < 0.05. ECOG PS and Inflammatory markers such as NLR, PLR, and neutrophilic count could serve as predictors of the development of thrombotic events in patients with NHL-DLBCL. Additionally, the occurrence of VTE during chemotherapy is an independent poor prognostic marker for overall survival (OS).

Use of Eltrombopag to Improve Thrombocytopenia and Tranfusion Requirement in Anti-CD19 CAR-T Cell-Treated Patients

Background/Objectives: Immune effector cell-associated hematotoxicity (ICAHT) is a frequent adverse event after chimeric antigen receptor (CAR)-T cell therapy. Grade ≥ 3 thrombocytopenia occurs in around one-third of patients, and many of them become platelet transfusion-dependent. Eltrombopag is a thrombopoietin receptor agonist (TPO-RA) able to accelerate megakaryopoiesis, which has been used successfully in patients with bone marrow failure and immune thrombocytopenia (ITP). Its role in managing thrombocytopenia and other cytopenias in CAR-T cell-treated patients has been scarcely addressed. Our aim was to report the safety and efficacy of this approach in patients included in the Spanish Group for Hematopoietic Transplantation and Cellular Therapy (GETH-TC) registry. Methods: This is a retrospective, multicenter, observational study. Patients who developed platelet transfusion dependence subsequently to CAR-T cells and received eltrombopag to improve platelet counts were recruited in 10 Spanish hospitals. Results: Thirty-eight patients were enrolled and followed up for a median (interquartile range [IQR]) of 175 (99, 489) days since CAR-T cell infusion. At the moment eltrombopag was indicated, 18 patients had thrombocytopenia and another severe cytopenia, while 8 patients had severe pancytopenia. After 32 (14, 38) days on eltrombopag, 29 (76.3%) patients recovered platelet transfusion independence. The number of platelet units transfused correlated with the time needed to restore platelet counts higher than 20 × 109/L (Rho = 0.639, p < 0.001). Non-responders to eltrombopag required more platelet units (58 [29, 69] vs. 12 [6, 26] in responders, p = 0.002). Nineteen out of twenty-three (82.6%) patients recovered from severe neutropenia after 22 (11, 31) days on eltrombopag. Twenty-nine out of thirty-five (82.9%) patients recovered red blood cell (RBC) transfusion independence after 29 (17, 44) days. Seven patients recovered all cell lineages while on treatment. No thromboembolic events were reported. Only two transient toxicities (cholestasis, hyperbilirubinemia) were reported during eltrombopag treatment, none of which compelled permanent drug withdrawal. Conclusions: Eltrombopag could be safely used to manage thrombocytopenia and accelerate transfusion independence in CAR-T cell-treated patients.

Incidence of and risk factors for venous thrombosis in hospitalized patients with hematologic malignancies: A single-center, prospective cohort study

OBJECTIVE

Incidence of venous thromboembolism (VTE) is higher than the expected in patients with hematologic malignancies and duration of hospitalization period increases the risk of thrombosis. The objective of this study was to investigate the incidence of and risk factors for venous thrombosis in hospitalized patients with hematologic malignancies.

METHODS

We designed a prospective cohort study and enrolled patients with hematologic malignancies, who had been hospitalized between 2020 and 2021. Thromboprophylaxis was given to all patients, other than those under a high risk of hemorrhage.

RESULTS

94 patients were enrolled. The incidence of superficial vein thrombosis was 11.7% and the incidence of deep vein thrombosis (including pulmonary embolism and catheter thrombosis) was 7.4%. Patients, who developed thrombosis, had statistically significantly longer hospital stays (21 vs. 11.5 days, p=0.023) and a higher number of hospitalizations (1 vs. 3, p=0.015) compared to those, who did not develop thrombosis. Patients, who had 3 or more risk factors for thrombosis, were found to be under the highest risk. (p=0.017, OR=4.32; 95% CI: 1.3-14.35). Furthermore, patients with recurrent hospitalizations (p=0.024, OR=1.49; 95% CI: 1.05-2.11) and higher fibrinogen levels (p=0.028, OR=1; 95% CI: 1-1.006) were under an increased risk of thrombosis.

CONCLUSION

Venous thrombosis is frequently seen in hospitalized patients with hematologic malignancies. A universally accepted risk scoring system is required for detection of patients, under a high risk for thrombosis.

Thrombosis risk prediction in lymphoma patients: A multi-institutional, retrospective model development and validation study

Venous thromboembolism (VTE) poses a significant risk to cancer patients receiving systemic therapy. The generalizability of pan-cancer models to lymphomas is limited. Currently, there are no reliable risk prediction models for thrombosis in patients with lymphoma. Our objective was to create a risk assessment model (RAM) specifically for lymphomas. We performed a retrospective cohort study to develop Fine and Gray sub-distribution hazard model for VTE and pulmonary embolism (PE)/ lower extremity deep vein thrombosis (LE-DVT) respectively in adult lymphoma patients from the Veterans Affairs national healthcare system (VA). External validations were performed at the Harris Health System (HHS) and the MD Anderson Cancer Center (MDACC). Time-dependent c-statistic and calibration curves were used to assess discrimination and fit. There were 10,313 (VA), 854 (HHS), and 1858 (MDACC) patients in the derivation and validation cohorts with diverse baseline. At 6 months, the VTE incidence was 5.8% (VA), 8.2% (HHS), and 8.8% (MDACC), respectively. The corresponding estimates for PE/LE-DVT were 3.9% (VA), 4.5% (HHS), and 3.7% (MDACC), respectively. The variables in the final RAM included lymphoma histology, body mass index, therapy type, recent hospitalization, history of VTE, history of paralysis/immobilization, and time to treatment initiation. The RAM had c-statistics of 0.68 in the derivation and 0.69 and 0.72 in the two external validation cohorts. The two models achieved a clear differentiation in risk stratification in each cohort. Our findings suggest that easy-to-implement, clinical-based model could be used to predict personalized VTE risk for lymphoma patients.

