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Kapteijn MY, Bakker N, Koekkoek JAF, Versteeg HH, Buijs JT. Venous Thromboembolism in Patients with Glioblastoma: Molecular Mechanisms and Clinical Implications. Thromb Haemost 2024. [PMID: 39168144 DOI: 10.1055/s-0044-1789592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
Patients with glioblastoma are among the cancer patients with the highest risk of developing venous thromboembolism (VTE). Long-term thromboprophylaxis is not generally prescribed because of the increased susceptibility of glioblastoma patients to intracranial hemorrhage. This review provides an overview of the current clinical standard for glioblastoma patients, as well as the molecular and genetic background which underlies the high incidence of VTE. The two main procoagulant proteins involved in glioblastoma-related VTE, podoplanin and tissue factor, are described, in addition to the genetic aberrations that can be linked to a hypercoagulable state in glioblastoma. Furthermore, possible novel biomarkers and future treatment strategies are discussed, along with the potential of sequencing approaches toward personalized risk prediction for VTE. A glioblastoma-specific VTE risk stratification model may help identifying those patients in which the increased risk of bleeding due to extended anticoagulation is outweighed by the decreased risk of VTE.
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Affiliation(s)
- Maaike Y Kapteijn
- Division of Thrombosis and Hemostasis, Department of Medicine, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Nina Bakker
- Division of Thrombosis and Hemostasis, Department of Medicine, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Johan A F Koekkoek
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henri H Versteeg
- Division of Thrombosis and Hemostasis, Department of Medicine, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen T Buijs
- Division of Thrombosis and Hemostasis, Department of Medicine, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Zhang Y, Zeng J, Bao S, Zhang B, Li X, Wang H, Cheng Y, Zhang H, Zu L, Xu X, Xu S, Song Z. Cancer progression and tumor hypercoagulability: a platelet perspective. J Thromb Thrombolysis 2024; 57:959-972. [PMID: 38760535 DOI: 10.1007/s11239-024-02993-0] [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] [Accepted: 04/26/2024] [Indexed: 05/19/2024]
Abstract
Venous thromboembolism, which is common in cancer patients and accompanies or even precedes malignant tumors, is known as cancer-related thrombosis and is an important cause of cancer- associated death. At present, the exact etiology of the elevated incidence of venous thrombosis in cancer patients remains elusive. Platelets play a crucial role in blood coagulation, which is intimately linked to the development of arterial thrombosis. Additionally, platelets contribute to tumor progression and facilitate immune evasion by tumors. Tumor cells can interact with the coagulation system through various mechanisms, such as producing hemostatic proteins, activating platelets, and directly adhering to normal cells. The relationship between platelets and malignant tumors is also significant. In this review article, we will explore these connections.
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Affiliation(s)
- Yifan Zhang
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Jingtong Zeng
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Shihao Bao
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Bo Zhang
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Xianjie Li
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Hanqing Wang
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Yuan Cheng
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Hao Zhang
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Lingling Zu
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaohong Xu
- Colleges of Nursing, Tianjin Medical University, Tianjin, China
| | - Song Xu
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China.
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China.
| | - Zuoqing Song
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China.
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China.
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3
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Veiga VC, Peres SV, Ostolin TLVDP, Moraes FR, Belucci TR, Clara CA, Cavalcanti AB, Chaddad-Neto FEA, Batistella GNDR, Neville IS, Baeta AM, Yamada CAF. Incidence of venous thromboembolism and bleeding in patients with malignant central nervous system neoplasm: Systematic review and meta-analysis. PLoS One 2024; 19:e0304682. [PMID: 38900739 PMCID: PMC11189257 DOI: 10.1371/journal.pone.0304682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 05/16/2024] [Indexed: 06/22/2024] Open
Abstract
Central nervous system (CNS) malignant neoplasms may lead to venous thromboembolism (VTE) and bleeding, which result in rehospitalization, morbidity and mortality. We aimed to assess the incidence of VTE and bleeding in this population. METHODS This systematic review and meta-analysis (PROSPERO CRD42023423949) were based on a standardized search of PubMed, Virtual Health Library and Cochrane (n = 1653) in July 2023. After duplicate removal, data screening and collection were conducted by independent reviewers. The combined rates and 95% confidence intervals for the incidence of VTE and bleeding were calculated using the random effects model with double arcsine transformation. Subgroup analyses were performed based on sex, age, income, and type of tumor. Heterogeneity was calculated using Cochran's Q test and I2 statistics. Egger's test and funnel graphs were used to assess publication bias. RESULTS Only 36 studies were included, mainly retrospective cohorts (n = 30, 83.3%) from North America (n = 20). Most studies included were published in high-income countries. The sample size of studies varied between 34 and 21,384 adult patients, mostly based on gliomas (n = 30,045). For overall malignant primary CNS neoplasm, the pooled incidence was 13.68% (95%CI 9.79; 18.79) and 11.60% (95%CI 6.16; 18.41) for VTE and bleeding, respectively. The subgroup with elderly people aged 60 or over had the highest incidence of VTE (32.27% - 95%CI 14.40;53.31). The studies presented few biases, being mostly high quality. Despite some variability among the studies, we observed consistent results by performing sensitivity analysis, which highlight the robustness of our findings. CONCLUSIONS Our study showed variability in the pooled incidence for both overall events and subgroup analyses. It was highlighted that individuals over 60 years old or diagnosed with GBM had a higher pooled incidence of VTE among those with overall CNS malignancies. It is important to note that the results of this meta-analysis refer mainly to studies carried out in high-income countries. This highlights the need for additional research in Latin America, and low- and middle-income countries.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Alex M. Baeta
- BP–A Beneficência Portuguesa de São Paulo, São Paulo, Brasil
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Roy DC, Wang TF, Lun R, Zahrai A, Mallick R, Burger D, Zitikyte G, Hawken S, Wells P. Circulating Blood Biomarkers and Risk of Venous Thromboembolism in Cancer Patients: A Systematic Review and Meta-Analysis. Thromb Haemost 2024. [PMID: 38768631 DOI: 10.1055/a-2330-1371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Cancer patients have an increased risk of venous thromboembolism (VTE). Currently, the availability of highly discriminatory prediction models for VTE in cancer patients is limited. The implementation of biomarkers in prediction models might lead to refined VTE risk prediction. In this systematic review and meta-analysis, we aimed to evaluate candidate biomarkers and their association with cancer-associated VTE. METHODS We searched Medline, EMBASE, and Cochrane Central for studies that evaluated biomarkers in adult cancer patients from inception to September 2022. We included studies reporting on VTE after a cancer diagnosis with biomarker measurements performed at a defined time point. Median/mean differences (for continuous measures) and odds ratios (for dichotomous measures) with 95% confidence intervals were estimated and pooled using random-effects models. RESULTS We included 113 studies in the systematic review. Of these, 50 studies were included in the meta-analysis. We identified two biomarkers at cancer diagnosis (factor VIII and time to peak thrombin), three biomarkers pre-chemotherapy (D-dimer, fibrinogen, and mean platelet volume), and one biomarker preoperatively (platelet count) that had significant median or mean differences. Additionally, we found that hemoglobin <100 g/L and white blood count >11 × 109/L were significantly associated with future VTE risk only when measured at cancer diagnosis. Pre-chemotherapy neutrophil-to-lymphocyte ratio ≥3 and preoperative platelet count ≥400 × 109/L were also found to be associated with future VTE risk. CONCLUSION In conclusion, this study identified nine candidate blood biomarkers that may help in optimizing VTE prediction in cancer patients that should be further explored in future studies.
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Affiliation(s)
- Danielle Carole Roy
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Tzu-Fei Wang
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ronda Lun
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Vascular Neurology, Stanford Healthcare, Palo Alto, California, United States
| | - Amin Zahrai
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Dylan Burger
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Gabriele Zitikyte
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Steven Hawken
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Philip Wells
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Kawano T, Mackman N. Cancer patients and ischemic stroke. Thromb Res 2024; 237:155-162. [PMID: 38603819 DOI: 10.1016/j.thromres.2024.03.019] [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: 12/26/2023] [Revised: 02/26/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024]
Abstract
Patients with cancer have an increased risk of ischemic stroke compared to the general population. Additionally, these patients have a worse prognosis compared to stroke patients without cancer. Activation of coagulation appears to play a key role in the pathophysiology of ischemic stroke in patients with cancer. However, the underlying mechanisms remain unknown. Moreover, we do not have a way to identify cancer patients with a high risk of stroke and cannot develop prevention strategies. Therefore, there is an urgent need for neurologists and oncologists to develop screening and prevention strategies for stroke in patients with cancer. In this review, we summarize the characteristics of cancer patients at a high risk of stroke, the predictors for the development of stroke and survival in cancer patients, and possible treatments.
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Affiliation(s)
- Tomohiro Kawano
- Department of Neurology, Kano general hospital, Osaka, Japan
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Tatsumi K. The pathogenesis of cancer-associated thrombosis. Int J Hematol 2024; 119:495-504. [PMID: 38421488 DOI: 10.1007/s12185-024-03735-x] [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: 12/04/2023] [Revised: 02/13/2024] [Accepted: 02/18/2024] [Indexed: 03/02/2024]
Abstract
Patients with cancer have a higher risk of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), compared to the general population. Cancer-associated thrombosis (CAT) is a thrombotic event that occurs as a complication of cancer or cancer therapy. Major factors determining VTE risk in cancer patients include not only treatment history and patient characteristics, but also cancer type and site. Cancer types can be broadly divided into three groups based on VTE risk: high risk (pancreatic, ovarian, brain, stomach, gynecologic, and hematologic), intermediate risk (colon and lung), and low risk (breast and prostate). This implies that the mechanism of VTE differs between cancer types and that specific VTE pathways may exist for different cancer types. This review summarizes the specific pathways that contribute to VTE in cancer patients, with a particular focus on leukocytosis, neutrophil extracellular traps (NETs), tissue factor (TF), thrombocytosis, podoplanin (PDPN), plasminogen activator inhibitor-1 (PAI-1), the intrinsic coagulation pathway, and von Willebrand factor (VWF).
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Affiliation(s)
- Kohei Tatsumi
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan.
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Rolling CC, Mohme M, Bokemeyer C, Westphal M, Riethdorf S, Lamszus K, Pantel K, Klingler F, Langer F. Circulating Tumor Cells and Thromboembolic Events in Patients with Glioblastoma. Hamostaseologie 2024. [PMID: 38636546 DOI: 10.1055/a-2251-6766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024] Open
Abstract
Patients with glioblastoma (GBM) are at increased risk for arterial and venous thromboembolism (TE). Risk factors include surgery, the use of corticosteroids, radiation, and chemotherapy, but also prothrombotic characteristics of the tumor itself such as expression of tissue factor, vascular endothelial growth factor, or podoplanin. Although distant metastases are extremely rare in this tumor entity, circulating tumor cells (CTCs) have been detected in a significant proportion of GBM patients, potentially linking local tumor growth characteristics to systemic hypercoagulability. We performed post hoc analysis of a study, in which GBM patients had been investigated for CTCs. Information on TE was retrieved from electronic patient charts. In total, 133 patients (median age, 63 years; interquartile range, 53-70 years) were analyzed. During follow-up, TE was documented in 14 patients (11%), including 8 venous and 6 arterial events. CTCs were detected in 26 patients (20%). Four (15%) patients with CTCs had a TE compared with 10 (9%) patients without CTCs. There was no difference in the frequency of TE events between patients with and those without detectable CTCs (p = 0.58). In summary, although our study confirms a high risk of TE in GBM patients, it does not point to an obvious association between CTCs and vascular thrombosis.
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Affiliation(s)
- Christina C Rolling
- Department of Oncology, Hematology and BMT with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malte Mohme
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carsten Bokemeyer
- Department of Oncology, Hematology and BMT with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sabine Riethdorf
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katrin Lamszus
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Klaus Pantel
- Department of Tumour Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Felix Klingler
- Department of Oncology, Hematology and BMT with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Langer
- Department of Oncology, Hematology and BMT with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Erhart F, Widhalm G, Kiesel B, Hackl M, Diendorfer A, Preusser M, Rössler K, Thaler J, Pabinger I, Ay C, Riedl J. The plasma miRNome and venous thromboembolism in high-grade glioma: miRNA Sequencing of a nested case-control cohort. J Cell Mol Med 2024; 28:e18149. [PMID: 38613361 PMCID: PMC11015389 DOI: 10.1111/jcmm.18149] [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: 08/27/2023] [Revised: 12/31/2023] [Accepted: 01/05/2024] [Indexed: 04/14/2024] Open
Abstract
Patients with high-grade gliomas are at high risk of venous thromboembolism (VTE). MicroRNAs (miRNAs) are small non-coding RNAs with multiple roles in tumour biology, haemostasis and platelet function. Their association with VTE risk in high-grade glioma has not been comprehensively mapped so far. We thus conducted a nested case-control study within 152 patients with WHO grade IV glioma that had been part of a prospective cohort study on VTE risk factors. At inclusion a single blood draw was taken, and patients were thereafter followed for a maximum of 2 years. During that time, 24 patients (16%) developed VTE. Of the other 128 patients, we randomly selected 24 age- and sex-matched controls. After quality control, the final group size was 21 patients with VTE during follow-up and 23 without VTE. Small RNA next-generation sequencing of plasma was performed. We observed that hsa-miR-451a was globally the most abundant miRNA. Notably, 51% of all miRNAs showed a correlation with platelet count. The analysis of miRNAs differentially regulated in VTE patients-with and without platelet adjustment-identified potential VTE biomarker candidates such as has-miR-221-3p. Therewith, we here provide one of the largest and deepest peripheral blood miRNA datasets of high-grade glioma patients so far, in which we identified first VTE biomarker candidates that can serve as the starting point for future research.
