1
|
Ranjan S, Leung D, Ghiaseddin AP, Taylor JW, Lobbous M, Dhawan A, Budhu JA, Coffee E, Melnick K, Chowdhary SA, Lu-Emerson C, Kurz SC, Burke JE, Lam K, Patel MP, Dunbar EM, Mohile NA, Peters KB. Practical guidance for direct oral anticoagulant use in the treatment of venous thromboembolism in primary and metastatic brain tumor patients. Cancer 2024; 130:1577-1589. [PMID: 38288941 DOI: 10.1002/cncr.35220] [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: 09/16/2023] [Revised: 11/17/2023] [Accepted: 11/27/2023] [Indexed: 04/13/2024]
Abstract
Management of venous thromboembolism (VTE) in patients with primary and metastatic brain tumors (BT) is challenging because of the risk of intracranial hemorrhage (ICH). There are no prospective clinical trials evaluating safety and efficacy of direct oral anticoagulants (DOACs), specifically in patients with BT, but they are widely used for VTE in this population. A group of neuro-oncology experts convened to provide practical clinical guidance for the off-label use of DOACs in treating VTE in patients with BT. We searched PubMed for the following terms: BTs, glioma, glioblastoma (GBM), brain metastasis, VTE, heparin, low-molecular-weight heparin (LWMH), DOACs, and ICH. Although prospective clinical trials are needed, the recommendations presented aim to assist clinicians in making informed decisions regarding DOACs for VTE in patients with BT.
Collapse
Affiliation(s)
- Surabhi Ranjan
- Department of Neurology, Cleveland Clinic Florida, Weston, Florida, USA
| | - Denise Leung
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ashley P Ghiaseddin
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Jennie W Taylor
- Department of Neurology, University of California, San Francisco, California, USA
| | - Mina Lobbous
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Andrew Dhawan
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Joshua A Budhu
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elizabeth Coffee
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kaitlyn Melnick
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Sajeel A Chowdhary
- Tampa General Hospital Cancer Institute, Tampa General Hospital, Tampa, Florida, USA
| | - Christine Lu-Emerson
- Department of Neurology, Maine Medical Center and Maine Health Cancer Care, Portland, Maine, USA
| | - Sylvia C Kurz
- Department of Neurology & Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Joy E Burke
- Department of Neurology, Beth Israel Lahey Health, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Keng Lam
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mallika P Patel
- Preston Robert Tisch Brain Tumor Center, Duke University, Durham, North Carolina, USA
| | | | - Nimish A Mohile
- Department of Neurology, University of Rochester, Rochester, New York, USA
| | - Katherine B Peters
- Preston Robert Tisch Brain Tumor Center, Duke University, Durham, North Carolina, USA
| |
Collapse
|
2
|
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.
Collapse
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.
| |
Collapse
|
3
|
Woods RR, Lesser GJ. Management of Thromboembolic Disease in Patients with Primary and Metastatic Brain Tumors. Curr Treat Options Oncol 2023; 24:1293-1303. [PMID: 37407888 PMCID: PMC10477143 DOI: 10.1007/s11864-023-01116-w] [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] [Accepted: 05/24/2023] [Indexed: 07/07/2023]
Abstract
OPINION STATEMENT Patients with primary brain tumors are at a substantially elevated risk of venous thromboembolism (VTE) compared to other disease states or other forms of malignancy. Deep venous thrombosis (DVT) and pulmonary embolism (PE), often complicate the care of patients with primary brain tumors, and treatment may pose specific unique risks and considerations for management. This paper critically reviews the relevant literature and the most common treatment options in addition to a discussion regarding the relative risk considerations for neurooncology patients facing thromboembolic disease.
