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Boire A, Burke K, Cox TR, Guise T, Jamal-Hanjani M, Janowitz T, Kaplan R, Lee R, Swanton C, Vander Heiden MG, Sahai E. Why do patients with cancer die? Nat Rev Cancer 2024; 24:578-589. [PMID: 38898221 PMCID: PMC7616303 DOI: 10.1038/s41568-024-00708-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/21/2024]
Abstract
Cancer is a major cause of global mortality, both in affluent countries and increasingly in developing nations. Many patients with cancer experience reduced life expectancy and have metastatic disease at the time of death. However, the more precise causes of mortality and patient deterioration before death remain poorly understood. This scarcity of information, particularly the lack of mechanistic insights, presents a challenge for the development of novel treatment strategies to improve the quality of, and potentially extend, life for patients with late-stage cancer. In addition, earlier deployment of existing strategies to prolong quality of life is highly desirable. In this Roadmap, we review the proximal causes of mortality in patients with cancer and discuss current knowledge about the interconnections between mechanisms that contribute to mortality, before finally proposing new and improved avenues for data collection, research and the development of treatment strategies that may improve quality of life for patients.
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Affiliation(s)
- Adrienne Boire
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katy Burke
- University College London Hospitals NHS Foundation Trust and Central and North West London NHS Foundation Trust Palliative Care Team, London, UK
| | - Thomas R Cox
- Cancer Ecosystems Program, The Garvan Institute of Medical Research and The Kinghorn Cancer Centre, Darlinghurst, New South Wales, Australia.
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, UNSW Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia.
| | - Theresa Guise
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariam Jamal-Hanjani
- Cancer Metastasis Laboratory, University College London Cancer Institute, London, UK
- Department of Oncology, University College London Hospitals, London, UK
- Cancer Research UK Lung Centre of Excellence, University College London Cancer Institute, London, UK
| | - Tobias Janowitz
- Cold Spring Harbour Laboratory, Cold Spring Harbour, New York, NY, USA
- Northwell Health Cancer Institute, New York, NY, USA
| | - Rosandra Kaplan
- Paediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rebecca Lee
- Tumour Cell Biology Laboratory, The Francis Crick Institute, London, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Charles Swanton
- Department of Oncology, University College London Hospitals, London, UK
- Cancer Research UK Lung Centre of Excellence, University College London Cancer Institute, London, UK
- Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute, London, UK
| | - Matthew G Vander Heiden
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Erik Sahai
- Tumour Cell Biology Laboratory, The Francis Crick Institute, London, UK.
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Pun H, Pang I, Leblanc K, Dhillon P, McEwan C, Patel P, Kumar R. Single center evaluation on the use of conditionally ordered low molecular weight heparins in malignant hematology patients with venous thromboembolism. J Oncol Pharm Pract 2024; 30:823-829. [PMID: 37501557 PMCID: PMC11179312 DOI: 10.1177/10781552231189695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Cancer and cancer-related treatments are significant independent risk factors for malignant hematology (MH) patients in developing venous thromboembolism (VTE). Treatment of VTE in MH patients at the Princess Margaret Cancer Centre is predominantly initiated with low molecular weight heparin (LMWH) in accordance with guidelines. While guidelines recommend against LMWH use in patients with thrombocytopenia, prescribers may order LMWH conditionally based on platelet values. Currently, there is a lack of consistent practice with variation in both the use of conditional orders as well as the threshold of platelet values for conditional orders. The objectives of the study were to (a) describe the use of conditionally ordered LMWH based on platelet values; (b) determine its safety by measuring administration concordance with conditional orders and bleeding event rates during inpatient admission; and (c) determine its efficacy by measuring the rate of worsening VTE or recurrence during inpatient admission. METHODS Electronic records of MH inpatients admitted between January 2017 and December 2019 and who were administered at least one dose of an LMWH for the treatment of VTE were screened. RESULTS One hundred and eight patients were screened to obtain 50 eligible patients with a median age of 59 years (SD = ±18.8 years). The most frequent MH diagnosis was acute lymphoblastic leukemia (30%). Sixty percent (n = 30) of patients received conditional orders. Out of 571 administrations, 543 (95%) were administered concordantly (Χ2(1) = 472, p < 0.0001). In this group of patients, 8 patients had either documented bleeding or experienced a drop in hemoglobin >10 g/L within a 72 h time frame. No patients experienced a recurrent VTE during inpatient treatment (for up to 40 days post-admission). CONCLUSIONS It appears that conditionally ordered LMWH can be concordantly administered and is safe and effective in the treatment of VTE in MH patients experiencing thrombocytopenia. There were no reports of worsening or new VTE in our small sample.
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Affiliation(s)
- Henry Pun
- University Health Network, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Ian Pang
- University Health Network, Toronto, Canada
| | - Kori Leblanc
- University Health Network, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | | | | | | | - Rajat Kumar
- University Health Network, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
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Adelborg K, Veres K, Horváth-Puhó E, Clouser M, Saad H, Sørensen HT. Risk and adverse clinical outcomes of thrombocytopenia among patients with solid tumors-a Danish population-based cohort study. Br J Cancer 2024; 130:1485-1492. [PMID: 38448749 PMCID: PMC11058247 DOI: 10.1038/s41416-024-02630-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Knowledge about thrombocytopenia among patients with solid tumors is scarce. We examined the risk of thrombocytopenia among patients with solid tumors and its association with adverse outcomes. METHODS Using Danish health registries, we identified all patients with incident solid tumors from 2015-2018 (n = 52,380) and a platelet count measurement within 2 weeks prior to or on their cancer diagnosis date. The risk of thrombocytopenia was categorized as grades 0 (any platelet count × 109/L): <150; 1: <100; 2: <75; 3: <50; 4: <25, and 5: <10. To study the outcomes, each patient with thrombocytopenia was matched with up to five cancer patients without thrombocytopenia by age, sex, cancer type, and stage. Cox regression was used to compute hazard ratios (HRs) of bleeding, transfusion, or death, adjusting for confounding factors. RESULTS The 1-year risk of thrombocytopenia was 23%, increasing to 30% at 4 years. This risk was higher in patients receiving chemotherapy (43% at 1 year and 49% at 4 years). Overall, patients with thrombocytopenia had higher 30-days rates of bleeding (HR = 1.72 [95% confidence interval, CI: 1.41-2.11]). Thrombocytopenia was also associated with an increased rate of transfusion, and death, but some of the risk estimates were imprecise. CONCLUSIONS The risk of thrombocytopenia was substantial among patients with solid tumors and associated with adverse outcomes.
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Affiliation(s)
- Kasper Adelborg
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Biochemistry, Thrombosis and Hemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Katalin Veres
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Erzsébet Horváth-Puhó
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.
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Ito S, Inoko M, Yamashita Y, Morimoto T, Kimura T. Thrombocytopenia and bleeding events in patients with venous thromboembolism. Eur J Intern Med 2024; 122:132-134. [PMID: 38238133 DOI: 10.1016/j.ejim.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 04/06/2024]
Affiliation(s)
- Shinya Ito
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan.
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan
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Drozdinsky G, Arad N, Spectre G, Livneh N, Poran I, Raanani P, Falanga A, Ten Cate H, Gafter-Gvili A, Leader A. Anticoagulation in cancer patients with atrial fibrillation and grade 3-4 thrombocytopenia. Thromb Res 2024; 235:92-97. [PMID: 38308884 DOI: 10.1016/j.thromres.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/03/2024] [Accepted: 01/17/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Atrial fibrillation or flutter (AF) is prevalent in cancer patients. Many of these patients have an indication for anticoagulation (AC) but are also at risk for developing chemotherapy-induced thrombocytopenia. There are scarce data regarding management of AC and risk of bleeding and thrombosis in cancer patients with AF and thrombocytopenia. AIM To assess anticoagulation management and incidence of bleeding and arterial thromboembolism (ATE) in cancer patients with AF and grade 3-4 thrombocytopenia (platelets <50 × 109/L). METHODS A retrospective cohort study included adults with active cancer, grade 3-4 thrombocytopenia and AF with CHA2DS2-VASc score ≥ 1. Patients were stratified according to AC discontinuation (No-AC) or continuation (Continue-AC) when platelets dropped below 50 × 109/L and followed for 30 days. The study outcomes were ATE (ischemic stroke, transient ischemic attack or systemic emboli) and major bleeding. Cox proportional hazards model was used to calculate hazard ratios (HR) with death as a competing risk (Fine and Gray model). RESULTS The cohort included 131 patients; 90 in the No-AC group and 41 in the Continue-AC group. Patient characteristics were balanced between the groups. The 30-day cumulative incidence of ATE was 2 % [95 % CI 0.4 %-7 %] in the No-AC group and 2 % [0.2 %-11 %] in the Continue-AC group (HR 0.92 [95 % CI 0.09-9.88]). The 30-day cumulative incidence of major bleeding was 7.8 % [95 % CI 3.40 %-14.52 %] and 2.44 % [95 % CI 0.18 %-11.22 %] in the No-AC and Continue-AC groups, respectively (HR 3.29 [95 % CI 0.42-26.04]). CONCLUSIONS The high rate of bleeding and low rate of ATE in thrombocytopenic cancer patients with AF suggests that holding AC during time-limited periods may be a reasonable approach.
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Affiliation(s)
- Genady Drozdinsky
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noam Arad
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Galia Spectre
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Nir Livneh
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Otolaryngology Head and Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel
| | - Itamar Poran
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pia Raanani
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Anna Falanga
- University of Milano-Bicocca, Department of Medicine, Milan, Italy; Immunohematology and Transfusion Medicine Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Hugo Ten Cate
- Thrombosis Expert Center, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Center for Thrombosis and Hemostasis, Gutenberg University Medical Center, Mainz, Germany
| | - Anat Gafter-Gvili
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel; Department of Medicine A, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel; Hematology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, US; Weill Cornell Medical College, New York, NY, USA.
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Gong FM, Liu FY, Ma X, Ma ST, Xiao HT, Jiang G, Qi TT. Effectiveness and economic evaluation of rhTPO and rhIL-11 in the treatment of cancer therapy induced thrombocytopenia based on real-world research. Front Pharmacol 2024; 15:1288964. [PMID: 38327986 PMCID: PMC10848320 DOI: 10.3389/fphar.2024.1288964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 01/09/2024] [Indexed: 02/09/2024] Open
Abstract
Objective: Based on real-world research, we aimed to evaluate the effectiveness and economy of recombinant human thrombopoietin (rhTPO) and recombinant human interleukin 11 (rhIL-11) in the treatment of cancer therapy induced thrombocytopenia (CTIT). Methods: We retrospectively collected clinical data of patients with CTIT who were treated with rhTPO or rhIL-11 in a single cancer hospital from January 2020 to December 2021. Propensity score matching (PSM) was applied to eliminate confounding factors. The measurements of effectiveness analysis were the platelet compliance rate, days of medication, days of compliance, highest platelet count after medication, platelet count elevation before and after medication, and the lowest platelet count after next-cycle cancer therapy. The economic evaluation was performed according to the results of the effectiveness evaluation. At the same time, patients were stratified according to type of tumor and grade of thrombocytopenia for subgroup analysis. Results: A total of 262 patients were collected and 174 patients were enrolled after PSM, 87 in the rhTPO group and 87 in the rhIL-11 group. In all patients, there were no significant differences in the platelet compliance rate, mean days of medication, median days of compliance, median highest platelet count after medication, and the median platelet count elevation before and after medication between the two groups (p > 0.05), but the median lowest platelet count after next-cycle cancer therapy in the rhTPO group was lower than that in the rhIL-11 group (p = 0.014). The subgroup analysis showed that the rhTPO group had longer mean days of medication than the rhIL-11 group in patients with hematological malignancies (p = 0.042), and a lower median lowest platelet count after next-cycle cancer therapy in patients with grade I/II thrombocytopenia than rhIL-11 group (p = 0.022), with no significant difference in other outcome indicators (p > 0.05). As there was no statistically significant difference in platelet compliance rate between the two groups, the cost-minimization analysis showed that the rhIL-11 group had lower treatment costs than the rhTPO group. Conclusion: RhTPO and rhIL-11 showed similar effectiveness in the treatment of CTIT, but rhIL-11 was more advantageous in economic cost.