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Affiliation(s)
- Friedrich Erhart
- Department of NeurosurgeryMedical University of ViennaViennaAustria
| | - Georg Widhalm
- Department of NeurosurgeryMedical University of ViennaViennaAustria
| | - Barbara Kiesel
- Department of NeurosurgeryMedical University of ViennaViennaAustria
| | | | | | - Matthias Preusser
- Clinical Division of OncologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Karl Rössler
- Department of NeurosurgeryMedical University of ViennaViennaAustria
| | - Johannes Thaler
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Ingrid Pabinger
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Cihan Ay
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Julia Riedl
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
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Malte AL, Højbjerg JA, Larsen JB. Platelet Parameters as Biomarkers for Thrombosis Risk in Cancer: A Systematic Review and Meta-analysis. Semin Thromb Hemost 2024; 50:360-383. [PMID: 36921613 DOI: 10.1055/s-0043-1764381] [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: 03/17/2023]
Abstract
Cancer-associated thrombosis (CAT) is a major cause of both morbidity and mortality in cancer patients. Platelet count has been investigated as a predictor of CAT in various settings while knowledge on platelet activation parameters is sparse. This report provides a systematic review and meta-analysis on available literature on associations between platelet count and/or function and arterial and venous thrombosis in adult cancer patients. The review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. PubMed and Embase were searched up to March 2022. The National Heart, Lung, and Blood Institute's tools were used for quality assessment. In total, 100 studies were included which investigated the association between CAT and platelet count (n = 90), platelet indices (n = 19), and platelet function/activation markers (n = 13) in patients with solid cancers (n = 61), hematological cancers (n = 17), or mixed cancer types (n = 22). Eighty-one studies had venous thrombosis as their outcome measure, while 4 had arterial thrombosis and 15 studies had both. We found significantly elevated odds ratio of 1.50 (95% confidence interval: 1.19-1.88) for thrombosis with higher platelet counts. We saw a tendency toward an association between markers of platelet activation in forms of mean platelet volume and soluble P selectin and both arterial and venous thrombosis. Only one study investigated dynamic platelet function using flow cytometry. In conclusion, platelet count is associated with CAT across different cancer types and settings. Platelet function or activation marker analysis may be valuable in assisting thrombosis risk assessment in cancer patients but is sparsely investigated so far.
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Affiliation(s)
- Anne Lind Malte
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Johanne Andersen Højbjerg
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Julie Brogaard Larsen
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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10
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Gyldenholm T, Hvas AM, Christensen TD, Larsen JB. Thrombin Generation Markers as Predictors of Cancer-Associated Venous Thromboembolism: A Systematic Review. Semin Thromb Hemost 2024; 50:384-401. [PMID: 37813372 DOI: 10.1055/s-0043-1775856] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Venous thromboembolism (VTE) is a main contributor to morbidity and mortality in cancer patients. Biomarkers with the potential to predict cancer-associated VTE are continually sought. Of these, markers of thrombin generation present a likely option. The present systematic review examines the ability of three widely used biomarkers of thrombin generation: prothrombin fragment 1.2 (F1.2), thrombin-antithrombin complex (TAT), and ex vivo thrombin generation, to predict VTE in both solid and hematologic adult cancer patients. Relevant studies were identified in the PubMed and Embase databases, and the review conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Each study was evaluated using the quality assessment tool from the National Heart, Lung, and Blood Institute. The review protocol was published on PROSPERO with identifier CRD42022362339. In total, 24 papers were included in the review: 11 reporting data on F1.2, 9 on TAT, and 12 on ex vivo thrombin generation. The quality ratings of the included studies varied from good (n = 13), fair (n = 8), to poor (n = 3) with a high heterogenicity. However, F1.2, TAT complex, and ex vivo thrombin generation were all found to be associated with the development of VTE. This association was most pronounced for F1.2. Furthermore, the determination of F1.2 was able to improve the precision of several established risk assessment scores. In conclusion, markers of thrombin generation were found to be elevated in cancer patients with VTE, and particularly, F1.2 was found to be a promising predictor of cancer-associated VTE.
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Affiliation(s)
- Tua Gyldenholm
- Department of Clinical Biochemistry, Thrombosis and Haemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Thomas Decker Christensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Julie Brogaard Larsen
- Department of Clinical Biochemistry, Thrombosis and Haemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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11
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Dasgupta P, Ou A, Lin H, Gregory T, Alfaro-Munoz KD, Yuan Y, Afshar-Khargan V, Kamiya-Matsuoka C, Rousseau JF, Majd NK. The risk and burden of thromboembolic and hemorrhagic events in patients with malignant gliomas receiving bevacizumab. J Neurooncol 2024:10.1007/s11060-023-04551-9. [PMID: 38372903 DOI: 10.1007/s11060-023-04551-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/20/2023] [Indexed: 02/20/2024]
Abstract
PURPOSE Bevacizumab has evolved as an integral treatment option for patients with high-grade gliomas. Little is known about clinical risk factors that predispose patients with high-grade gliomas receiving bevacizumab to VTE or ICH. We sought to characterize the clinical risk factors associated with risk of either event. METHODS In this multi-institutional retrospective study, we first evaluated patients with high-grade gliomas who were treated with bevacizumab at University of Texas MD Anderson Cancer Center from 2015-2021. We compared clinical and treatment-related factors among three cohorts: those who developed VTE, ICH, or neither. We further compared survival outcomes of these patients from the time of bevacizumab initiation. Then to further confirm our results in a non-cancer center hospital setting we evaluated patients from two Ascension Seton Hospitals in Austin, Texas which are affiliated with Dell Medical School at the University of Texas at Austin from 2017-2022. RESULTS We found that the presence of cerebral macrobleeding, defined as a magnetic susceptibility of > 1 cm3 on magnetic resonance imaging, was highly associated with risk of developing ICH after initiation of bevacizumab. Development of ICH was significantly associated with poorer survival outcomes. We did not find a statistically significant effect of VTE on survival after bevacizumab initiation. CONCLUSION In order to stratify the risk for developing ICH before the initiation of bevacizumab, we recommend to assess for the presence of cerebral macrobleeding as it is associated with ICH development.
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Affiliation(s)
- Pushan Dasgupta
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexander Ou
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Heather Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Timothy Gregory
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristin D Alfaro-Munoz
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ying Yuan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vahid Afshar-Khargan
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carlos Kamiya-Matsuoka
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Justin F Rousseau
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, 75390, USA.
| | - Nazanin K Majd
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Jo J, Diaz M, Horbinski C, Mackman N, Bagley S, Broekman M, Rak J, Perry J, Pabinger I, Key NS, Schiff D. Epidemiology, biology, and management of venous thromboembolism in gliomas: An interdisciplinary review. Neuro Oncol 2023; 25:1381-1394. [PMID: 37100086 PMCID: PMC10398809 DOI: 10.1093/neuonc/noad059] [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] [Indexed: 04/28/2023] Open
Abstract
Patients with diffuse glioma are at high risk of developing venous thromboembolism (VTE) over the course of the disease, with up to 30% incidence in patients with glioblastoma (GBM) and a lower but nonnegligible risk in lower-grade gliomas. Recent and ongoing efforts to identify clinical and laboratory biomarkers of patients at increased risk offer promise, but to date, there is no proven role for prophylaxis outside of the perioperative period. Emerging data suggest a higher risk of VTE in patients with isocitrate dehydrogenase (IDH) wild-type glioma and the potential mechanistic role of IDH mutation in the suppression of production of the procoagulants tissue factor and podoplanin. According to published guidelines, therapeutic anticoagulation with low molecular weight heparin (LMWH) or alternatively, direct oral anticoagulants (DOACs) in patients without increased risk of gastrointestinal or genitourinary bleeding is recommended for VTE treatment. Due to the elevated risk of intracranial hemorrhage (ICH) in GBM, anticoagulation treatment remains challenging and at times fraught. There are conflicting data on the risk of ICH with LMWH in patients with glioma; small retrospective studies suggest DOACs may convey lower ICH risk than LMWH. Investigational anticoagulants that prevent thrombosis without impairing hemostasis, such as factor XI inhibitors, may carry a better therapeutic index and are expected to enter clinical trials for cancer-associated thrombosis.
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Affiliation(s)
- Jasmin Jo
- Department of Internal Medicine, Division of Hematology and Oncology, East Carolina University, Greenville, NC, USA
| | - Maria Diaz
- Department of Neurology, Division of Neuro-Oncology, Columbia University, New York, NY, USA
| | - Craig Horbinski
- Department of Pathology, Northwestern University, Chicago, IL, USA
| | - Nigel Mackman
- Department of Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Stephen Bagley
- Department of Medicine, University of Pennsylvania, Philadelphia PA, USA
| | - Marika Broekman
- Department of Neurosurgery, University Medical Center, Utrecht, The Netherlands
| | - Janusz Rak
- Department of Pediatrics, McGill University, Montreal, Canada
| | - James Perry
- Department of Neurology, Sunnybrook Health Sciences Center, Toronto, Canada
| | - Ingrid Pabinger
- Department of Medicine, Medical University of Vienna, Vienna, Austria
| | - Nigel S Key
- Department of Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - David Schiff
- Department of Neurology, Division of Neuro-Oncology, University of Virginia, Charlottesville, VA, USA
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13
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Burdett KB, Unruh D, Drumm M, Steffens A, Lamano J, Judkins J, Schwartz M, Javier R, Amidei C, Lipp ES, Peters KB, Lai A, Eldred BSC, Heimberger AB, McCortney K, Scholtens DM, Horbinski C. Determining venous thromboembolism risk in patients with adult-type diffuse glioma. Blood 2023; 141:1322-1336. [PMID: 36399711 PMCID: PMC10082363 DOI: 10.1182/blood.2022017858] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/29/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022] Open
Abstract
Venous thromboembolism (VTE) is a life-threating condition that is common in patients with adult-type diffuse gliomas, yet thromboprophylaxis is controversial because of possible intracerebral hemorrhage. Effective VTE prediction models exist for other cancers, but not glioma. Our objective was to develop a VTE prediction tool to improve glioma patient care, incorporating clinical, blood-based, histologic, and molecular markers. We analyzed preoperative arterial blood, tumor tissue, and clinical-pathologic data (including next-generation sequencing data) from 258 patients with newly diagnosed World Health Organization (WHO) grade 2 to 4 adult-type diffuse gliomas. Forty-six (17.8%) experienced VTE. Tumor expression of tissue factor (TF) and podoplanin (PDPN) each positively correlated with VTE, although only circulating TF and D-dimers, not circulating PDPN, correlated with VTE risk. Gliomas with mutations in isocitrate dehydrogenase 1 (IDH1) or IDH2 (IDHmut) caused fewer VTEs; multivariable analysis suggested that this is due to IDHmut suppression of TF, not PDPN. In a predictive time-to-event model, the following predicted increased VTE risk in newly diagnosed patients with glioma: (1) history of VTE; (2) hypertension; (3) asthma; (4) white blood cell count; (5) WHO tumor grade; (6) patient age; and (7) body mass index. Conversely, IDHmut, hypothyroidism, and MGMT promoter methylation predicted reduced VTE risk. These 10 variables were used to create a web-based VTE prediction tool that was validated in 2 separate cohorts of patients with adult-type diffuse glioma from other institutions. This study extends our understanding of the VTE landscape in these tumors and provides evidence-based guidance for clinicians to mitigate VTE risk in patients with glioma.