Collapse
Affiliation(s)
- Ryan R. Woods
- Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157 USA
| | - Glenn J. Lesser
- Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157 USA
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Tschernia NP, Gulley JL. Tumor in the Crossfire: Inhibiting TGF-β to Enhance Cancer Immunotherapy. BioDrugs 2022; 36:153-180. [PMID: 35353346 PMCID: PMC8986721 DOI: 10.1007/s40259-022-00521-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 02/04/2023]
Abstract
Cancer immunotherapy using monoclonal antibodies targeting immune checkpoints has undoubtedly revolutionized the cancer treatment landscape in the last decade. Immune checkpoint inhibitors can elicit long-lasting, previously unheard-of responses in a number of tumor entities. Yet, even in such tumors as metastatic melanoma and non-small cell-lung cancer, in which immune checkpoint inhibition has become the first-line treatment of choice, only a minority of patients will benefit considerably from these treatments. This has been attributed to a number of factors, including an immune-suppressive tumor microenvironment (TME). Using different modalities to break these barriers is of utmost importance to expand the population of patients that benefit from immune checkpoint inhibition. The multifunctional cytokine transforming growth factor-β (TGF-β) has long been recognized as an immune-suppressive factor in the TME. A considerable number of drugs have been developed to target TGF-β, yet most of these have since been discontinued. The combination of anti-TGF-β agents with immune checkpoint inhibitors now has the potential to revive this target as a viable immunomodulatory therapeutic approach. Currently, a limited number of small molecular inhibitor and monoclonal antibody candidates that target TGF-β are in clinical development in combination with the following immune checkpoint inhibitors: SRK 181, an antibody inhibiting the activation of latent TGF-β1; NIS 793, a monoclonal antibody targeting TGF-β; and SHR 1701, a fusion protein consisting of an anti-PD-L1 monoclonal antibody fused with the extracellular domain of human TGF-β receptor II. Several small molecular inhibitors are also in development and are briefly reviewed: LY364947, a pyrazole-based small molecular inhibitor of the serine-threonine kinase activity of TGFβRI; SB-431542, an inhibitor targeting several TGF-β superfamily Type I activin receptor-like kinases as well as TGF-β1-induced nuclear Smad3 localization; and galunisertib, an oral small molecular inhibitor of the TGFβRI kinase. One of the most advanced agents in this area is bintrafusp alfa, a bifunctional fusion protein composed of the extracellular domain of TGF-β receptor II fused to a human IgG1 mAb blocking PD-L1. Bintrafusp alfa is currently in advanced clinical development and as an agent in this space with the most clinical experience, is a focused highlight of this review.
Collapse
Affiliation(s)
- Nicholas P Tschernia
- Genitourinary Malignancies Branch, Medical Oncology Service, National Cancer Institute, Building 10, Room 13N240, Bethesda, MD, 20892, USA
| | - James L Gulley
- Genitourinary Malignancies Branch, Medical Oncology Service, National Cancer Institute, Building 10, Room 13N240, Bethesda, MD, 20892, USA.
| |
Collapse
|
6
|
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.
Collapse
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.
| |
Collapse
|
7
|
Ehret F, Kaul D, Mose L, Budach V, Vajkoczy P, Fürweger C, Haidenberger A, Muacevic A, Mehrhof F, Kufeld M. Intracranial Hemorrhage in Patients with Anticoagulant Therapy Undergoing Stereotactic Radiosurgery for Brain Metastases: A Bi-Institutional Analysis. Cancers (Basel) 2022; 14:cancers14030465. [PMID: 35158734 PMCID: PMC8833468 DOI: 10.3390/cancers14030465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/09/2022] [Accepted: 01/12/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Stereotactic radiosurgery (SRS) is a well-established treatment modality for brain metastases (BM). Given the manifold implications of metastatic cancer on the body, affected patients have an increased risk of comorbidities, such as atrial fibrillation (AF) and venous thromboembolism (VTE), which includes pulmonary embolism (PE) and deep-vein thrombosis (DVT). These may require therapeutic anticoagulant therapy (ACT). Limited data are available on the risk of intracranial hemorrhage (ICH) after SRS for patients with BM who are receiving ACT. This bi-institutional analysis aimed to describe the bleeding risk for this patient subgroup. Methods: Patients with ACT at the time of single-fraction SRS for BM from two institutions were eligible for analysis. The cumulative incidence of ICH with death as a competing event was assessed during follow-up with magnetic resonance imaging or computed tomography. Results: Forty-one patients with 97 BM were included in the analyses. The median follow-up was 8.2 months (range: 1.7–77.5 months). The median and mean BM volumes were 0.47 and 1.19 cubic centimeters, respectively. The most common reasons for ACT were PE (41%), AF (34%), and DVT (7%). The ACT was mostly performed utilizing phenprocoumon (37%), novel oral anticoagulants (32%), or low-molecular-weight heparin (20%). Nine BM from a group of five patients with ICH after SRS were identified: none of them caused neurological or any other deficits. The 6-, 12-, and 18-month cumulative bleeding incidences per metastasis were 2.1%, 12.4%, and 12.4%, respectively. The metastases with previous bleeding events and those originating from malignant melanomas were found to more frequently demonstrate ICH after SRS (p = 0.02, p = 0.01). No surgical or medical intervention was necessary for ICH management, and no observed death was associated with an ICH. Conclusion: Patients receiving an ACT and single-fraction SRS for small- to medium-sized BM did not seem to have a clinically relevant risk of ICH. Previous bleeding and metastases originating from a malignant melanoma may favor bleeding events after SRS. Further studies are needed to validate our reported findings.
