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Prouse T, Mohammad MA, Ghosh S, Kumar N, Duhaylungsod ML, Majumder R, Majumder S. Pancreatic Cancer and Venous Thromboembolism. Int J Mol Sci 2024; 25:5661. [PMID: 38891849 PMCID: PMC11171482 DOI: 10.3390/ijms25115661] [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: 03/11/2024] [Revised: 05/09/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) accounts for more than 90% of all pancreatic cancers and is the most fatal of all cancers. The treatment response from combination chemotherapies is far from satisfactory and surgery remains the mainstay of curative strategies. These challenges warrant identifying effective treatments for combating this deadly cancer. PDAC tumor progression is associated with the robust activation of the coagulation system. Notably, cancer-associated thrombosis (CAT) is a significant risk factor in PDAC. CAT is a concept whereby cancer cells promote thromboembolism, primarily venous thromboembolism (VTE). Of all cancer types, PDAC is associated with the highest risk of developing VTE. Hypoxia in a PDAC tumor microenvironment also elevates thrombotic risk. Direct oral anticoagulants (DOACs) or low-molecular-weight heparin (LMWH) are used only as thromboprophylaxis in PDAC. However, a precision medicine approach is recommended to determine the precise dose and duration of thromboprophylaxis in clinical setting.
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Affiliation(s)
- Teagan Prouse
- Department of Interdisciplinary Oncology, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; (T.P.); (M.A.M.); (S.G.); (N.K.); (M.L.D.)
| | - Mohammad A. Mohammad
- Department of Interdisciplinary Oncology, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; (T.P.); (M.A.M.); (S.G.); (N.K.); (M.L.D.)
| | - Sonali Ghosh
- Department of Interdisciplinary Oncology, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; (T.P.); (M.A.M.); (S.G.); (N.K.); (M.L.D.)
| | - Narender Kumar
- Department of Interdisciplinary Oncology, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; (T.P.); (M.A.M.); (S.G.); (N.K.); (M.L.D.)
| | - Ma. Lorena Duhaylungsod
- Department of Interdisciplinary Oncology, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; (T.P.); (M.A.M.); (S.G.); (N.K.); (M.L.D.)
| | - Rinku Majumder
- Department of Interdisciplinary Oncology, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; (T.P.); (M.A.M.); (S.G.); (N.K.); (M.L.D.)
| | - Samarpan Majumder
- Department of Genetics, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA
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Willems RAL, Biesmans C, Campello E, Simioni P, de Laat B, de Vos-Geelen J, Roest M, Ten Cate H. Cellular Components Contributing to the Development of Venous Thrombosis in Patients with Pancreatic Cancer. Semin Thromb Hemost 2024; 50:429-442. [PMID: 38049115 DOI: 10.1055/s-0043-1777304] [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: 12/06/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive type of cancer and has a poor prognosis. Patients with PDAC are at high risk of developing thromboembolic events, which is a leading cause of morbidity and mortality following cancer progression. Plasma-derived coagulation is the most studied process in cancer-associated thrombosis. Other blood components, such as platelets, red blood cells, and white blood cells, have been gaining less attention. This narrative review addresses the literature on the role of cellular components in the development of venous thromboembolism (VTE) in patients with PDAC. Blood cells seem to play an important role in the development of VTE. Altered blood cell counts, i.e., leukocytosis, thrombocytosis, and anemia, have been found to associate with VTE risk. Tumor-related activation of leukocytes leads to the release of tissue factor-expressing microvesicles and the formation of neutrophil extracellular traps, initiating coagulation and forming a scaffold for thrombi. Tissue factor-expressing microvesicles are also thought to be released by PDAC cells. PDAC cells have been shown to stimulate platelet activation and aggregation, proposedly via the secretion of podoplanin and mucins. Hypofibrinolysis, partially explained by increased plasminogen activator inhibitor-1 activity, is observed in PDAC. In short, PDAC-associated hypercoagulability is a complex and multifactorial process. A better understanding of cellular contributions to hypercoagulability might lead to the improvement of diagnostic tests to identify PDAC patients at highest risk of VTE.
