Venous thromboembolism in patients with acute leukemia, lymphoma, and multiple myeloma

Venous thromboembolism in patients with acute myeloid leukemia: development of a predictive model

BACKGROUND

Patients with acute myeloid leukemia (AML) are at increased risk of venous thromboembolic events (VTE). However, thromboprophylaxis is largely underused.

OBJECTIVES

This study aimed to determine possible VTE development risk factors and to develop a novel predictive model.

METHODS

We conducted a retrospective cohort study of adult patients with newly diagnosed AML. We used univariate and multivariable logistic regression to estimate binary outcomes and identify potential predictors. Based on our final model, a dynamic nomogram was constructed with the goal of facilitating VTE probability calculation.

RESULTS

Out of 626 eligible patients with AML, 72 (11.5%) developed VTE during 6 months of follow-up. Six parameters were independent predictors: male sex (odds ratio [OR] 1.82, 95% confidence interval [CI]: 1.077-2.065), prior history of thrombotic events (OR 2.27, 95% CI: 1.4-4.96), international normalized ratio (OR 0.21, 95% CI: 0.05-0.95), Eastern Cooperative Oncology Group performance status (OR 0.71, 95% CI: 0.53-0.94), and intensive therapy (OR 2.05, 95% CI: 1.07-3.91). The C statistics for the model was 0.68. The model was adequately calibrated and internally validated. The decision-curve analysis suggested the use of thromboprophylaxis in patients with VTE risks between 8 and 20%.

CONCLUSION

We developed a novel and convenient tool that may assist clinicians in identifying patients whose VTE risk is high enough to warrant thromboprophylaxis.

Validation of the IMPEDE VTE score for prediction of venous thromboembolism in Chinese patients with multiple myeloma: A single-center retrospective cohort study

Multiple myeloma (MM) significantly increases the risk of venous thromboembolism (VTE) within 6 months of treatment initiation. The IMPEDE VTE score is a VTE risk prediction model which is recently incorporated into the National Comprehensive Cancer Network (NCCN) guidelines, but it lacks validation among Asians, including Chinese MM patients. We performed a retrospective chart review of 405 Chinese with newly diagnosed MM who started therapy at Beijing Jishuitan Hospital between April 2013 to October 2022. The 6-month cumulative incidence of VTE was 3.8 % (95 % CI:1.6-7.6), 8.6 % (95 % CI: 5.3-21.9) and 40.5 % (95 % CI: 24.9-55.7) in the low-, intermediate- and high-risk groups (P < 0.001), respectively. The C-statistic of the IMPEDE VTE scores for predicting VTE within 6 months of treatment initiation was 0.74 (95 % CI: 0.65-0.83). Of note, in this single-center cohort study, we propose that the anticoagulant LMWH may be more effective than the antiplatelet aspirin in potentially preventing VTE in newly diagnosed MM patients. Our findings suggest that the IMPEDE VTE score is a valid evidence-based risk stratification tool in Chinese patients with newly diagnosed MM.

An Evaluation of Hemostatic Dysregulation in Canine Multicentric Lymphoma

Multiple hemostatic abnormalities are associated with paraneoplastic syndrome and some malignant tumors. Lymphoma is the most common hematopoietic neoplasm in dogs, sometimes associated with hemostatic changes. The objectives of this study were to evaluate the behavior of coagulation parameters in dogs with multicentric lymphoma compared with diseased dogs without lymphoma, to separately evaluate the effect of immunophenotype (B lymphoma versus T lymphoma) on the variables of interest as well as the effect of disease stage (stage II to IV versus stage V). Specifically, a cross-sectional study was performed with a matched comparison group considering 170 dogs with B or T lymphoma (group 1) and 170 dogs with no lymphoma or other neoplastic processes but other diseases (group 0). Eight coagulation parameters were evaluated: platelet count (Plt), activated partial thromboplastin time (aPTT), prothrombin time (PT), thrombin time (TT), fibrinogen, fibrin/products of fibrinogen degradation (FDPs), fibrin D-dimers, and antithrombin (AT). Dogs with lymphoma showed prolonged PT and TT, decreased fibrinogen, increased FDP, and decreased Plt compared with group 0. The effect of disease stage was evaluated separately for dogs with stage II to IV lymphoma and dogs with stage V lymphoma; patients with stage II-IV lymphoma showed no significant differences, while in dogs with stage V lymphoma, a prolongation of PT and TT, a decrease in fibrinogen, an increase in FDPs and a decrease in Plt were found compared with the group 0. Finally, the comparison between B lymphoma and T lymphoma showed no significant differences in coagulation parameters between the two groups. Logistic regression analysis demonstrated that low fibrinogen and platelet levels were the most significant predictors of lymphoma in a cohort of canine patients. These hemostatic abnormalities in lymphoma appeared to be associated with the stage of the disease rather than the lymphoma immunophenotype. These findings pave the way for the possible scenario of lymphoma-associated fibrinolysis and the so far undescribed pattern of hyperfibrinolysis associated with the most severe stage of lymphoma.