Cancer-associated thrombosis in hematologic malignancies

Patients with hematologic malignancies are often complicated not only by severe bleeding due to thrombocytopenia and disseminated intravascular coagulation but also by thromboembolic events, just like in patients with solid cancers, and these events can negatively impact patient outcomes. Nevertheless, the prevention and treatment of cancer-associated thrombosis (CAT) in hematologic malignancies has not been adequately investigated due to the limited size, heterogeneity, and unique pathophysiology of the patient population. This article summarizes the current understanding, risk factors, prediction models, and optimal prevention and treatment strategies of CAT in hematologic malignancies on a disease-by-disease basis, including acute leukemia, lymphoma, myeloma, and myeloproliferative neoplasms. Specific considerations of novel molecular targeted therapeutics introduced in recent years, such as immunomodulatory drugs and tyrosine kinase inhibitors, are also discussed based on the latest clinical trials.

Zanubrutinib-lenalidomide-rituximab (ZR2) in unfit diffuse large B-cell lymphoma: efficient and tolerant

The objective of this study is to examine the effectiveness and safety of zanubrutinib, rituximab, and lenalidomide (ZR2) in unfit patients with diffuse large B-cell lymphoma (DLBCL). Thrombosis or bleeding risk of ZR2 regimen, especially when antiplatelet agents were co-prescribed, was also evaluated. We retrospectively reviewed unfit newly diagnosed (ND) and refractory or relapsed (R/R) patients with DLBCL who were administered with ZR2 regimen in two medical centers between December 2019 and February 2022. Response rates, progression-free survival (PFS), overall survival (OS), bleeding adverse events (AEs), and thrombosis episodes were analyzed. Furthermore, we investigated the effects of zanubrutinib alone or in combination with lenalidomide on platelet functions in vitro and in vivo. A total of 30 unfit patients (13 ND DLBCL and 17 R/R DLBCL patients) who received ZR2 regimen were enrolled in the study (median age: 69.5 years). The ultimate ORRs for the ND DLBCL and R/R DLBCL were 77.0% and 50.1%, respectively. The median follow-up was 16.6 months. The median PFS and OS were not achieved during the follow-up time. Subcutaneous hemorrhage AEs occurred in four cases, three cases suffered severe bleeding events, and thrombosis events were observed in two patients. ZR2 regimen inhibited platelet functions (aggregation, clot retraction, spreading and activation) in vitro and in vivo function testing especially in response to collagen. ZR2 is an efficient treatment option for unfit patients with DLBCL and could be well tolerated. Notably, this regimen inhibited platelet functions. Antiplatelet agents should be used with caution in patients treated with this regimen.

Nonthrombotic Pulmonary Embolism Associated With Non-Hodgkin Lymphoma

Nonthrombotic pulmonary embolism (NTPE) challenges the medical community with its diverse etiologies and potential life-threatening implications. The classification section delves into the multifaceted nature of NTPE, which includes various embolic agents that traverse the vascular system. From air and fat emboli to tumor and amniotic fluid emboli, this exploration of diverse etiologies sheds light on the complexity of NTPE. Diagnostic methods play a crucial role in the effective management of NTPE. This article describes a range of traditional and cutting-edge diagnostic techniques, from computed tomography angiography to novel biomarkers, enabling the accurate and timely identification of NTPE. NTPE treatment options are diverse and patient-specific, requiring customized approaches to address varying embolic sources. Anticoagulation, embolus removal, and emerging interventions under study are discussed, providing clinicians with a comprehensive understanding of management strategies. This article uncovers the rare but captivating association between NTPE and non-Hodgkin lymphoma. Although rare, documented cases have sparked curiosity among researchers and medical practitioners. We explore potential pathophysiological connections, discussing challenges and considerations when encountering this unique scenario. In conclusion, this captivating review encapsulates the multifaceted realm of NTPE, covering its classification, diagnostics, and treatment modalities. Moreover, it presents a fascinating connection with non-Hodgkin lymphoma. This article offers a comprehensive and concise review of NTPE, guiding readers through its intricate classification, diagnostic approaches, and therapeutic interventions.

