Women, thrombosis, and cancer: A gender-specific analysis

Secretomics reveals hormone-therapy of breast cancer may induce survival by facilitating hypercoagulation and immunomodulation in vitro

Tumour cell haematogenous dissemination is predicated on molecular changes that enhance their capacity for invasion and preparation of the pre-metastatic niche. It is increasingly evident that platelets play an essential role in this transformation. The systemic nature of signalling molecules and extravascular factors that participate in mediating platelet-tumour cell interactions led to the development of an in vitro co-culture using whole blood and breast tumour cells, allowing us to decipher the impact of hormone-therapy on tumour cells and associated changes in the plasma proteome. Using mass spectrometry, we determined dysregulation of proteins associated with maintaining an invasive tumour phenotype. Tumour changes in genes associated with EMT and survival were documented. This is postulated to be induced via tumour cell interactions with the coagulatory and immune systems. Results highlight tumour cell adaptability to both treatment and blood resulting in a pro-tumorigenic response and a hypercoagulatory state. We illustrate that the breast cancer cell secretome can be altered by hormone-therapy, subject to the tumour subphenotype and linked to platelet activation. More sophisticated co-culture systems are required to recapitulate these interactions to better understand tumorigenesis. Moreover, deeper plasma profiling, using abundant protein depleted and/or vesicle enriched strategies, will likely reveal additional secretory proteins related to tumour cell-platelet interactions.

Venous Thromboembolism in Women with Cancer with an Additional Focus on Breast and Gynecological Cancers

Cancer-associated venous thromboembolism (VTE) is common in women with cancer. Many clinical practice guidelines provide guidance for prevention and treatment; however, there are no specific recommendations for women. This is unfortunate because the proportion of women with breast- and gynecological cancers is high among patients with cancer-associated VTE. Thromboembolism often heralds cancer progression and poor prognosis and should—besides adequate anticoagulant management—also prompt reassessment and, if necessary, changes in cancer treatment. Recently, the new class of direct-acting oral anticoagulants (DOACs) has started to replace low-molecular-weight heparin as standard thromboprophylaxis and therapy in cancer patients. They are very effective, but they also carry a relevant risk of bleeding. Therefore, despite their ease of use, not every tumor patient qualifies for a DOAC, and this is especially true for gynecological tumor patients. Each prescription must be weighed individually. This review addresses specific aspects of VTE prophylaxis and management in women with cancer. Every physician who treats breast and gynecological cancers should be familiar with prophylaxis, diagnosis, and therapy of cancer-associated VTE. At the same time, patients should be informed by their physician what symptoms to look for and whom to contact if these symptoms occur, even outside of office hours and on weekends.

Thromboembolic Events Burden in Patients With Solid Tumors and Their Predisposing Factors

Introduction: The relationship between cancers and thromboembolic events is well established. In our study, we aim to determine the burden of thromboembolic events in patients with solid tumors and identify the risk factors related to their development.

Materials & Methods: Data on patients with solid tumors and thromboembolism between January 2013 and September 2014 were collected and analyzed.

Results: During the study period 174 patients were identified. Of which, 172 (98.9%) had venous thrombus embolism, 137 (79%) were diagnosed with deep vein thromboses, 67 (38.5%) with pulmonary embolism, 84 (48.3%) were symptomatic and 90 (51.7) were incidental at diagnosis. The most common patients and disease characteristics were female sex, high body mass index (BMI), metastatic stage, colorectal and breast primaries, and anti-neoplastic therapy.

Conclusion: Our study confirmed the high burden of thromboembolic events in cancer patients and the relevant factors associated with its development.

Current Fertility Preservation Options for Female Patients With Hodgkin Lymphoma

Importance

Many adolescents and young adults diagnosed with Hodgkin lymphoma (HL) experience disease progression requiring high-dose alkylating salvage therapy, which often results in permanent infertility.

Objective

The aim of this report is to discuss fertility preservation options in female patients with consideration of chemotherapeutic agents in HL.

Evidence Acquisition

An electronic literature review was performed utilizing a combination of the terms "Hodgkin lymphoma," "fertility preservation," "ovarian tissue cryopreservation," "oocyte cryopreservation," "embryo cryopreservation," and "gonadotropin-releasing hormone agonist." References and data from identified sources were searched and compiled to complete this review.