Collapse
Affiliation(s)
- Felix Ehret
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, 13353 Berlin, Germany; (D.K.); (V.B.); (F.M.)
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
- Correspondence:
| | - David Kaul
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, 13353 Berlin, Germany; (D.K.); (V.B.); (F.M.)
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité CyberKnife Center, 13353 Berlin, Germany;
| | - Lucas Mose
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
| | - Volker Budach
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, 13353 Berlin, Germany; (D.K.); (V.B.); (F.M.)
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité CyberKnife Center, 13353 Berlin, Germany;
| | - Peter Vajkoczy
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité CyberKnife Center, 13353 Berlin, Germany;
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurosurgery, 10117 Berlin, Germany
| | - Christoph Fürweger
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
- Department of Stereotaxy and Functional Neurosurgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Alfred Haidenberger
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
| | - Alexander Muacevic
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
| | - Felix Mehrhof
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, 13353 Berlin, Germany; (D.K.); (V.B.); (F.M.)
| | - Markus Kufeld
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
| |
Collapse
|
8
|
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.
Collapse
|
9
|
Dubinski D, Won SY, Voss M, Keil F, Miesbach W, Behmanesh B, Dosch M, Baumgarten P, Bernstock JD, Seifert V, Freiman TM, Gessler F. Direct oral anticoagulants vs. low-molecular-weight heparin for pulmonary embolism in patients with glioblastoma. Neurosurg Rev 2021; 45:451-457. [PMID: 33900495 PMCID: PMC8827361 DOI: 10.1007/s10143-021-01539-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/03/2021] [Accepted: 04/01/2021] [Indexed: 11/28/2022]
Abstract
Glioblastoma (GBM) is a cancer type with high thrombogenic potential and GBM patients are therefore at a particularly high risk for thrombotic events. To date, only limited data on anticoagulation management after pulmonary embolism (PE) in GBM is available and the sporadic use of DOACs remains off-label. A retrospective cohort analysis of patients with GBM and postoperative, thoracic CT scan confirmed PE was performed. Clinical course, follow-up at 6 and 12 months and the overall survival (OS) were evaluated using medical charts and neuroradiological data. Out of 584 GBM patients, 8% suffered from postoperative PE. Out of these, 30% received direct oral anticoagulants (DOACs) and 70% low-molecular-weight heparin (LMWH) for therapeutic anticoagulation. There was no significant difference in major intracranial hemorrhage (ICH), re-thrombosis, or re-embolism between the two cohorts. Although statistically non-significant, a tendency to reduced mRS at 6 and 12 months was observed in the LMWH cohort. Furthermore, patients receiving DOACs had a statistical benefit in OS. In our analysis, DOACs showed a satisfactory safety profile in terms of major ICH, re-thrombosis, and re-embolism compared to LMWH in GBM patients with postoperative PE. Prospective, randomized trials are urgent to evaluate DOACs for therapeutic anticoagulation in GBM patients with PE.