Assessing the risk of venous thromboembolism in patients with haematological cancers using three prediction models

PURPOSE

Assessment of individual VTE risk in cancer patients prior to chemotherapy is critical for determining necessity of interventions. Risk assessment models (RAM) are available but have not been validated for haematological malignancy. We aimed to assess the validity of the Vienna Cancer and Thrombosis Study (V-CATS) score in prediction of VTE in a variety of haematological malignancies.

METHODS

This is a prospective cohort study conducted on 81 newly diagnosed cancer patients undergoing chemotherapy. Demographic, clinical and cancer related data were collected, patients were followed up for 6 months, and VTE events were recorded. Khorana score (KS) was calculated. Plasma D-dimer and sP-selectin were measured, and then, V-CATS score was calculated. Receiver operator curve (ROC) was used to assess the sensitivity and specificity of RAMs. A modified V-CATS was generated and subsequently assessed by using new cut-off levels of d-dimer and sP-selectin based on ROC curve of the patients' results and compared the probability of VTE occurrence using all three RAMs.

RESULTS

Among the 81 patients included in this study, a total of 2.7% were diagnosed with advanced metastatic cancer. The most frequent cancer was non-Hodgkin lymphoma (39.5%), and 8 patients (9.8%) developed VTE events. The calculated probability of VTE occurrence using KS, V-CATS and modified V-CATS scores at cut-off levels ≥ 3 was 87.5%, 87.5% and 100%, respectively. The AUC in ROC curve of modified Vienna CATS score showed significant difference when compared to that of V-CATS and KS (P = 0.047 and 0.029, respectively).

CONCLUSION

The findings of our study highlight the value of three VTE risk assessment models in haematological malignancies. The modified V-CATS score demonstrated higher specificity compared to both V-CATS and KS, while all three scores exhibited similar sensitivity. We encourage the implementation of RAMs in haematological cancers for an appropriate use of thromboprophylaxis.

SARS-CoV-2 infection of human lung epithelial cells induces TMPRSS-mediated acute fibrin deposition

Severe COVID-associated lung injury is a major confounding factor of hospitalizations and death with no effective treatments. Here, we describe a non-classical fibrin clotting mechanism mediated by SARS-CoV-2 infected primary lung but not other susceptible epithelial cells. This infection-induced fibrin formation is observed in all variants of SARS-CoV-2 infections, and requires thrombin but is independent of tissue factor and other classical plasma coagulation factors. While prothrombin and fibrinogen levels are elevated in acute COVID BALF samples, fibrin clotting occurs only with the presence of viral infected but not uninfected lung epithelial cells. We suggest a viral-induced coagulation mechanism, in which prothrombin is activated by infection-induced transmembrane serine proteases, such as ST14 and TMPRSS11D, on NHBE cells. Our finding reveals the inefficiency of current plasma targeted anticoagulation therapy and suggests the need to develop a viral-induced ARDS animal model for treating respiratory airways with thrombin inhibitors.

Prevention and treatment of thrombosis in cancer and oncohematological patients

The purpose of the review is to highlight the current possibilities for the prevention and treatment of venous thrombotic complications in patients with cancer.

The data of 52 scientific sources published in the Russian and foreign press in 1997–2020 are considered.

Cancer patients are at high risk of thrombotic complications, which worsen the outcome of anticancer treatment and are one of the leading causes of death. Thrombosis in an oncological patient increases the risk of death by 30 times, which is associated with fatal thromboembolism and a more aggressive course of the disease. The leading role in the pathogenesis of thrombotic complications is played by disorders in the hemostasis system caused both by the tumor itself and by therapy. Low molecular weight heparins are considered the basis for specific prophylaxis of thromboembolic complications in cancer patients. The use of low molecular weight heparins after surgery and during chemotherapy effectively reduces the incidence of venous thrombosis. Direct oral anticoagulants are promising drugs for oral administration and are indicated as one of the treatment options for patients with tumor-associated thrombosis with a low risk of bleeding and no drug interactions with ongoing systemic chemotherapy.

