Bleeding Problems in the Cancer Patient

Associations Between Preimplant Cancer Type and Left Ventricular Assist Device Outcomes: An INTERMACS Registry Analysis

We used the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database to examine whether history of a solid versus hematologic malignancy impacts outcomes after left ventricular assist device (LVAD) implantation. We included LVAD recipients (2007-2017) with cancer history reported (N = 14,799, 21% female, 24% Black). Multivariate models examined the association between cancer type and post-LVAD mortality and adverse events. Competing risk analyses compared death and heart transplantation between cancer types and those without cancer in bridge-to-transplant (BTT) patients. A total of 909 (6.1%) patients had a history of cancer (4.9% solid tumor, 1.3% hematologic malignancy). Solid tumors were associated with higher mortality (adjusted hazard ratio [aHR] = 1.31, 95% confidence interval [CI] = 1.09-1.57), major bleeding (aHR = 1.15, 95% CI = 1.00-1.32), and pump thrombosis (aHR = 1.52, 95% CI = 1.09-2.13), whereas hematologic malignancies were associated with increased major infection (aHR = 1.43, 95% CI = 1.14-1.80). Compared to BTT patients without a history of cancer, solid tumor patients were less likely to undergo transplantation (adjusted subdistribution HR [aSHR] = 0.63, 95% CI = 0.45-0.89) and hematologic malignancy patients were as likely to experience death (aSHR = 1.16, 95% CI = 0.63-2.14) and transplantation (aSHR = 0.69, 95% CI = 0.44-1.08). Cancer history and type impact post-LVAD outcomes. As LVAD utilization in cancer survivors increases, we need strategies to improve post-LVAD outcomes in these patients.

The biomarkers and potential pathogenesis of lung cancer related cerebral hemorrhage

Cerebral hemorrhage is one of the common complications in patients with lung cancer (LC). Although cancer related cerebral hemorrhage was aware, the pathogenesis and biomarkers of lung cancer related cerebral hemorrhage (LCRCH) remained not well known. The aim of this study was to investigate the pathogenesis and plasma biomarkers of LCRCH.A retrospective review was conducted on acute cerebral hemorrhage patients with active LC who was admitted to the hospital between January 2007 and December 2017. A total of 56 patients with LCRCH (active LC patients with acute cerebral hemorrhage but without conventional vascular risks) was recruited. Meanwhile, 112 patients with active LC alone and gender, age, and subtype of cancer cell matched were recruited as control group.In LCRCH patients, most of the hemorrhagic lesions were located in lobes. And most of them with adenocarcinoma were in medium to terminal stage with poor prognosis short-term. Moreover, LCRCH patients had a lengthened prothrombin time (PT), elevated plasma carcinoembryonic antigen (CEA), cancer antigen 125 (CA125) and cancer antigen 199 (CA199) levels and decreased platelet (PLT) level than did the patients with LC. Multivariate logistic regression analysis showed that lengthened PT, elevated plasm CEA, and CA199 levels were independent risk factors for LCRCH.It was suggested that lengthened PT, elevated plasm CEA and CA199 levels associated with the pathogenesis of LCRCH, and that the Index derived from independent risks should be serve as a specific biomarker of LCRCH.

Transcatheter arterial embolization of acute bleeding as 24/7 service: predictors of outcome and mortality

OBJECTIVE

To analyze times of occurrence and identify risk factors (RFs) for technical and clinical failure and mortality of transcatheter arterial embolization (TAE) of acute bleeding in a major hospital.

METHODS

All TAEs performed at our hospital from 2006 to 2013 (n = 327) were retrospectively analyzed.

RESULTS

TAEs were performed during regular weekday hours in 165 (50%) and during off-hours in 162 (50%) cases. With 40 regular and 128 off-hours/week, 3.25 times more TAEs were performed during regular hours. There was an even distribution across weekdays (Mon-Fri:16.9 ± 1.5%), while fewer TAEs were performed on weekends (Sat: 8.3%, Sun: 7.3%). Technical success of TAEs was 93.9% with a clinical success of 79.2% and a 30-day mortality of 18.4%. Shock was an RF for technical failure (p = 0.022). RFs for clinical failure were low hemoglobin (Hb) (p = 0.021) and transfusion of ≥6 units packed cells (p = 0.009). Independent RFs for mortality were clinical failure (p < 0.001), coagulopathy (p = 0.005), and shock (p < 0.001).