Collapse
Affiliation(s)
- Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60598, Frankfurt, Germany.
| | - Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60598, Frankfurt, Germany
| | - Martin Voss
- Dr. Senckenberg Institute of Neurooncology, Goethe University Hospital, Frankfurt, Germany
| | - Fee Keil
- Institute of Neuroradiology, University Hospital, Goethe University, Frankfurt, Germany
| | - Wolfgang Miesbach
- Department of Hemostaseology and Transfusion Medicine, University Hospital, DRK-Blutspendedienst Baden-Württemberg-Hessen gGmbH, Frankfurt, Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60598, Frankfurt, Germany
| | - Max Dosch
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60598, Frankfurt, Germany
| | - Peter Baumgarten
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60598, Frankfurt, Germany
| | - Joshua D Bernstock
- Department of Neurosurgery, Birgham and Women's, Harvard Medical School, Boston, MA, USA
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60598, Frankfurt, Germany
| | - Thomas M Freiman
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60598, Frankfurt, Germany
| | - Florian Gessler
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60598, Frankfurt, Germany
| |
Collapse
|
10
|
Khasraw M, Weller M, Lorente D, Kolibaba K, Lee CK, Gedye C, I de La Fuente M, Vicente D, Reardon DA, Gan HK, Scott AM, Dussault I, Helwig C, Ojalvo LS, Gourmelon C, Groves M. Bintrafusp alfa (M7824), a bifunctional fusion protein targeting TGF-β and PD-L1: results from a phase I expansion cohort in patients with recurrent glioblastoma. Neurooncol Adv 2021; 3:vdab058. [PMID: 34056607 PMCID: PMC8156979 DOI: 10.1093/noajnl/vdab058] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background For patients with recurrent glioblastoma (rGBM), there are few options following treatment failure with radiotherapy plus temozolomide. Bintrafusp alfa is a first-in-class bifunctional fusion protein composed of the extracellular domain of the TGF-βRII receptor (a TGF-β “trap”) fused to a human IgG1 antibody blocking PD-L1. Methods In this phase I, open-label expansion cohort (NCT02517398), patients with rGBM that progressed after radiotherapy plus temozolomide received bintrafusp alfa 1200 mg Q2W until disease progression, unacceptable toxicity, or trial withdrawal. Response was assessed per RANO criteria. The primary endpoint was disease control rate (DCR); secondary endpoints included safety. Results As of August 24, 2018, 35 patients received bintrafusp alfa for a median of 1.8 (range, 0.5–20.7) months. Eight patients (22.9%) experienced disease control as assessed by an independent review committee: 2 had a partial response, 4 had stable disease, and 2 had non-complete response/non-progressive disease. Median progression-free survival (PFS) was 1.4 (95% confidence interval [CI], 1.2–1.6) months; 6- and 12-month PFS rates were 15.1% and 11.3%, respectively. Median overall survival (OS) was 5.3 (95% CI, 2.6–9.4) months; 6- and 12-month OS rates were 44.5% and 30.8%, respectively. The DCR (95% CI) was 66.7% (22.3–95.7%) for patients with IDH-mutant GBM (n = 6) and 13.8% (3.9–31.7%) for patients with IDH–wild-type GBM (n = 29). Disease control was seen regardless of PD-L1 expression. Twenty-five patients (71.4%) experienced treatment-related adverse events (grade ≥3; 17.1% [n = 6]). Conclusions The percentage of patients achieving disease control and the manageable safety profile may warrant further investigation of bintrafusp alfa in GBM.