Incidence of Upper Extremity Deep Vein Thrombosis in Acute Leukemia and Effect on Mortality

The cumulative incidence, risk factors, rate of subsequent venous thromboembolism (VTE) and bleeding and impact on mortality of isolated upper extremity deep vein thrombosis (UE DVT) in acute leukemia are not well-described. The California Cancer Registry, used to identify treated patients with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) diagnosed between 2009 and 2014, was linked with the statewide hospitalization database to determine cumulative incidences of UE DVT and subsequent VTE and bleeding after UE DVT diagnosis. Cox proportional hazards regression models were used to assess the association of UE DVT on the risk of subsequent pulmonary embolism (PE) or lower extremity deep vein thrombosis (LE DVT) and subsequent bleeding, and the impact of UE DVT on mortality. There were 5,072 patients identified: 3,252 had AML and 1,820 had ALL. Three- and 12-month cumulative incidences of UE DVT were 4.8% (95% confidence interval [CI]: 4.1–5.6) and 6.6% (95% CI: 5.8–7.5) for AML and 4.1% (95% CI: 3.2–5.1) and 5.9% (95% CI: 4.9–7.1) for ALL, respectively. Twelve-month cumulative incidences of subsequent VTE after an incident UE DVT diagnosis were 5.3% for AML and 12.2% for ALL. Twelve-month cumulative incidences of subsequent bleeding after an incident UE DVT diagnosis were 15.4% for AML and 21.1% for ALL. UE DVT was associated with an increased risk of subsequent bleeding for both AML (hazard ratio [HR]: 2.07; 95% CI: 1.60–2.68) and ALL (HR: 1.62; 95% CI: 1.02–2.57) but was not an independent risk factor for subsequent PE or LE DVT for either leukemia subtype. Isolated incident UE DVT was associated with increased leukemia-specific mortality for AML (HR: 1.42; 95% CI: 1.16–1.73) and ALL (HR: 1.80; 95% CI: 1.31–2.47). UE DVT is a relatively common complication among patients with AML and ALL and has a significant impact on bleeding and mortality. Further research is needed to determine appropriate therapy for this high-risk population.

Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Clinical Practice Guideline Update

PURPOSE

To provide updated recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer.

METHODS

PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs published from August 1, 2014, through December 4, 2018. ASCO convened an Expert Panel to review the evidence and revise previous recommendations as needed.

RESULTS

The systematic review included 35 publications on VTE prophylaxis and treatment and 18 publications on VTE risk assessment. Two RCTs of direct oral anticoagulants (DOACs) for the treatment of VTE in patients with cancer reported that edoxaban and rivaroxaban are effective but are linked with a higher risk of bleeding compared with low-molecular-weight heparin (LMWH) in patients with GI and potentially genitourinary cancers. Two additional RCTs reported on DOACs for thromboprophylaxis in ambulatory patients with cancer at increased risk of VTE.

RECOMMENDATIONS

Changes to previous recommendations: Clinicians may offer thromboprophylaxis with apixaban, rivaroxaban, or LMWH to selected high-risk outpatients with cancer; rivaroxaban and edoxaban have been added as options for VTE treatment; patients with brain metastases are now addressed in the VTE treatment section; and the recommendation regarding long-term postoperative LMWH has been expanded. Re-affirmed recommendations: Most hospitalized patients with cancer and an acute medical condition require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for all outpatients with cancer. Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days. Patients with cancer should be periodically assessed for VTE risk, and oncology professionals should provide patient education about the signs and symptoms of VTE.Additional information is available at www.asco.org/supportive-care-guidelines.

The incidence and risk factors of thrombosis and the need for thromboprophylaxis in lymphoma and leukemia patients: A 9-year single-center experience

Background

Patients with cancer are at increased risk of thromboembolic complications. There is no evidence-based guideline on the use of routine prophylaxis in hematological malignancies except in patients with multiple myeloma. The purpose of this study was to determine the incidence and risk factors of thrombosis and suggest a rationale for primary thromboprophylaxis in acute leukemia and lymphoma patients.

Patients and methods

A retrospective study was conducted on newly-diagnosed acute leukemia and lymphoma patients who presented at our institution from November 2009 to March 2018. The study included a total of 157 patients with acute leukemia and 238 patients with lymphoma. The groups were analyzed to determine the incidence and risk factors of thromboembolic complications.