CONCLUSION

Our results provide no evidence for a subjectively perceived increase in TAEs during off-hours but rather appear to show that most TAEs are performed during regular hours. Prompt TAE to control acute bleeding is crucial to prevent a drop in Hb with shock and the need for transfusion, which may promote coagulopathy and rebleeding, all of which are risk factors for a negative outcome.

ADVANCES IN KNOWLEDGE

The presented analysis provides insights of occurrences and risk factors for success of transcatheter arterial embolization in acute bleeding in a large study population.

Acquired haemophilia in cancer: A systematic and critical literature review

AIM

There is a paucity of data on the clinical presentation and management of cancer patients with acquired haemophilia (AH), we here report a systematic literature review on acquired haemophilia in the context of cancer.

METHODS

Treatment outcomes of AH were defined as complete response (CR), partial response (PR) or no response (NR), based on inhibitor eradication, coagulation factor VIII levels and bleeding control. Reported deaths were either related to cancer or bleeding.

RESULTS

Overall, 105 cases were collected and analyzed according to classification of cancer and efficacy of treatments for inhibitor and malignancy. The mean age was 68 years for both males (range 37-86 years) and females (range 43-89 years), 39 patients were female subjects and 66 were males. A solid cancer was diagnosed in 60 subjects, while 45 patients suffered a haematological malignancy. Solid cancers affected mainly males; however, the incidence of solid tumours vs haematological malignancies was not statistically significant (P = .09). Not all patients were treated for their underlying cancer, bleeding and/or inhibitor, in two cases outcome is unavailable. CR was reported in 62.1% (64/103) cases, PR in 9.7% (10/103) cases, NR with or without death was reported in 28.1% (29/103) cases.

CONCLUSION

CR was best achieved when successful and complete elimination of autoantibodies occurred contemporaneously with the successful treatment of the underlying malignancy. In some cases, recurrent autoantibodies were harbingers of relapsed cancer. Type of cancer, inhibitor titer, treatments administered for bleeding control and inhibitor eradication did not significantly affect clinical outcome of analyzed cases.

Hematology in palliative medicine

Advanced cancer and life-limiting chronic nonmalignant diseases are associated with a number of hematological problems. Anemia and coagulation disorders, principally venous thrombosis and thrombocytopenia, are most commonly observed. Patients undergoing chemotherapy and bone marrow transplant have unique problems that include neutropenias and chemotherapy-induced drug toxicities, which will not be covered in this article.

Lower Gastrointestinal Bleeding And Risk of Gastrointestinal Cancer

OBJECTIVES

Lower gastrointestinal (GI) bleeding is a well-known symptom of colorectal cancer (CRC). Whether incident GI bleeding is also a marker of other GI cancers remains unclear.

METHODS

This nationwide cohort study examined the risk of various GI cancer types in patients with lower GI bleeding. We used Danish medical registries to identify all patients with a first-time hospital diagnosis of lower GI bleeding during 1995-2011 and followed them for 10 years to identify subsequent GI cancer diagnoses. We computed absolute risks of cancer, treating death as a competing risk, and calculated standardized incidence ratios (SIRs) by comparing observed cancer cases with expected cancer incidence rates in the general population.

RESULTS

Among 58,593 patients with lower GI bleeding, we observed 2,806 GI cancers during complete 10-year follow-up. During the first year of follow-up, the absolute GI cancer risk was 3.6%, and the SIR of any GI cancer was 16.3 (95% confidence interval (CI): 15.6-17.0). Colorectal cancers accounted for the majority of diagnoses, but risks of all GI cancers were increased. During 1-5 years of follow-up, the SIR of any GI cancer declined to 1.36 (95% CI: 1.25-1.49), but risks remained increased for several GI cancers. Beyond 5 years of follow-up, the overall GI cancer risk was close to unity, with reduced risk of rectal cancer and increased risk of liver and pancreatic cancers.

CONCLUSIONS

A hospital-based diagnosis of lower GI bleeding is a strong clinical marker of prevalent GI cancer, particularly CRC. It also predicts an increased risk of any GI cancer beyond 1 year of follow-up.

Bleeding and thrombosis in the cancer patient

There is an increased risk not only of bleeding but also of thrombosis in the cancer patient. The double jeopardy creates an additional problem in their management and requires special attention. This review provides information on pathophysiology in the regulation of hemostasis, leading to bleeding and thrombotic complications. The process is complex with multiple factors being involved. In addition to the pathogenesis, a number of clinical syndromes, diagnostic methods and the management of hemostatic abnormalities in the cancer patient are presented. Potential effects of cancer treatment on these risks magnify the hazards encountered by the managing team. Wherever management is discussed, emphasis is placed on the scientific basis for the rationale of the therapeutic approach.