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Affiliation(s)
- Fa-Min Gong
- Department of Pharmacy, Cancer Hospital Affiliated to University of Electronic Science and Technology, Sichuan Cancer Center, Sichuan Cancer Hospital and Institute, Chengdu, Sichuan, China
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Collaborative Innovation Center, Chengdu, Sichuan, China
- Department of Pharmacy, Chongqing General Hospital, Chongqing, China
| | - Fu-Yue Liu
- Department of Pharmacy, Renshou County People’s Hospital, Meishan, Sichuan, China
| | - Xue Ma
- Department of Pharmacy, Cancer Hospital Affiliated to University of Electronic Science and Technology, Sichuan Cancer Center, Sichuan Cancer Hospital and Institute, Chengdu, Sichuan, China
| | - Song-Tao Ma
- School of Pharmacy, Chengdu Medical College, Chengdu, Sichuan, China
| | - Hong-Tao Xiao
- Department of Pharmacy, Cancer Hospital Affiliated to University of Electronic Science and Technology, Sichuan Cancer Center, Sichuan Cancer Hospital and Institute, Chengdu, Sichuan, China
| | - Gang Jiang
- Department of Pharmacy, Cancer Hospital Affiliated to University of Electronic Science and Technology, Sichuan Cancer Center, Sichuan Cancer Hospital and Institute, Chengdu, Sichuan, China
| | - Ting-Ting Qi
- Department of Pharmacy, Cancer Hospital Affiliated to University of Electronic Science and Technology, Sichuan Cancer Center, Sichuan Cancer Hospital and Institute, Chengdu, Sichuan, China
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Collaborative Innovation Center, Chengdu, Sichuan, China
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Iyengar V, Patell R, Ren S, Ma S, Pinson A, Barnett A, Elavalakanar P, Kazi DS, Neuberg D, Zwicker JI. Influence of thrombocytopenia on bleeding and vascular events in atrial fibrillation. Blood Adv 2023; 7:7516-7524. [PMID: 37756539 PMCID: PMC10761355 DOI: 10.1182/bloodadvances.2023011235] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/31/2023] [Accepted: 08/31/2023] [Indexed: 09/29/2023] Open
Abstract
Whether thrombocytopenia substantively increases the risk of hemorrhage associated with anticoagulation in patients with atrial fibrillation (AF) is not established. The purpose of this study was to compare rates of bleeding in patients with AF and thrombocytopenia (platelet count < 100 000/μL) to patients with AF and normal platelet counts (>150 000/μL). We performed a propensity score-matched, retrospective cohort study of adults (n = 1070) with a new diagnosis of AF who received a prescription for an oral anticoagulant between 2015 and 2020. The thrombocytopenia cohort was defined as having at least 2 platelet counts <100 000/μL on separate days in the period spanning the 12 weeks preceding the initiation of anticoagulation to 6 weeks after the initiation of anticoagulation. The primary end point was the 1-year cumulative incidence of major bleeding; secondary end points included clinically relevant bleeding, arterial and venous thrombotic events, and all-cause mortality. Patients with AF and thrombocytopenia experienced a higher 1-year cumulative incidence of major bleeding (13.3% vs 5.7%; P < .0001) and clinically relevant bleeding (24.5% vs 16.7%; P = .005) than the controls. Thrombocytopenia was identified as an independent risk factor for major bleeding (hazard ratio, 2.20; confidence interval, 1.36-3.58; P = .001), with increasing risk based on the severity of thrombocytopenia. The cumulative incidence of arterial thrombosis at 1 year was 3.6% in the group with thrombocytopenia and 1.5% in controls (Gray test, P = .08). These findings suggest that baseline platelet counts are an important biomarker for hemorrhagic outcomes in AF and that the degree of thrombocytopenia is an important factor in determining the level of risk.
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Affiliation(s)
- Varun Iyengar
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rushad Patell
- Harvard Medical School, Boston, MA
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, MA
| | - Siyang Ren
- Department of Data Science, Dana Farber Cancer Institute, Boston, MA
| | - Sirui Ma
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Amanda Pinson
- Harvard Medical School, Boston, MA
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, MA
| | - Amelia Barnett
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Pavania Elavalakanar
- Harvard Medical School, Boston, MA
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, MA
| | - Dhruv S. Kazi
- Harvard Medical School, Boston, MA
- Division of Cardiology, Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
| | - Donna Neuberg
- Department of Data Science, Dana Farber Cancer Institute, Boston, MA
| | - Jeffrey I. Zwicker
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
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Wang T, Liu X, Zhu Y, Zhang Y, Zhang Z, Huang G, Xu J. Antithrombotic strategy in cancer patients comorbid with acute coronary syndrome and atrial fibrillation. Front Cardiovasc Med 2023; 10:1325488. [PMID: 38162143 PMCID: PMC10756915 DOI: 10.3389/fcvm.2023.1325488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 11/27/2023] [Indexed: 01/03/2024] Open
Abstract
It has been shown that patients with cancer have a longer expected life duration, benefiting from advanced medical therapy. Meanwhile, the risk of suffering from cardiovascular disease (CVD) has been increasing with ageing. A growing number of studies have elucidated the association between cancer and CVD. Cancer, atrial fibrillation (AF) and coronary artery disease share some common factors and interact with each other, such as obesity, aging, diabetes, and inflammation, but the potential specific mechanism is still unclear. In addition, cancer-specific and therapy-related factors may increase the risk of embolism and bleeding in patients with cancer than in general population. However, current available embolic and bleeding risk scores applied in patients with CVD may not be applicable for risk assessment in cancer patients, which would be difficult for clinicians to select an appropriate antithrombotic regimen and ensure the balance between bleeding and embolism. Moreover, different types of cancer have distinct risks, which may increase the complexity of antithrombotic therapy. In this review, we review the literature related to cancer, AF, and acute coronary syndrome, focusing on the epidemiological status, physiological mechanism, embolism and bleeding risks, and strategies of antithrombotic therapy.
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Affiliation(s)
- Tianbo Wang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Xiaohan Liu
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Yuxin Zhu
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Yue Zhang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
| | - Zhen Zhang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
| | - Gang Huang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
| | - Junbo Xu
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
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9
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Kayano SS, Santana PV, Colella R, Colella MP, Caruso P. Lower platelet count and metastatic tumor are associated with increased risk of spontaneous bleeding in critically ill patients with cancer: An observational study. Transfusion 2023; 63:2311-2320. [PMID: 37818876 DOI: 10.1111/trf.17569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/13/2023] [Accepted: 09/20/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Thrombocytopenia is common in critically ill patients with cancer. However, the association of platelet count with spontaneous bleeding is controversial in critically ill patients and the association with cancer-related characteristics is unknown. METHODS This observational study includes patients with active cancer and severe thrombocytopenia. A logistic regression model adjusted for confounders was used to evaluate the association of daily platelet count and cancer-related characteristics (type of cancer and presence of metastasis) with spontaneous bleeding. Confounders were identified using directed acyclic graphs. RESULTS We screened 5822 patients, 255 (4.4%) met eligibility criteria resulting in 1401 daily observations. Fifty-three patients (20.8%) had spontaneous bleeding during the intensive care unit stay, 64% presenting minor, and 36% major bleeding. The adjusted odds ratio (OR) for spontaneous bleeding with platelet count between 49 and 20 × 109 /L was 4.6 (1.1-19.6), with platelet count between 19 and 10 × 109 /L was 14.2 (3.1-66.2), and with platelet count below 10 × 109 /L was 39.6 (6.9-228.5). The adjusted OR for spontaneous bleeding in patients with hematologic malignancies was 0.6 (0.4-1.2), and 4.3 (2.0-9.0) for patients with metastatic tumor. CONCLUSIONS In critically ill patients with active cancer and severe thrombocytopenia, lower counts of platelets and presence of metastasis are associated with increased risk of spontaneous bleeding, while hematologic malignancy is not associated with increased risk of spontaneous bleeding.
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Affiliation(s)
| | | | | | - Marina Pereira Colella
- Hematology and Hemotherapy Center of the University of Campinas (Hemocentro UNICAMP), Campinas, Brazil
| | - Pedro Caruso
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil
- Pulmonary Division, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
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Ghosh LD, Jain A. The prospects of microphysiological systems in modeling platelet pathophysiology in cancer. Platelets 2023; 34:2247489. [PMID: 37610007 PMCID: PMC10578702 DOI: 10.1080/09537104.2023.2247489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/10/2023] [Accepted: 08/02/2023] [Indexed: 08/24/2023]
Abstract
The contribution of platelets is well recognized in thrombosis and hemostasis. However, platelets also promote tumor progression and metastasis through their crosstalk with various cells of the tumor microenvironment (TME). For example, several cancer models continue to show that platelet functions are readily altered by cancer cells upon activation leading to the formation of platelet-tumor aggregates, triggering release of soluble factors from platelet granules and altering platelet turnover. Further, activated platelets protect tumor cells from shear forces in circulation and assault of cytotoxic natural killer (NK) cells. Platelet-secreted factors promote proliferation of malignant cells, metastasis, and chemoresistance. Much of our knowledge of platelet biology in cancer has been achieved with animal models, particularly murine. However, this preclinical understanding of the complex pathophysiology is yet to be fully realized and translated to clinical trials in terms of new approaches to treat cancer via controlling the platelet function. In this review, we summarize the current state of knowledge of platelet physiology obtained through existing in vivo and in vitro cancer models, the complex interactions of platelets with cancer cells in TME and the pathways by which platelets may confer chemoresistance. Since the FDA Modernization Act recently passed by the US government has made animal models optional in drug approvals, we critically examine the existing and futuristic value of employing bioengineered microphysiological systems and organ-chips to understand the mechanistic role of platelets in cancer metastasis and exploring novel therapeutic targets for cancer prevention and treatment.
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Affiliation(s)
- Lopamudra D. Ghosh
- Department of Biomedical Engineering, College of Engineering, Texas A&M University, College Station, Texas, USA
| | - Abhishek Jain
- Department of Biomedical Engineering, College of Engineering, Texas A&M University, College Station, Texas, USA
- Department of Medical Physiology, School of Medicine, Texas A&M Health Science Center, Bryan, Texas, USA
- Department of Cardiovascular Sciences, Houston Methodist Academic Institute, Houston, Texas, USA
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11
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Liao K, Zhang X, Liu J, Teng F, He Y, Cheng J, Yang Q, Zhang W, Xie Y, Guo D, Cao G, Xu Y, Huang B, Wang X. The role of platelets in the regulation of tumor growth and metastasis: the mechanisms and targeted therapy. MedComm (Beijing) 2023; 4:e350. [PMID: 37719444 PMCID: PMC10501337 DOI: 10.1002/mco2.350] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 07/21/2023] [Accepted: 07/23/2023] [Indexed: 09/19/2023] Open
Abstract
Platelets are a class of pluripotent cells that, in addition to hemostasis and maintaining vascular endothelial integrity, are also involved in tumor growth and distant metastasis. The tumor microenvironment is a complex and comprehensive system composed of tumor cells and their surrounding immune and inflammatory cells, tumor-related fibroblasts, nearby interstitial tissues, microvessels, and various cytokines and chemokines. As an important member of the tumor microenvironment, platelets can promote tumor invasion and metastasis through various mechanisms. Understanding the role of platelets in tumor metastasis is important for diagnosing the risk of metastasis and prolonging survival. In this study, we more fully elucidate the underlying mechanisms by which platelets promote tumor growth and metastasis by modulating processes, such as immune escape, angiogenesis, tumor cell homing, and tumor cell exudation, and further summarize the effects of platelet-tumor cell interactions in the tumor microenvironment and possible tumor treatment strategies based on platelet studies. Our summary will more comprehensively and clearly demonstrate the role of platelets in tumor metastasis, so as to help clinical judgment of the potential risk of metastasis in cancer patients, with a view to improving the prognosis of patients.
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Affiliation(s)
- Kaili Liao
- Jiangxi Province Key Laboratory of Laboratory MedicineJiangxi Provincial Clinical Research Center for Laboratory MedicineDepartment of Clinical LaboratoryThe Second Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Xue Zhang
- Queen Mary College of Nanchang UniversityNanchangChina
| | - Jie Liu
- School of Public HealthNanchang UniversityNanchangChina
| | - Feifei Teng
- School of Public HealthNanchang UniversityNanchangChina
| | - Yingcheng He
- Queen Mary College of Nanchang UniversityNanchangChina
| | - Jinting Cheng
- School of Public HealthNanchang UniversityNanchangChina
| | - Qijun Yang
- Queen Mary College of Nanchang UniversityNanchangChina
| | - Wenyige Zhang
- Queen Mary College of Nanchang UniversityNanchangChina
| | - Yuxuan Xie
- The Second Clinical Medical CollegeNanchang UniversityNanchangChina
| | - Daixin Guo
- School of Public HealthNanchang UniversityNanchangChina
| | - Gaoquan Cao
- The Fourth Clinical Medical CollegeNanchang UniversityNanchangChina
| | - Yanmei Xu
- Jiangxi Province Key Laboratory of Laboratory MedicineJiangxi Provincial Clinical Research Center for Laboratory MedicineDepartment of Clinical LaboratoryThe Second Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Bo Huang
- Jiangxi Province Key Laboratory of Laboratory MedicineJiangxi Provincial Clinical Research Center for Laboratory MedicineDepartment of Clinical LaboratoryThe Second Affiliated Hospital of Nanchang UniversityNanchangChina
| | - Xiaozhong Wang
- Jiangxi Province Key Laboratory of Laboratory MedicineJiangxi Provincial Clinical Research Center for Laboratory MedicineDepartment of Clinical LaboratoryThe Second Affiliated Hospital of Nanchang UniversityNanchangChina
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12
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Zhou F, Mu X, Li Z, Guo M, Wang J, Long P, Wan Y, Yuan T, Lv Y. Characteristics of Chinese herbal medicine mouthwash clinical studies: A bibliometric and content analysis. JOURNAL OF ETHNOPHARMACOLOGY 2023; 307:116210. [PMID: 36736713 DOI: 10.1016/j.jep.2023.116210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 12/18/2022] [Accepted: 01/23/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Fen Zhou
- School of Nursing, Beijing University of Chinese Medicine, Beijing, 10029, China.
| | - Xiaoying Mu
- School of Nursing, Beijing University of Chinese Medicine, Beijing, 10029, China.
| | - Zhaoyu Li
- School of Nursing, Capital Medical University, Beijing, 100069, China.
| | - Manjie Guo
- School of Nursing, Beijing University of Chinese Medicine, Beijing, 10029, China.
| | - Jianan Wang
- School of Nursing, Beijing University of Chinese Medicine, Beijing, 10029, China.
| | - Pengyi Long
- School of Nursing, Beijing University of Chinese Medicine, Beijing, 10029, China.
| | - Yujia Wan
- School of Nursing, Beijing University of Chinese Medicine, Beijing, 10029, China.
| | - Ting Yuan
- School of Nursing, Beijing University of Chinese Medicine, Beijing, 10029, China.
| | - Yunpeng Lv
- School of Nursing, Beijing University of Chinese Medicine, Beijing, 10029, China.