Results

The incidence of all thrombotic complications was 10.12% (40/395) including 11.4% (18/157) in patients with acute leukemia and 9.2% (22/238) in patients with lymphoma. The majority of events occurred in the first 6 months. Acute leukemia patients with thrombosis had a higher number of comorbidities than those without thrombosis ( p < 0.05). Lymphoma patients with thrombotic complications had significantly higher beta-2-microglobulin and lactate dehydrogenase levels compared to those without thrombosis ( p < 0.05). Major bleeding events developed in five (3.1%) acute leukemia patients and two (0.8%) lymphoma patients. All the major bleeding events occurred when the patients were thrombocytopenic (platelet < 50,000/mm3).

Conclusions

Acute leukemia patients with any comorbidity and lymphoma patients with higher lactate dehydrogenase and beta-2-microglobulin are at high risk of developing thromboembolic complications. The prophylactic use of anticoagulant should be considered for those patients especially in the first 6 months.

Platelet cut-off for anticoagulant therapy in thrombocytopenic patients with blood cancer and venous thromboembolism: an expert consensus

BACKGROUND

Management of venous thromboembolism (VTE) in patients with haematologic malignancies and thrombocytopenia is clinically challenging due to the related risks. No prospective studies or clinical trials have been carried out and, therefore, no solid evidence on this compelling issue is available.

METHODS

Given this, an expert panel endorsed by the Gruppo Italiano Malattie Ematologiche dell'Adulto Working Party on Thrombosis and Haemostasis was set up to produce a formal consensus, according to the RAND method, in order to issue clinical recommendations about the platelet (PLT) cut-off for safe administration of low molecular weight heparin (LMWH) in thrombocytopenic (PLT <100×109/L) adult patients with haematologic malignancies affected by acute (<1 month) or non-acute VTE.

RESULTS

In acute VTE, the panel suggests safe anticoagulation with LMWH at therapeutic doses for PLT between ≥50<100×109/L and at 50% dose reduction for PLT ≥30<50×109/L. In acute VTE for PLT <30×109/L, the following interventions are recommended: positioning of an inferior vena cava (IVC) filter with prophylactic LMWH administration and platelet transfusion. In non-acute VTE, anticoagulation with LMWH at therapeutic doses for PLT between ≥50<100×109/L or over and at 50% dose reduction for PLT ≥30<50×109/L is considered appropriate. The discontinuation of full or reduced therapeutic dose of LMWH is recommended for PLT <30×109/L, both in acute and non-acute VTE.

DISCUSSION

We suggest using dose-adjusted LMWH according to PLT to optimise anticoagulant treatment in patients at high bleeding risk.

Incidence of venous thromboembolism and use of anticoagulation in hematological malignancies: Critical review of the literature

Venous Thromboembolism (VTE) frequently complicates the course of hematologic malignancies (HM) and its incidence is similar to that observed in high-risk solid tumors. Despite that, pharmacologic prophylaxis and treatment of VTE in patients with HM is challenging, mainly because a severe thrombocytopenia frequently complicates the course of treatments or may be present since diagnosis, thus increasing the risk of bleeding. Therefore, in this setting, safe and effective methods of VTE prophylaxis and treatment have not been well defined and hematologists generally refer to guidelines produced for cancer patients that give indications on anticoagulation in patients with thrombocytopenia. In this review, besides to summarize the incidence and the available data on prophylaxis and treatment of VTE in HM, we give some advices on how to use antithrombotic drugs in patients with HM according to platelets count.

Identification of target gene of venous thromboembolism in patients with lymphoma via microarray analysis

Patients with lymphoma are at high risk of developing venous thromboembolism (VTE). The purpose of the present study was to identify the target gene associated with VTE for patients with lymphoma. Microarray data was downloaded from the gene expression omnibus database (GSE17078), which comprised the control group, 27 normal blood outgrowth endothelial cell (BOEC) samples, and the case group, 3 BOEC samples of venous thrombosis with protein C deficiency. Differentially expressed genes (DEGs) were identified by the Limma package of R. Gene ontology (GO) and Kyoto encyclopedia of genes and genomes (KEGG) pathway analyses were performed via the database for annotation, visualization and integrated discovery. Differentially coexpressed pairs were identified by the DCGL package of R. The subsequent protein-protein interaction (PPI) networks and gene coexpression networks were constructed by the Search Tool for the Retrieval of Interacting Genes/Proteins database, and were visualized by Cytoscape software. A total of 110 DEGs were obtained, including 73 upregulated and 37 downregulated genes. GO and KEGG pathway enrichment analyses identified 132 significant GO terms and 9 significant KEGG pathways. In total, 97 PPI pairs for PPI network and 309 differential coexpression pairs for the gene coexpression network were obtained. Additionally, the connective tissue growth factor (CTGF) gene was closely connected with other genes in the two networks. A total of 2 KEGG pathways were associated with VTE and CTGF may be the target gene of VTE in patients with lymphoma. The present study may identify the molecular mechanism of VTE, but additional clinical study is required to validate the results.