Cross-matched blood in colorectal surgery: a clinical waste?

AIM

This study was carried out to determine the rate of perioperative blood transfusion and to create an evidence-based approach to requesting blood for elective colorectal surgery.

METHOD

A comparative cohort study was carried out of 164 patients (107 men, 57 women, median age 68 years) who underwent major colorectal surgery. Details obtained included demographic and operative information, the number of units of blood cross-matched, units used, the reasons for transfusion and patient suitability for electronic issue (EI). The cross-match to transfusion ratio (C:T ratio) was calculated for each procedure and for the whole group of colorectal procedures.

RESULTS

Some 162 units of blood were cross-matched for 76 (46%) patients, with the remaining 88 (54%) being grouped with serum saved. Twenty-one (13%) were transfused with a total of 48 units of blood. The C:T ratio for all procedures was 3.4/1. The commonest indication for transfusion was anaemia. One patient required an emergency transfusion. The majority (78%) of patients were suitable for EI. There were no significant differences between the transfused and nontransfused groups with regard to age, diagnosis (malignant vs benign) and laparoscopic or open colorectal procedure.

CONCLUSION

Only a small proportion of patients undergoing elective major colorectal surgery require perioperative blood transfusions, most of which are nonurgent. Blood should not be routinely cross-matched in patients who are suitable for EI.

Stroke and cancer: a review

Stroke is a disabling disease and can add to the burden of patients already suffering from cancer. Several major mechanisms of stroke exist in cancer patients, which can be directly tumour related, because of coagulation disorders, infections, and therapy related. Stroke can also occur as the first sign of cancer, or lead to its detection. The classical literature suggests that stroke occurs more frequently in cancer patients than in the average population. More recent studies report a very similar incidence between cancer and non-cancer patients. However, there are several cancer-specific types and causes of stroke in cancer patients, which need to be considered in each patient. This review classifies stroke into ischaemic, haemorrhagic, cerebral venous thrombosis and other rarer types of cerebrovascular disease. Its aim is to identify the types of stroke most frequently associated with cancer, and give a practical view on the most common and most specific types of stroke. The diagnosis of the cause of stroke in cancer patients is crucial for treatment and prevention. Management of different stroke types will be briefly discussed.

Overt gastrointestinal bleeding in haematologic neoplasms

BACKGROUND AND AIM

Patients with acute leukaemia suffer from various haemorrhages, most frequently due to thrombocytopenia. We could not reach any information regarding the frequency of gastrointestinal bleeding in acute leukaemia and decided to search this complication in patients with acute and chronic leukaemias and myeloproliferative disorders, retrospectively.

PATIENTS AND METHODS

During a 6-year period, 291 patients with acute leukaemia, 52 patients with chronic leukaemia and 108 patients with myeloproliferative disorders had been followed. Thirty-two cases of overt gastrointestinal haemorrhage episodes (25 upper, 7 lower) were observed during the mentioned period.

RESULTS

The frequency of bleeding episodes was 7.1% (32/451) in haematologic malignancies as a whole, 5.8% (17/291) for acute leukaemia, 1.9% (1/52) for chronic leukaemia and 13% (14/108) for myeloproliferative disorders. If the patients with myeloproliferative disorders in blastic phase were analysed separately, the ratio was 30% (6/20). Oesophagogastroduodenoscopy, which could be performed in 8 of 25 upper gastrointestinal haemorrhage episodes, revealed erosive gastritis in five patients and duodenal ulcers in three patients. Neutropenic enterocolitis was the underlying cause in all of the seven patients with lower gastrointestinal haemorhage. Five out of the seven patients had acute leukaemia. In 7 bleeding attacks, out of 32, the ultimate result was death. Generally, the haemorrhage was only a contributing cause of mortality. All of the mortality cases were patients with acute leukaemia.

CONCLUSION

Especially, the patients with myeloproliferative disorders are prone to develop gastrointestinal haemorrhage. The manifestation is generally as upper gastrointestinal bleeding due to gastric erosions and duodenal ulcers. Lower gastrointestinal bleeding is frequently a problem of the patients with acute leukaemia. It is commonly a sign of neutropenic enterocolitis.