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13
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Lemiale V, Mabrouki A, Miry L, Mokart D, Pène F, Kouatchet A, Mayaux J, Bruneel F, Perez P, Meert AP, Moreau AS, Benoit D, Darmon M, Zafrani L, Clere-Jehl R. Sepsis-associated coagulopathy in onco-hematology patients presenting with thrombocytopenia: a multicentric observational study. Leuk Lymphoma 2023; 64:197-204. [PMID: 36305707 DOI: 10.1080/10428194.2022.2136971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Coagulation disorders increase mortality rate during septic shock, but the impact of concomitant hematological malignancies remains unknown. The study assessed coagulation disorders in onco-hematological patients with thrombocytopenia (<100 G/L) admitted to ICU for septic shock. Among 146 included patients, 50 patients had lymphoma and 49 patients had acute leukemia. ICU mortality rate was 43.8% (n = 64). Median increase in prothrombin time (PT) at day(d) 1 was 4.7 s (IQR 3.2-7.9) in ICU survivors vs. 6.4 s (IQR 4.5-13.7; p < 0.01) in non-survivors. Fibrinogen kinetics (increase in fibrinogen levels between d1 and d2) was +0.55 (-0.22-1.55) vs. +0.10 g/L (-0.40-0.50; p = 0.03) in surviving and non-surviving patients, respectively. PT increase ≥6 s at d1 (OR 5.5; 95% CI 1.1-6.0; p = 0.03) and mechanical ventilation (OR 7.4; 95% CI 3.3-17.7; p < 0.001) were independently associated with ICU mortality. This study provides information and new ways to identify hematological patients with high-risk mortality.
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Affiliation(s)
- Virginie Lemiale
- Department of Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Asma Mabrouki
- Department of Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Loïc Miry
- Neuro-Intensive Care Unit, Rothschild Foundation Hospital, France
| | - Djamel Mokart
- Medical and Surgical Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Frédéric Pène
- Service de Médecine Intensive-réanimation, Hôpital Cochin, AP-HP, Centre & Université Paris Cité, Paris, France
| | - Achille Kouatchet
- Medical Intensive Care Unit, Angers University Hospital, Angers, France
| | - Julien Mayaux
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Fabrice Bruneel
- Department of Critical Care, Versailles Hospital, Le Chesnay, France
| | - Pierre Perez
- Medical Intensive Care Unit, Hôpital Brabois, Vandoeuvre Les Nancy, France
| | - Anne-Pascale Meert
- Soins intensifs et urgences oncologiques, Service de Médecine interne, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Bruxelles, Belgique
| | - Anne-Sophie Moreau
- Pôle de médecine intensive réanimation, Hôpital Roger Salengro, CHU Lille, Lille cedex, France
| | - Dominique Benoit
- Medical Unit, Department of Intensive Care, Ghent University Hospitalc, Ghent, Belgium
| | - Michael Darmon
- Department of Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lara Zafrani
- Department of Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM U976, Human Immunology, Pathophysiology and Immunotherapy, Saint-Louis Teaching Hospital, Paris University, Paris, France
| | - Raphaël Clere-Jehl
- Department of Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Laboratoire d'ImmunoRhumatologie Moléculaire, INSERM (French National Institute of Health and Medical Research), UMR_S1109, Centre de Recherche d'Immunologie et d'Hématologie, Faculté de Médecine, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg Cedex, France
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14
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Goshua G, Bendapudi PK, Lee AI. Thrombosis questions from the inpatient wards. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:481-490. [PMID: 36485139 PMCID: PMC9819989 DOI: 10.1182/hematology.2022000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The multifaceted pathophysiologic processes that comprise thrombosis and thromboembolic diseases take on a particular urgency in the hospitalized setting. In this review, we explore 3 cases of thrombosis from the inpatient wards: purpura fulminans, cancer-associated thrombosis with thrombocytopenia, and coronavirus disease 2019 (COVID-19) and the use of dose-escalated anticoagulation therapy and antiplatelet agents. We discuss the evaluation and management of purpura fulminans and the roles of plasma transfusion, protein C and antithrombin replacement, and anticoagulation in treating this disease. We present a framework for evaluating the etiologies of thrombocytopenia in cancer and review 2 strategies for anticoagulation management in patients with cancer-associated thrombosis and thrombocytopenia, including recent prospective data supporting the use of dose-modified anticoagulation based on platelet count. Last, we dissect the major clinical trials of therapeutic- and intermediate-dose anticoagulation and antiplatelet therapy in hospitalized patients with COVID-19, reviewing key recommendations from consensus guidelines while highlighting ways in which institutional and patient-tailored practices regarding antithrombotic therapies in COVID-19 may differ. Together, the cases highlight the diverse and dramatic presentations of macro- and microvascular thrombosis as encountered on the inpatient wards.
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Affiliation(s)
- George Goshua
- Section of Hematology, Yale School of Medicine, New Haven, CT
| | - Pavan K Bendapudi
- Division of Hematology, Blood Transfusion Service, Massachusetts General Hospital; Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center; and Harvard Medical School, Boston, MA
| | - Alfred Ian Lee
- Section of Hematology, Yale School of Medicine, New Haven, CT
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15
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Zalunardo B, Panzavolta C, Bigolin P, Visonà A. Multidisciplinary Care for the Prevention and Treatment of Venous Thromboembolism in Patients with Cancer-Associated Thrombosis (CAT): Impact of Educational Interventions on CAT-Related Events and on Patients' and Clinicians' Awareness. Life (Basel) 2022; 12:life12101594. [PMID: 36295029 PMCID: PMC9605479 DOI: 10.3390/life12101594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/20/2022] [Accepted: 10/05/2022] [Indexed: 05/27/2023] Open
Abstract
Cancer is a leading cause of death. Venous thromboembolism (VTE) is an often-overlooked cause of morbidity and mortality in cancer patients that can be readily prevented and treated. Actions are needed to reduce the morbidity and mortality of patients with cancer-associated thrombosis (CAT). There is a need to increase awareness of the impact of CAT on cancer patients' morbidity and mortality, on their quality of life and to understand the importance of more effective preventions and treatments of VTE in cancer patients. Moreover, it is of great importance to systematically assess the risk of VTE in regard to patients, cancer and treatment-related factors. Unfortunately, there are unmet clinical needs in the prevention and treatment of cancer-associated VTE. In this review, we discuss an action plan to ensure an increased awareness of and education on the issues that need to be addressed in order to improve the provision of appropriate prevention, early diagnosis and effective and safe treatment of VTE to all cancer patients and, ultimately, to reduce morbidity and mortality.
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16
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Li X, Hu L, Tan C, Wang X, Ran Q, Chen L, Li Z. Platelet-promoting drug delivery efficiency for inhibition of tumor growth, metastasis, and recurrence. Front Oncol 2022; 12:983874. [PMID: 36276066 PMCID: PMC9582853 DOI: 10.3389/fonc.2022.983874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/20/2022] [Indexed: 11/25/2022] Open
Abstract
Nanomedicines are considered one of the promising strategies for anticancer therapy; however, the low targeting efficiency of nanomedicines in vivo is a great obstacle to their clinical applications. Camouflaging nanomedicines with either platelet membrane (PM) or platelet would significantly prolong the retention time of nanomedicines in the bloodstream, enhance the targeting ability of nanomedicines to tumor cells, and reduce the off-target effect of nanomedicines in major organs during the anticancer treatment. In the current review, the advantages of using PM or platelet as smart carriers for delivering nanomedicines to inhibit tumor growth, metastasis, and recurrence were summarized. The opportunities and challenges of this camouflaging strategy for anticancer treatment were also discussed.
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Affiliation(s)
- Xiaoliang Li
- Laboratory of Radiation Biology, Laboratory Medicine Center, Department of Blood Transfusion, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Lanyue Hu
- Laboratory of Radiation Biology, Laboratory Medicine Center, Department of Blood Transfusion, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Chengning Tan
- Laboratory of Radiation Biology, Laboratory Medicine Center, Department of Blood Transfusion, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Xiaojie Wang
- Laboratory of Radiation Biology, Laboratory Medicine Center, Department of Blood Transfusion, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Qian Ran
- Laboratory of Radiation Biology, Laboratory Medicine Center, Department of Blood Transfusion, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Li Chen
- Laboratory of Radiation Biology, Laboratory Medicine Center, Department of Blood Transfusion, The Second Affiliated Hospital, Army Medical University, Chongqing, China
- *Correspondence: Li Chen, ; Zhongjun Li,
| | - Zhongjun Li
- Laboratory of Radiation Biology, Laboratory Medicine Center, Department of Blood Transfusion, The Second Affiliated Hospital, Army Medical University, Chongqing, China
- State Key Laboratory of Trauma, Burn and Combined Injuries, The Second Affiliated Hospital, Army Medical University, Chongqing, China
- *Correspondence: Li Chen, ; Zhongjun Li,
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17
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Degliuomini MD, Armstrong K, Mauguen A, Slotkin EK, Roberts SS, Dunkel IJ, Clouser M, Ortiz MV, Soff GA. Chemotherapy-induced thrombocytopenia in pediatric oncology: Scope of the problem and opportunities for intervention. Pediatr Blood Cancer 2022; 69:e29776. [PMID: 35593014 PMCID: PMC9709583 DOI: 10.1002/pbc.29776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Chemotherapy-induced thrombocytopenia (CIT) is a known hematologic complication of oncology treatment. This single-institution study examines the degree with which CIT impacts specific pediatric solid tumor cohorts reflected by platelet transfusion burden and treatment modifications. PROCEDURE Data regarding clinically relevant CIT were obtained via a retrospective chart review of pediatric solid tumor patients treated at Memorial Sloan Kettering Cancer Center from 2013 to 2020. Patients were stratified based on histologic diagnoses as well as chemotherapy regimen. CIT impact was assessed through platelet transfusion means, chemotherapy dose reductions, and treatment delays. RESULTS A total of 150 patients were included with mean age 10.3 [0.2-21.0]. Patients receiving therapy for high-risk neuroblastoma and localized Ewing sarcoma, both of which included high-dose cyclophosphamide and doxorubicin, required the most platelet transfusions over the treatment course, with a mean of 13 and 9, respectively. Reduced relative dose intensity (RDI), due in part to CIT, was greatest for the patients receiving therapy for high-risk and intermediate-risk rhabdomyosarcoma. Fifty-six percent of high-risk patients experienced a reduced RDI during the final two cycles of treatment and 69% of intermediate-risk patients experienced one during the final four cycles of treatment. CONCLUSIONS The impact of CIT varied by the administered chemotherapy regimens and dose intensity of chemotherapy agents. This study demonstrated that CIT causes both marked platelet transfusion burden as well as treatment reduction and delay within certain solid tumor cohorts. This can lend to future studies aimed at reducing the burden of CIT and targeting the most at-risk populations.
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Affiliation(s)
- Melanie D Degliuomini
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Katherine Armstrong
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Pediatrics, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Audrey Mauguen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Emily K Slotkin
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Stephen S Roberts
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ira J Dunkel
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Mary Clouser
- Amgen Center for Observational Research, Thousand Oaks, California, USA
| | - Michael V Ortiz
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gerald A Soff
- Department of Medicine, University of Miami Health System, Miami, Florida, USA
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18
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Curtiaud A, Delmas C, Gantzer J, Zafrani L, Siegemund M, Meziani F, Merdji H. Cardiogenic shock among cancer patients. Front Cardiovasc Med 2022; 9:932400. [PMID: 36072868 PMCID: PMC9441759 DOI: 10.3389/fcvm.2022.932400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
Sophisticated cancer treatments, cardiovascular risk factors, and aging trigger acute cardiovascular diseases in an increasing number of cancer patients. Among acute cardiovascular diseases, cancer treatment, as well as the cancer disease itself, may induce a cardiogenic shock. Although increasing, these cardiogenic shocks are still relatively limited, and their management is a matter of debate in cancer patients. Etiologies that cause cardiogenic shock are slightly different from those of non-cancer patients, and management has some specific features always requiring a multidisciplinary approach. Recent guidelines and extensive data from the scientific literature can provide useful guidance for the management of these critical patients. Even if no etiologic therapy is available, maximal intensive supportive measures can often be justified, as most of these cardiogenic shocks are potentially reversible. In this review, we address the major etiologies that can lead to cardiogenic shock in cancer patients and discuss issues related to its management.
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Affiliation(s)
- Anais Curtiaud
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive-Réanimation, Strasbourg, France
| | - Clement Delmas
- Intensive Cardiac Care Unit, Cardiology Department, University Hospital of Rangueil, Toulouse, France
| | - Justine Gantzer
- Department of Medical Oncology, Strasbourg-Europe Cancer Institute (ICANS), Strasbourg, France
| | - Lara Zafrani
- Medical Intensive Care Unit, Saint-Louis Hospital, Assistance Publique des Hôpitaux de Paris, University of Paris, Paris, France
| | - Martin Siegemund
- Intensive Care Unit, Department of Acute Medicine, University Hospital, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Ferhat Meziani
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive-Réanimation, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Hamid Merdji
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive-Réanimation, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
- *Correspondence: Hamid Merdji
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19
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Lee S, Srivatsan A, Srinivasan VM, Chen SR, Burkhardt JK, Johnson JN, Raper DMS, Weinberg JS, Kan P. Middle meningeal artery embolization for chronic subdural hematoma in cancer patients with refractory thrombocytopenia. J Neurosurg 2022; 136:1273-1277. [PMID: 34624863 DOI: 10.3171/2021.5.jns21109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 05/03/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical evacuation of chronic subdural hematoma (SDH) in cancer patients is often contraindicated owing to refractory thrombocytopenia. Middle meningeal artery embolization (MMAE) recently emerged as a potential alternative to surgical evacuation for patients with chronic SDH. The goal of this study was to evaluate the safety and efficacy of MMAE for chronic SDH in cancer patients with refractory thrombocytopenia. METHODS A multiinstitutional registry was reviewed for clinical and radiographic outcomes of cancer patients with transfusion-refractory thrombocytopenia and baseline platelet count < 75 K/µl, who underwent MMAE for chronic SDH. RESULTS MMAE was performed on a total of 31 SDHs in 22 patients, with a mean ± SD (range) platelet count of 42.1 ± 18.3 (9-74) K/µl. At the longest follow-up, 24 SDHs (77%) had reduced in size, with 15 (48%) showing > 50% reduction. Two patients required surgical evacuation after MMAE. There was only 1 procedural complication; however, 16 patients (73%) ultimately died of cancer-related complications. Median survival was significantly longer in the 16 patients with improved SDH than the 6 patients with worsened SDH after MMAE (185 vs 24 days, p = 0.029). Length of procedure, technical success rate, SDH size reduction, and complication rate were not significantly differ between patients who underwent transfemoral and transradial approaches. CONCLUSIONS Transfemoral or transradial MMAE is a potential therapeutic option for thrombocytopenic cancer patients with SDH. However, treatment benefit may be marginal for patients with high disease burden and limited life expectancy. A prospective trial is warranted to address these questions.