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Affiliation(s)
- Ruth Anne Laura Willems
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Vascular Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Charlotte Biesmans
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Vascular Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Elena Campello
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Paolo Simioni
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Bas de Laat
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, Maastricht, The Netherlands
- Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, The Netherlands
| | - Judith de Vos-Geelen
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- GROW, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Mark Roest
- Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, The Netherlands
| | - Hugo Ten Cate
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Vascular Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, Maastricht, The Netherlands
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Zhang C, Zhu J, Zhang M, Yuan Z, Wang X, Ye C, Jiang H, Ye X. Prognostic nomogram for predicting lower extremity deep venous thrombosis in ruptured intracranial aneurysm patients who underwent endovascular treatment. Front Neurol 2023; 14:1202076. [PMID: 37609653 PMCID: PMC10440693 DOI: 10.3389/fneur.2023.1202076] [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: 04/07/2023] [Accepted: 06/30/2023] [Indexed: 08/24/2023] Open
Abstract
Background Lower extremity deep vein thrombosis (DVT) is one of the major postoperative complications in patients with ruptured intracranial aneurysms (RIA) who underwent endovascular treatment (EVT). However, patient-specific predictive models are still lacking. This study aimed to construct and validate a nomogram model for estimating the risk of lower extremity DVT for RIA patients who underwent EVT. Methods This cohort study enrolled 471 RIA patients who received EVT in our institution between 1 January 2020 to 4 February 2022. Perioperative information on participants is collected to develop and validate a nomogram for predicting lower extremity DVT in RIA patients after EVT. Predictive accuracy, discriminatory capability, and clinical effectiveness were evaluated by concordance index (C-index), calibration curves, and decision curve analysis. Result Multivariate logistic regression analysis showed that age, albumin, D-dimer, GCS score, middle cerebral artery aneurysm, and delayed cerebral ischemia were independent predictors for lower extremity DVT. The nomogram for assessing individual risk of lower extremity DVT indicated good predictive accuracy in the primary cohort (c-index, 0.92) and the validation cohort (c-index, 0.85), with a wide threshold probability range (4-82%) and superior net benefit. Conclusion The present study provided a reliable and convenient nomogram model developed with six optimal predictors to assess postoperative lower extremity DVT in RIA patients, which may benefit to strengthen the awareness of lower extremity DVT control and supply appropriate resources to forecast patients at high risk of RIA-related lower extremity DVT.
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Affiliation(s)
- Chengwei Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Wenzhou Medical University, Wenzhou, China
| | - Jiaqian Zhu
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Wenzhou Medical University, Wenzhou, China
| | - Minghong Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Wenzhou Medical University, Wenzhou, China
| | - Ziru Yuan
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Wenzhou Medical University, Wenzhou, China
| | - Xiaoxiong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Wenzhou Medical University, Wenzhou, China
| | - Chengxing Ye
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Wenzhou Medical University, Wenzhou, China
| | - Haojie Jiang
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Wenzhou Medical University, Wenzhou, China
| | - Xiong Ye
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Wenzhou Medical University, Wenzhou, China
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Swisher AR, Ornelas D, Ornelas D, Namazi G, Theodory B, Chitkara A, Desai A, Sethi P. Venous Thromboembolism in Metastatic Uterine Leiomyosarcoma: A Case Report and Review of the Literature. Case Rep Oncol 2023; 16:900-906. [PMID: 37900811 PMCID: PMC10601721 DOI: 10.1159/000531761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/13/2023] [Indexed: 10/31/2023] Open
Abstract
We report an unusual case of extensive deep vein thrombosis (DVT) and pulmonary embolism (PE) in the setting of metastatic uterine leiomyosarcoma. Recognition of the associated sequelae of this condition may improve short- and long-term outcomes. A 56-year-old black female with a history of uterine leiomyosarcoma diagnosed incidentally after total abdominal hysterectomy for fibroid uterus without initiation of chemoradiation treatment presented to the emergency department complaining of generalized weakness and progressively worsening stridor for 2 weeks. The patient was experiencing shortness of breath, dysphagia, and hoarseness. Physical exam was remarkable for rhonchi but was otherwise normal. Diagnostic imaging via CT of the abdomen, pelvis, and chest revealed DVTs of the left common and external iliac veins, the superior mesenteric artery, multiple pulmonary emboli of the right pulmonary artery, several nodular lesions within the lungs, and scattered peritoneal necrotic lesions, which were suspicious for metastatic disease. Additionally, CT of the neck showed an exophytic mass protruding into the airway from the subglottic region and thyromegaly with bilateral thyroid lobe nodules. The patient was subsequently started on Eliquis and chemotherapy. The rarity of this case is rooted in the extent of the patient's DVTs and PEs secondary to hypercoagulability in metastatic cancer. This presentation should be further evaluated to exclude thrombophilias or underlying malignancies. Drawing from the lessons of this case will help guide future clinical management regarding the care of metastatic uterine leiomyosarcoma.