Acquired haemophilia in a patient with gram-negative urosepsis and bladder cancer

We here report a patient who developed a high titer antibody to factor VIII (FVIII) during gram-negative urosepsis caused by enterobacter cloacae after complete resection of rectal cancer. The patient initially presented with a life threatening spontaneous hematothorax and multiple large haematomas. Coagulation studies revealed a severe FVIII deficiency <1% with a high FVIII antibody titer of 64 BU. The bleeding responded rapidly to infusions of recombinant factor VIIa. After achievement of a partial remission (FVIII activity 28%) by combined immunosuppressive therapy (prednisone, cyclophosphamide, plasmapheresis and immunoadsorption), subsequently, two relapses occurred following steroid tapering. Resumption of prednisone and cyclophosphamide treatment combined with immunoadsorption induced a second and third remission, respectively. After resection of a papillary carcinoma of the bladder 6 months later and continuous immunosuppressive therapy with cyclophosphamide, FVIII levels remained stable within normal ranges. This clinical course suggests that the cause of inhibitor formation against FVIII resulting in severe acquired haemophilia was multifactorial and was initiated by the gram-negative urosepsis and probably by the underlying malignancies.

Effective Management of Bleeding during Tumor Resection with a Collagen-Based Hemostatic Agent

In a prospective controlled trial hemostatic effectiveness of a novel collagen-based composite (CoStasis®) was compared with a collagen sponge applied with manual pressure at diffusely bleeding sites after surgical tumor resection. The proportion of subjects achieving complete cessation of bleeding within 10 minutes (i.e., hemostatic success) and the time to “complete hemostasis” were determined at raw surgical sites after tumor resection among 23 experimental and 30 control subjects. There was a similar distribution in tumor types (e.g., benign vs malignant) evaluated between treatment groups. A significantly greater proportion of experimental subjects achieved complete hemostasis within 10 minutes of observation compared with controls [23 of 23 (100%) vs 21 of 30 (70%); P = 0.003]. The median time required to achieve complete hemostasis was more than three times longer for subjects treated with the collagen sponge compared with subjects treated with CoStasis® (243 vs 78 seconds; P = 0.0001). Approximately 80 per cent of experimental subjects achieved complete hemostasis within 2 minutes compared with only 35 per cent of controls. There were no adverse events related to the experimental treatment in this study. These results support the use of this novel hemostatic agent to control diffuse surgical site bleeding after tumor resection at diverse anatomical locations.

Inhibitors against factor VIII in patients with cancer. Analysis of 41 patients

BACKGROUND

The spontaneous formation of neutralizing antibodies (inhibitors) to factor VIII (FVIII) in patients with cancer is a well known phenomenon. However, to the authors' knowledge there is lack of information in the literature with respect to the clinical course of these patients and the nature of the association between malignant tumors and acquired hemophilia.

METHODS

A retrospective study of 41 patients with cancer and acquired hemophilia was conducted. The patients were identified through a MEDLINE search between 1974-2000. All patients had detailed clinical and laboratory information available and descriptions of the course of the inhibitor in relation to cancer treatment. The patients were divided into two groups: responders and nonresponders. The stage of the tumor, inhibitor titer, FVIII level, and survival data were examined and compared between the two groups.

RESULTS

A total of 63 hemorrhagic episodes were reported in 25 patients with solid tumors and 16 patients with hematologic malignancies. The median inhibitor titer at the time of the diagnosis of acquired hemophilia was 14 Bethesda units (BU) (range, 1-435 BU). The complete response (CR) rate to treatment of the inhibitor was 70% and patients who achieved a CR were more likely to have early stage tumors (P = 0.0007) and a lower median inhibitor titer at the time of presentation compared with nonresponders (12 BU vs. 78 BU; P = 0.007). The overall survival was significantly higher in patients who achieved a CR compared with patients with a persistent inhibitor (75% vs. 17%; P = 0.0006).

CONCLUSIONS

Although it remains an uncommon occurrence, the development of inhibitors to FVIII should be considered as a cause of bleeding in some patients with malignant diseases. Because of the high response rate and the impact of this type of hemorrhage on cancer patients, efforts should be directed toward immunosuppression of the inhibitor in a fashion similar to that used in other patients with acquired hemophilia. To our knowledge the link between malignancy and the formation of antibodies to FVIII is unclear; however, it appears that treatment of cancer with chemotherapy or surgery may accelerate the eradication of the inhibitor in some patients. Long term prospective studies are needed to better assess the association between cancer and acquired hemophilia.