Results

Initial treatment of HL is often nonsterilizing; however, salvage therapy and conditioning for stem cell transplantation confer significant gonadotoxicity. Established fertility preservation options for pubertal females include embryo cryopreservation and oocyte cryopreservation. These options are contraindicated within 6 months of receipt of chemotherapy. Ovarian tissue cryopreservation is an option for patients who require salvage therapy within 6 months of first-line therapy.

Conclusions

Timing and choice of fertility preservation techniques depends on planned first-line chemotherapy and response to treatment. In patients initially treated with low-risk chemotherapy, it is reasonable to defer invasive fertility techniques until treatment failure; however, upfront fertility preservation should be considered in patients planning to undergo primary treatment with high-risk therapy.

Thrombotic risk factors in patients with superior vena cava syndrome undergoing chemotherapy via femoral inserted central catheter

OBJECTIVE

Our study aimed to scrutinize the incidence and risk factors of femoral inserted central catheter (FICC)-related thrombosis in patients with superior vena cava syndrome (SVCS) undergoing chemotherapy.

METHODS

A retrospective analysis of patients with SVCS undergoing chemotherapy who received FICC catheterization at the Xiangya Hospital, Central South University, Changsha City, Hunan Province between May 2012 and February 2019 was performed. Both asymptomatic thrombosis and symptomatic thrombosis were diagnosed by color doppler ultrasound (CDUS). Univariate and multivariate logistic regression analyses were performed to identify patient-, insertion-, and catheter-related factors.

RESULTS

Eight hundred and seventy-four patients with SVCS undergoing chemotherapy, with a total of 157,180 catheter days were enrolled in our study. FICC-related thrombosis was detected in 144 patients, and yielding an overall incidence of 16.47% or 0.92 events per 1000 catheter days. Of these, 19(2.17%) patients had symptomatic thrombosis. The mean time interval between FICC insertion and thrombosis onset was (10.40 ± 6.32) days and the mean catheter indwelling time was (179.84 ± 46.15) days. The history of deep venous thrombosis, treatment with vascular endothelial growth factor (VEGF) inhibitor (bevacizumab), puncture site (mid-thigh, groin), tip position and catheter size showed association with FICC-related thrombosis. Treatment with VEGF inhibitor [odds ratio (OR) = 2.779; 95%confidence interval (CI): 1.860-4.153; P < 0.001] and puncture site at the groin (OR = 10.843; 95%CI: 6.575-17.881; P < 0.001) were identified as independent risk factors of FICC-related thrombosis.

CONCLUSION

Treatment with VEGF inhibitor and puncture site at the groin during FICC catheterization were considered as high-risk factors in FICC-related thrombosis.

Dimethyl 2,2'-[2,2'-(ethane-1,1-diyl)bis(1H-indole-3,2-diyl)]-diacetate: a small molecule capable of nano-scale assembly, inhibiting venous thrombosis and inducing no bleeding side effect

Background

Due to the discovery that deep venous thrombosis (DVT) inhibitor is of chemotherapeutic importance, the nano-property of dimethyl 2,2′-[2,2′-(ethane-1,1-diyl) bis(1H-indole-3,2-diyl)]-diacetate (DEBIC), a recently reported antitumor agent, is worthy of characterization.

Materials and methods

One-pot reaction was used to prepare DEBIC. Electrospray Ionization (+/−)-Fourier Transform-Ion Cyclotron Resonance-Mass Spectrometer (ESI(+/−)-FT-ICR-MS), quadrupole Collision Induced Dissociation (qCID) and nuclear overhauser effect spectroscopy spectra were used to present the assembly of DEBIC. Transmission electron microscopy, scanning electron microscopy, atomic force microscopy and Faraday–Tyndall effect were used to visualize the nano-property of DEBIC. Rat models were used to evaluate DVT inhibition and the bleeding reaction of DEBIC.

Results

One-pot reaction can provide DEBIC in acceptable yield and high purity. In water, rat plasma and lyophilized powders of DEBIC existed as particles of small nano-size. In vivo DEBIC inhibited DVT in a dose-dependent manner. The minimal effective dose of DEBIC was 1.7 μmol/kg. Even the dose of 36 μmol/kg/day DEBIC did not induce bleeding side effect in DVT rats like in warfarin (0.82 μmol/kg/day).

Conclusion

DEBIC is a small molecule capable of nano-scale assembly, inhibiting venous thrombosis and inducing no bleeding side effect.