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Affiliation(s)
- Austin R. Swisher
- Minimally Invasive Gynecologic Surgery, University of California, Riverside, CA, USA
| | - Denise Ornelas
- Minimally Invasive Gynecologic Surgery, University of California, Riverside, CA, USA
| | - Diana Ornelas
- Minimally Invasive Gynecologic Surgery, University of California, Riverside, CA, USA
| | - Golnaz Namazi
- Minimally Invasive Gynecologic Surgery, University of California, Riverside, CA, USA
| | - Bassam Theodory
- Minimally Invasive Gynecologic Surgery, University of California, Riverside, CA, USA
| | - Akshit Chitkara
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, CA, USA
| | - Aditya Desai
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, CA, USA
| | - Prabhdeep Sethi
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, CA, USA
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García Adrián S, González AR, de Castro EM, Olmos VP, Morán LO, Del Prado PM, Fernández MS, Burón JDC, Escobar IG, Galán JM, Pérez AIF, Neria F, Lavin DC, Hernández BLDSV, Jiménez-Fonseca P, Muñoz Martín AJ. Incidence, risk factors, and evolution of venous thromboembolic events in patients diagnosed with pancreatic carcinoma and treated with chemotherapy on an outpatient basis. Eur J Intern Med 2022; 105:30-37. [PMID: 35931614 DOI: 10.1016/j.ejim.2022.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/20/2022] [Accepted: 07/26/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pancreatic carcinoma is one of the tumors associated with a higher risk for thromboembolic events, with incidence rates ranging from 5% to 41% in previous retrospective series. PATIENTS AND METHODS We conducted a retrospective study in eleven Spanish hospitals that included 666 patients diagnosed with pancreatic carcinoma (any stage) between 2008 and 2011 and treated with chemotherapy. The main objective was to evaluate the incidence of venous thromboembolic events (VTE) in this population, as well as potential risk factors for thrombosis. The impact of VTE on mortality was also assessed. RESULTS With a median follow-up of 9.3 months, the incidence of VTE was 22.1%; 52% were diagnosed incidentally. Our study was unable to confirm the ability of the Khorana score to discriminate between patients in the intermediate or high risk category for thrombosis. The presence of VTE proved to be an independent prognostic factor associated with increased risk of death (HR 2.39, 95% CI 1.96-2.92). Symptomatic events correlated with higher mortality than asymptomatic events (HR 1.72; 95% CI, 1.21-2.45; p = 0.002), but incidental VTE, including visceral vein thrombosis (VVT), negatively affected survival compared to patients without VTE. Subjects who developed VTE within the first 3 months of diagnosis of pancreatic carcinoma had lower survival rates than those with VTE after 3 months (HR 1.92, 95% CI 1.30-2.84; p<0.001). CONCLUSIONS Pancreatic carcinoma is associated with a high incidence of VTE, which, when present, correlates with worse survival, even when thrombosis is incidental. Early onset VTE has a particularly negative impact.
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Affiliation(s)
- Silvia García Adrián
- Medical Oncology Department, Hospital Universtario de Móstoles, C/ Dr. Luis Montes S/N, Madrid 28935, Spain; Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain.
| | - Adán Rodríguez González
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - Eva Martínez de Castro
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Vanessa Pachón Olmos
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Laura Ortega Morán
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Purificación Martínez Del Prado
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario de Basurto, Bilbao, Spain
| | - Mercedes Salgado Fernández
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Complejo Universitario de Orense, Orense, Spain
| | - José David Cumplido Burón
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital de Torrevieja, Torrevieja, Spain
| | - Ignacio García Escobar
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Joaquina Martínez Galán
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Ana Isabel Ferrer Pérez
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Fernando Neria
- Faculty of Medicine, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - Diego Cacho Lavin
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Borja López de San Vicente Hernández
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario de Basurto, Bilbao, Spain
| | - Paula Jiménez-Fonseca
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - Andrés J Muñoz Martín
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
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Yamai T, Ikezawa K, Hiraga E, Kawamoto Y, Hirao T, Higashi S, Daiku K, Maeda S, Abe Y, Urabe M, Kai Y, Takada R, Nakabori T, Fukutake N, Uehara H, Fujita M, Ohkawa K. Early detection of venous thromboembolism after the initiation of chemotherapy predicts a poor prognosis in patients with unresectable metastatic pancreatic cancer who underwent first-line chemotherapy with gemcitabine plus nab-paclitaxel. PLoS One 2022; 17:e0264653. [PMID: 35231078 PMCID: PMC8887762 DOI: 10.1371/journal.pone.0264653] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 02/14/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pancreatic cancer is associated with a high thromboembolism risk. We investigated the significance of early venous thromboembolism (VTE) detection in patients with unresectable metastatic pancreatic cancer (UR-MPC) who received first-line chemotherapy with gemcitabine plus nab-paclitaxel (GnP). METHODS This single-center retrospective study enrolled 174 patients with UR-MPC who underwent GnP as a first-line chemotherapy from April 2017 to March 2020. The early detection of VTE (deep venous thrombosis and pulmonary thromboembolism) was defined as diagnosis by the first follow-up CT scan after the initiation of chemotherapy. We compared the patients with early detection of VTE (VTE (+) group) with the others (VTE (-) group). We examined overall survival (OS), progress free survival (PFS), severe adverse events, and predictors associated with OS using the Cox proportional hazards model. RESULTS Early detection of VTE was observed in 17 patients (9.8%). Thirteen patients were diagnosed with VTE at treatment initiation, and four patients were diagnosed after treatment initiation. The median time to diagnosis after treatment initiation was 55 days (range: 31-71 days). Only 3 patients were symptomatic. The VTE (+) group exhibited worse OS and PFS than the VTE (-) group (OS: 259 days vs. 400 days, P < 0.001; PFS: 120 days vs. 162 days, P = 0.008). The frequency of grade 3-4 adverse events was not significantly different. Although the performance status was poorer in the VTE (+) group, VTE was identified as a statistically significant independent predictor for OS in multivariate analyses (HR, 1.87; 95% CI, 1.02-3.44; P = 0.041). CONCLUSIONS Early VTE detection is a predictor of a poor prognosis in UR-MPC patients who receive GnP as first-line chemotherapy, suggesting that screening VTE for patients with UR-MPC is crucial, even if patients are asymptomatic.
