Management of cancer-associated venous thromboembolism - a case-based practical approach

Syncope as the initial presentation of pulmonary embolism in two patients with hepatocellular carcinoma: Two case reports and literature review

RATIONALE

Pulmonary embolism (PE) has diverse clinical manifestations and syncope might be the first or only symptom of PE. Tumor disease usually presents with symptoms associated with the primary site, however, PE may be the first manifestation of occult tumors.

PATIENT CONCERNS

Here, we report 2 patients admitted to our hospital because of syncope. One patient had a chronic hepatitis B history of more than 20 years and the other patient had chronic heavy drinking for many years. Neither patient had been diagnosed with neoplastic disease before admission.

DIAGNOSES

Clinical examinations, including laboratory tests and imaging tests upon admission demonstrated PE resulting in syncope. Furthermore, malignant hepatocellular carcinoma (HCC), inferior vena cava, and right atrium tumor thrombus were diagnosed.

INTERVENTIONS

Thrombolysis and anti-coagulation therapy were performed immediately after the diagnosis of PE. Twenty-seven HCC patients with PE in 27 articles from 1962 to 2020 in the PubMed database were reviewed.

OUTCOMES

The improvement was achieved that no syncope recurred after treatment of PE. The oxygen partial pressure increased and the D-dimer level decreased. The clinical characteristics of 27 HCC patients with PE were summarized and analyzed.

LESSONS

It is important for clinicians to be aware that occult carcinoma might be a reason for patients with PE presenting with syncope. If PE cannot be explained by common causes, such as our patient, and HCC should be highly suspected when inferior vena cava and right atrial mass are found on imaging tests.

Use of antithrombotics at the end of life: an in-depth chart review study

Background

Antithrombotics are frequently prescribed for patients with a limited life expectancy. In the last phase of life, when treatment is primarily focused on optimizing patients’ quality of life, the use of antithrombotics should be reconsidered.

Methods

We performed a secondary analysis of a retrospective review of 180 medical records of patients who had died of a malignant or non-malignant disease, at home, in a hospice or in a hospital, in the Netherlands. All medication prescriptions and clinical notes of patients using antithrombotics in the last three months of life were reviewed manually. We subsequently developed case vignettes based on a purposive sample, with variation in setting, age, gender, type of medication, and underlying disease.

Results

In total 60% (n=108) of patients had used antithrombotics in the last three months of life. Of all patients using antithrombotics 33.3 % died at home, 21.3 % in a hospice and 45.4 % in a hospital. In total, 157 antithrombotic prescriptions were registered; 30 prescriptions of vitamin K antagonists, 60 of heparins, and 66 of platelet aggregation inhibitors. Of 51 patients using heparins, 32 only received a prophylactic dose. In 75.9 % of patients antithrombotics were continued until the last week before death. Case vignettes suggest that inability to swallow, bleeding complications or the dying phase were important factors in making decisions about the use of antithrombotics.

Conclusions

Antithrombotics in patients with a life limiting disease are often continued until shortly before death. Clinical guidance may support physicians to reconsider (dis)continuation of antithrombotics and discuss this with the patient.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00786-3.

Clinical presentations and outcomes in pulmonary embolism patients with cancer

To study whether a diagnosis of cancer affects the clinical presentation and outcomes of patients with pulmonary embolism (PE). A retrospective analysis was performed of all consecutive patients diagnosed with PE on a computed tomography scan from 2014 to 2016 at an urban tertiary-referral medical center. Baseline characteristics, treatment decisions, and mortality data were compared between study subjects with and without a known diagnosis of active cancer. There were 581 subjects, of which 187 (33.0%) had a diagnosis of cancer. On average, cancer subjects tended to be older (64.8 vs. 58.5 years, p < 0.01), had lower body mass index (BMI) (29.0 vs. 31.5 kg/m², p = 0.01), and were less likely to be active smokers (9.2% vs. 21.1%, p < 0.01), as compared to non-cancer subjects. Cancer subjects were also less likely to present with chest pain (18.2% vs. 37.4%, p < 0.01), syncope (2.7% vs. 6.6%, p = 0.05), bilateral PEs (50% vs. 60%, p = 0.025), and evidence of right heart strain (48% vs. 58%, p = 0.024). There was no difference in-hospital length of stay (8.9 vs. 9.4 days, p = 0.61) or rate of intensive care unit (ICU) admission (31.9% vs. 33.3%, p = 0.75) between the two groups. Presence of cancer increased the risk of all-cause one-year mortality (adjusted HR 9.7, 95% CI 4.8-19.7, p < 0.01); however, it did not independently affect in-hospital mortality (adjusted HR 2.9, 95% CI 0.86-9.87, p = 0.086). Patients with malignancy generally presented with less severe PE. In addition, malignancy did not independently increase the risk of in-hospital mortality among PE patients.

Anticoagulation treatment of cancer patients with deep or superficial leg vein thrombosis - a retrospective observational study of German statutory health insurance claims data (the CERTIFICAT initiative)