Map of thrombogenesis in viral infections and viral-driven tumours

Viruses are pathogenic agents responsible for approximately 10% of all human cancers and significantly contribute to the global cancer burden. Until now, eight viruses have been associated with the development of a broad range of malignancies, including solid and haematological tumours. Besides triggering and promoting oncogenesis, viral infections often go hand-in-hand with haemostatic changes, representing a potential risk factor for venous thromboembolism (VTE). Conversely, VTE is a cardiovascular condition that is particularly common among oncological patients, with a detrimental impact on patient prognosis. Despite an association between viral infections and coagulopathies, it is unclear whether viral-driven tumours have a different incidence and prognosis pattern of thromboembolism compared to non-viral-induced tumours. Thus, this review aims to analyse the existing evidence concerning the association of viruses and viral tumours with the occurrence of VTE. Except for hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infection, which are associated with a high risk of VTE, little evidence exists concerning the thrombogenic potential associated with oncoviruses. As for tumours that can be induced by oncoviruses, four levels of VTE risk are observed, with hepatocellular carcinoma (HCC) and gastric carcinoma (GC) associated with the highest risk and nasopharyngeal carcinoma (NPC) associated with the lowest risk. Unfortunately, the incidence of cancer-related VTE according to tumour aetiology is unknown. Given the negative impact of VTE in oncological patients, research is required to better understand the mechanisms underlying blood hypercoagulability in viral-driven tumours to improve VTE management and prognosis assessment in patients diagnosed with these tumours.

Characteristics and Predictors of Venous Thromboembolism Among Lymphoma Patients Undergoing Chemotherapy: A Cohort Study in China

Background: Venous thromboembolism (VTE) is a potential complication among lymphoma patients. We evaluated the incidence rate and predictors of VTE in lymphoma patients undergoing chemotherapy.

Methods: The present study retrospectively studied 1,069 patients with lymphoma who were treated with chemotherapy from 2018 to 2020. We investigated clinical predictors of VTE among all patients. The follow-up results were obtained via telephone communication and from inpatient and outpatient records.

Results: A total of 1,069 patients underwent chemotherapy for lymphoma. During a mean follow-up of 23.1 months, 52 (4.9%) patients developed VTE. According to a multivariate analysis, the five variables found to be independently associated with VTE were male sex (HR 2.273, 95% CI 1.197–4.316, p = 0.012), age >64-years-old (HR 2.256, 95% CI 1.017–5.005, p = 0.045), the number of cycles of chemotherapy (HR 4.579, 95% CI 1.173–17.883, p = 0.029), platelet count ≥350 × 10⁹/L (HR 2.533, 95% CI 1.187–5.406, p = 0.016), and D-dimer >0.5 mg/L (HR 4.367, 95% CI 2.124–8.981, p < 0.001).

Conclusion: This population-based study confirms the risk factors for VTE among patients with lymphoma who underwent chemotherapy and confirms that targeted thromboprophylaxis may reduce the burden of VTE in this population.

Immune activation and inflammatory biomarkers as predictors of venous thromboembolism in lymphoma patients

Background

Lymphomas are characterized by elevated synthesis of inflammatory soluble mediators that could trigger the development of venous thromboembolism (VTE). However, data on the relationship between specific immune dysregulation and VTE occurrence in patients with lymphoma are scarce. Therefore, this study aimed to assess the association between inflammatory markers and the risk of VTE development in patients with lymphoma.

Methods

The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lactate dehydrogenase (LDH), total protein (TP), and albumin were assessed in 706 patients with newly diagnosed or relapsed lymphoma. Data were collected for all VTE events, while the diagnosis of VTE was established objectively based on radiographic studies. ROC (receiver operating characteristic) curve analysis was performed to define the optimal cutoff values for predicting VTE.

Results

The majority of patients was diagnosed with aggressive non-Hodgkin lymphoma (58.8%) and had advanced stage disease (59.9%). Sixty-nine patients (9.8%) developed VTE. The NLR, PLR, ESR, CRP, and LDH were significantly higher in the patients with lymphoma with VTE, whereas the TP and albumin were significantly lower in those patients. Using the univariate regression analysis, the NLR, PLR, TP, albumin, LDH, and CRP were prognostic factors for VTE development. In the multivariate regression model, the NLR and CRP were independent prognostic factors for VTE development. ROC curve analysis demonstrated acceptable specificity and sensitivity of the parameters: NLR, PLR, and CRP for predicting VTE.

Conclusion

Inflammatory dysregulation plays an important role in VTE development in patients with lymphoma. Widely accessible, simple inflammatory parameters can classify patients with lymphoma at risk of VTE development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12959-022-00381-3.

Venous-thromboembolism and associated health care utilization in elderly patients with diffuse large B cell lymphoma

BACKGROUND

Patients with lymphoma have an increased risk of venous thromboembolism (VTE). The authors examined the risk of VTE and subsequent health care utilization in elderly patients with diffuse large B cell lymphoma (DLBCL).

METHODS

A total of 5537 DLBCL patients ≥66 years old enrolled in Medicare from the Surveillance, Epidemiology, and End Results registry and a noncancer control group of Medicare beneficiaries (n = 5537) were identified. Cumulative incidence function to examine the risk of VTE 12 months after DLBCL diagnosis was used. Fine and Gray method was used to examine the risk factors associated with VTE risk in multivariable models. Total number of hospitalizations, outpatient visits, and Medicare spending were compared in DLBCL patients with and without VTE.