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Affiliation(s)
- Takuo Yamai
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kenji Ikezawa
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Erika Hiraga
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yasuharu Kawamoto
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takeru Hirao
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Sena Higashi
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kazuma Daiku
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Shingo Maeda
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yutaro Abe
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Makiko Urabe
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yugo Kai
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ryoji Takada
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Tasuku Nakabori
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Nobuyasu Fukutake
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroyuki Uehara
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masashi Fujita
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Kazuyoshi Ohkawa
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
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Frere C. Burden of venous thromboembolism in patients with pancreatic cancer. World J Gastroenterol 2021; 27:2325-2340. [PMID: 34040325 PMCID: PMC8130043 DOI: 10.3748/wjg.v27.i19.2325] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/28/2021] [Accepted: 04/22/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer (PC) is a devastating malignancy with fewer than 10% of patients being alive at 5 years after diagnosis. Venous thromboembolism (VTE) occurs in approximatively 20% of patients with PC, resulting in increased morbidity, mortality and significant health care costs. The management of VTE is particularly challenging in these frail patients. Adequate selection of the most appropriate anticoagulant for each individual patient according to the current international guidelines is warranted for overcoming treatment challenges. The International Initiative on Thrombosis and Cancer multi-language web-based mobile application (downloadable for free at www.itaccme.com) has been developed to help clinicians in decision making in the most complex situations. In this narrative review, we will discuss the contemporary epidemiology and burden of VTE in PC patients, the performances and limitations of current risk assessment models to predict the risk of VTE, as well as evidence from recent clinical trials for the primary prophylaxis and treatment of cancer-associated VTE that support up-dated clinical practice guidelines.
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Affiliation(s)
- Corinne Frere
- Department of Haematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris F-75013, France
- INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, GRC 27 GRECO, Sorbonne Université, Paris F-75013, France
- Groupe Francophone Thrombose et Cancer, Saint-Louis Hospital, Paris F-75010, France
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Barrau M, Maoui K, Le Roy B, Roblin X, Mismetti P, Phelip JM, Williet N. Early venous thromboembolism is a strong prognostic factor in patients with advanced pancreatic ductal adenocarcinoma. J Cancer Res Clin Oncol 2021; 147:3447-3454. [PMID: 33715087 DOI: 10.1007/s00432-021-03590-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/07/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND There are still controversial data regarding the prognostic value of Venous ThromboEmbolism (VTE) in advanced Pancreatic Ductal AdenoCarcinoma (PDAC) and thromboprophylaxis is poorly prescribed despite international recommendations. METHODS Medical charts of patients consecutively treated for advanced PDAC from 2010 to 2019 were retrospectively reviewed. Progression-free survival (PFS) and overall survival (OS) were estimated using Kaplan-Meier method. Prognostic Factors were identified using a multivariate Cox's proportional hazard model. Early VTE was defined as VTE occurring within the three months following the PDAC diagnosis. RESULTS A total of 174 patients were included (median age: 67 years; males: 55.2%; performance status (PS) 0-1: 88.5%) with metastatic disease in 74.7%. At baseline, Khorana score was high (≥ 3) in the vast majority of cases (93.7%). The cumulative incidences of VTE were 12.4% (95% CI 7.3-17.2) at 3 months, 20.4% (95% CI 13.9-26.4) at 6 months and 28.1% (95% CI 20.0-35.3) at 12 months. Patients who experienced early VTE had shorter PFS (3.8 months vs. 7.1 months; HR = 2.02; 95% CI 1.21-3.37; p = 0.006) and shorter OS (8.0 months vs. 14.1 months; HR = 2.42; 95% CI 1.37-4.30; p = 0.002) compared to the others, independently of prognostic factors such as PS, liver metastases, carcinomatosis, and chemotherapy regimen. CONCLUSION early VTE is a strong prognostic factor in advanced PDAC and occurs in about one in 10 patients.