Antithrombotic therapy and platelet transfusions in hematologic malignancy patients presenting chemotherapy-induced thrombocytopenia: a French survey

BACKGROUND

Patients with hematologic malignancies are at high risk for both thrombosis and bleeding. During the prolonged periods of thrombocytopenia experienced by patients who are receiving intensive chemotherapy, clinicians often hesitate to prescribe any protection against thrombosis. In case of anticoagulant prescription, it is the prescribers' responsibility to weigh risks and benefits for each patient. Current guidelines exist but do not take into account types of thrombosis, patients' comorbidities, or previous bleeding events.

STUDY DESIGN AND METHODS

We proposed to gain insight into hematologists' beliefs about antithrombotic prescription in hematologic malignancy patients, to design future clinical trials. Therefore, we conducted a survey in France to evaluate the practices among a panel of hematologists.

RESULTS

We found that more than 92% of the respondents prescribed therapeutic anticoagulation in case of pulmonary embolism or deep venous thrombosis. In the case of therapeutic anticoagulation, only 64% of the physicians reconsidered treatment under a platelet threshold of 50 × 10⁹ /L. None of the respondents decided to renounce treatment, nor to discontinue it because of thrombocytopenia, except in distal venous thrombosis or superficial vein thrombosis. One-fifth of clinicians proposed the insertion of a vena cava filter.

CONCLUSION

As observed in the United States and Canada, we noticed discrepancies between recommendations and current practices in France. This highlights the urgent need to conduct studies to evaluate both efficacy and safety of antithrombotics in patients with hematologic cancer and thrombocytopenia.

Aplastic anemia and risk of deep vein thrombosis and pulmonary embolism: A nationwide cohort study

OBJECTIVES

Deep vein thrombosis (DVT) and pulmonary embolism (PE) constitute venous thromboembolism (VTE), which is not fully known in aplastic anemia (AA). Therefore, we investigated the incidence and risk of VTE in AA patients.

METHODS

We conducted a nationwide cohort study to investigate the risk of DVT and PE in patients with AA. We identified patients with newly diagnosed AA as the AA cohort between 2000 and 2010 from the National Health Insurance Research Database (NHIRD). The initial admission date for AA diagnosis was set as the index date. For each patient with AA, 4 patients without a history of AA, frequency matched by sex, age (every 5-y span), and year of index date, were the non-AA cohort. All patients were followed from the index date to the date of DVT or PE diagnosis, withdrawal from the NHIRD, or the end of 2011. Cox models were used to evaluate the risk of developing DVT and PE in the AA cohort.

RESULTS

We included 4001 and 15,998 patients in the AA and non-AA cohorts, respectively, and the overall incidence densities of VTE were significantly higher in the AA cohort than in the non-AA cohort (42.3 vs 10.2 per 10,000person-years). The AA cohort had a 2.56-fold higher risk of VTE (95% confidence interval [CI]=1.81-3.63) than did the non-AA cohort.

CONCLUSION

This nationwide cohort study indicated that AA is associated with increased incidence and risk of VTE.

Risk of venous thromboembolism in hospitalised cancer patients in England-a cohort study

Background

Venous thromboembolism (VTE) is a well-recognised and life-threatening complication in patients with cancer. However, the precise risk of VTE in hospitalised cancer patients in England has not been previously reported.

Methods

We conducted a cohort study using linked Hospital Episodes Statistics and Office for National Statistics mortality data. We determined the risk of VTE separately for 24 cancer sites following first hospitalisation for cancer (index date) and how this varied by age, proximity from hospital admission, administration of chemotherapy and calendar time.

Results

Between 1998 and 2012, 3,558,660 patients were hospitalised for cancer. The cancer sites with the highest risk of VTE during initial hospitalisation for cancer were pancreatic (4.9 %), ovarian (4 %) and liver (3.8 %). The three cancer sites with the highest risk of first VTE event within 6 months from discharge were pancreatic (3.7 %), oesophagus (3 %) and stomach (2.8 %). For most cancers, the risk of VTE within 6 months from discharge was higher amongst patients who underwent chemotherapy compared to those who did not. The impact of age on risk of VTE varied considerably between cancer sites.

Conclusions

The risk of VTE amongst patients hospitalised for cancer varies greatly by cancer site, age, proximity from hospital admission, and chemotherapy administration.

Electronic supplementary material

The online version of this article (doi:10.1186/s13045-016-0291-0) contains supplementary material, which is available to authorized users.