RESULTS

VTE was diagnosed in 8.3% DLBCL patients and 1.5% controls, yielding an 8.6-fold higher risk of VTE in DLBCL in adjusted analysis (95% confidence interval [CI], 6.62-11.20; P < .001). Multivariable regression analysis showed that precancer VTE history was associated with an increased risk of developing VTE after a DLBCL diagnosis (hazard ratio [HR], 5.39; 95% CI, 4.39-6.63), and Asian individuals were associated with a lower risk (HR, 0.54; 95% CI, 0.29-1.00). Patients newly diagnosed with VTE after lymphoma had a 1.7-fold higher rate of hospitalization and a 1.2-fold higher rate of outpatient visits compared to those without, resulting in excess Medicare spending of $22,208 in the first year after DLBCL diagnosis.

CONCLUSIONS

Elderly patients with DLBCL have an elevated risk of VTE resulting in excess health care utilization. VTE history before DLBCL was associated with increased risk of post-DLBCL VTE, and Asian individuals were associated with a lower risk of VTE.

Prevention of venous thromboembolism in hematologic neoplasms: an expert consensus from SEHH-SETH

Venous thromboembolism (VTE) is a serious complication in hematologic neoplasms, so finding adequate prevention strategies is an urgent requirement. However, prospective studies with large enough cohorts are scarce, limiting the development of evidence-based thromboprophylaxis guidelines. The present position paper is addressed to all hematologists treating patients affected by hematologic neoplasms with the aim to provide clinicians with a useful tool for the prevention of VTE.

The Application of the ThroLy Risk Assessment Model to Predict Venous Thromboembolism in Patients with Diffuse Large B-Cell Lymphoma

Background

Patients with aggressive lymphomas are at higher risk for venous thromboembolism (VTE). ThroLy is a risk assessment model (RAM) derived to predict the occurrence of VTE in various types of lymphomas. In this study, we assess the clinical application of ThroLy RAM in a unified group of patients with diffuse large B-cell lymphoma (DLBCL).

Methods

Hospital databases were searched for patients with DLBCL and radiologically-confirmed VTE. Items in the ThroLy RAM, including prior VTE, reduced mobility, obesity, extranodal disease, mediastinal involvement, neutropenia and hemoglobin < 10.0 g/dL, were retrospectively reviewed.

Results

A total of 524 patients, median age 49 (range: 18-90) years were included. Patients had high disease burden; 57.3% with stage III/IV and 34.0% with bulky disease. All were treated on unified guidelines; 63 (12.0%) had primary refractory disease. Venous thromboembolic events were reported in 71 (13.5%) patients. Among 121 patients with high (> 3) ThroLy score, 22.3% developed VTE compared to 8.4% and 12.4% in those with low and intermediate risk scores, respectively (P = .014). Simplifying the ThroLy model into two risk groups; high-risk (score ≥ 3) and low risk (score < 3) can still segregate patients; VTE developed in 44 (17.2%) high-risk patients (n = 256) compared to 27 (10.1%) in the low-risk group (n = 268), P = .038. Neutropenia, a component of the ThroLy, was encountered in only 14 (2.7%) patients.

Conclusions

ThroLy RAM can identify patients with DLBCL at high risk for VTE. Model can be modified by dividing patients into two, rather than three risk groups, and further simplified by omitting neutropenia.

How I treat and prevent venous thrombotic complications in patients with lymphoma

Venous thromboembolism (VTE) is a common complication occurring in 5-10% of patients with lymphoma. As the complexity of lymphoma management has increased with novel therapies, so too has the treatment of VTE. Therapeutic options for the treatment of cancer-associated VTE have expanded from only warfarin and low-molecular-weight heparins (LMWHs) to include the direct oral anticoagulants (DOACs) apixaban, edoxaban and rivaroxaban. There have been no head-to-head trials comparing different DOACs in this setting and randomized trials comparing a DOAC with LMWH dalteparin differ in trial design and results. Drug-drug interactions, drug-specific side effects and patient selection are important considerations when prescribing anticoagulant therapy. In all patients, the relative risks of thrombosis and bleeding, the availability of the anticoagulant, and the life expectancy of the patient are vital elements in selecting the most appropriate anticoagulant (which can vary over time) for the individual patient. We describe the intricacies and challenges of treating thrombotic complications in patients with lymphoma with an emphasis on evidence and guideline-based care.

Predisposing factors and effect of bundle nursing in PICC-related upper extremity deep venous thrombosis in patients with non-Hodgkin's lymphoma undergoing chemotherapy

OBJECTIVE

To explore the effects of bundle nursing on PICC-related upper extremity deep venous thrombosis (PICC-UEDVT) in patients with non-Hodgkin's lymphoma (NHL) who are undergoing chemotherapy, and contributing factors toward PICC-UEDVT.

METHODS

370 NHL patients undergoing chemotherapy in the Department of Hematology were selected prospectively and randomized into a control group (receiving routine nursing) and an observation group (receiving bundle nursing) using random number method. There were 185 patients in each group. The incidence of PICC-UEDVT and satisfaction rate towards nursing were calculated and risk factors for PICC-UEDVT were explored in the two groups.

RESULTS

The incidence of PICC-UEDVT was lower in the observation group (18 patients, 9.73%) than that of the control group (35 patients, 18.92%; P<0.05); the satisfaction rate towards nursing was higher in the observation group than the control group (P<0.05). Tumor stage, ECOG score >2, hemoglobin <100 g/L, and D-dimer >0.5 mg/L were factors that contributed to the occurrence of PICC-UEDVT in NHL patients (P<0.05).