Collapse
Affiliation(s)
- Mustafa Khasraw
- Royal North Shore Hospital, St Leonards, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Michael Weller
- University Hospital and University of Zurich, Zurich, Switzerland
| | - David Lorente
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Kathryn Kolibaba
- Compass Oncology, US Oncology Research, Vancouver, Washington, USA
| | | | - Craig Gedye
- Calvary Mater Newcastle, Waratah, New South Wales, Australia
| | | | - David Vicente
- Hospital Universitario Virgen Macarena, Seville, Spain
| | | | - Hui K Gan
- Tumour Targeting Laboratory, Olivia Newton-John Cancer Research Institute, Melbourne, Victoria, Australia.,School of Cancer Medicine, La Trobe University, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia
| | - Andrew M Scott
- Tumour Targeting Laboratory, Olivia Newton-John Cancer Research Institute, Melbourne, Victoria, Australia.,School of Cancer Medicine, La Trobe University, Melbourne, Victoria, Australia.,Department of Molecular Imaging and Therapy, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Isabelle Dussault
- EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts, USA.,Merck KGaA, Darmstadt, Germany
| | | | - Laureen S Ojalvo
- EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts, USA.,Merck KGaA, Darmstadt, Germany
| | | | | |
Collapse
|
11
|
Therapeutic anticoagulation for venous thromboembolism after recent brain surgery: Evaluating the risk of intracranial hemorrhage. Clin Neurol Neurosurg 2020; 197:106202. [DOI: 10.1016/j.clineuro.2020.106202] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/20/2020] [Accepted: 08/30/2020] [Indexed: 12/27/2022]
|
12
|
Carney BJ, Uhlmann EJ, Puligandla M, Mantia C, Weber GM, Neuberg DS, Zwicker JI. Anticoagulation after intracranial hemorrhage in brain tumors: Risk of recurrent hemorrhage and venous thromboembolism. Res Pract Thromb Haemost 2020; 4:860-865. [PMID: 32685895 PMCID: PMC7354400 DOI: 10.1002/rth2.12377] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/23/2020] [Accepted: 05/08/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Intracranial hemorrhage (ICH) is a common and often devastating outcome in patients with brain tumors. Despite this, there is little evidence to guide anticoagulation management following an initial ICH event. OBJECTIVES To analyze the risk of recurrent hemorrhagic and thrombotic outcomes after an initial ICH event in patients with brain tumors and prior venous thromboembolism (VTE). PATIENTS AND METHODS A retrospective cohort study was performed. Radiographic images obtained after initial ICH were reviewed for the primary outcomes of recurrent ICH and VTE. RESULTS AND CONCLUSIONS A total of 79 patients with brain tumors who developed ICH on anticoagulation for VTE were analyzed. Fifty-four patients (68.4%) restarted anticoagulation following ICH. The cumulative incidence of recurrent ICH at 1 year was 6.1% (95% confidence interval [CI], 1.5-15.3) following reinitiation of anticoagulation. Following a major ICH (defined as an ICH >10 mL in size, causing symptoms, or requiring intervention), the rate of recurrent ICH upon reexposure to anticoagulation was 14.5% (95% CI, 2.1-38.35), whereas the rate of recurrent ICH following smaller ICH was 2.6% (95% CI, 0.2%-12.0%). Mortality following a recurrent ICH on anticoagulation was 67% at 30 days. The cumulative incidence of recurrent VTE was significantly lower in the restart cohort compared to patients who did not restart anticoagulation (8.1% vs 35.3%; P = .003). We conclude that resumption of anticoagulation is lowest among patients with metastatic brain tumors with small initial ICH. Following an initial major ICH, resumption of anticoagulation was associated with a high rate of recurrent ICH.