Patterns of Venous Thromboembolism Prophylaxis During Treatment of Acute Leukemia: Results of a North American Web-Based Survey

BACKGROUND

Venous thromboembolism (VTE) occurs in 2% to 12% of patients with acute leukemia (AL) despite disease- and therapy-associated thrombocytopenia, and it can be associated with significant morbidity and mortality. Because of the few high-quality studies, there are no evidence-based guidelines for VTE prophylaxis in this patient population. We sought to determine the spectrum of practice regarding prevention of VTE in patients with AL during induction and consolidation therapies.

METHODS

We conducted a 19-question Web-based survey directed at North American providers caring for these patients. One hundred fifty-one of 215 responses received were eligible for analysis, with a response rate of 20.9% among physicians who treated leukemias.

RESULTS

Overall, 47% and 45% of providers reported using pharmacologic VTE prophylaxis during induction and consolidation phases, respectively. Approximately 15% of providers did not provide any VTE prophylaxis, while 36% used mechanical methods and ambulation. Among providers who did not recommend pharmacologic prophylaxis, the most commonly cited reasons were the perceived high risk of bleeding (51%), absence of data supporting use (38%), and perceived low risk of VTE (11%).

CONCLUSION

Large, prospective studies are needed to define the safest and most effective approach to VTE prevention in patients with AL.

Lymphoma and venous thromboembolism: influence on mortality

BACKGROUND

The population-based incidence of acute venous thromboembolism (VTE) in adult patients diagnosed with non-Hodgkin's lymphoma has not been established, and the effect of VTE on survival is not clear.

AIM

To determine the incidence of acute VTE in California residents diagnosed with lymphoma, and to determine the effect of acute VTE on survival.

METHODS

We used the California Cancer Registry coupled with the California Patient Discharge database to identify incident cases with lymphoma, 1991-1997, and the incidence of first-time VTE in these patients. Multivariable models were constructed to evaluate risk of developing acute VTE within 2 years, and a proportional hazard model was used to predict death within 2 years, using acute VTE as a time-dependent covariate.

RESULTS

There were 16,755 patients diagnosed with non-Hodgkin's lymphoma; 29% had low-grade, 66% intermediate/aggressive grade and 5.6% had high-grade lymphoma. Acute VTE developed in 3.6% of the patients by year 1 and 4.0% by the end of year 2. Significant predictors of acute VTE included advanced stage lymphoma, number of chronic comorbidities and advancing age. Significant predictors of death within 2 years included diagnosis of acute VTE, advanced stage disease, increasing number of co-morbidities, age over 75 years and intermediate or high grade histopathology. The effect of acute VTE on death increased as the time between lymphoma diagnosis and VTE diagnosis increased (HR=1.7 95%CI:1.5-1.9 for VTEs <6 months; HR=6.5 95%CI:4.7-8.9 VTEs 12-24 months).

CONCLUSIONS

Acute VTE developed frequently in patients with lymphoma, and VTE was a strong predictor of decreased survival.

Life-threatening complications and outcomes in patients with malignancies and severe pulmonary embolism

BACKGROUND

Data are scarce about ICU patients with malignancy and severe pulmonary embolism. Here, our main objective was to identify risk factors for life-threatening complications, organ failures, and death in ICU patients with severe pulmonary embolism, with special attention to the impact of malignancy. We also described the clinical features of PE in patients with and without malignancies.

METHODS

Data from consecutive adults admitted to our ICU in 2002-2011 with severe pulmonary embolism were collected retrospectively. Multivariate analysis was performed to look for factors associated with death, organ failures, or life-threatening complications (major bleeding, recurrent PE, and cardiac arrest).

RESULTS

Of 119 included patients (42 [35%] with bilateral pulmonary embolism), 41 had solid malignancies, 27 hematological malignancies, and 51 no malignancies. The most common symptoms were syncope (40%) and hemoptysis (18%) in patients with solid and hematological malignancies, respectively. Life-threatening complications occurred in 23 (19%) patients; risk factors were obesity (OR, 13.22; 1.93-90.70), disseminated intravascular coagulation/ischemic hepatitis (OR, 27.06; 5.14-142.46), fluid load ≥1000 mL/24 h (OR, 6.42; 1.60-25.76), and solid malignancy (OR, 5.45; 1.15-25.89). Inhospital mortality was 27/119 (23%) and respiratory or circulatory failure developed in 36 (30%) patients. Risk factors for these adverse outcomes were older age (OR, 1.04/year; 1.01-1.07), higher oxygen flow rate (OR, 1.28/L; 1.13-1.45); and renal failure (OR, 8.08; 2.50-26.11); whereas chest pain was protective (OR, 0.13; 0.04-0.48).