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Affiliation(s)
- Sungho Lee
- 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Aditya Srivatsan
- 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | | | - Jan-Karl Burkhardt
- 4Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | | | - Daniel M S Raper
- 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jeffrey S Weinberg
- 3Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peter Kan
- 5Department of Neurosurgery, The University of Texas Medical Branch, Galveston, Texas
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20
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Held N, Jung B, Baumann Kreuziger L. Management of cancer-associated thrombosis with thrombocytopenia: Impact of the ISTH guidance statement. Res Pract Thromb Haemost 2022; 6:e12726. [PMID: 35664532 PMCID: PMC9133434 DOI: 10.1002/rth2.12726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 04/01/2022] [Accepted: 04/12/2022] [Indexed: 11/09/2022] Open
Abstract
Background Optimal management of cancer-associated thrombosis (CAT) in patients with thrombocytopenia remains difficult given competing risks of recurrent thrombosis and increased bleeding. We determine the impact of the ISTH Scientific and Standardization Committee (SCC) guidance on CAT management and thrombocytopenia on platelet transfusion, bleeding, and recurrent thrombosis. Methods A retrospective review was performed of patients with CAT and thrombocytopenia who required anticoagulation for VTE for 11 months before and after implementation of the ISTH SCC guidance. Medical records were reviewed to identify the type of VTE event, number of platelet transfusions, incidence of bleeding, and VTE recurrence within pre- and postintervention time periods. Results A total of 41 and 80 cases were included in the preintervention and postintervention periods, respectively. The preintervention group showed a trend toward less acute VTE events (39% vs 55%; P = .05). The postintervention period had an increased per-patient platelet transfusion (median, 2.5 vs 4; P = .05). Nonmajor bleeding was increased in the postintervention group (2% vs 16%; P = 0.03) and included all six (8%) major hemorrhages (P = .09). There was numerically less recurrent thrombosis in the postintervention group (20% vs 8%; P = .07), which was not significantly different when accounting for acuity of VTE. Management adherence was strong, at 91%, in the postintervention group. Conclusion The ISTH guidance on management of cancer-associated thrombosis in patients with thrombocytopenia was successfully implemented in an academic medical center. There was no significant difference in bleeding or recurrent thrombosis outcomes after adjusting for acuity of VTE.
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Affiliation(s)
- Nicole Held
- Division of Hematology/Oncology, Department of MedicineMedical College of WisconsinMilwaukeeWisconsinUSA
| | | | - Lisa Baumann Kreuziger
- Division of Hematology/Oncology, Department of MedicineMedical College of WisconsinMilwaukeeWisconsinUSA
- Versiti Blood Research InstituteMilwaukeeWisconsinUSA
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21
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Pally A, Tennison J. Rehabilitation in the Setting of Untreated Cancer-Associated Acute Deep Vein Thrombosis. Integr Cancer Ther 2022; 21:15347354221074349. [PMID: 35112579 PMCID: PMC8819757 DOI: 10.1177/15347354221074349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Research is needed to guide the timing and safety of rehabilitation (physical and occupational therapy) in patients with acute deep venous thrombosis (DVT) that is untreated due to contraindications. CASE DESCRIPTION A 21-year-old man with Hodgkin lymphoma was admitted to the hospital for neutropenic fever. He developed gastrointestinal bleeding, diffuse alveolar hemorrhage, and bilateral lower-extremity DVT. He was not a candidate for chemical anticoagulation or placement of an inferior vena cava filter owing to thrombocytopenia. Rehabilitation was initially deferred because of concern that the thrombus could travel to the lungs, causing a pulmonary embolism. Rehabilitation was, however, started 4 days after the initial diagnosis of lower-extremity DVT to assess functional mobility and activities of daily living skills to prepare for discharge from the hospital. RESULTS The patient experienced no bleeding events during rehabilitation, and his acute, untreated DVT did not propagate based on clinical assessment. His Activity Measure for Post-Acute Care (AM-PAC) "6 Clicks" Basic Mobility score improved from 30.25 to 35.55 over the period of 11 days while he received rehabilitation. CONCLUSION Despite having an acute bilateral lower-extremity DVT that was untreatable owing to thrombocytopenia, the patient successfully participated in rehabilitation and improved his physical functional status without an adverse event. Untreated acute venous thromboembolism in the setting of recent history of major bleeding raise concerns about physical activity restrictions. It is critical to consider both the risks and benefits of mobilizing patients and prescribing exercises in patients with these conditions.
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Affiliation(s)
| | - Jegy Tennison
- The University of Texas MD Anderson Cancer Center, Houston, USA
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22
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Deng XH, Li J, Chen SJ, Xie YJ, Zhang J, Cen GY, Song YT, Liang ZJ. Clinical features of intracerebral hemorrhage in patients with colorectal cancer and its underlying pathogenesis. World J Gastrointest Oncol 2021; 13:2180-2189. [PMID: 35070050 PMCID: PMC8713314 DOI: 10.4251/wjgo.v13.i12.2180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/10/2021] [Accepted: 09/17/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The diagnosis of both cancer and intracerebral hemorrhage (ICH) in the same patient is not uncommon, but the clinical features and pathogenesis of patients with colorectal cancer (CRC) and ICH are still not well known.
AIM To investigate the clinical features and underlying pathogenesis of ICH in patients with CRC.
METHODS A retrospective review of CRC patients complicated with ICH from three centers between January 2014 and December 2020 was performed. Clinical data such as laboratory examinations, imaging features, prognosis, and underlying pathogenesis were analyzed.
RESULTS Of 16673 identified CRC patients, 20 (0.12%) suffered from ICH. There were 13 males and 7 females, with an average age (mean ± SD) of 68.45 ± 10.66 years. Fourteen patients (70%) had distant metastases and most patients (85%) showed an elevation of one or more cancer biomarkers. The hemorrhagic lesions in 13 patients (65%) were in the intracerebral lobe. Four patients were completely dependent and 4 died within 30 days after hemorrhage. Intratumoral hemorrhage (50%) and coagulopathy (50%) accounted for the majority of hemorrhages.
CONCLUSION Patients with ICH and CRC often have clinical features with lobar hemorrhage, distant metastases and poor prognosis. Intratumoral hemorrhage and coagulopathy are the main causes of ICH in patients with CRC.
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Affiliation(s)
- Xu-Hui Deng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
- Department of Neurology, The Affiliated Yuebei People’s Hospital of Shantou University Medical College, Shaoguan 512025, Guangdong Province, China
| | - Jing Li
- Department of General Medicine, The Affiliated Cancer Center of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Shi-Jian Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Yi-Ju Xie
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Jian Zhang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Geng-Yu Cen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Yi-Ting Song
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
| | - Zhi-Jian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Zhuang Autonomous Region, China
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23
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Gevaert SA, Halvorsen S, Sinnaeve PR, Sambola A, Gulati G, Lancellotti P, Van Der Meer P, Lyon AR, Farmakis D, Lee G, Boriani G, Wechalekar A, Okines A, Asteggiano R. Evaluation and management of cancer patients presenting with acute cardiovascular disease: a Consensus Document of the Acute CardioVascular Care (ACVC) association and the ESC council of Cardio-Oncology-Part 1: acute coronary syndromes and acute pericardial diseases. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:947-959. [PMID: 34453829 DOI: 10.1093/ehjacc/zuab056] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/22/2021] [Accepted: 06/30/2021] [Indexed: 12/24/2022]
Abstract
Advances in treatment, common cardiovascular (CV) risk factors and the ageing of the population have led to an increasing number of cancer patients presenting with acute CV diseases. These events may be related to the cancer itself or the cancer treatment. Acute cardiac care specialists must be aware of these acute CV complications and be able to manage them. This may require an individualized and multidisciplinary approach. We summarize the most common acute CV complications of cytotoxic, targeted, and immune-based therapies. This is followed by a proposal for a multidisciplinary approach where acute cardiologists work close together with the treating oncologists, haematologists, and radiation specialists, especially in situations where immediate therapeutic decisions are needed. In this first part, we further focus on the management of acute coronary syndromes and acute pericardial diseases in patients with cancer.
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Affiliation(s)
- Sofie A Gevaert
- Department of Cardiology, Ghent University Hospital, C Heymanslaan 10, 9000 Gent, Belgium
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
| | - Peter R Sinnaeve
- Department of Cardiology, University Hospital Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Antonia Sambola
- Department of Cardiology, University Hospital Vall d'Hebron, Universitat Autonòma, CIBER-CV, Passeig de la Vall d'Hebron 119, 08035 Barcelona, Spain
| | - Geeta Gulati
- Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Science and Department of Cardiology, CHU Sart Tilman, Avenue del'Hôpital 1, 4000 Liège, Belgium
| | - Peter Van Der Meer
- Department of Cardiology, University of Groningen University Medical Center Groningen and University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Alexander R Lyon
- Cardio-Oncology Clinic at Royal Brompton Hospital and Imperial College, Sydney street, SW3 6NP London, UK
| | - Dimitrios Farmakis
- University of Cyprus Medical School, Agio Nikolaou street 93, 2408 Nicosia, Cyprus
| | - Geraldine Lee
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College, Strand, WC2R 2LS London, UK
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia and Policlinico Di Modena, Via Giuseppe Campi 287, 41125 Modena, Italy
| | - Ashutosh Wechalekar
- Department of Haematology, University College London/University College London Hospitals, Huntley street 72, WC1E 6DD London, UK
| | - Alicia Okines
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Fulham road 203, SW3 6JJ London, UK
| | - Riccardo Asteggiano
- Insubria University, Via Ravasi 2, 21100 Varese, Italy.,LARC (Laboratorio Analisi e Ricerca Clinica), Via Mombarcaro 80, 10136 Turin, Italy
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24
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Anticoagulation in cancer-associated thromboembolism with thrombocytopenia: a prospective, multi-center cohort study. Blood Adv 2021; 5:5546-5553. [PMID: 34662892 PMCID: PMC8714719 DOI: 10.1182/bloodadvances.2021005966] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/29/2021] [Indexed: 11/23/2022] Open
Abstract
In patients with cancer with VTE and thrombocytopenia, modified-dose anticoagulation was associated with a lower rate of major hemorrhage. In this cohort, recurrent VTE was not observed after initiation of modified-dose anticoagulation.
Venous thromboembolism (VTE) with concurrent thrombocytopenia is frequently encountered in patients with cancer. Therapeutic anticoagulation in the setting of thrombocytopenia is associated with a high risk of hemorrhage. Retrospective analyses suggest the utility of modified-dose anticoagulation in this population. To assess the incidence of hemorrhage or thrombosis according to anticoagulation strategy, we performed a prospective, multicenter, observational study. Patients with active malignancy, acute VTE, and concurrent thrombocytopenia (platelet count <100 000/µL) were enrolled. The cumulative incidences of hemorrhage or recurrent VTE were determined considering death as a competing risk. Primary outcomes were centrally adjudicated and comparisons made according to initial treatment with full-dose or modified-dose anticoagulation. A total of 121 patients were enrolled at 6 hospitals. Seventy-five patients were initially treated with full-dose anticoagulation (62%) and 33 (27%) with modified-dose anticoagulation; 13 (11%) patients received no anticoagulation. Most patients who received modified-dose anticoagulation had a hematologic malignancy (31 of 33 [94%]) and an acute deep vein thrombosis (28 of 33 [85%]). In patients who initially received full-dose anticoagulation, the cumulative incidence of major hemorrhage at 60 days was 12.8% (95% confidence interval [CI], 4.9-20.8) and 6.6% (95% CI, 2.4-15.7) in those who received modified-dose anticoagulation (Fine-Gray hazard ratio, 2.18; 95% CI, 1.21-3.93). The cumulative incidence of recurrent VTE at 60 days in patients who initially received full-dose anticoagulation was 5.6% (95% CI, 0.2-11) and 0% in patients who received modified-dose anticoagulation. In conclusion, modified-dose anticoagulation appears to be a safe alternative to therapeutic anticoagulation in patients with cancer who develop deep vein thrombosis in the setting of thrombocytopenia.
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25
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Frere C, Font C, Esposito F, Crichi B, Girard P, Janus N. Incidence, risk factors, and management of bleeding in patients receiving anticoagulants for the treatment of cancer-associated thrombosis. Support Care Cancer 2021; 30:2919-2931. [PMID: 34617159 DOI: 10.1007/s00520-021-06598-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/26/2021] [Indexed: 12/19/2022]
Abstract
Updated clinical practice guidelines recommend the long-term use of low-molecular-weight heparins or direct oral anticoagulants as the preferred option for the treatment of cancer-associated thrombosis (CAT), using a personalized approach matching the right drug to the right patient. In most cases, the benefit of anticoagulant therapy outweighs the risk. However, the long-term use of anticoagulants is associated with a non-negligible risk of bleeding, which constitutes a rare but serious adverse effect. Bleeding complications have been reported to be overall 2 to 3 times more frequent in cancer patients with CAT receiving anticoagulation than in non-cancer patients, with a reported incidence of major bleeding ranging from 2.4 to 16.0% in randomized controlled trials (RCT). In the absence of validated risk assessment model to predict the risk of bleeding in these patients, a careful evaluation of each individual profile, with adequate selection of the most appropriate anticoagulant for each individual patient, is warranted for overcoming management challenges, taking in account the numerous factors which may potentiate the overall bleeding risk in these complex patients, such as advanced or metastatic disease, older age, anemia, thrombocytopenia, renal impairment, liver dysfunction, and concomitant anticancer therapies. The purpose of this review is to call for awareness on bleeding complications as a major safety issue of CAT treatment and to summarize data from recent RCT and real-world studies on the incidence and risk factors for bleeding in this unique and challenging population to further help clinicians in decision-making.