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Affiliation(s)
- Mathilde Barrau
- University Hospital of Saint-Etienne, Saint-Priest en Jarez, France
| | - Khawla Maoui
- University Hospital of Saint-Etienne, Saint-Priest en Jarez, France
| | - Bertrand Le Roy
- University Hospital of Saint-Etienne, Saint-Priest en Jarez, France
| | - Xavier Roblin
- University Hospital of Saint-Etienne, Saint-Priest en Jarez, France
| | - Patrick Mismetti
- University Hospital of Saint-Etienne, Saint-Priest en Jarez, France
| | - Jean-Marc Phelip
- University Hospital of Saint-Etienne, Saint-Priest en Jarez, France
| | - Nicolas Williet
- University Hospital of Saint-Etienne, Saint-Priest en Jarez, France.
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Suzuki T, Hori R, Takeuchi K, Yamamura R, Katoh H, Noji Y, Yamaguchi M, Fujino S. Venous Thromboembolism in Japanese Patients With Pancreatic Cancer. Clin Appl Thromb Hemost 2021; 27:10760296211051766. [PMID: 34730013 PMCID: PMC8573688 DOI: 10.1177/10760296211051766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/31/2021] [Accepted: 09/21/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer-related deaths in Japan. Previous studies from other countries have reported venous thromboembolism prevalence rates of 12 to 36% in patients with pancreatic cancer. In this study, we aimed to determine the incidence of VTE in patients with PDAC in Japan and compare the characteristics of patients with and without VTE. METHODS In this retrospective cohort study, clinicopathological characteristics of patients with and without concomitant VTE were compared. PATIENTS Patients with PDAC treated at Fukui Prefectural Hospital, Japan from 2010 to 2019. RESULTS The 1-year survival rate of all patients with pancreatic cancer was 40.7%. Among 432 patients with PDAC, 31 developed VTE. Seventeen (55%) patients received anticoagulant therapy. Compared with the non-VTE group, the VTE group had significantly more patients whose body mass index was >25 kg/m² (p = .035) and had a significantly higher rate of chemotherapy (p = .024). There was no significant difference in median survival time from PDAC diagnosis between the VTE and non-VTE groups. The 6-month mortality rate after VTE diagnosis was 54.8%. PDAC-related death was the most frequent cause of death, and thrombus-related death was not observed. CONCLUSION Several baseline characteristics differed between patients with and without VTE. The incidence of VTE in patients with PDAC is high. However, because the prognosis of PDAC itself remains quite poor, VTE may not have a significant effect on prognosis.
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Affiliation(s)
- Takahito Suzuki
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
| | - Reina Hori
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
| | - Kazutaka Takeuchi
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
| | - Ryo Yamamura
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
| | - Hiromasa Katoh
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
| | - Yoshihiro Noji
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
| | - Masato Yamaguchi
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
| | - Susumu Fujino
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
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10
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Prognostic factors for VTE and bleeding in hospitalized medical patients: a systematic review and meta-analysis. Blood 2020; 135:1788-1810. [PMID: 32092132 DOI: 10.1182/blood.2019003603] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/12/2020] [Indexed: 12/29/2022] Open
Abstract
There may be many predictors of venous thromboembolism (VTE) and bleeding in hospitalized medical patients, but until now, systematic reviews and assessments of the certainty of the evidence have not been published. We conducted a systematic review to identify prognostic factors for VTE and bleeding in hospitalized medical patients and searched Medline and EMBASE from inception through May 2018. We considered studies that identified potential prognostic factors for VTE and bleeding in hospitalized adult medical patients. Reviewers extracted data in duplicate and independently and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. Of 69 410 citations, we included 17 studies in our analysis: 14 that reported on VTE, and 3 that reported on bleeding. For VTE, moderate-certainty evidence showed a probable association with older age; elevated C-reactive protein (CRP), D-dimer, and fibrinogen levels; tachycardia; thrombocytosis; leukocytosis; fever; leg edema; lower Barthel Index (BI) score; immobility; paresis; previous history of VTE; thrombophilia; malignancy; critical illness; and infections. For bleeding, moderate-certainty evidence showed a probable association with older age, sex, anemia, obesity, low hemoglobin, gastroduodenal ulcers, rehospitalization, critical illness, thrombocytopenia, blood dyscrasias, hepatic disease, renal failure, antithrombotic medication, and presence of a central venous catheter. Elevated CRP, a lower BI, a history of malignancy, and elevated heart rate are not included in most VTE risk assessment models. This study informs risk prediction in the management of hospitalized medical patients for VTE and bleeding; it also informs guidelines for VTE prevention and future research.