Background: Thrombosis is a common complication of cancer with a negative impact on quality of life and overall prognosis. Guidelines recommend low-molecular-weight heparin (LMWH) as initial and prolonged anticoagulation treatment. Little is known about current treatment patterns of these patients in ambulatory care. Patients and methods: The current retrospective observational study interrogates a large German statutory health insurance claims database in order to understand which kind of data can be extracted and analysed. An age- and sex-adjusted sample of about 4.1 million insured people from 2011 to 2016 could be used. Cancer patients with incident deep and superficial leg vein thrombosis were identified. Patients with preexisting cancer were allocated to a normal risk group; those who suffered from simultaneously diagnosed cancer and thrombosis were classified as high-risk group. Results: We identified 322,600 patients with inpatient or outpatient documented cancer diagnosis in at least two different quarters within one year. 87,755 patients were identified with an incident deep or superficial vein thrombosis. 8,201 patients suffered from both cancer and incident thrombosis. 56.9% of the patients received an anticoagulation regimen with predominant LMWH prescription, 24.2% vitamin K antagonists, 17.2% direct oral anticoagulants; in 1.7% of patients, no predominant anticoagulant drug/regime could be identified. On average, patients were prescribed anticoagulants for 4.5 months. An estimate of clinically relevant gastrointestinal bleeding could be derived (1.8% of patients). Conclusions: The dataset allows assigning detailed information of anticoagulant prescriptions in ambulatory care to well-defined groups of cancer patients. A first analysis suggests that in Germany current medical care of patients with cancer-related deep or superficial vein thrombosis does not entirely comply with guideline recommendations regarding type and duration of anticoagulation.

Practical considerations for the use of direct oral anticoagulants in oncology patients

Oncology patients are at a high risk of experiencing venous thromboembolism. Historically, venous thromboembolisms in cancer patients have been managed with low-molecular-weight heparin on the basis of the CLOT trial published in 2003. However, recent prospective data provide evidence for safe and effective direct oral anticoagulant use in this population. The purpose of this review article is to evaluate the current body of literature surrounding direct oral anticoagulant use in the oncology population and to highlight key practical considerations when prescribing these agents for patients with cancer.

Evaluation of direct oral anticoagulants for the treatment of cancer-associated thrombosis: an update

Cancer is associated with an increased risk of venous thromboembolism of four to sixfold. Cancer-related interventions such as chemotherapy, hormonal therapy and indwelling central venous catheters also increase the risk of venous thromboembolism. Low molecular weight heparin for at least 3-6 months is the current standard of care for the treatment of cancer associated venous thromboembolism. Anticoagulation should be continued as long as the cancer is active. Over the past few years, direct oral anticoagulants have emerged, including one direct thrombin inhibitor (dabigatran etexilate) and three factor Xa inhibitors (apixaban, edoxaban and rivaroxaban). In the randomized controlled trials comparing direct oral anticoagulants with vitamin K antagonists, the direct oral anticoagulants all provide non-inferior in prevention of thromboembolic events in patients with atrial fibrillation, for the prevention and treatment of venous thromboembolism and in acute coronary syndrome. In people with cancer, these drugs have emerged as attractive alternatives for the treatment of venous thromboembolism with the potential to overcome the limitations of low molecular weight heparin. Randomized controlled studies comparing direct oral anticoagulants to low molecular weight heparin in cancer patients are still limited and direct oral anticoagulants are not recommended for the treatment of cancer associated venous thromboembolism yet. However, new emerging data are supporting the use of direct oral anticoagulants in cancer-associated thrombosis. Here, we review recent data on the evidence related to the efficacy and safety of direct oral anticoagulants for the treatment of venous thromboembolism in patients with cancer.

Anticoagulation in Cancer Patients: a Summary of Pitfalls to Avoid

PURPOSE OF REVIEW

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in cancer patients, and its management is often associated with complications including risk of recurrent VTE and bleeding. Here, we review the current data on pitfalls during anticoagulation in cancer patients and measures necessary to avoid them.

RECENT FINDINGS

Although low-molecular-weight heparin monotherapy has been the standard of treatment for several years, emerging data for direct oral anticoagulants (DOACs) are leading to new paradigms in treatment. Reports of recent randomized trials suggest a lower risk of recurrent thrombosis but higher risk of bleeding, particularly in gastrointestinal cancer patients, with DOACs. Careful patient selection and individualization of therapy based on risk of bleeding as well as recurrent VTE are keys. Problems like bleeding, recurrence, thrombocytopenia, drug-drug interactions, renal impairment, nausea-vomiting along with concerns about adherence arise during anticoagulation in cancer patients. However, with adequate pre-treatment assessment, correct anticoagulant selection and proper monitoring during anticoagulation, these issues can be addressed safely and effectively.

Submassive Pulmonary Thromboembolism in a Patient with Thrombocytopenia: Therapeutic Challenge

Venous thromboembolic disease is an important cause of mortality worldwide. A widely recognized risk factor is active neoplasia, mainly hematological tumors, in which associated thrombocytopenia can be a frequent complication. We present the case of a patient with submassive pulmonary thromboembolism associated with severe thrombocytopenia with signs of right heart failure and a requirement for systemic thrombolysis and anticoagulation, however with absolute contraindication for them. The case establishes a therapeutic challenge for the treating group, leading us to carry out an extensive search of the literature and propose a management algorithm in this complex situation.

Syncope as the initial presentation of pulmonary embolism in a young adult with testicular tumor: A case report and literature review

RATIONALE

Venous thrombus embolism (VTE) includes deep-vein thrombosis (DVT) and pulmonary embolism (PE) which may be an initial symptom for patients with cancer. PE has diverse clinical manifestations and is a rare complication of testicular tumor (TT).

PATIENT CONCERNS

Here, we report a 21-year-old man admitted to our hospital due to syncope.

DIAGNOSES

Clinical examinations upon admission demonstrated PE resulting in syncope. Further, a malignant TT, liver metastasis, and inferior vena cava (IVC) thrombosis were diagnosed.

INTERVENTIONS

Low molecular heparin was administered immediately after PE was diagnosed.

OUTCOMES

The patient suffered from cardiac arrest on hospitalization.

LESSONS

Physicians should consider the possibility of TT when a young male patient presents with syncope and is diagnosed with PE that cannot be explained by a common cause. Treatment for TT and PE should be performed as early as possible to improve the prognosis of patients combine with TT and PE.