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Affiliation(s)
- Corinne Frere
- Institute of Cardiometabolism And Nutrition, GRC 27 GRECO, Sorbonne Université, INSERM UMRS_1166, Paris, France
- Department of Haematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Carme Font
- Department of Internal Medicine, Hospital Clinic, Barcelona, Spain
| | | | - Benjamin Crichi
- Department of Internal Medicine, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, 75010, Paris, France
| | - Philippe Girard
- Département Thoracique, Institut Mutualiste Montsouris, Paris, France
- FCRIN INNOVTE, Paris, France
| | - Nicolas Janus
- Global Thrombosis Strategy, Medical Affairs, Leo Pharma, Voisins-le-Bretonneux, France.
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26
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Grencheski EA, Kochi MN, Politi FVA, dos Santos TM, de Brito CMM, Yamaguti WP, Righetti RF. Bleeding frequency during physiotherapy in thrombocytopenic patients undergoing hematopoietic stem cell transplantation. PLoS One 2021; 16:e0255413. [PMID: 34329360 PMCID: PMC8323874 DOI: 10.1371/journal.pone.0255413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/15/2021] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND During hematopoietic stem cell transplantation (HSCT) the patients perform activities of low and moderate intensity because have reduced hematological lineages, leaving them susceptible to hemorrhagic events. The objective of this study was to describe the frequency of bleeding events, severity, and possible association with physical exercise in thrombocytopenic patients. METHODS A retrospective study with seventy-seven HSCT patients hospitalised, that had a platelet count ≤ 50,000 /μL and received physical exercise during physiotherapy intervention. RESULTS Regarding bleeding events, only six were related to physical exercise, and bleeding events occurred more frequently at platelet levels ≤ 10,000 /μL. The most frequent bleeding event was epistaxis, considered of low severity, and with the moderate possibility of being related to physical exercise; followed by extremity hematoma, considered of medium severity and highly related to physical exercise. In this study, there was no occurrence of bleeding events considered of high severity. CONCLUSION Bleeding frequency in supervised physical exercise during physiotherapy in adults with thrombocytopenia undergoing HSCT is minor and relatively rare but occurs more frequently in patients with platelet count ≤10,000 /μL. These results encourage the maintenance of physical activity in this population who is at high risk of developing immobility-related complications.
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27
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Nandini C, Madhunapantula SV, Bovilla VR, Ali M, Mruthunjaya K, Santhepete MN, Jayashree K. Platelet enhancement by Carica papaya L. leaf fractions in cyclophosphamide induced thrombocytopenic rats is due to elevated expression of CD110 receptor on megakaryocytes. JOURNAL OF ETHNOPHARMACOLOGY 2021; 275:114074. [PMID: 33831466 DOI: 10.1016/j.jep.2021.114074] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/23/2021] [Accepted: 03/23/2021] [Indexed: 06/12/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Carica papaya leaf juice/decoction has been in use in folk medicine in Srilanka, Malaysia and in few parts of India for enhancing the platelet counts in dengue. In Siddha medicine, a traditional form of medicine in India, papaya leaf juice has been used for increasing the platelet counts. Papaya leaf has been reported to enhance blood volume in ancient Ayurveda books in India. Carica papaya leaf is well known for its platelet enhancement activity. Although many preclinical and clinical studies have demonstrated the ability of papaya leaf juice for platelet enhancement, but the underlying mechanisms are still unclear. AIM OF THE STUDY The study is aimed at identifying the key ingredients of papaya leaf extract and elucidate the mechanism (s) of action of the identified potent component in mitigating thrombocytopenia (Thp). MATERIALS AND METHODS C. papaya leaf juice was subjected for sequential fractionation to identify the anti-thrombocytopenic phytochemicals. In vivo, stable thrombocytopenia was induced by subcutaneous injection of 70 mg/kg cyclophosphamide (Cyp). After induction, rats were treated with 200 and 400 mg/kg body weight papaya leaf juice and with identified fractions for 14 days. Serum thrombopoietin level was estimated using ELISA. CD110/cMpl, a receptor for thrombopoietin on platelets was measured by western blotting. RESULTS Administration of cyclophosphamide for 6 days induced thrombocytopenia (210.4 ± 14.2 × 103 cells/μL) in rats. Treating thrombocytopenic rats with papaya leaf juice and butanol fraction for 14 days significantly increased the platelet count to 1073.50 ± 29.6 and 1189.80 ± 36.5 × 103 cells/μL, respectively. C.papaya extracts normalized the elevated bleeding and clotting time and decreased oxidative markers by increasing endogenous antioxidants. A marginal increase in the serum thrombopoietin (TPO) level was observed in Cyp treated group compared to normal and treatment groups. Low expression of CD110/cMpl receptor found in Cyp treated group was enhanced by C. papaya extracts (CPJ) and CPJ-BT. Furthermore, examination of the morphology of bone marrow megakaryocytes, histopathology of liver and kidneys revealed the ability of CPJ and fractions in mitigating Cyp-induced thrombocytopenia in rats. CONCLUSION C. papaya leaf juice enhances the platelet count in chemotherapy-induced thrombocytopenia by increasing the expression of CD110 receptor on the megakaryocytes. Hence, activating CD110 receptor might be a viable strategy to increase the platelet production in individuals suffering from thrombocytopenia.
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Affiliation(s)
- C Nandini
- Department of Pharmacology, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Mysuru, Karnataka, India
| | - SubbaRao V Madhunapantula
- Centre of Excellence in Molecular Biology and Regenerative Medicine (CEMR), JSS Medical College, JSS Academy of Higher Education & Research, Mysuru, Karnataka, India.
| | - Venugopal R Bovilla
- Centre of Excellence in Molecular Biology and Regenerative Medicine (CEMR), JSS Medical College, JSS Academy of Higher Education & Research, Mysuru, Karnataka, India
| | - Mohammad Ali
- Department of Pharmacology, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Mysuru, Karnataka, India
| | - K Mruthunjaya
- Department of Pharmacognosy, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Mysuru, Karnataka, India
| | - Manjula N Santhepete
- Department of Pharmacology, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Mysuru, Karnataka, India.
| | - K Jayashree
- Department of Pathology, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru, Karnataka, India.
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28
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Saunders J, Niswander LM, McGrath KE, Koniski A, Catherman SC, Ture SK, Medhora M, Kingsley PD, Calvi LM, Williams JP, Morrell CN, Palis J. Long-acting PGE2 and Lisinopril Mitigate H-ARS. Radiat Res 2021; 196:284-296. [PMID: 34153091 DOI: 10.1667/rade-20-00113.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 05/24/2021] [Indexed: 11/03/2022]
Abstract
Thrombocytopenia is a major complication in hematopoietic-acute radiation syndrome (H-ARS) that increases the risk of mortality from uncontrolled hemorrhage. There is a great demand for new therapies to improve survival and mitigate bleeding in H-ARS. Thrombopoiesis requires interactions between megakaryocytes (MKs) and endothelial cells. 16, 16-dimethyl prostaglandin E2 (dmPGE2), a longer-acting analogue of PGE2, promotes hematopoietic recovery after total-body irradiation (TBI), and various angiotensin-converting enzyme (ACE) inhibitors mitigate endothelial injury after radiation exposure. Here, we tested a combination therapy of dmPGE2 and lisinopril to mitigate thrombocytopenia in murine models of H-ARS following TBI. After 7.75 Gy TBI, dmPGE2 and lisinopril each increased survival relative to vehicle controls. Importantly, combined dmPGE2 and lisinopril therapy enhanced survival greater than either individual agent. Studies performed after 4 Gy TBI revealed reduced numbers of marrow MKs and circulating platelets. In addition, sublethal TBI induced abnormalities both in MK maturation and in in vitro and in vivo platelet function. dmPGE2, alone and in combination with lisinopril, improved recovery of marrow MKs and peripheral platelets. Finally, sublethal TBI transiently reduced the number of marrow Lin-CD45-CD31+Sca-1- sinusoidal endothelial cells, while combined dmPGE2 and lisinopril treatment, but not single-agent treatment, accelerated their recovery. Taken together, these data support the concept that combined dmPGE2 and lisinopril therapy improves thrombocytopenia and survival by promoting recovery of the MK lineage, as well as the MK niche, in the setting of H-ARS.
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Affiliation(s)
- J Saunders
- Center for Pediatric Research, University of Rochester Medical Center, Rochester, New York.,Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
| | - L M Niswander
- Center for Pediatric Research, University of Rochester Medical Center, Rochester, New York.,Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
| | - K E McGrath
- Center for Pediatric Research, University of Rochester Medical Center, Rochester, New York.,Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - A Koniski
- Center for Pediatric Research, University of Rochester Medical Center, Rochester, New York.,Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - S C Catherman
- Center for Pediatric Research, University of Rochester Medical Center, Rochester, New York.,Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - S K Ture
- Aab Cardiovascular Research Institute, University of Rochester Medical Center, Rochester, New York
| | - M Medhora
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - P D Kingsley
- Center for Pediatric Research, University of Rochester Medical Center, Rochester, New York.,Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - L M Calvi
- Department of Medicine, University of Rochester Medical Center, Rochester, New York.,Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - J P Williams
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York.,Department of Environmental Medicine, University of Rochester Medical Center, Rochester, New York
| | - C N Morrell
- Aab Cardiovascular Research Institute, University of Rochester Medical Center, Rochester, New York.,Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - J Palis
- Center for Pediatric Research, University of Rochester Medical Center, Rochester, New York.,Department of Pediatrics, University of Rochester Medical Center, Rochester, New York.,Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
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29
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Idowu O, Ifeanyi-Pillette I, Owusu-Agyemang P, Holmes A, Kwater P, Jackson T, Mena G, Lasala J, Heir JS. The quantra hemostasis analyzer compared to thromboelastography (TEG) in the surgical oncologic population: A prospective observational trial. J Surg Oncol 2021; 124:894-905. [PMID: 34137038 DOI: 10.1002/jso.26578] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/23/2021] [Accepted: 06/06/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Management of coagulopathy during major oncologic surgery can be multifactorial and challenging. Viscoelastic assays (VEAs) can be useful in providing vital data about the mechanism of coagulopathy in these dynamic circumstances. OBJECTIVES A prospective nonrandomized observational study with the aim of describing the coagulation parameters of patients undergoing major oncologic surgery using the Quantra® and TEG® 5000 systems. Our secondary objectives included the correlation between Quantra and TEG parameters, and the times to result for both technologies. METHODS This study included 74 adults undergoing oncologic surgery with an anticipated blood loss of more than 500 ml. For each subject, whole blood samples for each device were collected at multiple points perioperatively for comparison. RESULTS Correlation coefficients between Quantra and TEG parameters were 0.8 and above, indicating a very strong correlation (p < .001). Correlation coefficients between conventional laboratory tests and Quantra ranged from 0.74 to 0.83, indicating a moderate correlation (p < .001). The mean time to obtain results and total processing time was shorter for Quantra in comparison to TEG. CONCLUSIONS Quantra parameters strongly correlated with TEG parameters; however, Quantra parameters were available in shorter amount of time as it is specifically designed as a closed point of care device.
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Affiliation(s)
- Olakunle Idowu
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ifey Ifeanyi-Pillette
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pascal Owusu-Agyemang
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Allen Holmes
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Piotr Kwater
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Timothy Jackson
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jagtar Singh Heir
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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30
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Kwok CS, Wong CW, Kontopantelis E, Barac A, Brown SA, Velagapudi P, Hilliard AA, Bharadwaj AS, Chadi Alraies M, Mohamed M, Bhatt DL, Mamas MA. Percutaneous coronary intervention in patients with cancer and readmissions within 90 days for acute myocardial infarction and bleeding in the USA. Eur Heart J 2021; 42:1019-1034. [PMID: 33681960 DOI: 10.1093/eurheartj/ehaa1032] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/13/2020] [Accepted: 12/14/2020] [Indexed: 01/04/2023] Open
Abstract
AIMS The post-discharge outcomes of patients with cancer who undergo PCI are not well understood. This study evaluates the rates of readmissions within 90 days for acute myocardial infarction (AMI) and bleeding among patients with cancer who undergo percutaneous coronary intervention (PCI). METHODS AND RESULTS Patients treated with PCI in the years from 2010 to 2014 in the US Nationwide Readmission Database were evaluated for the influence of cancer on 90-day readmissions for AMI and bleeding. A total of 1 933 324 patients were included in the analysis (2.7% active cancer, 6.8% previous history of cancer). The 90-day readmission for AMI after PCI was higher in patients with active cancer (12.1% in lung, 10.8% in colon, 7.5% in breast, 7.0% in prostate, and 9.1% for all cancers) compared to 5.6% among patients with no cancer. The 90-day readmission for bleeding after PCI was higher in patients with active cancer (4.2% in colon, 1.5% in lung, 1.4% in prostate, 0.6% in breast, and 1.6% in all cancer) compared to 0.6% among patients with no cancer. The average time to AMI readmission ranged from 26.7 days for lung cancer to 30.5 days in colon cancer, while the average time to bleeding readmission had a higher range from 38.2 days in colon cancer to 42.7 days in breast cancer. CONCLUSIONS Following PCI, patients with cancer have increased risk for readmissions for AMI or bleeding, with the magnitude of risk depending on both cancer type and the presence of metastasis.