Collapse
Affiliation(s)
- Brian J. Carney
- Division of Hemostasis and ThrombosisBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMassachusettsUSA
| | - Erik J. Uhlmann
- Department of NeurologyBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMassachusettsUSA
| | - Maneka Puligandla
- Department of Data SciencesDana‐Farber Cancer InstituteBostonMassachusettsUSA
| | - Charlene Mantia
- Division of Hematology and OncologyBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMassachusettsUSA
| | - Griffin M. Weber
- Interdisciplinary Medicine and BiotechnologyBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMassachusettsUSA
| | - Donna S. Neuberg
- Department of Data SciencesDana‐Farber Cancer InstituteBostonMassachusettsUSA
| | - Jeffrey I. Zwicker
- Division of Hemostasis and ThrombosisBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMassachusettsUSA
| |
Collapse
|
13
|
Porfidia A, Giordano M, Sturiale CL, D'Arrigo S, Donadini MP, Olivi A, Ageno W, Pola R. Risk of intracranial bleeding in patients with primary brain cancer receiving therapeutic anticoagulation for venous thromboembolism: A meta-analysis. Brain Behav 2020; 10:e01638. [PMID: 32314875 PMCID: PMC7303369 DOI: 10.1002/brb3.1638] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/24/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) is common in glioma patients. Also, spontaneous intracerebral hemorrhage (ICH) is frequently observed in subjects with primary brain tumors. Thus, the management of anticoagulant therapy for VTE is challenging and controversial in these patients. We performed a meta-analysis to clarify the risk of ICH in glioma patients treated with anticoagulant therapy for VTE compared to glioma patients without VTE. MATERIALS AND METHODS A systematic search of the literature was conducted using PubMed, Scopus, and EMBASE databases between January 1980 and January 2019 without language restrictions. Summary statistics for ICH were obtained by calculating the odds ratio (OR) using a random effects model, and heterogeneity across studies was estimated by the I2 statistic. The Newcastle-Ottawa Scale was used to evaluate the quality of studies. RESULTS A total of 368 studies were initially identified. Of these, 346 were excluded after title review. The remaining 22 studies were reviewed in detail. According to the PICO criteria, 15 studies were excluded. Finally, 7 studies were included in the meta-analysis. The OR for ICH in glioma patients receiving therapeutic anticoagulation for VTE versus those who did not receive anticoagulation was 3.66 (95% confidence interval [CI], 1.84-7.29; I2 = 31%). CONCLUSIONS This meta-analysis demonstrates that anticoagulation for VTE increases the risk of ICH in subjects with malignant brain tumors. Future studies are warranted to fully understand the best medical treatment of VTE in glioma patients.
Collapse
Affiliation(s)
- Angelo Porfidia
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marzia Giordano
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carmelo L Sturiale
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Sonia D'Arrigo
- Department of Anesthesiology and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco P Donadini
- Department of Medicine and Surgery, Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Circolo e Fondazione Macchi, ASST Sette Laghi, Varese, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Circolo e Fondazione Macchi, ASST Sette Laghi, Varese, Italy
| | - Roberto Pola
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
14
|
Muster V, Gary T. Incidence, Therapy, and Bleeding Risk-Cancer- Associated Thrombosis in Patients with Glioblastoma. Cancers (Basel) 2020; 12:E1354. [PMID: 32466430 PMCID: PMC7353056 DOI: 10.3390/cancers12061354] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/21/2020] [Accepted: 05/24/2020] [Indexed: 12/21/2022] Open
Abstract
Cancer is an independent risk factor for the development of venous thromboembolism (VTE). Glioblastomas are amongst cancer types with the most thrombogenic potential and patients are at a particularly high risk of VTE with an incidence up to 20-30% per year. Currently, major efforts are underway to gain novel insights into risk factors and pathomechanisms to provide a better understanding of development of VTE in patients with primary brain tumors. Treatment of VTE requires therapeutic anticoagulation, which accordingly to recently-published guidelines should be performed using low molecular weight heparin or, in case of low bleeding risk, using a direct oral anticoagulant. However, this can be very challenging due to an increased risk of intracranial hemorrhage in this patient group. Furthermore, limited data are available on the subgroup of patients with primary brain tumors.
Collapse
Affiliation(s)
- Viktoria Muster
- Division of Vascular Medicine, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria;
| | | |
Collapse
|
15
|
Duong A, Sing S, Taketa C, Miske A, Segal E, Garcia D. Practical considerations for the use of direct oral anticoagulants in oncology patients. J Oncol Pharm Pract 2019; 26:692-702. [PMID: 31840565 DOI: 10.1177/1078155219893008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Oncology patients are at a high risk of experiencing venous thromboembolism. Historically, venous thromboembolisms in cancer patients have been managed with low-molecular-weight heparin on the basis of the CLOT trial published in 2003. However, recent prospective data provide evidence for safe and effective direct oral anticoagulant use in this population. The purpose of this review article is to evaluate the current body of literature surrounding direct oral anticoagulant use in the oncology population and to highlight key practical considerations when prescribing these agents for patients with cancer.