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11
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Primary Thromboprophylaxis in Ambulatory Pancreatic Cancer Patients Receiving Chemotherapy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cancers (Basel) 2020; 12:cancers12082028. [PMID: 32722064 PMCID: PMC7464699 DOI: 10.3390/cancers12082028] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/16/2020] [Accepted: 07/22/2020] [Indexed: 02/07/2023] Open
Abstract
Patients with pancreatic cancer (PC) carry the highest risk of venous thromboembolism (VTE) amongst all cancer patients. Appropriate use of primary thromboprophylaxis might significantly and safely reduce its burden. We performed a systematic review of published studies and meeting abstracts using MEDLINE and EMBASE through July 2020 to evaluate the efficacy and safety of primary thromboprophylaxis in ambulatory PC patients receiving chemotherapy. The Mantel–Haenszel random effect model was used to estimate the pooled event-based risk ratio (RR) and the pooled absolute risk difference (RD) with a 95% confidence interval (CI). Five randomized controlled studies with 1003 PC patients were included in this meta-analysis. Compared to placebo, thromboprophylaxis significantly decreased the risk of VTE (pooled RR 0.31, 95% CI 0.19–0.51, p < 0.00001, I2 = 8%; absolute RD −0.08, 95% CI −0.12–−0.05, p < 0.00001, I2 = 0%), with an estimated number needed to treat of 11.9 patients to prevent one VTE event. Similar reductions of VTE were observed in studies with parenteral (RR 0.30, 95% CI 0.17–0.53) versus oral anticoagulants (RR 0.37, 95% CI 0.14–0.99) and in studies using prophylactic doses of anticoagulants (RR 0.34, 95% CI 0.17–0.70) versus supra-prophylactic doses of anticoagulants (RR 0.27, 95% CI 0.08–0.90). The pooled RR for major bleeding was 1.08 (95% CI 0.47–2.52, p = 0.85, I2 = 0%) and the absolute RD was 0.00 (95% CI −0.02–0.03, p = 0.85, I2 = 0%). Evidence supports a net clinical benefit of thromboprophylaxis in ambulatory PC patients receiving chemotherapy. Adequately powered randomized phase III studies assessing the most effective anticoagulant and the optimal dose, schedule and duration of thromboprophylaxis to be used are warranted.
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12
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Frere C, Bournet B, Gourgou S, Fraisse J, Canivet C, Connors JM, Buscail L, Farge D. Incidence of Venous Thromboembolism in Patients With Newly Diagnosed Pancreatic Cancer and Factors Associated With Outcomes. Gastroenterology 2020; 158:1346-1358.e4. [PMID: 31843588 DOI: 10.1053/j.gastro.2019.12.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pancreatic ductal adenocarcinoma (PDAC) is associated with the highest incidence of venous thromboembolism (VTE) of any cancer type. However, little is known about risk factors for VTE or its outcomes in patients with PDAC. METHODS We collected data from a prospective, observational study performed at multiple centers in France from May 2014 through November 2018 (the Base Clinico-Biologique de l'Adénocarcinome Pancréatique [BACAP] study) linked to a database of patients with a new diagnosis of PDAC of any stage. Data were collected from 731 patients at baseline and during clinical follow-up or in the event of symptoms. The primary endpoint was the onset of VTE during follow-up. The secondary endpoints were progression-free survival (PFS) and overall survival (OS) times. RESULTS During a median follow-up of 19.3 months, 152 patients (20.79%) developed a VTE. The median time from PDAC diagnosis to the onset of VTE was 4.49 months. Cumulative incidence values of VTE were 8.07% (95% confidence interval [CI], 6.31-10.29) at 3 months and 19.21% (95% CI, 16.27-22.62) at 12 months. In multivariate analysis, PDAC primary tumor location (isthmus vs head: hazard ratio [HR], 2.06; 95% CI, 1.09-3.91; P = .027) and stage (locally advanced vs resectable or borderline: HR, 1.66; 95% CI, 1.10-2.51, P = .016; metastatic vs resectable or borderline: HR, 2.50; 95% CI, 1.64-3.79; P < .001) were independent risk factors for the onset of VTE. Patients who developed VTE during follow-up had shorter times of PFS (HR, 1.74; 95% CI, 1.19-2.54; P = .004) and OS (HR, 2.02; 95% CI, 1.57-2.60; P < .001). CONCLUSION In an analysis of data from the BACAP study, we found that frequent and early onsets of VTE after diagnoses of PDAC are associated with significant decreases in times of PFS and OS. Studies are needed to determine whether primary prophylaxis of VTE in patients with PDAC will improve morbidity and mortality related to VTE. (ClinicalTrials.gov, Number: clinicaltrials.gov as number NCT02818829).