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Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK.,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Chun Wai Wong
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK
| | - Evangelos Kontopantelis
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, UK
| | - Ana Barac
- Department of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington DC, USA
| | - Sherry-Ann Brown
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Poonam Velagapudi
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Anthony A Hilliard
- Department of Medicine, Division of Cardiology, Linda University School of Medicine, Loma Linda, CA, USA
| | - Aditya S Bharadwaj
- Department of Medicine, Division of Cardiology, Linda University School of Medicine, Loma Linda, CA, USA
| | - M Chadi Alraies
- Department of Cardiology, Wayne State University, Detroit Medical Center, Detroit Heart Hospital, MI, USA
| | - Mohamed Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK.,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Deepak L Bhatt
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK.,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
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31
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Menichelli D, Vicario T, Ameri P, Toma M, Violi F, Pignatelli P, Pastori D. Cancer and atrial fibrillation: Epidemiology, mechanisms, and anticoagulation treatment. Prog Cardiovasc Dis 2021; 66:28-36. [PMID: 33915139 DOI: 10.1016/j.pcad.2021.04.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 12/14/2022]
Abstract
Cancer patients are at an increased risk of developing atrial fibrillation (AF) and thrombosis. However, the management of anticoagulation in patients with both diseases may be challenging, and data on these patients are lacking. We summarize the current evidence on the incidence and prevalence of cancer in AF and vice versa and provide some practical considerations on the management of oral anticoagulation in specific clinical situations. Low-molecular weight heparins are not approved for thromboprophylaxis in AF, and management of warfarin can be difficult. The use of direct oral anticoagulants may be particularly attractive for their rapid onset/offset action and lower bleeding risk.
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Affiliation(s)
- Danilo Menichelli
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Tommasa Vicario
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy; Emergency Department, Policlinico Tor Vergata Hospital, Rome, Italy
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Internal Medicine, University of Genova, Genova, Italy
| | - Matteo Toma
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Internal Medicine, University of Genova, Genova, Italy
| | - Francesco Violi
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy; Mediterranea Cardiocentro, Naples, Italy
| | - Pasquale Pignatelli
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy; Mediterranea Cardiocentro, Naples, Italy
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.
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32
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Leader A, Hofstetter L, Spectre G. Challenges and Advances in Managing Thrombocytopenic Cancer Patients. J Clin Med 2021; 10:1169. [PMID: 33799591 PMCID: PMC8000983 DOI: 10.3390/jcm10061169] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/02/2021] [Accepted: 03/08/2021] [Indexed: 12/16/2022] Open
Abstract
Cancer patients have varying incidence, depth and duration of thrombocytopenia. The mainstay of managing severe chemotherapy-induced thrombocytopenia (CIT) in cancer is the use of platelet transfusions. While prophylactic platelet transfusions reduce the bleeding rate, multiple unmet needs remain, such as high residual rates of bleeding, and anticancer treatment dose reductions/delays. Accordingly, the following promising results in other settings, antifibrinolytic drugs have been evaluated for prevention and treatment of bleeding in patients with hematological malignancies and solid tumors. In addition, Thrombopoeitin receptor agonists have been studied for two major implications in cancer: treatment of severe thrombocytopenia associated with myelodysplastic syndrome and acute myeloid leukemia; primary and secondary prevention of CIT in solid tumors in order to maintain dose density and intensity of anti-cancer treatment. Furthermore, thrombocytopenic cancer patients are often prescribed antithrombotic medication for indications arising prior or post cancer diagnosis. Balancing the bleeding and thrombotic risks in such patients represents a unique clinical challenge. This review focuses upon non-transfusion-based approaches to managing thrombocytopenia and the associated bleeding risk in cancer, and also addresses the management of antithrombotic therapy in thrombocytopenic cancer patients.
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Affiliation(s)
- Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 4941492, Israel; (L.H.); (G.S.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Liron Hofstetter
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 4941492, Israel; (L.H.); (G.S.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Galia Spectre
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 4941492, Israel; (L.H.); (G.S.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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33
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Powsner EH, Harris JC, Day ES. Biomimetic Nanoparticles for the Treatment of Hematologic Malignancies. ADVANCED NANOBIOMED RESEARCH 2021. [DOI: 10.1002/anbr.202000047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Emily H. Powsner
- Department of Biomedical Engineering University of Delaware 161 Colburn Lab Newark DE 19716 USA
| | - Jenna C. Harris
- Department of Materials Science and Engineering University of Delaware 127 The Green Newark DE 19716 USA
| | - Emily S. Day
- Department of Biomedical Engineering University of Delaware 161 Colburn Lab Newark DE 19716 USA
- Department of Materials Science and Engineering University of Delaware 127 The Green Newark DE 19716 USA
- Center for Translational Cancer Research Helen F. Graham Cancer Center and Research Institute 4701 Ogletown Stanton Road Newark DE 19713 USA
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Livneh N, Braeken D, Drozdinsky G, Gafter-Gvili A, Seelig J, Rozovski U, Berger T, Raanani P, Falanga A, Ten Cate H, Spectre G, Leader A. Anticoagulation in patients with atrial fibrillation, thrombocytopenia and hematological malignancy. J Thromb Thrombolysis 2021; 52:590-596. [PMID: 33523384 DOI: 10.1007/s11239-021-02393-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 01/21/2023]
Abstract
Managing anticoagulation in hematological malignancy patients with atrial fibrillation and thrombocytopenia is a clinical challenge with limited data. We aimed to identify anticoagulation management strategies and evaluate bleeding and thrombosis rates associated with each approach. A retrospective cohort study in Israel and the Netherlands was conducted. Patients with hematological malignancy and atrial fibrillation were indexed when platelets were < 50 × 109/L and followed for 30 days. The cohort included 61 patients of whom 42 (69%) had anticoagulation held at index. On multivariate analysis, holding anticoagulation was associated with age < 65 years and atrial fibrillation diagnosed within 30 days prior index. Clinically relevant bleeding was diagnosed in 7 (16.7%) and 1 (5.3%) of patients who had anticoagulation held and continued respectively, while arterial thromboembolism occurred in 1 patient in each group (2.4% and 5.3%, respectively). All-cause mortality rate was high at 45%. Accordingly, the 30-day bleeding risk may outweigh the risk of arterial thromboembolism in hematological malignancy, platelets < 50 × 109/L and atrial fibrillation.
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Affiliation(s)
- Nir Livneh
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dionne Braeken
- Thrombosis Expert Center, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Anat Gafter-Gvili
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Internal Medicine A, Rabin Medical Center, Petah Tikva, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, 39 Jabotinsky, 4941492, Petah Tikva, Israel
| | - Jaap Seelig
- Department of Cardiology, Hospital Rijnstate, Arnhem, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Uri Rozovski
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, 39 Jabotinsky, 4941492, Petah Tikva, Israel
| | - Tamar Berger
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, 39 Jabotinsky, 4941492, Petah Tikva, Israel
| | - Pia Raanani
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, 39 Jabotinsky, 4941492, Petah Tikva, Israel
| | - Anna Falanga
- Immunohematology and Transfusion Medicine Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Hugo Ten Cate
- Thrombosis Expert Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Galia Spectre
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, 39 Jabotinsky, 4941492, Petah Tikva, Israel
| | - Avi Leader
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, 39 Jabotinsky, 4941492, Petah Tikva, Israel.
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
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35
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Mohtashami M, Razavi A, Abolhassani H, Aghamohammadi A, Yazdani R. Primary Immunodeficiency and Thrombocytopenia. Int Rev Immunol 2021; 41:135-159. [PMID: 33464134 DOI: 10.1080/08830185.2020.1868454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Primary immunodeficiency (PID) or Inborn errors of immunity (IEI) refers to a heterogeneous group of disorders characterized by immune system impairment. Although patients with IEI manifest highly variable symptoms, the most common clinical manifestations are recurrent infections, autoimmunity and malignancies. Some patients present hematological abnormality including thrombocytopenia due to different pathogenic mechanisms. This review focuses on primary and secondary thrombocytopenia as a complication, which can occur in IEI. Based on the International Union of Immunological Societies phenotypic classification for IEI, the several innate and adaptive immunodeficiency disorders can lead to thrombocytopenia. This review, for the first time, describes manifestation, mechanism and therapeutic modalities for thrombocytopenia in different classes of IEI.
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Affiliation(s)
- Maryam Mohtashami
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran.,Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran
| | - Azadehsadat Razavi
- Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran.,Department of Animal Biology, Faculty of Biology Sciences, University of Kharazmi, Tehran, Iran.,Cancer Immunology Project (CIP), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Hassan Abolhassani
- Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran.,Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Yazdani
- Research Center for Immunodeficiencies, Tehran University of Medical Sciences, Tehran, Iran
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36
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Faria AVS, Andrade SS, Peppelenbosch MP, Ferreira-Halder CV, Fuhler GM. Platelets in aging and cancer-"double-edged sword". Cancer Metastasis Rev 2020; 39:1205-1221. [PMID: 32869161 PMCID: PMC7458881 DOI: 10.1007/s10555-020-09926-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/12/2020] [Indexed: 02/06/2023]
Abstract
Platelets control hemostasis and play a key role in inflammation and immunity. However, platelet function may change during aging, and a role for these versatile cells in many age-related pathological processes is emerging. In addition to a well-known role in cardiovascular disease, platelet activity is now thought to contribute to cancer cell metastasis and tumor-associated venous thromboembolism (VTE) development. Worldwide, the great majority of all patients with cardiovascular disease and some with cancer receive anti-platelet therapy to reduce the risk of thrombosis. However, not only do thrombotic diseases remain a leading cause of morbidity and mortality, cancer, especially metastasis, is still the second cause of death worldwide. Understanding how platelets change during aging and how they may contribute to aging-related diseases such as cancer may contribute to steps taken along the road towards a "healthy aging" strategy. Here, we review the changes that occur in platelets during aging, and investigate how these versatile blood components contribute to cancer progression.
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Affiliation(s)
- Alessandra V S Faria
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, NL-3000 CA, Rotterdam, The Netherlands
- Department of Biochemistry and Tissue Biology, University of Campinas, UNICAMP, Campinas, SP, 13083-862, Brazil
| | | | - Maikel P Peppelenbosch
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, NL-3000 CA, Rotterdam, The Netherlands
| | - Carmen V Ferreira-Halder
- Department of Biochemistry and Tissue Biology, University of Campinas, UNICAMP, Campinas, SP, 13083-862, Brazil
| | - Gwenny M Fuhler
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, NL-3000 CA, Rotterdam, The Netherlands.
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37
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Lam J, Tavares E, Luk SO. Outcomes with enoxaparin dose reductions during thrombocytopenia in patients with hematopoietic stem cell transplantation (HSCT). J Oncol Pharm Pract 2020; 27:1364-1370. [DOI: 10.1177/1078155220957747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Appropriate dosing of therapeutic anticoagulation during periods of thrombocytopenia remains uncertain for patients undergoing hematopoietic stem cell transplants (HSCT). There is a paucity of literature on treatment outcomes for HSCT patients treated with non-prophylactic, but reduced doses of therapeutic anticoagulation during thrombocytopenia. The primary objective was to determine the incidence of major bleeding events during thrombocytopenia when reduced-dose enoxaparin was administered. Methods This is a retrospective review of patients with a venous thromboembolic event (VTE) who underwent HSCT and received reduced-dose enoxaparin during thrombocytopenia at the Massachusetts General Hospital (MGH) from April 1, 2016 to August 31, 2018. Incidence of recurrent VTE and bleeding events for up to one month were investigated. Rates of recurrent VTE and enoxaparin dose adjustments (0.5 mg/kg twice daily vs 1 mg/kg daily) were also reviewed. Results Out of 172 patients reviewed, 27 patients met inclusion criteria. There were no recurrent VTEs within one month of initial enoxaparin dose reduction. There was one major bleeding episode that occurred while a patient was on full-dose enoxaparin; believed to be related to cyclophosphamide cardiopulmonary toxicity and resulted in death. There were six non-major bleeding episodes, only one of which was clinically significant and resulted in the discontinuation of enoxaparin. Conclusion Our evaluation of therapeutic enoxaparin dose reductions for thrombocytopenia in the HSCT patient population found this practice to be effective in reducing the recurrence of VTE with no major bleeding adverse events. However, the rate of non-significant minor bleeds should be monitored while on reduced-dose enoxaparin.
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Affiliation(s)
- Jenna Lam
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Erica Tavares
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Samantha O Luk
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
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38
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Hepatic thrombopoietin gene silencing reduces platelet count and breast cancer progression in transgenic MMTV-PyMT mice. Blood Adv 2020; 3:3080-3091. [PMID: 31648335 DOI: 10.1182/bloodadvances.2019000250] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 09/20/2019] [Indexed: 11/20/2022] Open
Abstract
In humans, platelet count within the normal range is required for physiological hemostasis, but, adversely, platelets also support pathological thrombosis. Moreover, by releasing growth factors, they may enhance neoplastic proliferation. We hypothesize that platelet count correlates with platelet-dependent pathologies, even within the range of hemostatic competence. Because platelet production is promoted by thrombopoietin signaling through the myeloproliferative leukemia virus oncogene (cMPL), a receptor expressed on megakaryocytes, we evaluated the feasibility of selective targeting of hepatic thrombopoietin production to test this hypothesis. We synthesized murine- and primate-specific antisense oligonucleotides (THPO-ASO) that silence hepatic thrombopoietin gene (THPO) expression without blocking extrahepatic THPO. Repeated doses of THPO-ASO were administered to mice and a baboon, causing a sustained 50% decline in plasma thrombopoietin levels and platelet count within 4 weeks in both species. To investigate whether reducing platelet count within the translationally relevant hemostatic range could alter a neoplastic process, we administered THPO-ASO to 6-week-old transgenic MMTV-PyMT mice that develop early ductal atypia that progresses into cMPL-negative fatal metastatic breast cancer within 2 to 3 months. THPO-ASO treatment increased the average time to euthanasia (primary humane endpoint) at 2 cm3 combined palpable tumor volume. Our results show that THPO-ASO reduced blood platelet count, plasma platelet factor 4, vascular endothelial growth factor, thrombopoietin levels, bone marrow megakaryocyte density, tumor growth rate, proliferation index, vascularization, platelet and macrophage content, and pulmonary metastases vs untreated controls. These findings confirm that sustained and moderate pharmacological platelet count reduction is feasible with THPO-ASO administration and can delay progression of certain platelet-dependent pathological processes within a safe hemostatic platelet count range.
