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Bansal VV, Mitchell O, Bregio C, Witmer HDD, Dhiman A, Godley FA, Ong C, Berger Y, Reddy B, Churpek JE, Drazer MW, Eng OS, Kindler HL, Turaga KK. Venous Thromboembolism in Peritoneal Mesothelioma: Uncovering the Hidden Risk. Ann Surg Oncol 2024; 31:3339-3349. [PMID: 38372861 DOI: 10.1245/s10434-024-15030-4] [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: 10/25/2023] [Accepted: 01/25/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a common complication in patients with abdominal malignancies. Despite known associations between pleural mesothelioma and increased VTE risk, the characteristics of VTE in patients with peritoneal mesothelioma (PeM) remain undescribed. METHODS Patients treated for PeM were retrospectively identified from our institutional database. The frequency of VTE was assessed and logistic regression modeling was employed to assess VTE risk factors. The association between VTE and overall survival was also ascertained. Recommended thromboprophylaxis for patients who underwent surgery at our institution comprised a single preoperative dose of prophylactic anticoagulation, followed by daily dosing for four weeks postoperatively. RESULTS Among 120 PeM patients, 26 (21.7%) experienced VTE, including 19/91 (20.9%) surgical patients, 4/23 (17.4%) patients who received systemic therapy, and 3/6 (50%) patients who underwent observation (p = 0.21). Most events were symptomatic (n = 16, 62%) and were attributable to pulmonary emboli (n = 16, 62%). The 90-day postoperative VTE rate was 4.4% (4/91), including 1 of 60 patients who underwent index surgical intervention at our institution and 3 patients with surgery elsewhere. A low serum albumin concentration was associated with VTE in non-surgical patients (odds ratio 0.12, confidence interval [CI] 0.02-0.72; p = 0.03). No significant difference in overall survival was observed between patients with and without VTE (median 46.0 months [CI 24.9-67.0] vs. 55.0 months [CI 27.5-82.5]; hazard ratio 0.98 [CI 0.54-1.81], p = 0.98). CONCLUSIONS A high risk of VTE was observed in PeM patients, warranting suspicion throughout the disease trajectory. Postoperative VTE rates were within acceptable limits with 4-week thromboprophylaxis.
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Affiliation(s)
- Varun V Bansal
- Division of Surgical Oncology, Yale School of Medicine, New Haven, CT, USA
| | - Owen Mitchell
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Celyn Bregio
- Pritzker School of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Hunter D D Witmer
- Division of General Surgery and Surgical Oncology, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Ankit Dhiman
- Department of Surgery, Medical College of Georgia, Augusta, GA, USA
| | - Frederick A Godley
- Division of General Surgery and Surgical Oncology, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Cecilia Ong
- Division of General Surgery and Surgical Oncology, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Yaniv Berger
- Department of Surgery, Sheba Medical Center, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Biren Reddy
- Division of General Surgery and Surgical Oncology, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Jane E Churpek
- Division of Hematology, Medical Oncology, and Palliative Care, Department of Medicine, University of Wisconsin, Madison, WI, USA
| | - Michael W Drazer
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Oliver S Eng
- Division of Surgical Oncology, Department of Surgery, University of California Irvine, Orange, CA, USA
| | - Hedy L Kindler
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Kiran K Turaga
- Division of Surgical Oncology, Yale School of Medicine, New Haven, CT, USA.