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Affiliation(s)
- Corinne Frere
- Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism and Nutrition, Paris, France; Assistance Publique Hôpitaux de Paris, Department of Haematology, Pitié-Salpêtrière Hospital, Paris, France
| | - Barbara Bournet
- University of Toulouse, Toulouse, France; CHU de Toulouse, Department of Gastroenterology and Pancreatology, Toulouse, France
| | - Sophie Gourgou
- Université de Montpellier, Institut du Cancer de Montpellier-Unité de Biométrie, Montpellier, France
| | - Julien Fraisse
- Université de Montpellier, Institut du Cancer de Montpellier-Unité de Biométrie, Montpellier, France
| | - Cindy Canivet
- University of Toulouse, Toulouse, France; CHU de Toulouse, Department of Gastroenterology and Pancreatology, Toulouse, France
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Louis Buscail
- University of Toulouse, Toulouse, France; CHU de Toulouse, Department of Gastroenterology and Pancreatology, Toulouse, France
| | - Dominique Farge
- Université de Paris, Institut Universitaire d'Hématologie, Paris, France; Assistance Publique Hôpitaux de Paris, Saint-Louis Hospital, Internal Medicine, Autoimmune and Vascular Disease Unit, Paris, France; Department of Medicine, McGill University, Montreal, Québec, Canada.
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13
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Farge D, Bournet B, Conroy T, Vicaut E, Rak J, Zogoulous G, Barkun J, Ouaissi M, Buscail L, Frere C. Primary Thromboprophylaxis in Pancreatic Cancer Patients: Why Clinical Practice Guidelines Should Be Implemented. Cancers (Basel) 2020; 12:E618. [PMID: 32155940 PMCID: PMC7139861 DOI: 10.3390/cancers12030618] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 02/27/2020] [Accepted: 03/04/2020] [Indexed: 12/13/2022] Open
Abstract
Exocrine pancreatic ductal adenocarcinoma, simply referred to as pancreatic cancer (PC) has the worst prognosis of any malignancy. Despite recent advances in the use of adjuvant chemotherapy in PC, the prognosis remains poor, with fewer than 8% of patients being alive at 5 years after diagnosis. The prevalence of PC has steadily increased over the past decades, and it is projected to become the second-leading cause of cancer-related death by 2030. In this context, optimizing and integrating supportive care is important to improve quality of life and survival. Venous thromboembolism (VTE) is a common but preventable complication in PC patients. VTE occurs in one out of five PC patients and is associated with significantly reduced progression-free survival and overall survival. The appropriate use of primary thromboprophylaxis can drastically and safely reduce the rates of VTE in PC patients as shown from subgroup analysis of non-PC targeted placebo-controlled randomized trials of cancer patients and from two dedicated controlled randomized trials in locally advanced PC patients receiving chemotherapy. Therefore, primary thromboprophylaxis with a Grade 1B evidence level is recommended in locally advanced PC patients receiving chemotherapy by the International Initiative on Cancer and Thrombosis clinical practice guidelines since 2013. However, its use and potential significant clinical benefit continues to be underrecognized worldwide. This narrative review aims to summarize the main recent advances in the field including on the use of individualized risk assessment models to stratify the risk of VTE in each patient with individual available treatment options.
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Affiliation(s)
- Dominique Farge
- Institut Universitaire d’Hématologie, Université de Paris, EA 3518, F-75010 Paris, France
- Assistance Publique Hôpitaux de Paris, Saint-Louis Hospital, Internal Medicine, Autoimmune and Vascular Disease Unit, F-75010 Paris, France
- Department of Medicine, McGill University, Montreal, Québec, QC H4A 3J1, Canada
| | - Barbara Bournet
- University of Toulouse, F-31059 Toulouse, France; (B.B.); (L.B.)
- CHU de Toulouse, Department of Gastroenterology and Pancreatology, F-31059 Toulouse, France
| | - Thierry Conroy
- Institut de Cancérologie de Lorraine, Department of Medical Oncology, Université de Lorraine, APEMAC, EA4360, F-54519 Vandoeuvre-lès-Nancy, France;
| | - Eric Vicaut
- Department of Biostatistics, Université de Paris, F-75010 Paris, France;
- Assistance Publique Hôpitaux de Paris, Department of Biostatistics, Fernand Widal Hospital, F-75010 Paris, France
| | - Janusz Rak
- McGill University and the Research Institute of the McGill University Health Centre, Montreal, Québec, QC H4A 3J1, Canada; (J.R.)
| | - George Zogoulous
- McGill University and the Research Institute of the McGill University Health Centre, Montreal, Québec, QC H4A 3J1, Canada; (J.R.)
| | - Jefferey Barkun
- McGill University and the Research Institute of the McGill University Health Centre, Montreal, Québec, QC H4A 3J1, Canada; (J.R.)
| | - Mehdi Ouaissi
- Department of Digestive, Oncological, Endocrine, and Hepatic Surgery, and Hepatic Transplantation, Trousseau Hospital, CHRU Trousseau, F-37170 Chambray-les-Tours, France;
| | - Louis Buscail
- University of Toulouse, F-31059 Toulouse, France; (B.B.); (L.B.)