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39
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Acute palliative care unit-initiated interventions for advanced cancer patients at the end of life: prediction of impending death based on Glasgow Prognostic Score. Support Care Cancer 2020; 29:1557-1564. [PMID: 32734391 DOI: 10.1007/s00520-020-05638-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Unexpected death occurred in an unexpectedly high proportion of advanced cancer patients in the acute palliative care unit (APCU) setting and associated with fewer signs of impending death. Recognition of patients at high risk of approaching death, especially immediately after admitting APCU among clinicians, can improve the end-of-life trajectory. Our objective was accurate prognostication within a few days of admission. METHODS Patients admitted to an APCU of the NTT Medical Center Tokyo, Tokyo, Japan, between April 2009 and December 2016 were retrospectively examined. The Glasgow Prognostic Score (GPS) was optimized with concomitant neutrophilia, lymphocytopenia, thrombocytopenia, anemia, and monocytosis. Kaplan-Meier survival curves were estimated, and independent predictors for 3-day mortality were identified using univariate and multivariate analyses. The sensitivity, specificity, and likelihood ratios (LRs) associated with imminent death were also assessed. RESULTS Nine hundred ninety-one patients were included; 52.9% was male. The median age was 72 years. The median survival was 13 days (IQ range 6 to 26), and 11.7% died within 3 days of admission. Significant difference in survival with a GPS of 2 was observed in GPS optimized with concomitant thrombocytopenia, and it was the only significant predictor associated with 3-day mortality (p = 0.004), which had high specificity (> 95%) and high positive LR (> 5). CONCLUSION The prognostic value of the GPS was enhanced by adding thrombocytopenia. The concurrent use of the GPS and platelet count improved the prognostication of limited time of survival and could assist in the personal and clinical decisions for advanced cancer patients.
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40
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Leader A, Gurevich-Shapiro A, Spectre G. Anticoagulant and antiplatelet treatment in cancer patients with thrombocytopenia. Thromb Res 2020; 191 Suppl 1:S68-S73. [DOI: 10.1016/s0049-3848(20)30400-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/23/2019] [Accepted: 01/03/2020] [Indexed: 12/30/2022]
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41
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An Episode of Pseudothrombocytopenia during Pembrolizumab Therapy in NSCLC Patient. Case Rep Oncol Med 2020; 2020:4196178. [PMID: 32455036 PMCID: PMC7232686 DOI: 10.1155/2020/4196178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 04/23/2020] [Indexed: 12/26/2022] Open
Abstract
Immunotherapy with immune checkpoint inhibitors (ICI) is a new option of treatment in a growing range of neoplasms. In addition to an antitumor effect, ICI are associated with autoimmune reactions resulting in a wide spectrum of toxicities that have not been seen in patients receiving chemotherapy. In this article, we present a case of a patient with advanced lung adenocarcinoma who developed an EDTA-dependent pseudothrombocytopenia (PTCP) during pembrolizumab therapy. To the best of our knowledge, this is the first reported case of EDTA-dependent PTCP occurring during immunotherapy treatment of nonsmall lung cell cancer with ICI. The phenomenon of EDTA-dependent PTCP may prompt clinical decisions, as unnecessary transfusions or even exclusion from pembrolizumab therapy. Therefore, it is important to be aware of PTCP as a possible side effect of this therapy.
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42
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Pfaundler N, Limacher A, Stalder O, Méan M, Rodondi N, Baumgartner C, Aujesky D. Prognosis in patients with cancer-associated venous thromboembolism: Comparison of the RIETE-VTE and modified Ottawa score. J Thromb Haemost 2020; 18:1154-1161. [PMID: 32124545 DOI: 10.1111/jth.14783] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/31/2020] [Accepted: 02/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The RIETE-VTE score was derived to risk-stratify patients with cancer-associated venous thromboembolism (CAT). OBJECTIVES To externally validate the RIETE-VTE score and to compare its prognostic performance with the modified Ottawa score. PATIENTS/METHODS We studied 178 elderly patients with CAT in a prospective multicenter cohort and assessed 30-day all-cause mortality, 90-day overall complications (mortality, major bleeding, or venous thromboembolism [VTE] recurrence), and 6-month VTE recurrence. Patients were stratified into RIETE-VTE and modified Ottawa score risk classes (low, intermediate, high). We compared the discriminative power (area under the receiver operating characteristic [ROC] curve) to predict mortality, overall complications, and VTE recurrence. RESULTS Fifteen patients (8.4%) died within 30 days, 42 (23.6%) experienced an overall complication by day 90, and 6 (3.4%) had recurrent VTE within 6 months. The RIETE-VTE and the modified Ottawa score classified similar proportions of patients as low risk (35.4% versus 31.5%; P = .37). No low-risk patient died within 30 days. Low-risk patients identified by the RIETE-VTE and modified Ottawa score had similar rates of overall complications (7.9% versus 8.9%) and VTE recurrence (1.6% versus 1.8%). The modified Ottawa score and the RIETE-VTE score had similar areas under the ROC curve for predicting all-cause mortality (0.84 versus 0.75; P = .21), overall complications (0.74 versus 0.68; P = .26), and VTE recurrence (0.67 versus 0.64; P = .78). CONCLUSIONS Both the RIETE-VTE and modified Ottawa score accurately identified elderly patients with CAT who are at low risk for short-term mortality and who are potential candidates for outpatient care.
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Affiliation(s)
- Nubio Pfaundler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Limacher
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Odile Stalder
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Marie Méan
- Department of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Manne BK, Bhatlekar S, Middleton EA, Weyrich AS, Borst O, Rondina MT. Phospho-inositide-dependent kinase 1 regulates signal dependent translation in megakaryocytes and platelets. J Thromb Haemost 2020; 18:1183-1196. [PMID: 31997536 PMCID: PMC7192796 DOI: 10.1111/jth.14748] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 12/19/2019] [Accepted: 01/27/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Regulated protein synthesis is essential for megakaryocyte (MK) and platelet functions, including platelet production and activation. PDK1 (phosphoinositide-dependent kinase 1) regulates platelet functional responses and has been associated with circulating platelet counts. Whether PDK1 also directly regulates protein synthetic responses in MKs and platelets, and platelet production by MKs, remains unknown. OBJECTIVE To determine if PDK1 regulates protein synthesis in MKs and platelets. METHODS Pharmacologic PDK1 inhibitors (BX-795) and mice where PDK1 was selectively ablated in MKs and platelets (PDK1-/- ) were used. PDK1 signaling in MKs and platelets (human and murine) were assessed by immunoblots. Activation-dependent translation initiation and protein synthesis in MKs and platelets was assessed by probing for dissociation of eIF4E from 4EBP1, and using m7-GTP pulldowns and S35 methionine incorporation assays. Proplatelet formation by MKs, synthesis of Bcl-3 and MARCKs protein, and clot retraction were employed for functional assays. RESULTS Inhibiting or ablating PDK1 in MKs and platelets abolished the phosphorylation of 4EBP1 and eIF4E by preventing activation of the PI3K and MAPK pathways. Inhibiting PDK1 also prevented dissociation of eIF4E from 4EBP1, decreased binding of eIF4E to m7GTP (required for translation initiation), and significantly reduced de novo protein synthesis. Inhibiting PDK1 reduced proplatelet formation by human MKs and blocked MARCKs protein synthesis. In both human and murine platelets, PDK1 controlled Bcl-3 synthesis. Inhibition of PDK1 led to complete failure of clot retraction in vitro. CONCLUSIONS PDK1 is a previously unidentified translational regulator in MKs and platelets, controlling protein synthetic responses, proplatelet formation, and clot retraction.
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Affiliation(s)
- Bhanu Kanth Manne
- Department of Internal Medicine & The Molecular Medicine Program, University of Utah, Salt Lake City, UT, 84112 USA
| | - Seema Bhatlekar
- Department of Internal Medicine & The Molecular Medicine Program, University of Utah, Salt Lake City, UT, 84112 USA
| | - Elizabeth A. Middleton
- Department of Internal Medicine & The Molecular Medicine Program, University of Utah, Salt Lake City, UT, 84112 USA
| | - Andrew S. Weyrich
- Department of Internal Medicine & The Molecular Medicine Program, University of Utah, Salt Lake City, UT, 84112 USA
- Department of Pathology, University of Utah, Salt Lake City, UT, 84112 USA
| | - Oliver Borst
- Department of Cardiology and Cardiovascular Medicine, University of Tübingen, Tübingen, 72076 Germany
| | - Matthew T. Rondina
- Department of Internal Medicine & The Molecular Medicine Program, University of Utah, Salt Lake City, UT, 84112 USA
- Department of Internal Medicine, GRECC, George E. Wahlen VAMC, Salt Lake City, UT, 84148
- Department of Pathology, University of Utah, Salt Lake City, UT, 84112 USA
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Wei Y, Yang Q, Qin Q, Chen Y, Quan X, Wei J, Zhou L, Wang D, Li H, Li G, Li S, Liang Z. Profiling of the Risk Factors and Designing of a Model to Identify Ischemic Stroke in Patients with Non-Hodgkin Lymphoma: A Multicenter Retrospective Study. Eur Neurol 2020; 83:41-48. [PMID: 32344398 DOI: 10.1159/000506046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 01/18/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The occurrence of ischemic stroke in patients with non-Hodgkin lymphoma (NHL) is not well understood. This study aimed to determine independent risk factors to identity ischemic stroke in non-Hodgkin lymphoma-associated ischemic stroke (NHLAIS) patients. METHODS This retrospective study was conducted on NHLAIS patients and age- and gender-matched NHL patients. We collected clinical data of patients in both groups and used multiple logistic regression analysis to identify independent risk factors for NHLAIS. A receiver operating characteristic (ROC) analysis was used to establish an identification model based on potential risk factors of NHLAIS. RESULTS Sixty-three NHLAIS patients and 63 NHL patients were enrolled. Stage III/IV (58/63, 92.1%) and multiple arterial infarcts (44/63, 69.8%) were common among NHLAIS patients. Notably, NHLAIS patients had higher levels of serum fibrinogen (FIB), D-dimer, and ferritin (SF) and prolonged thromboplastin time and prothrombin time (PT) compared with NHL patients (all p < 0.05). Elevated FIB, D-dimer, and SF and prolonged PT were independent risk factors for NHLAIS. The area under the ROC curve of the identification model of NHLAIS patients was largest compared to that of other risk factors (0.838, 95% confidence interval: 0.759-0.899) (p < 0.05). CONCLUSION This study reveals that elevated serum FIB, D-dimer, and SF and prolonged PT are potential independent risk factors of NHLAIS. The identification model established in this study may help monitor NHL patients who are at high risk of developing NHLAIS.
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Affiliation(s)
- Yunfei Wei
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China.,Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Qingqing Yang
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Qixiong Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ya Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xuemei Quan
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jing Wei
- Department of Neurology, The Affiliated Tumor Hospital of Guangxi Medical University, Nanning, China
| | - Liyuan Zhou
- Department of Neurology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Dacheng Wang
- Department of Neurology, The Ninth Affiliated Hospital of Guangxi Medical University, Beihai, China
| | - Haihong Li
- Department of Neurology, Fusui County People's Hospital, Chongzuo, China
| | - Guohui Li
- Department of Neurology, Wuzhou Red Cross Hospital, Wuzhou, China
| | - Shengyu Li
- Department of Neurology, Wuming County People's Hospital, Nanning, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China,
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45
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Incidence of Bleeding Complications With Flexible Bronchoscopy in Cancer Patients With Thrombocytopenia. J Bronchology Interv Pulmonol 2020; 26:280-286. [PMID: 30973520 DOI: 10.1097/lbr.0000000000000590] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Bronchoscopy is a safe procedure, but current guidelines recommend transfusion for platelets <20 K/μL. Studies of bronchoscopy in thrombocytopenia are limited. OBJECTIVES Our objective was to evaluate the incidence of bleeding with flexible bronchoscopy in those with thrombocytopenia especially those <20 K/μL. METHOD We performed a retrospective review of all flexible bronchoscopies between June 1, 2008 and December 31, 2010. Biopsies and therapeutic procedures were excluded. The χ, Fisher exact, and Rank-sum test were conducted to evaluate associations of clinically significant bleeding. RESULTS There were 1711 patients who underwent 2053 flexible bronchoscopies. Cancer diagnosis included hematologic (61.3%) and solid organ malignancy (34.9%). Half of the bronchoscopies had moderate to severe thrombocytopenia (<100 K/μL) with the following ranges: 14.7% with 50 to <100 K/μL, 20.6% with 20 to <50 K/μL, 10.6% with 10 to <20 K/μL, 4.1% with <10 K/μL. Platelet transfusion was given in 90.6% of those with platelets <10 K/μL and 55.5% of those with platelets 10 to <20 K/μL. The nasal route for bronchoscopy was used in 92.4%. Bleeding complication rate however was 1.1% (0.2% major) and not affected by platelets. CONCLUSION Bronchoscopy with lavage can be safely performed without platelet transfusion in those with platelets of ≥10 K/μL. In the absence of nasal bleeding, trauma, or deformity, the nasal route can be used for bronchoscopy.