Sex-specific age threshold for increased risk of retinal vein occlusion in Koreans

PURPOSE

Retinal vein occlusion (RVO) is one of most common retinal vascular disorders. It can lead to visual impairment and subsequent socioeconomic loss among the working population. RVO peak incidence is known to occur in the fifth and sixth decades of life, and is more predominant in males. To date, there has been no consensus regarding the optimal screening age for individuals at high risk for RVO, or whether sex-dependent cut-offs may be appropriate. Therefore, the purpose of this study was to predict the sex-specific age threshold for increased risk of RVO in Koreans.

METHODS

The analysis was based on data from the Korean National Health Insurance Database from 2013. Patients diagnosed with new cases of RVO from January 2013 to December 2013 were included. Individuals younger than 20 years of age and those with other retinal diseases were excluded. Multivariate logistic regression analysis and odds ratios with 95% confidence intervals were conducted to identify the age-related risk factors for RVO. A receiver operating characteristic (ROC) curve for RVO incidence was constructed.

RESULTS

Among the 754,749 individuals included in the study, 623 (0.08%) developed RVO. The optimal cut-off age for increased risk of RVO was 54 years overall, (sensitivity 0.78, specificity 0.70), 48 years in males (sensitivity 0.90, specificity 0.58), and 54 years in females (sensitivity 0.80, specificity 0.68). The incidence of RVO in females over 50 years of age was 3 times higher than that in females under the age of 50 after adjusting for confounding factors, and these differences tended to increase with age. The area under the ROC curve was 0.80 (95% CI; 0.79-0.82) overall, 0.81 (95% CI; 0.79-0.83) in males, and 0.79 (95% CI; 0.78-0.81) in females.

CONCLUSION

RVO incidence was higher in females, and increased more rapidly with age. The incidence of RVO more than doubled after 50 years of age for both sexes after adjusting for confounding factors. Females had an older age cut-off for RVO than males. However, the clinical impact of the use of sex-specific age cut-offs for RVO would benefit from additional validation from further studies.

Venous thromboembolism with EGFR monoclonal antibody necitumumab in stage IV non-small cell lung cancer: A retrospective cohort analysis

INTRODUCTION

Metastatic non-small cell lung cancer (NSCLC) is a recognized risk factor for VTE. Some systemic treatments may increase this risk further. Here, we present the risk of VTE and its prognostic significance for patients treated with chemotherapy (chemo) and the EGFR monoclonal antibody necitumumab (neci) for metastatic NSCLC.

METHODS

Four trials of 1st-line treatment for Stage IV NSCLC were analyzed: two randomized phase 3 studies of cisplatin/gemcitabine ±neci in squamous NSCLC (SQUIRE: N = 1079) and cisplatin/pemetrexed ±neci in non-squamous NSCLC (INSPIRE: N = 616); JFCL (N = 161), a randomized phase 2 trial of carboplatin/paclitaxel ±neci in squamous NSCLC; and JFCK (N = 61), a single arm phase 2 trial of cisplatin/gemcitabine +neci in squamous NSCLC. A Cox proportional hazards model with VTE as a time-dependent covariate was used for overall survival (OS) analyses.

RESULTS

Neci + chemo was associated with an increased risk of VTE (Relative Risk [RR]: 1.579; 95% CI: 1.155-2.158). History of VTE (RR: 1.899; 95% CI: 1.142-3.156) and prior cardiac/cardiovascular events (RR: 1.514; 95% CI: 1.102-2.082) were associated with increased risk of VTE. Decreased VTE risk was seen with: male sex (RR: 0.696; 95% CI: 0.502-0.964), eastern European geographic region (RR: 0.387; 95% CI: 0.267-0.562) and squamous cell pathology (RR: 0.653; 95% CI: 0.483-0.883). VTE occurrence showed no association with OS (HR: 1.121; 95% CI: 0.930-1.351).

CONCLUSION

Our data suggest that certain patient characteristics such as prior history of VTE and non-squamous histology might be associated with an increased risk of on-treatment VTE in NSCLC, although in this study, overall survival was not affected. Further studies to develop measures for identifying high-risk patients are needed to inform treatment decisions as well as VTE management and prophylaxis.

Pregnancy-related venous thromboembolism and risk of occult cancer

The cancer risk during the first year after a pregnancy-related venous thromboembolism episode is higher than expected.An aggressive search for cancer in women with pregnancy-related venous thromboembolism is probably not warranted, due to low absolute risk.