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Affiliation(s)
| | | | - Michael Drumm
- Department of Neurological Surgery, Northwestern University, Chicago, IL
- Lou and Jean Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Alicia Steffens
- Department of Neurological Surgery, Northwestern University, Chicago, IL
- Lou and Jean Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Jonathan Lamano
- Department of Neurosurgery, Stanford University, Stanford, CA
| | - Jonathan Judkins
- Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Margaret Schwartz
- Department of Neurological Surgery, Northwestern University, Chicago, IL
- Lou and Jean Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Rodrigo Javier
- University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Christina Amidei
- Department of Neurological Surgery, Northwestern University, Chicago, IL
- Lou and Jean Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Eric S. Lipp
- The Preston Robert Tisch Brain Tumor Center, Department of Neurosurgery, Duke University Medical Center, Durham, NC
| | - Katherine B. Peters
- The Preston Robert Tisch Brain Tumor Center, Department of Neurosurgery, Duke University Medical Center, Durham, NC
| | - Albert Lai
- Department of Neurology, University of California, Los Angeles, CA
| | | | - Amy B. Heimberger
- Department of Neurological Surgery, Northwestern University, Chicago, IL
- Lou and Jean Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Kathleen McCortney
- Department of Neurological Surgery, Northwestern University, Chicago, IL
- Lou and Jean Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | | | - Craig Horbinski
- Department of Neurological Surgery, Northwestern University, Chicago, IL
- Lou and Jean Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
- Department of Pathology, Northwestern University, Chicago, IL
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14
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Zhang X, Zhang C, Ma Z, Zhang Y. Soluble P-selectin level in patients with cancer-associated venous and artery thromboembolism: a systematic review and meta-analysis. Arch Med Sci 2023; 19:274-282. [PMID: 36817657 PMCID: PMC9897104 DOI: 10.5114/aoms/159039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/05/2013] [Indexed: 01/18/2023] Open
Affiliation(s)
- Xueli Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, China
- Department of Respiratory and Critical Care Medicine, Beijing Shunyi District Hospital, Beijing, China
| | - Chen Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, China
| | - Zhuo Ma
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yuhui Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, China
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15
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Antithrombin Activity and Association with Risk of Thrombosis and Mortality in Patients with Cancer. Int J Mol Sci 2022; 23:ijms232415770. [PMID: 36555414 PMCID: PMC9784494 DOI: 10.3390/ijms232415770] [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: 10/12/2022] [Revised: 11/24/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022] Open
Abstract
Venous and arterial thromboembolism (VTE/ATE) are common complications in cancer patients. Antithrombin deficiency is a risk factor for thrombosis in the general population, but its connection to risk of cancer-associated thrombosis is unclear. We investigated the association of antithrombin activity levels with risk of cancer-associated VTE/ATE and all-cause mortality in an observational cohort study including patients with cancer, the Vienna Cancer and Thrombosis Study. In total, 1127 patients were included (45% female, median age: 62 years). Amongst these subjects, 110 (9.7%) patients were diagnosed with VTE, 32 (2.8%) with ATE, and 563 (49.9%) died. Antithrombin was not associated with a risk of VTE (subdistribution hazard ratio (SHR): 1.00 per 1% increase in antithrombin level; 95% CI: 0.99-1.01) or ATE (SHR: 1.00; 95% CI: 0.98-1.03). However, antithrombin showed a u-shaped association with the risk of all-cause death, i.e., patients with very low but also very high levels had poorer overall survival. In the subgroup of patients with brain tumors, higher antithrombin levels were associated with ATE risk (SHR: 1.02 per 1% increase; 95% CI: 1.00-1.04) and mortality (HR: 1.01 per 1% increase; 95% CI: 1.00-1.02). Both high and low antithrombin activity was associated with the risk of death. However, no association with cancer-associated VTE and ATE across all cancer types was found, with the exception of in brain tumors.
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16
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Sanfilippo KM, Wang TF, Carrier M, Falanga A, Gage BF, Khorana AA, Maraveyas A, Soff GA, Wells PS, Zwicker JI. Standardization of risk prediction model reporting in cancer-associated thrombosis: Communication from the ISTH SSC subcommittee on hemostasis and malignancy. J Thromb Haemost 2022; 20:1920-1927. [PMID: 35635332 DOI: 10.1111/jth.15759] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 11/27/2022]
Abstract
Since the development of the Khorana score to predict risk of cancer-associated venous thromboembolism (VTE), many modified and de novo risk prediction models (RPMs) have been proposed. Comparison of the prognostic performance across models requires comprehensive reporting and standardized methods for model development, validation and evaluation. To improve the standardization of RPM reporting, the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) tool was published in 2015. To better understand the quality of reporting and development of RPMs for cancer-associated VTE, we performed a literature search of published RPMs and assessed each model using the TRIPOD checklist. Our results yielded 29 RPMs for which 30 items were evaluated. There was a non-significant (p = 0.15) improvement in reporting of the 30 items in the post-TRIPOD era (81%) versus the pre-TRIPOD era (75%). Of seven items (title, sample size, missing data handling, baseline demographics, methods and results for model performance, and supplemental resources) with the lowest reporting in the pre-TRIPOD era (<70%), there was an average improvement of 22% in the post-TRIPOD era. Only two of the 22 studies published in the post-TRIPOD era acknowledged compliance with TRIPOD. Informed by the results of this assessment, the Scientific and Standardization Committee (SSC) Subcommittee on Hemostasis & Malignancy of the International Society on Thrombosis and Hemostasis (ISTH) advocates for standardization of four key elements of RPMs for cancer-associated VTE: (1) inclusion of the TRIPOD checklist, (2) clear definition of the derivation population, with justification of sample size, (3) clear definition of predictors, and (4) external validation prior to implementation.
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Affiliation(s)
- Kristen M Sanfilippo
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
- John Cochran Saint Louis Veterans Administration Medical Center, Saint Louis, Missouri, USA
| | - Tzu-Fei Wang
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Anna Falanga
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Brian F Gage
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Alok A Khorana
- Taussig Cancer Institute, Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Anthony Maraveyas
- Faculty of Health Sciences, Joint Centre for Cancer Studies, The Hull York Medical School, Castle Hill Hospital, Hull, UK
| | - Gerald A Soff
- Department of Medicine, University of Miami Health System/Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - Phillip S Wells
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Jeffrey I Zwicker
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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17
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A Novel Thrombosis-Related Signature for Predicting Survival and Drug Compounds in Glioblastoma. JOURNAL OF ONCOLOGY 2022; 2022:6792850. [PMID: 35874629 PMCID: PMC9300384 DOI: 10.1155/2022/6792850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/12/2022] [Indexed: 12/02/2022]
Abstract
Glioblastoma is the most common primary tumor in the central nervous system, and thrombosis-associated genes are related to its occurrence and progression. Univariate Cox and LASSO regression analysis were utilized to develop a new prognostic signature based on thrombosis-associated genes. Gene ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and HALLMARK were used for functional annotation of risk signature. ESTIMATE, MCP-counter, xCell, and TIMER algorithms were used to quantify immune infiltration in the tumor microenvironment. Genomics of Drug Sensitivity in Cancer (GDSC) was used for selecting potential drug compounds. Risk signature based on thrombosis-associated genes shows moderate performance in prognosis prediction. The functional annotation of the risk signature indicates that the signaling pathways related to the cell cycle, apoptosis, tumorigenesis, and immune suppression are rich in the high-risk group. Somatic mutation analysis shows that tumor-suppressive gene TP53 and oncogene PTEN have higher expression in low-risk and high-risk groups, respectively. Potential drug compounds are explored in risk score groups and show higher AUC values in the low-risk score group. A nomogram with valuable prognostic factors exhibits high sensitivity in predicting the survival outcome of GBM patients. Our research screens out multiple thromboses-associated genes with remarkable clinical significance in GBM and further develops a meaningful prognostic risk signature predicting drug sensitivity and survival outcome.
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18
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Weze KO, Obisesan OH, Dardari ZA, Cainzos-Achirica M, Dzaye O, Graham G, Miedema MD, Yeboah J, DeFilippis AP, Nasir K, Blaha MJ, Osei AD. The Interplay of Race/Ethnicity and Obesity on the Incidence of Venous Thromboembolism. Am J Prev Med 2022; 63:e11-e20. [PMID: 35260291 PMCID: PMC9232870 DOI: 10.1016/j.amepre.2021.12.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/20/2021] [Accepted: 12/21/2021] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Factors predisposing asymptomatic individuals within the community to venous thromboembolism are not fully understood. This study characterizes the incidence and determinants of venous thromboembolism among the Multiethnic Study of Atherosclerosis cohort with a focus on race/ethnicity and obesity. METHODS This study (analyzed in 2020-2021) used the Multiethnic Study of Atherosclerosis cohort (2000-2017), which included participants with diverse ethnic/racial backgrounds aged 45-84 years without cardiovascular disease at baseline. The primary endpoint was time to diagnosis of venous thromboembolism defined using International Classification of Diseases codes (415, 451, 453, 126, 180, and 182). Multivariable-adjusted hazard ratios of the predictors of venous thromboembolism were calculated with a focus on the interaction between obesity and race/ethnicity categories. RESULTS Over a median follow-up period of 14 years, 233 individuals developed venous thromboembolism. Incidence rates (per 1,000 person-years) varied across racial/ethnic groups with the highest incidence among Black (4.02) followed by White (2.98), Hispanic (2.08), and Chinese (0.79) participants. There was a stepwise increase in the incidence rate of venous thromboembolism with increasing BMI regardless of race/ethnicity: normal (1.95), overweight (2.52), obese (3.63), and morbidly obese (4.55). The association between BMI and venous thromboembolism was strongest among non-White women with the highest incidence rate for obese (4.8) compared with non-obese (1.6). The interaction among obesity, gender, and race was statistically significant (p=0.01) in non-White obese women. Risk of venous thromboembolism increased with age for all race/ethnicities. CONCLUSIONS This study finds that obesity may confer an increased risk for venous thromboembolism among non-White women compared with other groups-White men, White women, and non-White men.
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Affiliation(s)
- Kelechi O Weze
- Department of Medicine, Howard University Hospital, Washington, District of Columbia; Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University, Baltimore, Maryland
| | - Olufunmilayo H Obisesan
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University, Baltimore, Maryland
| | - Zeina A Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University, Baltimore, Maryland
| | | | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University, Baltimore, Maryland
| | - Garth Graham
- Healthcare and Public Health, Google Inc., Mountain View, California
| | | | - Joseph Yeboah
- Department of Cardiology, Wake Forest University, Winston-Salem, North Carolina
| | | | - Khurram Nasir
- Department of Cardiology, Houston Methodist Hospital, Houston, Texas
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University, Baltimore, Maryland.
| | - Albert D Osei
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University, Baltimore, Maryland; Department of Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland
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19
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Eisele A, Seystahl K, Rushing EJ, Roth P, Le Rhun E, Weller M, Gramatzki D. Venous thromboembolic events in glioblastoma patients: an epidemiological study. Eur J Neurol 2022; 29:2386-2397. [PMID: 35545894 PMCID: PMC9543144 DOI: 10.1111/ene.15404] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 04/04/2022] [Accepted: 05/04/2022] [Indexed: 12/01/2022]
Abstract
Background and purpose Venous thromboembolic events (VTEs) are a major complication in cancer patients, and therefore, also in brain cancer patients, anticoagulants are considered appropriate in the treatment of VTEs. Methods Frequency, risk factors, and treatment of VTEs, as well as associated complications, were assessed in a population‐based cohort of glioblastoma patients in the Canton of Zurich, Switzerland. Correlations between clinical data and survival were retrospectively analyzed using the log‐rank test and Cox regression models. Results Four hundred fourteen glioblastoma patients with isocitrate dehydrogenase wild‐type status were identified. VTEs were documented in 65 patients (15.7%). Median time from tumor diagnosis to the occurrence of a VTE was 1.8 months, and 27 patients were diagnosed with VTEs postoperatively (within 35 days; 42.2%). History of a prior VTE was more common in patients who developed VTEs than in those who did not (p = 0.004). Bevacizumab treatment at any time during the disease course was not associated with occurrence of VTEs (p = 0.593). Most patients with VTEs (n = 61, 93.8%) were treated with therapeutic anticoagulation. Complications occurred in 14 patients (23.0%), mainly intracranial hemorrhages (n = 7, 11.5%). Overall survival did not differ between patients diagnosed with VTEs and those who had no VTE (p = 0.139). Tumor progression was the major cause of death (n = 283, 90.7%), and only three patients (1.0%) died in association with acute VTEs. Conclusions Venous thromboembolic events occurred early in the disease course, suggesting that the implementation of primary venous thromboembolism prophylaxis during first‐line chemoradiotherapy could be explored in a randomized setting.