CONCLUSION

Tumor stage, ECOG score >2, reduced hemoglobin, and increased D-dimer levels are predisposing factors for PICC-UEDVT in NHL patients. However, bundle nursing can reduce the incidence of PICC-UEDVT and increase the satisfaction rate towards nursing.

Venous thromboembolic events in T-cell lymphoma patients: Incidence, risk factors and clinical features

INTRODUCTION

Patients with hematologic malignancies are prone to developing thromboembolism. The incidence, risk factors and clinical features for developing venous thromboembolism (VTE) are not well-elucidated in patients with T-cell lymphoma.

MATERIALS AND METHODS

The present study retrospectively analyzed 668 patients with VTE, including pulmonary embolism (PE) and deep vein thrombosis (DVT), who were admitted to Tianjin Medical University Cancer Institute and Hospital and Sun Yat-sen University Cancer Center from January 2006 to December 2018. All patients were diagnosed with T-cell lymphoma, and all episodes of symptomatic VTE were confirmed by imaging and ultrasound. The follow-up results were obtained through telephone communication and outpatient visits.

RESULTS

A total of 668 patients were analyzed. Thirty-three (4.94%) patients had at least one episode of VTE, and all of which were deep vein thrombosis alone. All VTEs occurred in patients who received chemotherapy, while no VTE occurred in patients who did not receive chemotherapy. By univariate analysis, central venous catheter (CVC) (odds ratio [OR] 6.63, confidence interval [CI] 2.24-19.57, P = 0.001), Eastern Cooperative Oncology Group (ECOG) performance status 2, 3, or 4 (OR: 62.15, CI: 15.42-250.48, P = 0.000), and stage III or IV (OR: 4.06, CI: 1.00-16.40, P = 0.049) were identified as risk factors for developing VTE. By multivariate analysis, CVC (OR: 3.23, CI: 1.49-7.23, P = 0.003) and stage III or IV (OR: 2.30, CI: 1.06-4.97, P = 0.035) were still significant risk factors for developing VTE.

CONCLUSION

The incidence of VTE in the present study population was comparable to that of lymphoma patients, other than T-cell lymphoma, and VTE was associated with CVC and advanced stage.

Cancer Therapy-Associated Thrombosis

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Prevalence of Venous Thromboembolism in Kumasi: A Postmortem-Based Study in a Tertiary Hospital in Ghana

Background

There is a dearth of publications on the prevalence of venous thromboembolism in Ghana. Knowledge of the prevalence of venous thromboembolism, which is often undetected clinically, will help save lives as appropriate interventions can be made as well as provide a general clue to clinicians on detecting venous thromboembolism and pulmonary embolism.

Methods

The study employs a retrospective design with data extracted from the Autopsy Daybook of the Pathology unit, Komfo Anokye Teaching Hospital, 2009 to 2016. Data on patients' demographics were retrieved to establish diagnoses and age and gender distribution. Analysis was made of pulmonary embolism and deep vein thrombosis as a cause of death recorded on death certificates using the criteria of the International Classification of Diseases, version 10.

Results

A total of 150 cases of deep vein thrombosis and/or pulmonary embolism were available for the study period and the results showed an average age of 45.3 years with a standard deviation of 19.96. The ages ranged between 3 years and 96 years with the age group 31 to 40 years being the modal age group. Males recorded the highest number of cases with 92 (59.35%) compared to females with 63 (40.65%). Respiratory disorders, of which pneumonia is the most prevalent, are the leading clinical condition that is often misdiagnosed in place of pulmonary thromboembolism.

Conclusion

VTE is a major health problem especially among the elderly, but unfortunately the clinical diagnosis is usually missed by clinicians hence the need to maintain a high suspicion index.

Venous thromboembolism in primary central nervous system lymphoma during frontline chemoimmunotherapy

BACKGROUND

In primary central nervous system lymphoma (PCNSL), venous thromboembolism (VTE) can cause significant morbidity and hinder chemotherapy delivery.

OBJECTIVES

To assess VTE incidence, timing and adequacy of inpatient and outpatient VTE prophylaxis in patients with PCNSL receiving chemoimmunotherapy with curative intent.

PATIENTS/METHODS

We reviewed patients diagnosed with PCNSL between 1997 and 2018 who received methotrexate, procarbazine, and vincristine ± Rituximab. Patient demographics, VTE prophylaxis and incidence, adverse events of anticoagulation, and survival outcomes were collected.

RESULTS

Fifty-one PCNSL patients were included (median 67 years [range, 32-87], 30 males [59%]). Thirteen patients (25%, 95% confidence interval [CI], 14-40) developed VTE at a median of 1.6 months from diagnosis (range, 0-4). Patients with Khorana Risk Score ≥2 were more likely to have VTE than those with a KRS < 2 (60% vs 15%; P = .01). Eighty-five percent had deviations from inpatient VTE prophylaxis guidelines, and outpatient prophylaxis was not routinely administered. Three patients required inferior vena cava filters. Hemorrhagic complications of anticoagulation included an intracranial hemorrhage from therapeutic anticoagulation and three cases of major bleeding from prophylactic anticoagulation. No patients died from VTE or its treatment.