Reversion of primary hyperfibrinogenolysis in patients with hormone-refractory prostate cancer using docetaxel

Tumor-associated proteases play a major role in determining the biologic behavior and aggressiveness of prostate cancer. Several authors have described the association between the increased levels of urokinase plasminogen activator in the plasma and in the malignant prostatic tissue with the metastatic potential of prostate cancer. However, the direct effect of this activity in producing fibronogenolysis in patients with prostate cancer has not been addressed. To evaluate the role of chemotherapy in reversing fibrinogenolysis in patients with prostate cancer, eight patients with hormone-refractory prostate cancer, bleeding, and laboratory evidence of primary hyperfibrinogenolysis were treated with docetaxel. The drug was given 48 hr after initiation of all supportive measures. Laboratory data, including plasminogen, alpha 2-antiplasmin, and fibrinogen, were recorded before and after treatment. Prostate-specific antigen (PSA) was measured at the time of referral and before subsequent cycles (3 weeks). Five patients had resolution of the fibrinolytic process after one cycle of treatment with docetaxel. This was demonstrated by improvement in both the laboratory parameters and the bleeding episodes. Further follow-up showed stabilization of the hematologic parameters and reduction in PSA values in these patients. Two patients died from uncontrolled bleeding despite all supportive measures. One patient did not demonstrate response to this treatment in terms of normalization of the fibrinolytic indicators or reduction in PSA. Primary fibrinogenolysis associated with metastatic prostate cancer is a serious complication. Docetaxel appears to be effective in reversing this process in some hormone-refractory patients. Although this response appears to be due to antitumor activity, a direct effect on the fibrinolytic pathway induced by the tumor cannot be excluded. Further work in this area is warranted.

Etiology and treatment of acquired coagulopathies in the critically ill adult and child

Excessive bleeding frequently complicates the care of critically ill patients. Except in the case of trauma or inpatients with known coagulopathies, the bleeding is generally not directly related to the illness that results in admission to the intensive care unit. In general, the causes of the bleeding can be divided into three categories: consumptive coagulopathies, bleeding related to "hepatic issues," and iatrogenic causes. In most circumstances, the pathogenesis and management of these acquired coagulopathies do not differ between the adult and child patient. However, some differences do exist in regards to the clinical manifestations and management of some consumptive coagulopathies. This article reviews the more common causes of bleeding in the critically ill patient and outlines diagnostic and treatment approaches for these patients. Particular emphasis will be placed on the differences in presentation and management where differences exist.

Thrombosis and hemorrhage in oncology patients

As outlined in this review, patients with cancer may harbor many alterations of hemostasis. These are multifaceted and must be considered when trying to control hemorrhage or thrombosis in cancer patients. Also, hemorrhage or thrombosis is often the final fatal event in many patients with metastatic solid tumor or hematologic malignancies. Patients with malignancy present a major clinical challenge in this new era of oncologic awareness and more aggressive care, which has led to prolonged survival for patients and a longer time frame during which these complications may develop. Therefore, these complications are occurring more commonly. It is important to realize that these alterations of hemostasis exist and must be approached in a sequential and logical manner with respect to diagnosis; only in this way can responsible, efficacious, and rational therapy be delivered to patients. By far the most common alteration of hemostasis in malignancy is that of hemorrhage associated with thrombocytopenia, either drug-induced, or radiation-induced, or from bone marrow invasion. Hemorrhage resulting from DIC, however, is also quite common and may present as hemorrhage, thrombosis, thromboembolus, or any combination thereof. Many antineoplastic drugs and radiation therapy may lead to or significantly enhance hemorrhage in patients with malignancy. Thrombosis, also commonly seen in patients with malignancy, is often a manifestation of low-grade DIC. When approaching the patient with malignancy and either hemorrhage or thrombosis, all the potential defects in hemostasis must be considered, defined from the laboratory standpoint, and treated in as precise and logical manner as possible.

Hemostatic disorders in cats: a retrospective study and review of the literature

Hemostasis profiles from 101 cats presented for medical or surgical evaluation to The Ohio State University Veterinary Teaching Hospital from 1986 through 1991 were reviewed retrospectively; 69% were abnormal. Commonly identified abnormalities included a mixed hemostatic defect compatible with disseminated intravascular coagulation, thrombocytopenia, isolated prolongation of the activated partial thromboplastin time (APTT), and prolongation of both the APTT and one-stage prothrombin time. The most common disorders associated with abnormal hemostasis profiles in this study were liver disease, neoplasia, and feline infectious peritonitis.