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Affiliation(s)
- Amanda Eisele
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Katharina Seystahl
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Elisabeth J Rushing
- Department of Neuropathology, University Hospital Zurich, Zurich, Switzerland
| | - Patrick Roth
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Emilie Le Rhun
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Dorothee Gramatzki
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
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20
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Rosell A, Martinod K, Mackman N, Thålin C. Neutrophil extracellular traps and cancer-associated thrombosis. Thromb Res 2022; 213 Suppl 1:S35-S41. [DOI: 10.1016/j.thromres.2021.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 11/24/2022]
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21
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Huang Y, Ding H, Luo M, Li S, Xie C, Zhong Y, Li Z. Combined analysis of clinical and laboratory markers to predict the risk of venous thromboembolism in patients with IDH1 wild-type glioblastoma. Support Care Cancer 2022; 30:6063-6069. [PMID: 35419733 DOI: 10.1007/s00520-022-07050-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 04/06/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE We have combined analysis of clinical and laboratory markers to try to find an optimal model to predict venous thromboembolism in isocitrate dehydrogenase 1 (IDH1) wild-type glioblastoma (GBM) by a prospective research. METHODS Patients with newly histologically confirmed IDH1 wild-type (IDH1wt) GBM were recruited for this study. Status of IDH1, PTEN, P53, BRAF, MGMT promoter methylation (MGMTp), and TERT promoter (TERTp) was determined using genetic sequencing through polymerase chain reaction (PCR). Amplification of EGFR was established through fluorescence in situ hybridization (FISH). Competing risk regression model was performed to calculate the risk of VTE. Clinical and laboratory parameters that were independently predicted risk of VTE were used to develop a risk assessment model (RAM). RESULTS One hundred thirty-one patients with IDH1wt GBM were included in the present analysis. A total of 48/131 patients (36.6%) developed VTE. D-dimer, ECOG score, and EGFR amplification were suggested to be significantly associated with the VTE risk in multivariable analysis. High ECOG score (>2), high D-dimer (>1.6 μg/ml), and EGFR amplification were used as the strongest independent predictors of increased risk of VTE. The cumulative incidence of VTE was 17.2% for patients with score 0 (n =29), 23.6% for patients with score 1 (n =55), and 63.8% for patients with score 2 (n = 35) or score 3 (n = 12) by application of a RAM. CONCLUSIONS In IDH1wt GBM patients, by applying a VTE risk assessment model, we could identify patients with a very high and low risk of VTE.
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Affiliation(s)
- Yong Huang
- Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Shuiguohu street, 168 Donghu road, Wuhan, Hubei, China.,Hubei Cancer Clinical Study Center, Wuhan University, Wuhan, Hubei, China
| | - Haixia Ding
- Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Shuiguohu street, 168 Donghu road, Wuhan, Hubei, China.,Hubei Cancer Clinical Study Center, Wuhan University, Wuhan, Hubei, China
| | - Min Luo
- Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Shuiguohu street, 168 Donghu road, Wuhan, Hubei, China.,Hubei Cancer Clinical Study Center, Wuhan University, Wuhan, Hubei, China
| | - Sirui Li
- Department of Radiology, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, China
| | - Conghua Xie
- Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Shuiguohu street, 168 Donghu road, Wuhan, Hubei, China.,Hubei Cancer Clinical Study Center, Wuhan University, Wuhan, Hubei, China
| | - Yahua Zhong
- Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Shuiguohu street, 168 Donghu road, Wuhan, Hubei, China. .,Hubei Cancer Clinical Study Center, Wuhan University, Wuhan, Hubei, China.
| | - Zhiqiang Li
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, China
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22
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Diaz M, Jo J. Venous Thrombotic Events and Anticoagulation in Brain Tumor Patients. Curr Oncol Rep 2022; 24:493-500. [PMID: 35179708 DOI: 10.1007/s11912-021-01178-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Brain tumor patients have a 20-30% risk of venous thromboembolism (VTE), with management complicated by risk of intracranial hemorrhage (ICH). Here we review the epidemiology, pathogenesis, and recommended management of VTE in brain tumors. RECENT FINDINGS New risk factors and molecular mechanisms of VTE in brain tumor patients have emerged, including the protective effect of IDH mutation in gliomas and the potential role of podoplanin-mediated platelet aggregation in thrombogenesis in these tumors. Recent studies show that the risk of ICH is not significantly higher in brain tumor patients receiving anticoagulation. Based on systemic cancer trials, direct oral anticoagulants (DOACs) may be a suitable alternative to traditional heparin treatment, but the applicability of these findings to brain tumors is unclear. Anticoagulation is indicated in the treatment of VTE for brain tumor patients, and appears to be reasonably safe; based on retrospective evidence, DOACs may be a reasonable agent.
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Affiliation(s)
- Maria Diaz
- Department of Neurology, Neurology Department, Memorial Sloan Kettering Cancer Center, 1275 York Avenue7th floor, New York, NY, C-71610065, USA
| | - Jasmin Jo
- Department of Internal Medicine, Division of Hematology and Oncology, East Carolina University, Brody 3E137, 600 Moye Blvd, NC, 27834, Greenville, USA.
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23
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Abstract
Cancer-associated thrombosis (including venous thromboembolism (VTE) and arterial events) is highly consequential for patients with cancer and is associated with worsened survival. Despite substantial improvements in cancer treatment, the risk of VTE has increased in recent years; VTE rates additionally depend on the type of cancer (with pancreas, stomach and primary brain tumours having the highest risk) as well as on individual patient's and cancer treatment factors. Multiple cancer-specific mechanisms of VTE have been identified and can be classified as mechanisms in which the tumour expresses proteins that alter host systems, such as levels of platelets and leukocytes, and in which the tumour expresses procoagulant proteins released into the circulation that directly activate the coagulation cascade or platelets, such as tissue factor and podoplanin, respectively. As signs and symptoms of VTE may be non-specific, diagnosis requires clinical assessment, evaluation of pre-test probability, and objective diagnostic testing with ultrasonography or CT. Risk assessment tools have been validated to identify patients at risk of VTE. Primary prevention of VTE (thromboprophylaxis) has long been recommended in the inpatient and post-surgical settings, and is now an option in the outpatient setting for individuals with high-risk cancer. Anticoagulant therapy is the cornerstone of therapy, with low molecular weight heparin or newer options such as direct oral anticoagulants. Personalized treatment incorporating risk of bleeding and patient preferences is essential, especially as a diagnosis of VTE is often considered by patients even more distressing than their cancer diagnosis, and can severely affect the quality of life. Future research should focus on current knowledge gaps including optimizing risk assessment tools, biomarker discovery, next-generation anticoagulant development and implementation science.
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Risk assessment models of cancer-associated thrombosis - Potentials and perspectives. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Yerrabothala S, Gourley BL, Ford JC, Ahmed SR, Guerin SJ, Porter M, Wishart HA, Ernstoff MS, Fadul CE, Ornstein DL. Systemic coagulation is activated in patients with meningioma and glioblastoma. J Neurooncol 2021; 155:173-180. [PMID: 34652553 DOI: 10.1007/s11060-021-03865-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/04/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Up to 30% of patients with glioblastoma (GBM) develop venous thromboembolism (VTE) over the course of the disease. Although not as high, the risk for VTE is also increased in patients with meningioma. Direct measurement of peak thrombin generation (TG) allows quantitative assessment of systemic coagulation activation in patients with GBM and meningioma. Our aim was to determine the extent of systemic coagulation activation induced by brain tumors, to measure the shift between pre- and post-operative peak TG in patients with GBM, and to assess the relationship between pre-surgical peak TG and pre-operative brain tumor volume on imaging. METHODS Pre- and post-surgical plasma samples were obtained from successive patients with GBM and once from patients with meningioma and healthy age- and sex-matched blood donor controls. TG was measured using the calibrated automated thrombogram (CAT) assay, and tumor volumes were measured in pre-surgical MRI scans. RESULTS Pre-surgical peak TG was higher in patients with GBM than in controls (288.6 ± 54.1 nM vs 187.1 ± 41.7 nM, respectively, P < 0.001), and, in the nine patients with GBM and paired data available, peak TG was significantly reduced after surgery (323 ± 38 nM vs 265 ± 52 nM, respectively, P = 0.007). Similarly, subjects with meningioma demonstrated higher peak TG compared to controls (242.2 ± 54.9 nM vs 177.7 ± 57.0 nM, respectively, P < 0.001). There was no association between peak TG and pre-operative tumor volume or overall survival. CONCLUSION Our results indicate that systemic coagulation activation occurs with both meningioma and GBM, but to a greater degree in the latter. Preoperative peak TG did not correlate with tumor volume, but removal of GBM caused a significant decrease in coagulation activation.
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Affiliation(s)
- Swaroopa Yerrabothala
- Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | | | - James C Ford
- Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Syed Rakin Ahmed
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,Harvard Graduate Program in Biophysics, Harvard Medical School, Harvard University, Cambridge, MA, USA.,Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Stephen J Guerin
- Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Marc Porter
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,University of Rochester Medical Center, Rochester, NY, USA
| | - Heather A Wishart
- Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Marc S Ernstoff
- Cancer Treatment and Diagnosis, Developmental Therapy Program, National Cancer Institute, Bethesda, MD, USA
| | - Camilo E Fadul
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Deborah L Ornstein
- Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. .,Geisel School of Medicine at Dartmouth, Hanover, NH, USA. .,Department of Pathology & Laboratory Medicine, Dartmouth Hitchcock Medical Center and Norris Cotton Cancer Center, 1 Medical Center Dr., Lebanon, NH, 03756, USA.
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Winther-Larsen A, Sandfeld-Paulsen B, Hvas AM. New Insights in Coagulation and Fibrinolysis in Patients with Primary Brain Cancer: A Systematic Review. Semin Thromb Hemost 2021; 48:323-337. [PMID: 34624915 DOI: 10.1055/s-0041-1733961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Patients with primary brain tumors have a high incidence of thrombosis and hemorrhage. The underlying mechanism is believed to be derangement of their hemostatic system. To get nearer a clarification of this, we aimed to systematically review the existing literature regarding primary and secondary hemostasis as well as fibrinolysis in patients with primary brain tumor. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The databases PubMed, Embase, and Web of Science were searched on December 15, 2020, without time restrictions. Studies were included if they evaluated at least one blood coagulation and/or fibrinolysis parameter in patients with primary brain cancer. In total, 26 articles including 3,288 patients were included. Overall, increased activity of secondary hemostasis was observed as increased prothrombin fragment 1 + 2 and endogenous thrombin generation levels were found in glioma patients compared with controls. Furthermore, data showed a state of hypofibrinolysis with increased plasminogen activator inhibitor 1 and prolonged clot lysis time in glioma patients. In contrast, no consistent increase in the primary hemostasis was identified; however, data suggested that increased sP-selectin could be a biomarker of increased venous thromboembolism risk and that increased platelet count may be prognostic for survival. Lastly, data indicated that fibrinogen and D-dimer could hold prognostic value. In conclusion, this review indicates that an increased activity of secondary hemostasis and impaired fibrinolysis could be important players in the pathogeneses behind the high risk of thromboembolisms observed in brain cancer patients. Thus, long-term thromboprophylaxis may be beneficial and additional studies addressing this issue are wanted.
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Affiliation(s)
- Anne Winther-Larsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | | | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Mir Seyed Nazari P, Berghoff AS, Preusser M, Moik F, Posch F, Ricken G, Riedl J, Hell L, Marosi C, Hainfellner JA, Pabinger I, Ay C. Association of programmed cell death ligand 1 and circulating lymphocytes with risk of venous thromboembolism in patients with glioma. ESMO Open 2021; 5:e000647. [PMID: 32424065 PMCID: PMC7239522 DOI: 10.1136/esmoopen-2019-000647] [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: 11/26/2019] [Revised: 02/12/2020] [Accepted: 03/09/2020] [Indexed: 12/22/2022] Open
Abstract
Introduction The role of the adaptive immune system in the pathophysiology of cancer-associated venous thromboembolism (VTE) has not been investigated in detail. Programmed cell death ligand 1 (PD-L1) is an immune checkpoint molecule responsible for immune evasion in several cancer entities, as expression on tumour cells silences the T cell-mediated immune response. Given the interrelation between inflammation, haemostasis and cancer, we aimed to investigate the association of players of the adaptive immunity (eg, lymphocytes, tumour PD-L1) with risk of VTE in patients with glioma, one of the most prothrombotic cancer types. Methods In this prospective observational single-centre cohort study, patients with newly diagnosed glioma or regrowth after resection were included. Primary endpoint was objectively confirmed VTE. At study inclusion, a blood draw was performed. Tumour PD-L1 expression was assessed via immunohistochemistry. Results In total, 193 patients were included. PD-L1 expression in ≥1% of tumour cells was observed in 20/193 (10.4%) glioma. In multivariable cox-regression analysis, on adjustment for age, sex and WHO grade IV, systemic lymphocyte counts were significantly associated with risk of VTE (HR per 1 G/L increase (95% CI): 1.15 (1.03 to 1.29), p=0.013). In contrast, no significant difference in risk of VTE was found regarding the PD-L1 status: the cumulative 24 months probability of VTE was 17.0% in patients with no PD-L1 and 11.8% in those with PD-L1 expressing tumours (p=0.663). Conclusion In summary, PD-L1 expression was not associated with risk of VTE. Interestingly, peripheral lymphocytes, which are key players in adaptive immunity, were linked to an increased risk of glioma-associated VTE.
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Affiliation(s)
- Pegah Mir Seyed Nazari
- Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Anna S Berghoff
- Division of Oncology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Matthias Preusser
- Division of Oncology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Florian Moik
- Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Florian Posch
- Division of Oncology, Medical University of Graz, Graz, Austria
| | - Gerda Ricken
- Institute of Neurology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Julia Riedl
- Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Lena Hell
- Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Christine Marosi
- Division of Oncology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Johannes A Hainfellner
- Institute of Neurology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria; I M Sechenov First Moscow State Medical University, Moscow, Russian Federation.