Collapse
Affiliation(s)
- Arianne Duong
- Department of Pharmacy, University of Washington, Seattle, WA, USA.,Department of Pharmacy, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Sarah Sing
- Department of Pharmacy, University of Washington, Seattle, WA, USA.,Department of Pharmacy, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Cathy Taketa
- Department of Pharmacy, University of Washington, Seattle, WA, USA.,Department of Pharmacy, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Abby Miske
- Department of Pharmacy, University of Washington, Seattle, WA, USA.,Department of Pharmacy, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Eve Segal
- Department of Pharmacy, University of Washington, Seattle, WA, USA.,Department of Pharmacy, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - David Garcia
- Department of Hematology, University of Washington School of Medicine, Seattle, WA, USA
| |
Collapse
|
16
|
Wei YC, Chen KF, Wu CL, Lee TW, Liu CH, Shyu YC, Lin CP. Stroke Rate Increases Around the Time of Cancer Diagnosis. Front Neurol 2019; 10:579. [PMID: 31231302 PMCID: PMC6566310 DOI: 10.3389/fneur.2019.00579] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/16/2019] [Indexed: 12/15/2022] Open
Abstract
Objective: To test whether strokes increase around the time of cancer diagnosis, we comprehensively examined the correlations of cancer and stroke by employing a population-based cohort study design. Methods: One million people insured under the Taiwan's National Health Insurance program in 2005 were randomly sampled to create the study's dataset. According to the presence of cancer and/or stroke, patients were separated into cancer and stroke, cancer-only, and stroke-only groups. Diagnoses of cancer, stroke, and comorbidities were defined according to ICD9-CM codes. Cancer and non-cancer populations were matched by age at cancer diagnosis, gender, and stroke risk factors, and each patient with cancer was matched with two non-cancer controls nested in the same year of cancer diagnosis. The hazards of stroke and cumulative incidences within a year after cancer diagnosis were evaluated using Fine and Gray's subdistributional hazard model. Results: The temporal distribution of first-ever stroke in patients with both cancer and stroke was a sharpened bell shape that peaked between 0.5 years before and after cancer diagnosis. Frequencies of stroke were further adjusted by number of cancer survivors. The monthly event rate of stroke remained nested around the time of cancer diagnosis in all strokes. Brain malignancies, lung cancer, gastric cancer, prostate cancer, and leukemia patients obtained higher ratio of stroke, while breast cancer and thyroid cancer patients had low percentage of combining stroke. When compared to non-cancer matched control, the hazard of stroke within one year after cancer diagnosis was increased by cancer at a subdistributional hazard ratio of 1.72 (95% confident interval 1.48 to 2.01; p < 0.0001). Conclusions: Cancer increased the risk of stroke and stroke events were nested around the time of cancer diagnosis, occurring 0.5 years prior to cancer on average regardless of stroke type.