CONCLUSIONS

Patients with newly diagnosed PCNSL are at high risk of VTE. Further research is required into optimal VTE prophylaxis in PCNSL.

Aggressive lymphoma subtype is a risk factor for venous thrombosis. Development of lymphoma - specific venous thrombosis prediction models

Venous thromboembolic events (VTE) are a frequent complication of lymphoma. We conducted a retrospective analysis to compare VTE risk in diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL). Subjects were randomly assigned to training and validation sets to identify risk factors of VTE and evaluate risk model performance, including the Khorana score. A group of 790 patients were diagnosed from 2002 to 2014 (DLBCL = 542, FL = 248). Median follow- up was 49 months. We observed 106 VTE, with higher incidence in DLBCL (5-year cumulative incidence = 16.3% vs 3.8% in FL patients). Five-year OS for patients with VTE was 51.4% vs 73.1% in patients without VTE (P < .001). Baseline VTE risk factors identified in the training cohort included lymphoma subtype, previous VTE, ECOG performance status ≥2, decreased albumin, increased calcium, elevated WBC, absolute lymphocyte count or monocyte count, and presence of bulky disease. Addition of new variables to the Khorana score improved its performance measured by Akaike information criterion and Concordance index. A new risk model including lymphoma subtype, albumin, WBC count, and bulky disease was validated in time-based ROC analyses. These findings were confirmed in the validation cohort. Lymphoma subtypes have different VTE risk. The effect of lymphoma subtype was independent from disease burden and the use of systemic therapy. The Khorana risk-score was validated in time to event analyses, and a more robust lymphoma-specific VTE risk score is proposed. These findings suggest lymphoma patients with highest VTE risk can be identified with baseline parameters.

Venous Thromboembolism in Lymphoma: Risk Stratification and Antithrombotic Prophylaxis

Lymphoma is listed among the neoplasias with a high risk of venous thromboembolism (VTE). Risk factors for VTE appear to differ from risk factors in solid tumors. We review the literature of the last 20 years for reports identifying these risk factors in cohorts consisting exclusively of lymphoma patients. We selected 25 publications. The most frequent studies were analyses of retrospective single-center cohorts. We also included two reports of pooled analyses of clinical trials, two meta-analyses, two analyses of patient registries, and three analyses of population-based databases. The VTE risk is the highest upfront during the first two months after lymphoma diagnosis and decreases over time. This upfront risk may be related to tumor burden and the start of chemotherapy as contributing factors. Factors consistently reported as VTE risk factors are aggressive histology, a performance status ECOG ≥ 2 leading to increased immobility, more extensive disease, and localization to particular sites, such as central nervous system (CNS) and mediastinal mass. Association between laboratory values that are part of risk assessment models in solid tumors and VTE risk in lymphomas are very inconsistent. Recently, VTE risk scores for lymphoma were developed that need further validation, before they can be used for risk stratification and primary prophylaxis. Knowledge of VTE risk factors in lymphomas may help in the evaluation of the individual risk-benefit ratio of prophylaxis and help to design prospective studies on primary prophylaxis in lymphoma.

Abnormal pretreatment coagulation factor levels correlate with poor prognosis in patients with early-stage extranodal nasal-type natural/killer T cell lymphoma

Coagulative dysfunction is frequently observed among patients with extranodal nasal-type natural killer/T cell lymphoma (NKTCL) in our clinical practice. However, the true prognostic value of coagulation factors in patients with NKTCL has not been evaluated systemically. Data for patients with stage I/II NKTCL who were treated in the Cancer Hospital, Chinese Academy of Medical Sciences, from January 2008 to January 2019 were collected retrospectively. The patients enrolled in this study were initially diagnosed as having early-stage disease. The patients' baseline characteristics and pretreatment laboratory tests for coagulation function, including fibrinogen (FIB) and D-dimer (D-D), were reviewed and analyzed. The influence of coagulative factors on the responses and prognosis of patients with early-stage NKTCL was evaluated. Among 394 patients assessed, 154 were included in this study. Abnormal coagulation function was found in nearly half of the patients (48.1%). Univariate analysis showed that reduced complete remission (CR) was associated with elevated D-D (P = 0.001) and elevated FIB levels (P = 0.006). The D-D level was demonstrated as associated with unfavorable progression-free survival (PFS) (P = 0.003) and overall survival (OS) (P = 0.002). Multivariate analysis indicated that an elevated D-D level was an independent factor for poor clinical response (P = 0.019), PFS (P = 0.046), and OS (P = 0.024). Elevated pretreatment levels of coagulation factors, especially D-D and plasma FIB, are unfavorable predictors for clinical response, OS, and PFS in early-stage NKTCL.

The Incidence of Venous Thromboembolism and Impact on Survival in Hodgkin Lymphoma

BACKGROUND

Thrombosis increase the acute and long-term morbidity and mortality in malignancy patients. We analyzed venous thromboembolism (VTE) in patients with Hodgkin lymphoma, the impact of VTE on survival, predisposing factors for VTE, and predicting value of Khorana and ThroLy score models.

PATIENTS AND METHODS

We included 150 adult patients with Hodgkin lymphoma between January 2010 and 2018 at our university hospital.