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Koudriavtseva T, Villani V, Lorenzano S, Giannarelli D, Di Domenico EG, Stefanile A, Maschio M, D'Agosto G, Pimpinelli F, Tanzilli A, Galiè E, Pace A. Neutrophil-to-lymphocyte ratio, Factor VIII and Antithrombin III: inflammatory-clotting biomarkers in glioma. EXCLI JOURNAL 2021; 20:1152-1169. [PMID: 34345234 PMCID: PMC8326499 DOI: 10.17179/excli2021-3831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/02/2021] [Indexed: 11/10/2022]
Abstract
One of the key difficulties in glioma treatment is our limited ability to consistently assess cancer response or progression either by neuroimaging or specific blood biomarkers. An ideal biomarker could be measured through non-invasive methods such as blood-based biomarkers, aiding both early diagnosis and monitoring disease evolution. This is a single-center, case-control, 10-year retrospective, longitudinal study. We evaluated routine coagulation factors in 138 glioma patients (45 Females/93 Males; median [range] age, 56.4 [27-82] years; 64 non-recurrent/74 recurrent) and, for comparison, in 56 relapsing-remitting MS patients (41 Females/15 Males; 40.8 [25-62] years, 35 stable/21 active) and 23 controls (16 Females/7 Males; 41.7 [24-62] years) as well as Neutrophil-to-lymphocyte ratio (NLR) in subgroups of 127 glioma patients, 33 MS patients and 23 healthy controls. Secondly, we assessed whether these indicators could be predictive of overall (OS) and progression-free survival (PFS) in glioma patients. NLR, d-dimer, Antithrombin III and Factor VIII were significantly higher in glioma patients compared to both MS patients and controls (p<0.0001 for all). ROC curves confirmed that either NLR, Antithrombin III or Factor VIII were moderately accurate biomarkers (0.7<AUC<0.9) for glioma patients compared to other two groups whereas d-dimer was a moderately accurate marker for glioma only when compared to controls. In multivariable analysis, NLR ≥ 4.3 (median) (HR 1.53 [95 % CI 1.04-2.26], p=0.03) together with the Karnofsky Performance Status (KPS) ≥ 80 (median) (0.46 [0.31-0.69], p<0.0001) and use of steroids (1.75 [1.19-2.57], p=0.004) resulted independent predictors of OS while only KPS was independently associated with PFS. Our study showed increased levels of either NLR, Antithrombin III, Factor VIII, or d-dimer in glioma patients compared to MS patients and controls, where the first three represented moderately accurate biomarkers for this cancer. Among these markers, only NLR was found to be predictive for OS along with severe disability and steroid therapy.
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Affiliation(s)
- Tatiana Koudriavtseva
- Department of Clinical Experimental Oncology, IRCCS Regina Elena National Cancer Institute, IFO, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Veronica Villani
- Department of Clinical Experimental Oncology, IRCCS Regina Elena National Cancer Institute, IFO, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Svetlana Lorenzano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Diana Giannarelli
- Biostatistics, IRCCS Regina Elena National Cancer Institute, IFO, Rome, Italy
| | - Enea Gino Di Domenico
- Clinical Pathology and Microbiology Unit, IRCCS San Gallicano Institute, IFO, Rome, Italy
| | - Annunziata Stefanile
- Department of Clinical Experimental Oncology, IRCCS Regina Elena National Cancer Institute, IFO, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Marta Maschio
- Department of Clinical Experimental Oncology, IRCCS Regina Elena National Cancer Institute, IFO, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Giovanna D'Agosto
- Clinical Pathology and Microbiology Unit, IRCCS San Gallicano Institute, IFO, Rome, Italy
| | - Fulvia Pimpinelli
- Clinical Pathology and Microbiology Unit, IRCCS San Gallicano Institute, IFO, Rome, Italy
| | - Antonio Tanzilli
- Department of Clinical Experimental Oncology, IRCCS Regina Elena National Cancer Institute, IFO, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Edvina Galiè
- Department of Clinical Experimental Oncology, IRCCS Regina Elena National Cancer Institute, IFO, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Andrea Pace
- Department of Clinical Experimental Oncology, IRCCS Regina Elena National Cancer Institute, IFO, Via Elio Chianesi 53, 00144, Rome, Italy
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Selby R, Duffy ER, Berny-Lang MA, Andry CD, Lee AYY. Impact of specific preclinical variables on coagulation biomarkers in cancer-associated thrombosis. Thromb Res 2021; 191 Suppl 1:S26-S30. [PMID: 32736774 DOI: 10.1016/s0049-3848(20)30393-5] [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: 10/03/2019] [Revised: 11/18/2019] [Accepted: 11/24/2019] [Indexed: 10/23/2022]
Abstract
Coagulation biomarkers are being actively studied for their diagnostic and prognostic value in patients with venous thromboembolism and cancer, as well as in the study of pathogenic mechanisms between cancer and thrombosis. For the results of such studies to be accurate and reproducible, attention must be paid to minimize sources of error in all phases of testing. The pre-analytical phase of laboratory testing is known to be fraught with the majority of errors. Coagulation testing is particularly susceptible to conditions during collection, processing, transport and storage of specimens which can lead to clinically significant errors in results. In addition, changes in pre-analytical conditions can impact different biomarkers differently. Therefore, research studies investigating coagulation biomarkers must carefully standardize not just the analytical phase, but also the pre-analytical phase of testing to ensure accuracy and reliability. We briefly review the impact of pre-analytical conditions on coagulation testing in general, and on specific biomarkers in cancer and thrombosis. In addition, we provide recommendations to reduce pre-analytical errors by developing and sharing standard operating procedures that specifically target standardization of methodologies for collecting specimens and measuring current and emerging coagulation biomarkers in cancer studies.
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Affiliation(s)
- Rita Selby
- Departments of Laboratory Medicine and Pathobiology & Medicine, University of Toronto, Toronto, ON, Canada
| | - Elizabeth R Duffy
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Michelle A Berny-Lang
- Center for Strategic Scientific Initiatives, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Christopher D Andry
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Agnes Y Y Lee
- University of British Columbia, British Columbia Cancer Agency, Vancouver, BC, Canada.
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Muster V, Gary T. Contrasts in Glioblastoma-Venous Thromboembolism versus Bleeding Risk. Cells 2021; 10:cells10061414. [PMID: 34200229 PMCID: PMC8228034 DOI: 10.3390/cells10061414] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 12/13/2022] Open
Abstract
Glioblastoma is among the tumor entities with an extreme thrombogenic potential and patients are at very high risk of developing a venous thromboembolism (VTE) over the course of the disease, with an incidence of up to 30% per year. Major efforts are currently being made to understand and gain novel insights into the underlying pathomechanisms of the development of VTE in patients with glioblastoma and to find appropriate biomarkers. Yet, patients with glioblastoma not only face a high thromboembolic risk but are also at risk of bleeding events. In the case of VTE, a therapeutic anticoagulation with low molecular weight heparin or, in the case of low bleeding risk, treatment with a direct oral anticoagulant, is recommended, according to recently published guidelines. With respect to an elevated bleeding risk in glioblastoma patients, therapeutic anticoagulation remains challenging in this patient group and prospective data for this vulnerable patient group are scarce, particularly with regard to direct oral anticoagulants.
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31
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Zoccarato M, Nardetto L, Basile AM, Giometto B, Zagonel V, Lombardi G. Seizures, Edema, Thrombosis, and Hemorrhages: An Update Review on the Medical Management of Gliomas. Front Oncol 2021; 11:617966. [PMID: 33828976 PMCID: PMC8019972 DOI: 10.3389/fonc.2021.617966] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/04/2021] [Indexed: 12/21/2022] Open
Abstract
Patients affected with gliomas develop a complex set of clinical manifestations that deeply impact on quality of life and overall survival. Brain tumor-related epilepsy is frequently the first manifestation of gliomas or may occur during the course of disease; the underlying mechanisms have not been fully explained and depend on both patient and tumor factors. Novel treatment options derive from the growing use of third-generation antiepileptic drugs. Vasogenic edema and elevated intracranial pressure cause a considerable burden of symptoms, especially in high-grade glioma, requiring an adequate use of corticosteroids. Patients with gliomas present with an elevated risk of tumor-associated venous thromboembolism whose prophylaxis and treatment are challenging, considering also the availability of new oral anticoagulant drugs. Moreover, intracerebral hemorrhages can complicate the course of the illness both due to tumor-specific characteristics, patient comorbidities, and side effects of antithrombotic and antitumoral therapies. This paper aims to review recent advances in these clinical issues, discussing the medical management of gliomas through an updated literature review.
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Affiliation(s)
- Marco Zoccarato
- Neurology Unit, O.S.A., Azienda Ospedale-Università, Padua, Italy
| | - Lucia Nardetto
- Neurology Unit, O.S.A., Azienda Ospedale-Università, Padua, Italy
| | | | - Bruno Giometto
- Neurology Unit, Trento Hospital, Azienda Provinciale per i Servizi Sanitari (APSS) di Trento, Trento, Italy
| | - Vittorina Zagonel
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCSS, Padua, Italy
| | - Giuseppe Lombardi
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCSS, Padua, Italy
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Burth S, Ohmann M, Kronsteiner D, Kieser M, Löw S, Riedemann L, Laible M, Berberich A, Drüschler K, Rizos T, Wick A, Winkler F, Wick W, Nagel S. Prophylactic anticoagulation in patients with glioblastoma or brain metastases and atrial fibrillation: an increased risk for intracranial hemorrhage? J Neurooncol 2021; 152:483-490. [PMID: 33674992 PMCID: PMC8084835 DOI: 10.1007/s11060-021-03716-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/12/2021] [Indexed: 11/27/2022]
Abstract
Purpose Patients with glioblastoma (GBM) or brain metastases (MET) and atrial fibrillation (AF) might be at an increased risk of intracranial hemorrhage (ICH) due to anticoagulation (AC). Our aim was to assess this risk. Methods Our institution’s database (from 2005 to 2017) was screened for patients with GBM or MET and AF with an indication for AC according to their CHA2DS2VASc stroke risk score (≥ 2). Required follow-up was at least 3 months. AC was either performed with heparins, phenprocoumon or non-Vitamin K antagonist oral anticoagulants. Applying the propensity score approach, patient cohorts (matched according to primary tumor, age, sex) were generated (GBM [or MET] with AF ± AC, GBM [or MET] without AF/AC, no GBM [or MET] but AF on AC). ICH was defined as clinical deterioration caused by new blood on imaging. A log rank test was performed to compare the risk for ICH between the three groups. Results In total, 104 patients were identified of which 49 with GBM (37% on AC) and 37 with MET (46% on AC) were successfully matched. Median follow up was 8.6 and 7.2 months, respectively. ICH occurred in 10.2% of GBM + AF and 12.2% GBM-AF, whereas 8% of patients with AF on AC suffered ICH (p = 0.076). 13.5% of patients with MET + AF had ICHs, in the controls it was 16% for MET-AF and 8% for AF on AC (p = 0.11). Conclusion AC did not seem to influence the incidence of ICH in patients with glioblastoma or brain metastases within follow up of just under 9 months. Supplementary Information The online version contains supplementary material available at 10.1007/s11060-021-03716-8.
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Affiliation(s)
- Sina Burth
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Mona Ohmann
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Dorothea Kronsteiner
- Institute of Medical Biometry and Informatics, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry and Informatics, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Sarah Löw
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Lars Riedemann
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Mona Laible
- Department of Neurology, Ulm University Hospital, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Anne Berberich
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Katharina Drüschler
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Antje Wick
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Frank Winkler
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Wolfgang Wick
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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33
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Roth P, Pace A, Le Rhun E, Weller M, Ay C, Cohen-Jonathan Moyal E, Coomans M, Giusti R, Jordan K, Nishikawa R, Winkler F, Hong JT, Ruda R, Villà S, Taphoorn MJB, Wick W, Preusser M. Neurological and vascular complications of primary and secondary brain tumours: EANO-ESMO Clinical Practice Guidelines for prophylaxis, diagnosis, treatment and follow-up. Ann Oncol 2021; 32:171-182. [PMID: 33246022 DOI: 10.1016/j.annonc.2020.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 02/08/2023] Open
Affiliation(s)
- P Roth
- Department of Neurology and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - A Pace
- Neuroncology Unit, IRCCS Regina Elena Cancer Institute, Rome, Italy
| | - E Le Rhun
- Department of Neurology and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland; Université Lille, U-1192, Lille, France; Inserm, U-1192, Lille, France; Centre Hospitalier Universitaire CHU, Lille, General and Stereotaxic Neurosurgery Service, Lille, France; Oscar Lambret Center, Breast Cancer Department, Lille, France
| | - M Weller
- Department of Neurology and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - C Ay
- Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Vienna, Austria
| | - E Cohen-Jonathan Moyal
- Radiation Oncology Department, Institut Claudius Regaud, Université Paul Sabatier, Toulouse, France; Institut Universitaire du Cancer de Toulouse IUCT Oncopole, Toulouse, France
| | - M Coomans
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - R Giusti
- Medical Oncology Unit, Azienda Ospedaliero Universitaria Sant'Andrea, Rome, Italy
| | - K Jordan
- Department of Medicine V, Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - R Nishikawa
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - F Winkler
- Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany; Clinical Cooperation Unit Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK), Heidelberg, Germany
| | - J T Hong
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, Seoul, The Catholic University of Korea, Republic of Korea
| | - R Ruda
- Department of Neuro-Oncology, City of Health and Science and University of Turin, Turin, Italy
| | - S Villà
- Catalan Institute of Oncology, HU Germans Trias, Badalona, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M J B Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - W Wick
- Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - M Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Abstract
There is increasing awareness that platelets play a significant role in creating a hypercoagulable environment that mediates tumor progression, beyond their classical hemostatic function. Platelets have heterogenic responses to agonists, and differential release and uptake of bioactive molecules may be manipulated via reciprocal cross-talk with cells of the tumor microenvironment. Platelets thus promote tumor progression by enhancing tumor growth, promoting the development of tumor-associated vasculature and encouraging invasion. In the metastatic process, platelets form the shield that protects tumor cells from high-velocity forces and immunosurveillance, while ensuring the establishment of the pre-metastatic niche. This review presents the complexity of these concepts, considering platelets as biomarkers for diagnosis, prognosis and potentially as therapeutic targets in cancer.