CONCLUSION

In this study, solid malignancy was a risk factor for life-threatening complications but not for death.

A retrospective study of venous thromboembolism in acute leukemia patients treated at the University of Texas MD Anderson Cancer Center

The purpose was to determine the incidence and prevalence of venous thromboembolism (VTE) in acute leukemia patients from our institution. We conducted a retrospective study on newly diagnosed acute leukemia patients who presented at our institution from November 1999 to May 2005. Descriptive statistics and cross-tabulation were used to describe patient characteristics. Measures of morbidity were used to address VTE risk. Chi-square testing, Fisher's exact testing, Mann-Whitney analyses, or median testing were used to determine between-group differences. Data analyses were conducted using Stata version 11 (Stata Corp., College Station, TX). Two hundred and ninety-nine patients with acute lymphoblastic leukemia (ALL) and 996 patients with acute myeloid leukemia (AML) were included. After excluding patients diagnosed with VTE prior to or at the time of leukemia diagnosis, during the mean time follow-up period of 2.5 years (range: 0.0025-10.3 years), the overall incidence rate of VTE was 3.7 per 100 person-years: 4.2 per 100 person-years for ALL and 3.4 per 100 person-years for AML. Among all patients, the majority (80.6%) developed VTE within 12 months after diagnosis and during thrombocytopenia. The most common VTE was central venous catheter (CVC)-associated upper-extremity deep venous thrombosis. Pulmonary embolism occurred in 15% of ALL patients and 8% of AML patients. VTE recurred in 20.7% of ALL patients and 18.6% of AML patients. VTE occurs frequently in patients with acute leukemia. Studies are needed to identify risk factors for the development and recurrence of VTE among patients with acute leukemia and to establish more effective methods for preventing and treating VTEs in leukemia patients who have thrombocytopenia and/or CVC.

Contributing role of extracellular vesicles on vascular endothelium haemostatic balance in cancer

Extracellular vesicles (EVs) generated during tumourigenesis are thought to play a major role in the hypercoagulant state observed in cancer patients. They exhibit negatively charged phospholipids and tissue factor (TF) that promote coagulation cascade activation. In addition, they contain surface proteins and cytoplasmic molecules, both originating from the producing cell that can impact target cells’ expression. By targeting endothelial cells of blood vessels, these EVs could disturb the physiological anticoagulant properties of these cells and be partly responsible for the vascular endothelium activation observed in cancer patients. Indeed, vascular endothelium naturally exhibits heparin-like proteoglycan, TF pathway inhibitor and protein C anticoagulant pathway that prevent thrombosis in physiological condition. An overexpression of TF and a decreased expression of coagulation cascade inhibitors have been reported after EVs’ treatment of endothelial cells. The induction of apoptosis and an increased expression of platelet adhesion molecules have also been highlighted. These events may promote thrombus formation in cancer. The aim of this paper is to provide a targeted review on the current evidence and knowledge of roles and impact of EVs on endothelial surface anticoagulant and procoagulant factors and cellular adhesion molecules expression.

Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update

PURPOSE

To provide recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. Prophylaxis in the outpatient, inpatient, and perioperative settings was considered, as were treatment and use of anticoagulation as a cancer-directed therapy.

METHODS

A systematic review of the literature published from December 2007 to December 2012 was completed in MEDLINE and the Cochrane Collaboration Library. An Update Committee reviewed evidence to determine which recommendations required revision.

RESULTS

Forty-two publications met eligibility criteria, including 16 systematic reviews and 24 randomized controlled trials.

RECOMMENDATIONS

Most hospitalized patients with cancer require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for outpatients with cancer. It may be considered for selected high-risk patients. Patients with multiple myeloma receiving antiangiogenesis agents with chemotherapy and/or dexamethasone should receive prophylaxis with either low-molecular weight heparin (LMWH) or low-dose aspirin. Patients undergoing major cancer surgery should receive prophylaxis, starting before surgery and continuing for at least 7 to 10 days. Extending prophylaxis up to 4 weeks should be considered in those with high-risk features. LMWH is recommended for the initial 5 to 10 days of treatment for deep vein thrombosis and pulmonary embolism as well as for long-term (6 months) secondary prophylaxis. Use of novel oral anticoagulants is not currently recommended for patients with malignancy and VTE. Anticoagulation should not be used for cancer treatment in the absence of other indications. Patients with cancer should be periodically assessed for VTE risk. Oncology professionals should provide patient education about the signs and symptoms of VTE.