RESULTS

VTE was observed in 31 patients (20.7%). The types of VTE were 18 upper and 3 lower extremity deep vein thrombosis and 10 pulmonary embolism (1 with lower extremity deep vein thrombosis). Twenty-nine patients developed VTE during the treatment with a median time of episode as 5 months. In logistic regression analysis, a body mass index of >32 kg/m², high fibrinogen levels, initial thrombocytosis and leukocytosis, splenic and extranodal involvement, presence of a central venous line, advanced stage, line of treatment status of thromboprophylaxis, VTE timing, and better Eastern Cooperative Oncology Group performance scores were observed to be related with VTE. Kaplan Meier survival analysis showed a negative impact of VTE on survival. Khorana and ThroLy risk assessment models were found predictive for VTE (P = .000 and P = .003, respectively), although only ThroLy score was associated with the survival.

CONCLUSION

Thromboprophylaxis and precautions for VTE in patients with Hodgkin lymphoma according to validated risk assessment models can improve prognosis and quality of life owing to the impact of VTE on survival in the study.

Venous thromboembolic complications in lymphoma patients

Lymphomas represent a heterogeneous group of malignant hematological diseases with high risk for development of venous thromboembolic complications (VTE). Consequently, VTE significantly impacts morbidity and mortality in these patients. Another concern is the financial burden of the healthcare system caused by diagnostic and therapeutic procedures of cancer-associated thrombosis (CAT). The complex biology of lymphoma, in conjunction with patient and treatment related risk factors for the development of VTE, results in a procoagulant hemostatic dysregulation. Considering the incidence of VTE in patients with lymphoma, there is an emerging demand for both reliable risks assessment model (RAM) for prediction of VTE, as well as for effective VTE prophylaxis and treatment. The clinical course of patients with malignant diseases is accompanied by a wide range of potential treatment complications, making the task of prevention and treatment of VTE even more challenging. In recent years, great progress has been achieved in understanding the pathophysiological mechanisms of thrombotic complications, while the significant number of randomized controlled trials (RCT) have provided standards of prophylaxis and treatment of VTE complications in patients with malignancy. In comparison to previous recommendations and guidelines for CAT, the use of direct oral anticoagulants (DOAC) has been gradually approaching low molecular weight heparins (LMWH) in terms of efficacy and safety profile in these indications. This systematic review is focused on the latest pathophysiological advances, risk factors assessment, prophylactic and therapeutic recommendations and guidelines concerning VTE in patients with lymphoma.

Incidence and characteristics of venous thromboembolism in Asian patients with primary central nervous system lymphoma undergoing chemotherapy

BACKGROUND

Venous thromboembolism (VTE) may lead to diminished quality of life and ultimately worse prognosis in cancer patients, but there is limited data on the incidence, risk factors and mortality impact of VTE in Asian primary central nervous system lymphoma (PCNSL) patients.

OBJECTIVES

To report the incidence, risk factors and mortality impact of VTE in Asian PCNSL patients.

METHODS

From 7 academic centers in Korea, 235 newly diagnosed PCNSL patients undergoing chemotherapy were retrospectively identified during period of January 2004 to September 2018.

RESULTS

All patients but 12 (6 T-cell, 6 other B-cell) had diffuse large B-cell lymphoma. During the median follow-up of 21 months, 33 patient (14.0%) developed VTE. Of the VTE events, 11 (33.3%) were deep vein thrombosis (DVT), 15 (45.5%) were pulmonary thromboembolism (PTE), and 7 (21.2%) were DVT with PTE. The median time to VTE was 2 months and the one-year actuarial incidence was 11.7%. On multivariate analysis, ECOG performance ≥2, age >60 years, female sex, and Hb <10 g/dL were independently associated with VTE. The patients with VTE were associated with shorter disease specific survival (P = 0.046) and overall survival (P = 0.022).

CONCLUSION

Overall, the incidence of VTE in Asian PCNSL seems to be lower compared to Western population. As VTE development is associated with overall survival and indicative of relapse, careful close monitoring is warranted.

Risk of venous thromboembolism in patients with non-Hodgkin lymphoma surviving blood or marrow transplantation

BACKGROUND

Patients with non-Hodgkin lymphoma (NHL) have an increased risk of venous thromboembolism (VTE), particularly when they are receiving treatment. Blood or marrow transplantation (BMT) is recommended for relapsed/refractory NHL, and the risk of VTE after these patients undergo BMT is uncertain.

METHODS

Patients with NHL who survived 2 years or longer after BMT were surveyed for long-term health outcomes, including VTE. The median follow-up was 8.1 years (interquartile range, 5.6-12.9 years). The risk of VTE in 734 patients with NHL versus 897 siblings without a history of cancer and the risk factors associated with VTE were analyzed.