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Lundbech M, Damsbo M, Krag AE, Hvas AM. Changes in Coagulation in Cancer Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Treatment (HIPEC)-A Systematic Review. Semin Thromb Hemost 2024; 50:474-488. [PMID: 36828005 DOI: 10.1055/s-0043-1764125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
Venous thromboembolism and postoperative bleeding are complications of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this systematic review was to summarize current knowledge on the effect of cytoreductive surgery with HIPEC on coagulation and fibrinolysis within 10 days after surgery. Studies were identified in PubMed, Embase, and Web of Science on December 12, 2022. Data on biomarkers of coagulation and fibrinolysis measured preoperatively up to the 10th postoperative day were extracted. Among 15 included studies, 13 studies reported markers of primary hemostasis. Eleven studies found reduced platelet count following cytoreductive surgery with HIPEC and two studies reported reduced platelet function. Twelve studies reported impaired secondary hemostasis until postoperative day 10 indicated by prolonged international normalized ratio, prothrombin time, and activated partial thromboplastin time. Fibrinogen was decreased in three studies from preoperative to postoperative day 3 switching to increased levels until postoperative day 10. In accordance, three studies found reduced maximum amplitude and maximum clot firmness by thromboelastography/thromboelastometry (ROTEM/TEG) on the first postoperative day indicating impaired clot strength. Four studies demonstrated increased d-dimer, factor (F) VIII, and thrombin generation during the 10 postoperative days. Four studies investigated fibrinolysis by ROTEM/TEG and plasminogen activator inhibitor-1 (PAI-1) after cytoreductive surgery with HIPEC reporting contradictive results. In conclusion, a decrease in platelet count and subtle changes in secondary hemostasis were found following cytoreductive surgery with HIPEC. Data on the effect of cytoreductive surgery with HIPEC on fibrinolysis are sparse and this needs to be further investigated.
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Affiliation(s)
- Mikkel Lundbech
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Matilde Damsbo
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Andreas Engel Krag
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Plastic Surgery Research Unit, Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
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Mindukshev I, Fock E, Dobrylko I, Sudnitsyna J, Gambaryan S, Panteleev MA. Platelet Hemostasis Reactions at Different Temperatures Correlate with Intracellular Calcium Concentration. Int J Mol Sci 2022; 23:ijms231810667. [PMID: 36142580 PMCID: PMC9505593 DOI: 10.3390/ijms231810667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/05/2022] [Accepted: 09/05/2022] [Indexed: 11/22/2022] Open
Abstract
Hypo- and hyperthermia affect both primary and secondary hemostasis; however, there are controversial data concerning platelet activation and the underlying mechanisms under hypo- and hyperthermia. The discrepancies in the data could be partly explained by different approaches to hemostatic reactions analysis. We applied a new LaSca-TMF laser particle analyzer for a simultaneous fluorescence and laser scattering analysis of platelet responses at different temperatures. Human platelets were activated by ADP in a wide range of temperatures, and platelet transformations (e.g., a shape change reaction, aggregation and clot formation) and the intracellular calcium concentration ([Ca2+]i) were analyzed by LaSca-TMF and confocal microscopy. The platelet shape change reaction gradually increased with a rising temperature. The platelet aggregation strongly decreased at low ADP concentrations with the augmentation of the temperature and was independent of the temperature at high ADP concentrations. In contrast, the clotting time decreased with a temperature increase. Similar to the aggregation response, a rise in [Ca2+]i triggered by low ADP concentrations was higher under hypothermic conditions and the differences were independent of the temperature at high ADP concentrations. We showed that the key reactions of cellular hemostasis are differentially regulated by temperature and demonstrated for the first time that an accelerated aggregation under hypothermic conditions directly correlated with an increased level in [Ca2+]i in platelets.
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Affiliation(s)
- Igor Mindukshev
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, 44 Thorez Ave., 194223 Saint Petersburg, Russia
| | - Ekaterina Fock
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, 44 Thorez Ave., 194223 Saint Petersburg, Russia
| | - Irina Dobrylko
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, 44 Thorez Ave., 194223 Saint Petersburg, Russia
| | - Julia Sudnitsyna
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, 44 Thorez Ave., 194223 Saint Petersburg, Russia
- Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences, 30 Srednyaya Kalitnikovskaya St., 109029 Moscow, Russia
| | - Stepan Gambaryan
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, 44 Thorez Ave., 194223 Saint Petersburg, Russia
- Correspondence: (S.G.); (M.A.P.)
| | - Mikhail A. Panteleev
- Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences, 30 Srednyaya Kalitnikovskaya St., 109029 Moscow, Russia
- Correspondence: (S.G.); (M.A.P.)