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Affiliation(s)
- Tanya N Augustine
- School of Anatomical Sciences, Faculty of the Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
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Lee A, Arasaratnam M, Chan DLH, Khasraw M, Howell VM, Wheeler H. Anti-epidermal growth factor receptor therapy for glioblastoma in adults. Cochrane Database Syst Rev 2020; 5:CD013238. [PMID: 32395825 PMCID: PMC7389448 DOI: 10.1002/14651858.cd013238.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Glioblastoma is an uncommon but highly aggressive type of brain tumour. Significant gains have been achieved in the molecular understanding and the pathogenesis of glioblastomas, however clinical improvements are difficult to obtain for many reasons. The current standard of care involves maximal safe surgical resection followed by chemoradiation and then adjuvant chemotherapy European Organisation for Research and Treatment of Cancer and the NCIC Clinical Trials Group (EORTC-NCIC) protocol with a median survival of 14.6 months. Successive phase III international randomised controlled studies have failed to significantly demonstrate survival advantage with newer drugs. Epidermal growth factor receptor (EGFR) is observed to be aberrant in 30% to 60% of glioblastomas. The receptor aberrancy is driven by abnormal gene amplification, receptor mutation, or both, in particular the extracellular vIII domain. EGFR abnormalities are common in solid tumours, and the advent of anti-EGFR therapies in non-small cell lung cancer and colorectal adenocarcinomas have greatly improved clinical outcomes. Anti-EGFR therapies have been investigated amongst glioblastomas, however questions remain about its ongoing role in glioblastoma management. This review aimed to report on the available evidence to date and perform a systematic analysis on the risks and benefits of use of anti-EGFR therapies in glioblastomas. OBJECTIVES To evaluate the efficacy and harms of anti-EGFR therapies for glioblastoma in adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, EBM Reviews databases, with supplementary handsearches to identify all available and relevant studies to 20 April 2020. SELECTION CRITERIA All randomised controlled trials (RCTs) using anti-EGFR therapies in adults with glioblastoma were eligible for inclusion. Anti-EGFR therapies included tyrosine kinase inhibitors, monoclonal antibodies, or vaccines. The comparison included investigational product added to standard of care versus standard of care or placebo, or investigational product against standard of care or placebo. DATA COLLECTION AND ANALYSIS The authorship team screened the search results and recorded the extracted data for analysis. We used standard Cochrane methodology to performed quantitative meta-analysis if two or more studies had appropriate and available data. Otherwise, we conducted a qualitative and descriptive analysis. We used the GRADE system to rate the certainty of the evidence. The analysis was performed along the two clinical settings: first-line (after surgery) and recurrent disease (after failure of first line treatment). Where information was available, we documented overall survival, progression-free survival, adverse events, and quality of life data from eligible studies. MAIN RESULTS The combined searches initially identified 912 records (after removal of duplicates), and further screening resulted in 19 records for full consideration. We identified nine eligible studies for inclusion in the review. There were three first-line studies and six recurrent studies. Five studies used tyrosine kinase inhibitors (TKIs); two studies used monoclonal antibodies; and two studies used targeted vaccines. More recent studies presented greater detail in the conduct of their studies and thus had a lower risk of bias. We observed no evidence benefit in overall survival with the use of anti-EGFR therapy in the first-line or recurrent setting (hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.76 to 1.04; 3 RCTs, 1000 participants, moderate-certainty evidence; and HR 0.79, 95% CI 0.51 to 1.21, 4 RCTs, 489 participants, low-certainty evidence, respectively). All the interventions were generally well tolerated with low-certainty evidence for lymphopenia (odds ratio (OR) 0.97, 95% CI 0.19 to 4.81; 4 RCTs, 1146 participants), neutropenia (OR 1.29, 95% CI 0.82 to 2.03; 4 RCTs, 1146 participants), and thrombocytopenia (OR 3.69, 95% CI 0.51 to 26.51; 4 RCTs, 1146 participants). A notable toxicity relates to ABT-414, where significant ocular issues were detected. The addition of anti-EGFR therapy showed no evidence of an increase in progression-free survival (PFS) in the first-line setting (HR 0.94, 95% CI 0.81 to 1.10; 2 RCTs, 894 participants, low-certainty evidence). In the recurrent setting, there was an increase in PFS with the use of anti-EGFR therapy (HR 0.75, 95% CI 0.58 to 0.96, 3 RCTs, 275 participants, low-certainty evidence). The available quality of life assessment data showed that anti-EGFR therapies were neither detrimental or beneficial when compared to standard care (not estimable). AUTHORS' CONCLUSIONS In summary, there is no evidence of a demonstrable overall survival benefit with the addition of anti-EGFR therapy in first-line and recurrent glioblastomas. Newer drugs that are specially designed for glioblastoma targets may raise the possibility of success in this population, but data are lacking at present. Future studies should be more selective in pursuing people displaying specific EGFR targets.
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Affiliation(s)
- Adrian Lee
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, Australia
| | | | - David Lok Hang Chan
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, Australia
| | - Mustafa Khasraw
- NHMRC Clinical Trials Centre, The University of Sydney, Camperdown, Australia
| | - Viive M Howell
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, Australia
| | - Helen Wheeler
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, Australia
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Abstract
OBJECTIVES Critically ill patients with deranged conventional coagulation tests are often perceived to have an increased bleeding risk. Whether anticoagulant prophylaxis for these patients should be withheld is contentious. This study assessed the ability of using in vitro clot strength, as measured by thromboelastography, to predict thromboembolism in patients with abnormal coagulation profiles. DESIGN Prospective cohort study. SETTING A tertiary ICU. PATIENTS Two-hundred and fifteen critically ill coagulopathic patients with thrombocytopenia and/or a derangement in at least one conventional coagulation test (international normalized ratio or activated partial thromboplastin time) within 48 hours of ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thromboelastography was performed for all study patients, and plasma thrombotic biomarkers were measured in a nested cohort (n = 40). Of the 215 patients included, 34 patients (16%) developed subsequent thromboembolism-predominantly among those with a normal (maximum amplitude, 54-72 mm) or increased (maximum amplitude, > 72 mm) in vitro clot strength on thromboelastography (91%; area under the receiver-operating characteristic curve, 0.74; 95% CI, 0.64-0.83). The ability of the maximum amplitude to predict thromboembolism was comparable to plasma P-selectin concentrations (thromboembolism, 78.3 ng/mL vs no thromboembolism, 59.5 ng/mL; p = 0.031; area under the receiver-operating characteristic curve, 0.73; 95% CI, 0.52-0.95). In addition, patients with an increased maximum amplitude were also less likely to receive blood product transfusions within 24 hours of testing compared with those with a subnormal maximum amplitude (12.8% vs 69.2%, respectively; area under the receiver-operating characteristic curve, 0.74; 95% CI, 0.67-0.80). CONCLUSIONS In patients with abnormal coagulation profiles, an increased in vitro clot strength on thromboelastography was associated with an increased risk of thromboembolism, and a reduced risk of requiring transfusion compared with those with a normal or reduced in vitro clot strength.
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Mir Seyed Nazari P, Marosi C, Moik F, Riedl J, Özer Ö, Berghoff AS, Preusser M, Hainfellner JA, Pabinger I, Zlabinger GJ, Ay C. Low Systemic Levels of Chemokine C-C Motif Ligand 3 (CCL3) are Associated with a High Risk of Venous Thromboembolism in Patients with Glioma. Cancers (Basel) 2019; 11:cancers11122020. [PMID: 31847343 PMCID: PMC6966639 DOI: 10.3390/cancers11122020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/05/2019] [Accepted: 12/10/2019] [Indexed: 12/16/2022] Open
Abstract
A tight interplay between inflammation and hemostasis has been described as a potential driver for developing venous thromboembolism (VTE). Here, we investigated the association of systemic cytokine levels and risk of VTE in patients with glioma. This analysis was conducted within the prospective, observational Vienna Cancer and Thrombosis Study. Patients with glioma were included at time of diagnosis or progression and were observed for a maximum of two years. Primary endpoint was objectively confirmed VTE. At study entry, a single blood draw was performed. A panel of nine cytokines was measured in serum samples with the xMAP technology developed by Luminex. Results: Overall, 76 glioma patients were included in this analysis, and 10 (13.2%) of them developed VTE during the follow-up. Chemokine C-C motif ligand 3 (CCL3) levels were inversely associated with risk of VTE (hazard ratio [HR] per double increase, 95% confidence interval [CI]: 0.385, 95% CI: 0.161–0.925, p = 0.033), while there was no association between the risk of VTE and serum levels of interleukin (IL)-1β, IL-4, IL-6, IL-8, IL-10, IL-11, tumor necrosis factor (TNF)-α and vascular endothelial growth factor (VEGF), respectively. In conclusion, low serum levels of CCL3 were associated with an increased risk of VTE. CCL3 might serve as a potential biomarker to predict VTE risk in patients with glioma.
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Affiliation(s)
- Pegah Mir Seyed Nazari
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (P.M.S.N.); (F.M.); (J.R.); (Ö.Ö.); (I.P.)
| | - Christine Marosi
- Division of Oncology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (C.M.); (A.S.B.); (M.P.)
| | - Florian Moik
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (P.M.S.N.); (F.M.); (J.R.); (Ö.Ö.); (I.P.)
| | - Julia Riedl
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (P.M.S.N.); (F.M.); (J.R.); (Ö.Ö.); (I.P.)
| | - Öykü Özer
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (P.M.S.N.); (F.M.); (J.R.); (Ö.Ö.); (I.P.)
| | - Anna Sophie Berghoff
- Division of Oncology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (C.M.); (A.S.B.); (M.P.)
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (C.M.); (A.S.B.); (M.P.)
| | - Johannes A. Hainfellner
- Institute of Neurology and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria;
| | - Ingrid Pabinger
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (P.M.S.N.); (F.M.); (J.R.); (Ö.Ö.); (I.P.)
| | - Gerhard J. Zlabinger
- Institute of Immunology, Center of Pathophysiology, Infectiology and Immunology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Cihan Ay
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (P.M.S.N.); (F.M.); (J.R.); (Ö.Ö.); (I.P.)
- I.M. Sechenov First Moscow State Medical University (Sechenov University), 119146 Moscow, Russia
- Correspondence:
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Aly A, Smith F, Glancz LJ, Mccabe A, Coventry J, Dawson K, Boam S, Smith S. Idh-1 Status and Venous Thromboembolism in Glioma Patients. J Surg Oncol 2019. [DOI: 10.31487/j.jso.2019.04.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Venous thromboembolic events (VTE) are common causes of morbidity and mortality in glioblastoma patients. Mutation in the isocitrate dehydrogenase 1 enzyme (IDH1) is frequent in secondary glioblastoma and results in altered metabolomics.
Objectives: This study evaluates whether IDH-1 status correlates with incidence of VTE in glioblastoma patients.
Methods: Observational study of 398 cases of patients with glioblastoma, who all underwent surgery in a regional Neurosurgical centre between April 2012 and December 2014. IDH -1 status and Tissue factor (F3) protein expression were assessed by immunohistochemistry. Deep venous thrombosis (DVT) and pulmonary embolism (PE) were diagnosed by Doppler ultrasound and pulmonary CT angiogram respectively.