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Agha AM, Gill C, Balanescu DV, Donisan T, Palaskas N, Lopez-Mattei J, Hassan S, Kim PY, Charitakis K, Cilingiroglu M, Oo TH, Kroll M, Durand JB, Hirsch-Ginsberg C, Marmagkiolis K, Iliescu C. Identifying Hemostatic Thresholds in Cancer Patients Undergoing Coronary Angiography Based on Platelet Count and Thromboelastography. Front Cardiovasc Med 2020; 7:9. [PMID: 32118047 PMCID: PMC7033624 DOI: 10.3389/fcvm.2020.00009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/21/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives: To evaluate the role of platelet count and thromboelastogram (TEG) in the treatment of thrombocytopenic cancer patients with suspected coronary artery disease (CAD). Background: Cancer patients with CAD and thrombocytopenia are often treated non-invasively (i.e., without coronary angiography when clinically indicated) due to perceived high risk of bleeding. We sought to evaluate coagulability based on TEG and determine if platelet count and TEG could predict bleeding risk/mortality among cancer patients undergoing coronary angiography (CA). Methods: Baseline demographics, platelet count, and TEG parameters were recorded among cancer patients that underwent CA and had a concomitant TEG. Logistic regression and univariate proportional hazards regression analysis were performed to determine the impact of platelet count and coagulability on 24-month overall survival (OS). Results: All patients with platelet count <20,000/mm3 and nearly all patients with platelet count 20,000–49,000/mm3 were hypocoagulable based on TEG results. In contrast, nearly all patients with platelet counts of 50,000–99,999/mm3 had normal TEG results and OS similar to those with platelet counts of ≥100,000/mm3. Coagulability based on TEG was not associated with OS. However, a platelet count of <50,000/mm3 was associated with worse 24-month OS (hazard ratio = 2.76; p = 0.0072) when compared with a platelet count of ≥100,000/mm3. No major bleeding complications were observed in all groups. Conclusion: The majority of cancer patients with platelet counts of <50,000/mm3 were hypocoagulable based on TEG and had worse OS at 24 months. The relatively normal TEGs in the >50,000/mm3 groups, as well as the improved survival, suggest that with appropriate clinical indication and risk/benefit assessment, a cut-off of 50,000/mm3 platelets can be considered for CA in cancer patients.
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Affiliation(s)
- Ali M Agha
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Clarence Gill
- Department of Cardiology, University of Texas Health Science Center at Houston, Houston, TX, United States
| | | | - Teodora Donisan
- Department of Cardiology, MD Anderson Cancer Center, Houston, TX, United States
| | - Nicolas Palaskas
- Department of Cardiology, MD Anderson Cancer Center, Houston, TX, United States
| | - Juan Lopez-Mattei
- Department of Cardiology, MD Anderson Cancer Center, Houston, TX, United States
| | - Saamir Hassan
- Department of Cardiology, MD Anderson Cancer Center, Houston, TX, United States
| | - Peter Y Kim
- Department of Cardiology, MD Anderson Cancer Center, Houston, TX, United States
| | - Konstantinos Charitakis
- Department of Cardiology, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Mehmet Cilingiroglu
- Department of Cardiology, University of Arkansas, Little Rock, AR, United States
| | - Thein Hlaing Oo
- Department of Hematology, MD Anderson Cancer Center, Houston, TX, United States
| | - Michael Kroll
- Department of Hematology, MD Anderson Cancer Center, Houston, TX, United States
| | - Jean Bernard Durand
- Department of Cardiology, MD Anderson Cancer Center, Houston, TX, United States
| | | | | | - Cezar Iliescu
- Department of Cardiology, MD Anderson Cancer Center, Houston, TX, United States
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Boulas KA, Paraskeva A, Triantafyllidis A, Hatzigeorgiadis A. Unexplained isolated acute severe thrombocytopenia after surgery for a recurrent malignant retroperitoneal tumor presenting with colon perforation: A case study of a disastrous complication. Int J Surg Case Rep 2020; 67:91-94. [PMID: 32045860 PMCID: PMC7015829 DOI: 10.1016/j.ijscr.2020.01.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/22/2020] [Accepted: 01/24/2020] [Indexed: 11/17/2022] Open
Abstract
Thrombocytopenia in cancer patients is correlated with poor prognosis. Drugs, sepsis, HIT, DIC, ITP are the most common causes of postoperative thrombocytopenia. Prompt diagnosis is essential as management varies considerably depending on etiology. Secondary ITP has not previously been associated with a retroperitoneal tumor. Kasabach-Merritt syndrome has not previously been associated with a retroperitoneal tumor.
Introduction Tumor- or treatment- induced thrombocytopenia in solid cancer patients is common. In the postoperative setting, diagnosis of thrombocytopenia become more complex as infection, sepsis, drugs and transfusion come also into the equation. Presentation of case Herein, the case an otherwise-healthy 71-year-old male patient with a sizable recurrent malignant retroperitoneal tumor under pazopanib admitted with colon perforation and submitted to emergency left colectomy with end transverse colostomy is presented. Immediate postoperative period characterized by massive primary tumor growth and isolated acute severe thrombocytopenia. The patient treated with combined prednisone, IVIg and platelets transfusion along with medication discontinuation with no response. Discussion Sepsis-, drug- and heparin-induced thrombocytopenia, disseminated intravascular coagulopathy and secondary (sepsis-, drug-, transfusion- or tumor-induced) immune thrombocytopenia (ITP) were included in the differential diagnosis. Based on exclusion, secondary drug- or tumor-induced ITP was the most prominent diagnosis. Concomitant presentation of thrombocytopenia along with massive primary tumor growth made Kasabach-Merritt syndrome also a probable diagnosis. However, neither secondary ITP nor Kasabach-Merritt syndrome has previously been associated with a retroperitoneal tumor in the literature. Conclusion Although management of thrombocytopenia depends on etiology, in our patient’s case the diagnosis of secondary ITP and directed management did not result in a successful outcome.
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Affiliation(s)
- K A Boulas
- Department of General Surgery, General Hospital of Drama, Drama, Greece.
| | - A Paraskeva
- Department of General Surgery, General Hospital of Drama, Drama, Greece
| | - A Triantafyllidis
- Department of General Surgery, General Hospital of Drama, Drama, Greece
| | - A Hatzigeorgiadis
- Department of General Surgery, General Hospital of Drama, Drama, Greece
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Catani MV, Savini I, Tullio V, Gasperi V. The "Janus Face" of Platelets in Cancer. Int J Mol Sci 2020; 21:ijms21030788. [PMID: 31991775 PMCID: PMC7037171 DOI: 10.3390/ijms21030788] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 12/20/2022] Open
Abstract
Besides their vital role in hemostasis and thrombosis, platelets are also recognized to be involved in cancer, where they play an unexpected central role: They actively influence cancer cell behavior, but, on the other hand, platelet physiology and phenotype are impacted by tumor cells. The existence of this platelet-cancer loop is supported by a large number of experimental and human studies reporting an association between alterations in platelet number and functions and cancer, often in a way dependent on patient, cancer type and treatment. Herein, we shall report on an update on platelet-cancer relationships, with a particular emphasis on how platelets might exert either a protective or a deleterious action in all steps of cancer progression. To this end, we will describe the impact of (i) platelet count, (ii) bioactive molecules secreted upon platelet activation, and (iii) microvesicle-derived miRNAs on cancer behavior. Potential explanations of conflicting results are also reported: Both intrinsic (heterogeneity in platelet-derived bioactive molecules with either inhibitory or stimulatory properties; features of cancer cell types, such as aggressiveness and/or tumour stage) and extrinsic (heterogeneous characteristics of cancer patients, study design and sample preparation) factors, together with other confounding elements, contribute to “the Janus face” of platelets in cancer. Given the difficulty to establish the univocal role of platelets in a tumor, a better understanding of their exact contribution is warranted, in order to identify an efficient therapeutic strategy for cancer management, as well as for better prevention, screening and risk assessment protocols.
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Affiliation(s)
- Maria Valeria Catani
- Correspondence: (M.V.C.); (V.G.); Tel.: +39-06-72596465 (M.V.C.); +39-06-72596465 (V.G.)
| | | | | | - Valeria Gasperi
- Correspondence: (M.V.C.); (V.G.); Tel.: +39-06-72596465 (M.V.C.); +39-06-72596465 (V.G.)
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49
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Wu VCC, Wang CL, Huang YT, Lan WC, Wu M, Kuo CF, Chen SW, Chu PH, Wen MS, Kuo CC, Chang SH. Novel Oral Anticoagulant versus Warfarin in Cancer Patients with Atrial Fibrillation: An 8-Year Population-Based Cohort Study. J Cancer 2020; 11:92-99. [PMID: 31892976 PMCID: PMC6930400 DOI: 10.7150/jca.36468] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 09/20/2019] [Indexed: 11/05/2022] Open
Abstract
Background: Cancer patients with atrial fibrillation (AF) were excluded in the major clinical trials. We therefore investigated the efficacy and safety of novel oral anticoagulant (NOAC) versus warfarin in these patients. Methods: Data were retrieved from Taiwan National Health Insurance Research Database during 2010-2017 for patients with AF, excluding those without cancer or >1 cancer, not using anticoagulant, switching of agents, patients age <18, and cancer and AF diagnosed >1 month apart. Primary outcomes are ischemic stroke (IS)/systemic embolism (SE), GI bleeding, major bleeding, intracranial hemorrhage (ICH), acute myocardial infarction (AMI), and death from any cause at 6 months and 1 year. Results: After exclusion criteria and propensity score matching, there were 336 patients in each group. Patients on NOAC had significantly reduced IS/SE (HR=0.45, 95% CI=0.25-0.82), major bleeding (HR=0.21, 95% CI=0.05-0.96), and no ICH at 6 months. In addition, IS/SE (HR=0.42, 95% CI=0.24-0.74), major bleeding (HR=0.26, 95% CI=0.09-0.76), and no ICH at 1 year compared to patients on warfarin. There was no difference on GI bleeding, AMI, and death from any cause at 6 months and at 1 year. Conclusion: In cancer patients with AF, NOAC were associated with significant reduced IS/SE, major bleeding, and ICH compared to warfarin.
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Affiliation(s)
- Victor Chien-Chia Wu
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chun-Li Wang
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Yu-Tung Huang
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan.,Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan
| | - Wen-Ching Lan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
| | - Michael Wu
- Divison of Cardiovascular Medicine, Arrhythmia Services Section, Rhode Island Hospital, Warren Alpert School of Medicine, Brown University, Providence, USA
| | - Chang-Fu Kuo
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan.,Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Shao-Wei Chen
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
| | - Pao-Hsien Chu
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Ming-Shien Wen
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chi-Ching Kuo
- Institute of Organic and Polymeric Materials, National Taipei University of Technology, Taipei, Taiwan
| | - Shang-Hung Chang
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan.,Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan
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50
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Gusdon AM, Nyquist PA, Torres-Lopez VM, Leasure AC, Falcone GJ, Sheth KN, Sansing LH, Hanley DF, Malani R. Perihematomal Edema After Intracerebral Hemorrhage in Patients With Active Malignancy. Stroke 2019; 51:129-136. [PMID: 31744426 DOI: 10.1161/strokeaha.119.027085] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background and Purpose- Patients with active malignancy are at risk for intracerebral hemorrhage (ICH). We aimed to characterize perihematomal edema (PHE) and hematoma volumes after spontaneous nontraumatic ICH in patients with cancer without central nervous system involvement. Methods- Patients with active malignancy who developed ICH were retrospectively identified through automated searches of institutional databases. Control patients were identified with ICH and without active cancer. Demographic and cancer-specific data were obtained by chart review. Hematoma and PHE volumes were determined using semiautomated methodology. Univariate and multivariate linear regression models were created to assess which variables were associated with hematoma and PHE expansion. Results- Patients with cancer (N=80) and controls (N=136) had similar demographics (all P>0.20), although hypertension was more prevalent among controls (P=0.004). Most patients with cancer had received recent chemotherapy (n=45, 56%) and had recurrence of malignancy (n=43, 54%). Patients with cancer were thrombocytopenic (median platelet count 90 000 [interquartile range, 17 500-211 500]), and most had undergone blood product transfusion (n=41, 51%), predominantly platelets (n=38, 48%). Thirty-day mortality was 36% (n=29). Patients with cancer had significantly increased PHE volumes (23.67 versus 8.61 mL; P=1.88×10-9) and PHE-to-ICH volume ratios (2.26 versus 0.99; P=2.20×10-16). In multivariate analyses, variables associated with PHE growth among patients with cancer were ICH volume (β=1.29 [95% CI, 1.58-1.30] P=1.30×10-5) and platelet transfusion (β=15.67 [95% CI, 3.61-27.74] P=0.014). Variables associated with 30-day mortality were ICH volume (odds ratio, 1.06 [95% CI, 1.03-1.10] P=6.76×10-5), PHE volume (odds ratio, 1.07 [95% CI, 1.04-1.09] P=7.40×10-6), PHE growth (odds ratio, 1.05 [95% CI, 1.01-1.10] P=0.01), and platelet transfusion (odds ratio, 1.48 [95% CI, 1.22-1.79] P=0.0001). Conclusions- Patients with active cancer who develop ICH have increased PHE volumes. PHE growth was independent of thrombocytopenia but associated with blood product transfusion. Thirty-day mortality was associated with PHE and ICH volumes and blood product transfusion.
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Affiliation(s)
- Aaron M Gusdon
- From the Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (A.M.G., P.A.N.)
| | - Paul A Nyquist
- From the Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (A.M.G., P.A.N.).,Division of Brain Injury Outcomes (BIOS), Johns Hopkins University School of Medicine, Baltimore, MD (P.A.N., D.F.H.)
| | - Victor M Torres-Lopez
- Department of Neurology, Yale University School of Medicine, New Haven, CT (V.M.T.-L., A.C.L., G.J.F., K.N.S., L.H.S.)
| | - Audrey C Leasure
- Department of Neurology, Yale University School of Medicine, New Haven, CT (V.M.T.-L., A.C.L., G.J.F., K.N.S., L.H.S.)
| | - Guido J Falcone
- Department of Neurology, Yale University School of Medicine, New Haven, CT (V.M.T.-L., A.C.L., G.J.F., K.N.S., L.H.S.)
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT (V.M.T.-L., A.C.L., G.J.F., K.N.S., L.H.S.)
| | - Lauren H Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, CT (V.M.T.-L., A.C.L., G.J.F., K.N.S., L.H.S.)
| | - Daniel F Hanley
- Division of Brain Injury Outcomes (BIOS), Johns Hopkins University School of Medicine, Baltimore, MD (P.A.N., D.F.H.)
| | - Rachna Malani
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY (R.M.)
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