[Thromboembolic events in malignant diseases]

There is a bidirectional connection between tumors and thrombosis. On one hand, thromboembolic events are more frequent in cases of malignancies, on the other hand, proliferation of tumor cells, progression of the malignant process and metastasis formation are facilitated by the activation of the hemostatic system. Thromboembolic events are associated with a worse prognosis in case of patients with malignant diseases. Thromboembolism is the second most frequent cause of death in patients with malignant tumors. Mortality is twice as high in patients with thromboembolism compared to those without it. The incidence of thromboembolism shows an increasing tendency. There has been a 28% increase among hospitalized cancer patients between 1995 and 2003. One reason is that the new anti-tumor agents have more pronounced prothrombotic activity than those of traditional chemotherapeutic drugs. Assessment of the thrombotic risk of cancer patients becomes more important. Several guidelines have been published concerning the prevention and treatment of thromboembolism in patients with malignancy. The risk of thrombosis is influenced not only by the type of malignancy but there are also large individual differences. Furthermore, the risk of thrombosis changes during the disease process in the same patient. Perioperative thromboprophylaxis is a very important issue considering oncologic surgery. Thromboprophylaxis of oncologic patients has a high significance in respect of morbidity and mortality. However, thromboprophylaxis may also cause serious complications thus the correct risk assessment of cancer patients is very important.

Soluble endothelial protein C receptor (sEPCR) is likely a biomarker of cancer-associated hypercoagulability in human hematologic malignancies

Elevated plasma level of soluble endothelial protein C receptor (sEPCR) may be an indicator of thrombotic risk. The present study aims to correlate leukemia-associated hypercoagulability to high level plasma sEPCR and proposes its measurement in routine clinical practice. EPCR expressions in leukemic cell lines were determined by flow cytometry, immunocytochemistry, and reverse transcription polymerase chain reaction (RT-PCR). EPCR gene sequence of a candidate cell line HL-60 was also determined. Plasma samples (n = 76) and bone marrow aspirates (n = 72) from 148 patients with hematologic malignancies and 101 healthy volunteers were analyzed by enzyme-linked immunosorbent assay (ELISA) via a retrospective study for sEPCR and D-dimer. All leukemic cell lines were found to express EPCR. Also, HL-60 EPCR gene sequence showed extensive similarities with the endothelial reference gene. All single nucleotide polymorphisms (SNPs) originally described and some new SNPs were revealed in the promoter and intronic regions. Among these patients 67% had plasma sEPCR level higher than the controls (100 ± 28 ng/mL), wherein 16.3% patients had experienced a previous thrombotic event. These patients were divided into: group-1 (n = 45) with amount of plasmatic sEPCR below 100 ng/mL, group-2 (n = 45) where the concentration of sEPCR was between 100 and 200, and group-3 (n = 20) higher than 200 ng/mL. The numbers of thrombotic incidence recorded in each group were four, six, and eight, respectively. These results reveal that EPCR is expressed not only by a wide range of human malignant hematological cells but also the detection of plasma sEPCR levels provides a powerful insight into thrombotic risk assessment in cancer patients, especially when it surpasses 200 ng/mL.

Anticoagulant and Anti-thrombotic Treatments in the Management of Hematological Malignancies in a Home Care Program

Aim:

Anticoagulants (AC) and anti-platelet (AP) agents are widely administered to patients with hematological malignancies (HM). However, HM patients may be at high risk of bleeding and hemorrhagic complications, because of different form of coagulopathies and several degrees of thrombocytopenia.

Materials and Methods:

A prospective evaluation of the use of anticoagulant and anti-thrombotic agents as well as of bleeding and thrombotic complications in a consecutive cohort of patients, which were followed during the first semester of 2010 by our home care service, was performed. In this regard, three pharmacological class of agents, such as oral anticoagulants (warfarin and acenocumarine), low molecular weight heparin (LMWH) and anti-platelet (AP) drugs were considered.

Results:

Out of 129 patients, 26 (20%) were treated with AC/AP drugs. Warfarin, acenocumarine, LMWH as well as AP were used in 7, 11 and 12 patients, respectively. Adverse events (bleeding) were observed in 3 patients (11.5%), 2 cases being on warfarin (replaced by LMWH) and 1 being AP (suspension without replacement); out of the 3 patients with bleeding, none presented thrombocytopenia.

Conclusions:

Despite the frequent findings of hemostatic disorders in a population of frail patients managed in a home care setting, our experience demonstrated that the use of AC/AP drugs has been very rarely responsible for significant complications.