RESULTS

BMT survivors of NHL were at increased risk for VTE in comparison with siblings (odds ratio for allogeneic BMT survivors, 4.61; P < .0001; odds ratio for autologous BMT survivors, 1.75; P = .035). The cumulative incidence of VTE was 6.3% ± 0.9% at 5 years after BMT and 8.1% ± 1.1% at 10 years after BMT. In allogeneic BMT recipients, an increased body mass index (BMI; hazard ratio [HR] for BMI of 25-30 kg/m² , 3.52; 95% confidence interval [CI], 1.43-8.64; P = .006; HR for BMI > 30 kg/m² , 3.44; 95% CI, 1.15-10.23; P = .027) and a history of chronic graft-versus-host disease (HR, 3.33; 95% CI, 1.59-6.97; P = .001) were associated with an increased risk of VTE. Among autologous BMT recipients, a diagnosis of coronary artery disease (HR, 5.94; 95% CI, 1.7-20.71; P = .005) and prior treatment with carmustine (HR, 4.91; 95% CI, 1.66-14.51; P = .004) were associated with increased VTE risk.

CONCLUSIONS

Patients with NHL who survive BMT are at risk for developing late occurring VTE, and ongoing vigilance for this complication is required. Future studies assessing the role of thromboprophylaxis in high-risk patients with NHL are needed.

Clinical Characteristics of Patients With CRVO in One Eye With Subsequent RVO in The Fellow Eye: A Retrospective Observational Study

BACKGROUND AND OBJECTIVE

To compare risk factors in patients with a central retinal vein occlusion (CRVO) in the first eye and a subsequent retinal vein occlusion (RVO) in the fellow eye versus those with only unilateral CRVO.

PATIENTS AND METHODS

Records of patients who presented to the Duke Eye Center with unilateral CRVO were evaluated. Logistic regression models were performed to identify potential covariates of subsequent development of RVO in the fellow eye.

RESULTS

Of the 287 patients with CRVO in one eye, 31 (10.8%) developed an RVO in the fellow eye during a mean ± standard deviation follow-up of 36.7 months ± 38.86 months. The conversion rate of unilateral-to-bilateral RVO was 3.4% per year. Several comorbidities were observed to be unique to 25.8% of patients with bilateral RVO. Patients who used oral pentoxifylline (P = .008) or those who had an ischemic CRVO in the first eye (P = .001) were less likely to develop an RVO in the fellow eye.

CONCLUSION

This information may be used to develop a predictive model to assess the risk of developing bilateral RVO in patients with unilateral CRVO. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:444-449.].

Venous thromboembolism incidence in hematologic malignancies

Venous thromboembolism (VTE) remains a major cause of morbidity and mortality in patients with cancer. Although some very well validated scores delineate the risk of VTE by cancer subtype and other risk factors, hematologic malignancies are underrepresented in these models. This subgroup represents a unique entity that undergoes therapy that can be thrombogenic. The overall risk of VTE in patients with leukemia depends on the use of L-asparaginase treatment, older age, comorbidities and central venous catheters. Patients with acute promyelocytic leukemia are at particularly high risk of VTE but also have an increased risk of bleeding. Patients with aggressive lymphomas have a high incidence of VTE, roughly 10%. Patients with multiple myeloma at highest risk of VTE are those receiving immunomodulatory agents such as thalidomide or lenalidomide. Allogeneic stem cell transplantation carries a risk of thrombosis, particularly in patients developing graft versus host disease. This review summarizes the incidence of VTE in leukemia, lymphoma, myeloma and stem cell transplantation and provides practical guidance for preventing and managing VTE in patients with hematologic malignancies.

Venous thromboembolic events in lymphoma patients: Actual relationships between epidemiology, mechanisms, clinical profile and treatment

Venous thromboembolic events (VTE) are an underestimated health problem in patients with lymphoma. Many factors contribute to the pathogenesis of thromboembolism and the interplay between various mechanisms that provoke VTE is still poorly understood. The identification of parameters that are associated with an increased risk of VTE in lymphoma patients led to the creation of several risk-assessment models. The models that evaluate potential VTE risk in lymphoma patients in particular are quite limited, and have to be validated in larger study populations. Furthermore, the VTE prophylaxis in lymphoma patients is largely underused, despite the incidence of VTE. The lack of adequate guidelines for the prophylaxis and treatment of VTE in lymphoma patients, together with a cautious approach due to an increased risk of bleeding, demands great efforts to ensure the implementation of current knowledge in order to reduce the incidence and complications of VTE in lymphoma patients.

Epidemiology of venous thromboembolism in hematological cancers: The Scandinavian Thrombosis and Cancer (STAC) cohort

INTRODUCTION

Venous thromboembolism (VTE) is an important cause of morbidity and mortality in cancer patients, however the risk of VTE differs according to cancer type. Hematological cancers have varying phenotypes. Incidence rates (IR) of VTE in different hematological cancer types have not been investigated in a cancer-exposed subset of the general population.

METHODS

In a population-based cohort, we estimated incidence rates of VTE among patients with six subtypes of hematological cancer and among age and sex matched reference subjects.

RESULTS

During a mean follow-up of 4.8years, 30 objectively confirmed first-time symptomatic VTEs occurred among 838 subjects with hematological cancer. The IR of VTE was higher in all types of cancer except for indolent lymphoma but including chronic lymphocytic leukemia compared with reference subjects both during the first year after cancer diagnosis and 1-5years after diagnosis. IR of VTE for indolent lymphoma was not higher than controls.

CONCLUSION

The IRs of VTE were increased in all types of hematological cancer (including chronic lymphocytic leukemia) compared with reference subjects except indolent lymphomas.