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HIPEC as a risk factor for postoperative coagulopathy after cytoreductive surgery for peritoneal metastases. Updates Surg 2022; 74:1715-1723. [PMID: 35932406 DOI: 10.1007/s13304-022-01340-3] [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: 12/22/2021] [Accepted: 07/19/2022] [Indexed: 10/15/2022]
Abstract
AIM OF THE STUDY Postoperative coagulopathy is a poorly investigated condition after Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC). This study aims to evaluate the occurrence and risk factors of coagulative disorders after surgery for peritoneal metastases. PATIENTS AND METHODS The records were extracted from a prospectively maintained database of consecutive patients who underwent CRS between January 2018 and September 2020. The study was approved by the local Ethics Committee. For each patient, the coagulation profile (CP), which included international normalized ratio (INR), partial thromboplastin time (aPTT), and platelets (PLTS) before surgery, intensive care unit admission,1st, 3rd, 5th postoperative day (POD) and the day before discharge was collected. Risk factors for postoperative coagulopathy were identified at multivariate analysis. RESULTS During the study period, 125 patients were included in the study. Among these, 48 (38.4%) underwent CRS only, and 77 (61.6%) CRS followed by HIPEC. Twenty-one patients (16.8%) developed severe coagulopathy, 5 (10.4%) after CRS and 16 (20.8%) after CRS-HIPEC. At multivariate analysis, HIPEC and blood loss ≥ 500 ml represented independent risk factors for severe alteration of INR > 1.5 (p = 0.05, OR 1.2) and PLTS < 75 109/L (p = 0.03, OR 1.3), respectively. CONCLUSION HIPEC is an independent risk factor for postoperative coagulopathy after CRS. Further studies are necessary to assess the usefulness of the point-of-care test in patients treated with CRS-HIPEC.
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Lundbech M, Krag AE, Iversen LH, Hvas AM. Postoperative bleeding and venous thromboembolism in colorectal cancer patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:17-33. [PMID: 34626208 DOI: 10.1007/s00384-021-04021-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has improved survival for selected patients with peritoneal metastases from colorectal cancer. Previous studies report conflicting rates of postoperative bleeding and venous thromboembolism (VTE) after CRS + HIPEC. The aim of the present study was to systematically review the literature and to estimate the overall 30-day incidence of postoperative bleeding and the overall 90-day incidence of VTE after CRS + HIPEC. METHODS Studies were identified in PubMed, Embase, and Web of Science on 29 April 2021. Data were extracted for a qualitative synthesis and to estimate an overall mean incidence in the meta-analysis. RESULTS Fourteen studies with a total of 3268 patients were included in the systematic review. Postoperative bleeding incidence rates within 30 days ranged from 1.7 to 8.3% with an overall 30-day postoperative bleeding incidence with [95% CI] at 4.2 [2.6;6.2]%. VTE incidence rates within 90 days ranged from 0.2 to 13.6% with an overall 90-day VTE incidence with [95% CI] at 2.7 [1;5.2]% after CRS + HIPEC. CONCLUSION This systematic review and meta-analysis indicate a low risk for postoperative bleeding within 30 days and VTE within 90 days after CRS + HIPEC for peritoneal metastases from colorectal cancer.
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Affiliation(s)
- Mikkel Lundbech
- Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Andreas Engel Krag
- Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.,Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Lene Hjerrild Iversen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark. .,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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Abstract
A new cancer diagnosis is expected to affect approximately 1.9 million people in the United States in 2021. A small percentage of these patients will experience an emergent cancer-related complication. Oncologic emergencies may be encountered in emergency departments or require intensive care management. Patients newly diagnosed with cancer are more likely to present with emergencies related to the underlying malignancies. Oncologic emergencies can have various manifestations, ranging from mechanical obstruction due to tumor growth to metabolic derangements due to abnormal secretions from the tumor. Therefore, early identification and treatment of life-threatening oncologic events is critical. Although there are several different types of oncologic emergencies, this article focuses on metabolic emergencies (tumor lysis syndrome and cytoreductive hyperthermic intraperitoneal chemotherapy) and structural emergencies (increased intracranial pressure and vena cava thrombus). The purpose of this article is to provide acute care clinicians with an overview of selected oncologic emergencies and their evidence-based management.
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Affiliation(s)
- Ninotchka Brydges
- Ninotchka Brydges is Manager and Advanced Practice Provider, Department of Critical Care Medicine, Division of Anesthesia, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston TX 77030
| | - Garry J Brydges
- Garry J. Brydges is Director, Anesthesia Safety and Quality, Department of Anesthesiology, Division of Anesthesia, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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