Results: 336 cases were wild type (WT) IDH-1 (94.1%) and 21 cases were IDH-1 mutated (R132H) (5.9%). 51 patients had a thromboembolic event (15.3%), with all cases of VTE in WT IDH-1 tumours, a rate of 21.8% within this group. IDH-1 status had a significant correlation with VTE (p=0.033 Fisher exact test). As expected, mutant IDH was associated with prolonged patient survival (p=0.024 Log rank). The mean expression in IDH-1 wild type GBM was 7.14 and in R132h mutant GBM was 4.87 (log2 scale). This was highly statistically significant with a corrected P value of less than 0.0001.
Conclusion: A significant association exists between IDH1 status in glioblastoma patients and the risk of VTE. Patients with wild type IDH-1 appear at high risk of VTE and appropriate precautions should be considered
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Riedl J, Ay C. Venous Thromboembolism in Brain Tumors: Risk Factors, Molecular Mechanisms, and Clinical Challenges. Semin Thromb Hemost 2019; 45:334-341. [PMID: 31041803 DOI: 10.1055/s-0039-1688493] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Venous thromboembolism (VTE) is a common complication in patients with primary brain tumors, with up to 20% of patients per year having a VTE event. Clinical risk factors for VTE include glioblastoma subtype, paresis, or surgery. Furthermore, specific factors playing a role in tumor biology were recently identified to predispose to prothrombotic risk. For instance, mutations in the isocitrate dehydrogenase 1 (IDH1) gene, which occurs in a subgroup of glioma, correlate with risk of VTE, with low incidence in patients with presence of an IDH1 mutation compared with those with IDH1 wild-type status. In addition, expression of the glycoprotein podoplanin on brain tumors was associated with both intratumoral thrombi and high risk of VTE. As podoplanin has the ability to activate platelets, a mechanistic role of podoplanin-mediated platelet activation in VTE development has been suggested. From a clinical point of view, the management of patients with primary brain tumors and VTE is challenging. Anticoagulation is required to treat patients; however, it is associated with increased risk of intracranial hemorrhage. This review focuses on describing the epidemiology, risk factors, and mechanisms of brain tumor-associated thrombosis and discusses clinical challenges in the prevention and treatment of VTE in patients with brain tumors.
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Affiliation(s)
- Julia Riedl
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.,I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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Elmoamly S, Mattar M, Yacoub MF, Afif A. Can Biomarkers of Coagulation, Platelet Activation, and Inflammation Predict Venous Thromboembolism in Patients with Haematological Malignancies? Acta Haematol 2019; 141:245-253. [PMID: 30965330 DOI: 10.1159/000496914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 01/15/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND The incidence of venous thromboembolism (VTE) in haematological malignancies varies according to the type and grade of the disease and clinical variables, and there is a need to develop a tool to predict the occurrence of VTE in cancer patients at diagnosis to tailor prophylactic anticoagulation use during treatment. OBJECTIVE To study the incidence of VTE in haematological malignancies and clarify whether vascular and inflammatory biomarkers could be used as predictors of VTE in those patients. METHODS This was a prospective observational cohort study. Hypercoagulability and inflammatory biomarkers were assayed in a group of 171 patients with haematological malignancies at diagnosis. These markers included (1) coagulation and fibrinolysis activation markers (D-dimer, fibrinogen, antithrombin, plasminogen activator inhibitor 1), (2) endothelial and platelet activation markers (von Willebrand factor and soluble P-selectin), and (3) inflammatory markers (tumour necrosis factor αand interleukin 6). The end point was mortality or symptomatic VTE. RESULTS/CONCLUSION The incidence of symptomatic VTE was 7%. None of the tested biomarkers showed statistical significance as predictors for the occurrence of VTE in haematological malignancies. However, there were statistically significant associations between the occurrence of VTE and central venous access device insertion, the prothrombin time, and the erythrocyte sedimentation rate. An ESR above 106.5 mm/h is associated with increased VTE occurrence.
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Affiliation(s)
- Shereef Elmoamly
- Department of Internal Medicine and Clinical Haematology, Faculty of Medicine, Cairo University, Cairo, Egypt,
| | - Mervat Mattar
- Department of Internal Medicine and Clinical Haematology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maha F Yacoub
- Department of Internal Medicine and Clinical Haematology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alaa Afif
- Department of Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Lee A, Arasaratnam M, Chan DLH, Khasraw M, Howell VM, Wheeler H, Platt J. Anti-epidermal growth factor receptor therapy for glioblastoma in adults. Hippokratia 2019. [DOI: 10.1002/14651858.cd013238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Adrian Lee
- Royal North Shore Hospital; Department of Medical Oncology; Kolling Institute Sydney New South Wales Australia 2065
| | - Malmaruha Arasaratnam
- Royal North Shore Hospital; Department of Medical Oncology; Kolling Institute Sydney New South Wales Australia 2065
| | - David Lok Hang Chan
- Royal North Shore Hospital; Department of Medical Oncology; Kolling Institute Sydney New South Wales Australia 2065
| | - Mustafa Khasraw
- NHMRC Clinical Trials Centre, The University of Sydney; Camperdown Australia
| | - Viive M Howell
- Royal North Shore Hospital; Department of Medical Oncology; Kolling Institute Sydney New South Wales Australia 2065
| | - Helen Wheeler
- Royal North Shore Hospital; Department of Medical Oncology; Pacific Highway St Leonards NSW Australia 2065
| | - Joanne Platt
- Royal United Hospital; Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group; 1st Floor, Education Centre Royal United Hospital Bath UK BA1 3NG
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Adult height and risk of 50 diseases: a combined epidemiological and genetic analysis. BMC Med 2018; 16:187. [PMID: 30355295 PMCID: PMC6201543 DOI: 10.1186/s12916-018-1175-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/12/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Adult height is associated with risk of several diseases, but the breadth of such associations and whether these associations are primary or due to confounding are unclear. We examined the association of adult height with 50 diseases spanning multiple body systems using both epidemiological and genetic approaches, the latter to identify un-confounded associations and possible underlying mechanisms. METHODS We examined the associations for adult height (using logistic regression adjusted for potential confounders) and genetically determined height (using a two-sample Mendelian randomisation approach with height-associated genetic variants as instrumental variables) in 417,434 individuals of white ethnic background participating in the UK Biobank. We undertook pathway analysis of height-associated genes to identify biological processes that could link height and specific diseases. RESULTS Height was associated with 32 diseases and genetically determined height associated with 12 diseases. Of these, 11 diseases showed a concordant association in both analyses, with taller height associated with reduced risks of coronary artery disease (odds ratio per standard deviation (SD) increase in height ORepi = 0.80, 95% CI 0.78-0.81; OR per SD increase in genetically determined height ORgen = 0.86, 95% CI 0.82-0.90), hypertension (ORepi = 0.83, 95% CI 0.82-0.84; ORgen = 0.88, 95% CI 0.85-0.91), gastro-oesophageal reflux disease (ORepi = 0.85, 95% CI 0.84-0.86; ORgen = 0.94, 95% CI 0.92-0.97), diaphragmatic hernia (ORepi = 0.81, 95% CI 0.79-0.82; ORgen = 0.91, 95% CI 0.88-0.94), but increased risks of atrial fibrillation (ORepi = 1.42, 95% CI 1.38-1.45; ORgen = 1.33, 95% CI 1.26-1.40), venous thromboembolism (ORepi = 1.18, 95% CI 1.16-1.21; ORgen = 1.15, 95% CI 1.11-1.19), intervertebral disc disorder (ORepi = 1.15, 95% CI 1.13-1.18; ORgen = 1.14, 95% CI 1.09-1.20), hip fracture (ORepi = 1.19, 95% CI 1.12-1.26; ORgen = 1.27, 95% CI 1.17-1.39), vasculitis (ORepi = 1.15, 95% CI 1.11-1.19; ORgen = 1.20, 95% CI 1.14-1.28), cancer overall (ORepi = 1.09, 95% CI 1.08-1.11; ORgen = 1.06, 95% CI 1.04-1.08) and breast cancer (ORepi = 1.08, 95% CI 1.06-1.10; ORgen = 1.07, 95% CI 1.03-1.11). Pathway analysis showed multiple height-associated pathways associating with individual diseases. CONCLUSIONS Adult height is associated with risk of a range of diseases. We confirmed previously reported height associations for coronary artery disease, atrial fibrillation, venous thromboembolism, intervertebral disc disorder, hip fracture and cancer and identified potential novel associations for gastro-oesophageal reflux disease, diaphragmatic hernia and vasculitis. Multiple biological mechanisms affecting height may affect the risks of these diseases.
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Mir Seyed Nazari P, Riedl J, Pabinger I, Ay C. The role of podoplanin in cancer-associated thrombosis. Thromb Res 2018; 164 Suppl 1:S34-S39. [PMID: 29703483 DOI: 10.1016/j.thromres.2018.01.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/08/2018] [Accepted: 01/10/2018] [Indexed: 12/21/2022]
Abstract
Venous thromboembolism (VTE) is a frequent and life-threatening complication in patients with cancer. The underlying mechanisms of cancer-associated VTE are still not completely understood. However, emerging studies indicate that the mechanisms differ across tumor types. A recent study revealed that in patients with brain tumors, podoplanin overexpression is strongly correlated with intratumoral thrombotic vessels, hypercoagulability and increased VTE risk. In vitro experiments demonstrated that platelet aggregation induced by human glioblastoma cells was highly podoplanin-dependent. Podoplanin is a transmembrane glycoprotein with the ability to induce platelet activation via the platelet-receptor CLEC-2. Moreover, podoplanin is a lymphatic endothelial marker and exhibits substantial functions during embryonic development. It is variously upregulated by many cancers including primary brain tumors and linked to malignant progression and poor survival. In vivo studies have indicated that the podoplanin-CLEC-2 axis might be mechanistically involved in the development of venous thrombosis. In this review, we discuss the role of podoplanin in promoting cancer-associated VTE. Since podoplanin is associated with VTE risk in brain tumor patients, it could be a useful biomarker to identify patients at very high VTE risk. Those patients may benefit from primary thromboprophylaxis. In addition, the podoplanin-CLEC-2 axis might serve as an attractive target for new therapies against cancer-associated VTE.
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Affiliation(s)
- Pegah Mir Seyed Nazari
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Austria
| | - Julia Riedl
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Austria.
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Pabinger I, van Es N, Heinze G, Posch F, Riedl J, Reitter EM, Di Nisio M, Cesarman-Maus G, Kraaijpoel N, Zielinski CC, Büller HR, Ay C. A clinical prediction model for cancer-associated venous thromboembolism: a development and validation study in two independent prospective cohorts. LANCET HAEMATOLOGY 2018; 5:e289-e298. [PMID: 29885940 DOI: 10.1016/s2352-3026(18)30063-2] [Citation(s) in RCA: 213] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/20/2018] [Accepted: 04/22/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Venous thromboembolism is a common complication of cancer, but the risk of developing venous thromboembolism varies greatly among individuals and depends on numerous factors, including type of cancer. We aimed to develop and externally validate a clinical prediction model for cancer-associated venous thromboembolism. METHODS We used data from the prospective Vienna Cancer and Thrombosis Study (CATS) cohort (n=1423) to select prognostic variables for inclusion in the model. We then validated the model in the prospective Multinational Cohort Study to Identify Cancer Patients at High Risk of Venous Thromboembolism (MICA) cohort (n=832). We calculated c-indices to show how the predicted incidence of objectively confirmed venous thromboembolism at 6 months compared with the cumulative 6-month incidences observed in both cohorts. FINDINGS Two variables were selected for inclusion in the final clinical prediction model: tumour-site risk category (low or intermediate vs high vs very high) and continuous D-dimer concentrations. The multivariable subdistribution hazard ratios were 1·96 (95% CI 1·41-2·72; p=0·0001) for high or very high versus low or intermediate and 1·32 (95% CI 1·12-1·56; p=0·001) per doubling of D-dimer concentration. The cross-validated c-indices of the final model were 0·66 (95% CI 0·63-0·67) in CATS and 0·68 (0·62-0·74) in MICA. The clinical prediction model was adequately calibrated in both cohorts. INTERPRETATION An externally validated clinical prediction model incorporating only one clinical factor (tumour-site category) and one biomarker (D-dimer) predicted the risk of venous thromboembolism in ambulatory patients with solid cancers. This simple model is a considerable improvement on previous models for predicting cancer-associated venous thromboembolism, and could aid physicians in selection of patients who will likely benefit from thromboprophylaxis. FUNDING Austrian Science Fund, Austrian National Bank Memorial Fund, and participating hospitals.