Collapse
Affiliation(s)
- Yi-Chia Wei
- Department of Neurology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Keelung, Taiwan
- Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Kuan-Fu Chen
- Clinical Informatics and Medical Statistics Research Center, Chung Gung University, Taoyuan, Taiwan
- Department of Emergency, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chia-Lun Wu
- Department of Neurology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Keelung, Taiwan
| | - Tay-Wey Lee
- Biostatistical Consultation Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chi-Hung Liu
- Department of Neurology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Chiau Shyu
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Ching-Po Lin
- Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan
| |
Collapse
|
17
|
Carney BJ, Uhlmann EJ, Puligandla M, Mantia C, Weber GM, Neuberg DS, Zwicker JI. Intracranial hemorrhage with direct oral anticoagulants in patients with brain tumors. J Thromb Haemost 2019; 17:72-76. [PMID: 30450803 DOI: 10.1111/jth.14336] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Indexed: 11/29/2022]
Abstract
Essentials Intracranial hemorrhage (ICH) is common in patients with brain tumors. We compared rates of ICH with DOACs and low molecular weight heparin. DOACs were associated with a lower incidence of ICH in primary brain tumors. DOACs appear safe to administer to patients with brain tumors. SUMMARY: Background Direct oral anticoagulants (DOACs) are efficacious in the treatment of cancer-associated thrombosis but are associated with an increased risk of hemorrhage compared with low-molecular-weight heparin in certain malignancies. Whether the DOACs increase the incidence of intracranial hemorrhage (ICH) in patients with brain tumors is not established. Objectives To determine the cumulative incidence of ICH in DOACs compared with Low-molecular-weight heparin (LMWH) in patients with brain tumors and venous thromboembolism. Patients and methods A retrospective comparative cohort study was performed. Radiographic images for all ICH events were reviewed and the primary endpoint was cumulative incidence of ICH at 12 months following initiation of anticoagulation. Results and conclusions A total of 172 patients with brain tumors were evaluated (42 DOAC and 131 LMWH). In the primary brain tumor cohort (n = 67), the cumulative incidence of any ICH was 0% in patients receiving DOACs vs. 36.8% (95% confidence interval [CI], 22.3-51.3%) in those treated with LMWH, with a major ICH incidence of 18.2% (95% CI, 8.4-31.0). In the brain metastases cohort (n = 105), DOACs did not increase the risk of any ICH relative to enoxaparin, with an incidence of 27.8% (95% CI, 5.5-56.7%) compared with 52.9% (95% CI, 37.4-66.2%). Similarly, DOAC did not increase the incidence of major ICH in brain metastases, with a cumulative incidence 11.1% (95% CI, 0.5-40.6%) vs. 17.8% (95% CI, 10.2-27.2%). We conclude that DOACs are not associated with an increased incidence of ICH relative to LMWH in patients with brain metastases or primary brain tumors.
Collapse
Affiliation(s)
- B J Carney
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - E J Uhlmann
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - M Puligandla
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - C Mantia
- Division of Hematology and Oncology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - G M Weber
- Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center and Center for Biomedical Informatics, Boston, MA, USA
| | - D S Neuberg
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - J I Zwicker
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
18
|
Rozanov ID, Shirikov EI, Balkanov AS, Gaganov LE, Vasilenko IA. [Some features controlling the blood D-dimer level after resection of malignant brain glioma]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 81:64-68. [PMID: 29393288 DOI: 10.17116/neiro201781664-68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A high blood D-dimer level is often diagnosed in patients with malignant brain glioma (MBG), with 24% of these patients being detected with deep vein thrombosis of the leg and/or pulmonary embolism (PE). The cause of an elevated blood D-dimer level in most other cases remains unclear. The purpose of this study is to identify the features associated with an increased blood D-dimer level in patients after MBG resection, which may be used to improve the efficacy of adjuvant radiation therapy (ART). RESULTS The study included 50 patients. Three to four weeks after resection of malignant brain glioma (MBG), the blood D-dimer level was determined in patients immediately before the onset of ART. An increase in the blood D-dimer level more than by 0.25 μg/mL was detected in 78% of patients. More often, a high D-dimer level was detected in patients aged 60 years or more. In the same age group, an increase in the D-dimer level was significantly larger (p<0.05) than in younger patients (1.2 and 0.6 μg/mL, respectively). The degree of brain tumor malignancy did not affect the rate and value of an increase in the blood D-dimer level. CONCLUSION Our findings indicate that an increased blood D-dimer level in patients without symptoms of venous thrombosis after craniotomy for MBG is more pronounced in patients aged 60 years and over. The degree of glioma malignancy has no significant effect on this indicator.
Collapse
Affiliation(s)
- I D Rozanov
- Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia, 129110
| | - E I Shirikov
- Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia, 129110
| | - A S Balkanov
- Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia, 129110
| | - L E Gaganov
- Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia, 129110
| | - I A Vasilenko
- Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia, 129110
| |
Collapse
|