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Affiliation(s)
- Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria.
| | - Nick van Es
- Department of Vascular Medicine, Academic Medical Centre Amsterdam, University of Amsterdam, Amsterdam, Netherlands
| | - Georg Heinze
- Department of Medicine I, and Section for Clinical Biometrics, Centre for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Florian Posch
- Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria; Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Julia Riedl
- Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Eva-Maria Reitter
- Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, G D'Annunzio University, Chieti, Italy
| | | | - Noémie Kraaijpoel
- Department of Vascular Medicine, Academic Medical Centre Amsterdam, University of Amsterdam, Amsterdam, Netherlands
| | | | - Harry Roger Büller
- Department of Vascular Medicine, Academic Medical Centre Amsterdam, University of Amsterdam, Amsterdam, Netherlands
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
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Mir Seyed Nazari P, Riedl J, Preusser M, Posch F, Thaler J, Marosi C, Birner P, Ricken G, Hainfellner JA, Pabinger I, Ay C. Combination of isocitrate dehydrogenase 1 (IDH1) mutation and podoplanin expression in brain tumors identifies patients at high or low risk of venous thromboembolism. J Thromb Haemost 2018; 16:1121-1127. [PMID: 29676036 PMCID: PMC6099350 DOI: 10.1111/jth.14129] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Indexed: 12/11/2022]
Abstract
Essentials Risk stratification for venous thromboembolism (VTE) in patients with brain tumors is challenging. Patients with IDH1 wildtype and high podoplanin expression have a 6-month VTE risk of 18.2%. Patients with IDH1 mutation and no podoplanin expression have a 6-month VTE risk of 0%. IDH1 mutation and podoplanin overexpression in primary brain tumors appear to be exclusive. SUMMARY Background Venous thromboembolism (VTE) is a frequent complication in primary brain tumor patients. Independent studies revealed that podoplanin expression in brain tumors is associated with increased VTE risk, whereas the isocitrate dehydrogenase 1 (IDH1) mutation is associated with very low VTE risk. Objectives To investigate the interrelation between intratumoral podoplanin expression and IDH1 mutation, and their mutual impact on VTE development. Patients/Methods In a prospective cohort study, intratumoral IDH1 R132H mutation and podoplanin were determined in brain tumor specimens (mainly glioma) by immunohistochemistry. The primary endpoint of the study was symptomatic VTE during a 2-year follow-up. Results All brain tumors that expressed podoplanin to a medium-high extent showed also an IDH1 wild-type status. A score based on IDH1 status and podoplanin expression levels allowed prediction of the risk of VTE. Patients with wild-type IDH1 brain tumors and high podoplanin expression had a significantly increased VTE risk compared with those with mutant IDH1 tumors and no podoplanin expression (6-month risk 18.2% vs. 0%). Conclusions IDH1 mutation and podoplanin overexpression seem to be exclusive. Although brain tumor patients with IDH1 mutation are at very low risk of VTE, the risk of VTE in patients with IDH1 wild-type tumors is strongly linked to podoplanin expression levels.
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Affiliation(s)
- P. Mir Seyed Nazari
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IComprehensive Cancer CenterCenter Medical University of ViennaViennaAustria
| | - J. Riedl
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IComprehensive Cancer CenterCenter Medical University of ViennaViennaAustria
| | - M. Preusser
- Clinical Division of OncologyDepartment of Medicine IComprehensive Cancer CenterMedical University of ViennaViennaAustria
| | - F. Posch
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IComprehensive Cancer CenterCenter Medical University of ViennaViennaAustria
- Division of OncologyDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - J. Thaler
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IComprehensive Cancer CenterCenter Medical University of ViennaViennaAustria
| | - C. Marosi
- Clinical Division of OncologyDepartment of Medicine IComprehensive Cancer CenterMedical University of ViennaViennaAustria
| | - P. Birner
- Clinical Institute of PathologyMedical University of ViennaViennaAustria
| | - G. Ricken
- Institute of NeurologyMedical University of ViennaViennaAustria
| | | | - I. Pabinger
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IComprehensive Cancer CenterCenter Medical University of ViennaViennaAustria
| | - C. Ay
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IComprehensive Cancer CenterCenter Medical University of ViennaViennaAustria
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Cancer-associated pathways and biomarkers of venous thrombosis. Blood 2017; 130:1499-1506. [PMID: 28807983 DOI: 10.1182/blood-2017-03-743211] [Citation(s) in RCA: 243] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 08/02/2017] [Indexed: 12/14/2022] Open
Abstract
Cancer patients have an increased risk of venous thromboembolism (VTE). In this review, we summarize common and cancer type-specific pathways of VTE in cancer patients. Increased levels of leukocytes, platelets, and tissue factor-positive (TF+) microvesicles (MVs) are all potential factors that alone or in combination increase cancer-associated thrombosis. Patients with lung or colorectal cancer often exhibit leukocytosis. Neutrophils could increase VTE in cancer patients by releasing neutrophil extracellular traps whereas monocytes may express TF. Thrombocytosis is often observed in gastrointestinal, lung, breast, and ovarian cancer and this could decrease the threshold required for VTE. Soluble P-selectin has been identified as a biomarker of cancer-associated thrombosis in a general cancer population and may reflect activation of the endothelium. P-selectin expression by the endothelium may enhance VTE by increasing the recruitment of leukocytes. Studies in patients with pancreatic or brain cancer suggest that elevated levels of PAI-1 may contribute to VTE. Although elevated levels of TF+ MVs have been observed in patients with different types of cancer, an association between TF+ MVs and VTE has been observed only in pancreatic cancer. Podoplanin expression is associated with VTE in patients with brain cancer and may activate platelets. Future studies should measure multiple biomarkers in each cancer type to determine whether combinations of biomarkers can be used as predictors of VTE. A better understanding of the pathways that increase VTE in cancer patients may lead to the development of new therapies to reduce the morbidity and mortality associated with thrombosis.
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Jansohn E, Bengzon J, Kander T, Schött U. A pilot study on the applicability of thromboelastometry in detecting brain tumour-induced hypercoagulation. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 77:289-294. [DOI: 10.1080/00365513.2017.1306877] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Podoplanin expression in primary brain tumors induces platelet aggregation and increases risk of venous thromboembolism. Blood 2017; 129:1831-1839. [PMID: 28073783 DOI: 10.1182/blood-2016-06-720714] [Citation(s) in RCA: 150] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 01/04/2017] [Indexed: 12/17/2022] Open
Abstract
Venous thromboembolism (VTE) is common in patients with brain tumors, and underlying mechanisms are unclear. We hypothesized that podoplanin, a sialomucin-like glycoprotein, increases the risk of VTE in primary brain tumors via its ability to induce platelet aggregation. Immunohistochemical staining against podoplanin and intratumoral platelet aggregates was performed in brain tumor specimens of 213 patients (mostly high-grade gliomas [89%]) included in the Vienna Cancer and Thrombosis Study, a prospective observational cohort study of patients with newly diagnosed cancer or progressive disease aimed at identifying patients at risk of VTE. Platelet aggregation in response to primary human glioblastoma cells was investigated in vitro. During 2-year follow-up, 29 (13.6%) patients developed VTE. One-hundred fifty-one tumor specimens stained positive for podoplanin (33 high expression, 47 medium expression, 71 low expression). Patients with podoplanin-positive tumors had lower peripheral blood platelet counts (P < .001) and higher D-dimer levels (P < .001). Podoplanin staining intensity was associated with increasing levels of intravascular platelet aggregates in tumor specimens (P < .001). High podoplanin expression was associated with an increased risk of VTE (hazard ratio for high vs no podoplanin expression: 5.71; 95% confidence interval, 1.52-21.26; P =010), independent of age, sex, and tumor type. Podoplanin-positive primary glioblastoma cells induced aggregation of human platelets in vitro, which could be abrogated by an antipodoplanin antibody. In conclusion, high podoplanin expression in primary brain tumors induces platelet aggregation, correlates with hypercoagulability, and is associated with increased risk of VTE. Our data indicate novel insights into the pathogenesis of VTE in primary brain tumors.
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Unruh D, Schwarze SR, Khoury L, Thomas C, Wu M, Chen L, Chen R, Liu Y, Schwartz MA, Amidei C, Kumthekar P, Benjamin CG, Song K, Dawson C, Rispoli JM, Fatterpekar G, Golfinos JG, Kondziolka D, Karajannis M, Pacione D, Zagzag D, McIntyre T, Snuderl M, Horbinski C. Mutant IDH1 and thrombosis in gliomas. Acta Neuropathol 2016; 132:917-930. [PMID: 27664011 PMCID: PMC5640980 DOI: 10.1007/s00401-016-1620-7] [Citation(s) in RCA: 121] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 09/16/2016] [Accepted: 09/16/2016] [Indexed: 10/21/2022]
Abstract
Mutant isocitrate dehydrogenase 1 (IDH1) is common in gliomas, and produces D-2-hydroxyglutarate (D-2-HG). The full effects of IDH1 mutations on glioma biology and tumor microenvironment are unknown. We analyzed a discovery cohort of 169 World Health Organization (WHO) grade II-IV gliomas, followed by a validation cohort of 148 cases, for IDH1 mutations, intratumoral microthrombi, and venous thromboemboli (VTE). 430 gliomas from The Cancer Genome Atlas were analyzed for mRNAs associated with coagulation, and 95 gliomas in a tissue microarray were assessed for tissue factor (TF) protein. In vitro and in vivo assays evaluated platelet aggregation and clotting time in the presence of mutant IDH1 or D-2-HG. VTE occurred in 26-30 % of patients with wild-type IDH1 gliomas, but not in patients with mutant IDH1 gliomas (0 %). IDH1 mutation status was the most powerful predictive marker for VTE, independent of variables such as GBM diagnosis and prolonged hospital stay. Microthrombi were far less common within mutant IDH1 gliomas regardless of WHO grade (85-90 % in wild-type versus 2-6 % in mutant), and were an independent predictor of IDH1 wild-type status. Among all 35 coagulation-associated genes, F3 mRNA, encoding TF, showed the strongest inverse relationship with IDH1 mutations. Mutant IDH1 gliomas had F3 gene promoter hypermethylation, with lower TF protein expression. D-2-HG rapidly inhibited platelet aggregation and blood clotting via a novel calcium-dependent, methylation-independent mechanism. Mutant IDH1 glioma engraftment in mice significantly prolonged bleeding time. Our data suggest that mutant IDH1 has potent antithrombotic activity within gliomas and throughout the peripheral circulation. These findings have implications for the pathologic evaluation of gliomas, the effect of altered isocitrate metabolism on tumor microenvironment, and risk assessment of glioma patients for VTE.
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Affiliation(s)
- Dusten Unruh
- Department of Neurosurgery, Northwestern University, Tarry 2-705, 300 East Superior Street, Chicago, IL, 60611, USA
| | | | - Laith Khoury
- Department of Neurosurgery, University of Kentucky, Lexington, KY, USA
| | - Cheddhi Thomas
- Department of Pathology, New York University, New York, NY, USA
| | - Meijing Wu
- Department of Neurosurgery, Northwestern University, Tarry 2-705, 300 East Superior Street, Chicago, IL, 60611, USA
| | - Li Chen
- Department of Biostatistics, University of Kentucky, Lexington, KY, USA
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - Rui Chen
- Department of Cellular and Molecular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Yinxing Liu
- Department of Pathology, University of Kentucky, Lexington, KY, USA
| | | | - Christina Amidei
- Department of Neurosurgery, Northwestern University, Tarry 2-705, 300 East Superior Street, Chicago, IL, 60611, USA
| | - Priya Kumthekar
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | | | | | | | | | | | - John G Golfinos
- Department of Neurosurgery, New York University, New York, NY, USA
| | | | | | - Donato Pacione
- Department of Neurosurgery, New York University, New York, NY, USA
| | - David Zagzag
- Department of Pathology, New York University, New York, NY, USA
- Department of Neurosurgery, New York University, New York, NY, USA
| | - Thomas McIntyre
- Department of Cellular and Molecular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Matija Snuderl
- Department of Pathology, New York University, New York, NY, USA
| | - Craig Horbinski
- Department of Neurosurgery, Northwestern University, Tarry 2-705, 300 East Superior Street, Chicago, IL, 60611, USA.
- Department of Pathology, Northwestern University, Chicago, IL, USA.
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Jacobs B, Obi A, Wakefield T. Diagnostic biomarkers in venous thromboembolic disease. J Vasc Surg Venous Lymphat Disord 2016; 4:508-17. [PMID: 27639008 DOI: 10.1016/j.jvsv.2016.02.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 02/29/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a common disease with serious, often fatal sequelae. The optimal strategy for diagnosis of VTE remains unclear, although considerable progress has been made in this area. Several new biomarkers have showed promise for diagnosis of VTE, and more are under active investigation. We reviewed the literature for studies evaluating these diagnostic biomarkers. METHODS We reviewed the English literature between 1990 and 2015, searching for papers evaluating diagnostic performance of biomarkers in VTE. RESULTS D-dimer, a fibrin degradation product, has been thoroughly investigated, and performs well in select populations, although it is best as a rule-out test because of its generally low specificity. Soluble P-selectin, a marker of endothelial activation, has shown good diagnostic performance in several studies but has not yet been adopted widely. Others, including cellular adhesion molecules, tissue factor, circulating microparticles, and C-reactive protein, are under investigation, with varying results in a few studies. CONCLUSIONS At this time, D-dimer and P-selectin remain the most clinically valuable. New biomarkers are needed for clinical use in VTE.
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Affiliation(s)
- Benjamin Jacobs
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
| | - Andrea Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Thomas Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
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