- CHU de Toulouse, Department of Gastroenterology and Pancreatology, F-31059 Toulouse, France
| | - Corinne Frere
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM UMRS_1166, GRC 27 GRECO, F-75013 Paris, France;
- Assistance Publique Hôpitaux de Paris, Department of Haematology, Pitié-Salpêtrière Hospital, F-75013 Paris, France
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14
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Godinho J, Casa‐Nova M, Moreira‐Pinto J, Simões P, Paralta Branco F, Leal‐Costa L, Faria A, Lopes F, Teixeira JA, Passos‐Coelho JL. ONKOTEV Score as a Predictive Tool for Thromboembolic Events in Pancreatic Cancer-A Retrospective Analysis. Oncologist 2020; 25:e284-e290. [PMID: 32043787 PMCID: PMC7011666 DOI: 10.1634/theoncologist.2019-0510] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 09/30/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a frequent complication in patients with cancer and causes considerable morbidity and mortality. The risk of VTE is higher in patients with pancreatic cancer and is often associated with treatment delays or interruptions. Recently, the ONKOTEV score was proposed as a VTE risk predictor model for patients with cancer, but its validation is still ongoing. PATIENTS AND METHODS We conducted a retrospective study to determine the incidence of VTE and to evaluate the ONKOTEV score as a VTE predictive tool in a population of patients with pancreatic cancer. RESULTS Between February 2012 and May 2017, 165 patients were included in the study. The median age was 73 years, 45.5% of patients were female, and 55.8% had stage IV disease. Fifty-one patients had a VTE (30.9%); 23.5% had pulmonary embolism, 25.5% had deep venous thrombosis, and 51.0% had visceral VTE (VsT). At a median follow-up time of 6.3 months, cumulative incidence of VTE was less than 10% for ONKOTEV scores 0 or 1 and approximately 40% and 70% for scores 2 and ≥3, respectively. CONCLUSION The high VTE incidence observed in this study is consistent with prior reports. Patients at high risk for VTE with no increase in hemorrhagic risk should be considered for primary thromboprophylaxis. The ONKOTEV score may stratify VTE risk in patients with pancreatic cancer, with ONKOTEV score ≥2 being associated with a higher VTE occurrence. IMPLICATIONS FOR PRACTICE Venous thromboembolism (VTE) is a frequent complication of patients with pancreatic cancer and causes considerable morbidity, treatment delays or interruptions, and mortality. Thromboprophylaxis is not used routinely in ambulatory patients. Tools to stratify the risk of VTE are important to help select patients who may benefit from thromboprophylaxis. Recently, the ONKOTEV score was proposed as a VTE risk predictor model for patients with cancer, but its validation is still ongoing. In this patient series, ONKOTEV score ≥2 was associated with high VTE occurrence and may stratify VTE risk in patients with pancreatic cancer, suggesting that ONKOTEV can be considered to select patients with pancreatic cancer for primary thromboprophylaxis.
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Affiliation(s)
| | | | | | | | | | | | - Ana Faria
- Hospital Beatriz ÂngeloLouresPortugal
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15
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The relationship between pancreatic cancer and hypercoagulability: a comprehensive review on epidemiological and biological issues. Br J Cancer 2019; 121:359-371. [PMID: 31327867 PMCID: PMC6738049 DOI: 10.1038/s41416-019-0510-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 05/13/2019] [Accepted: 05/28/2019] [Indexed: 12/15/2022] Open
Abstract
It has long been recognised that pancreatic cancer induces a hypercoagulable state that may lead to clinically apparent thrombosis. Although the relationship between pancreatic cancer and hypercoagulability is well described, the underlying pathological mechanism(s) and the interplay between these pathways remain a matter of intensive study. This review summarises existing data on epidemiology and pathogenesis of thrombotic complications in pancreatic cancer with a particular emphasis on novel pathophysiological pathways. Pancreatic cancer is characterised by high tumoural expression of tissue factor, activation of leukocytes with the release of neutrophil extracellular traps, the dissemination of tumour-derived microvesicles that promote hypercoagulability and increased platelet activation. Furthermore, other coagulation pathways probably contribute to these processes, such as those that involve heparanase, podoplanin and hypofibrinolysis. In the era in which heparin and its derivatives—the currently recommended therapy for cancer-associated thrombosis—might be superseded by direct oral anticoagulants, novel data from mouse models of cancer-associated thrombosis suggest the possibility of future personalised therapeutic approaches. In this dynamic era for cancer-associated thrombosis, the discovery of novel prothrombotic and proinflammatory mechanisms will potentially uncover pharmacological targets to prevent and treat thrombosis without adversely affecting haemostasis.
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16
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Diaz Quintero LA, Fuentes HE, Tafur AJ, Majmudar K, Salazar Adum JP, Golemi I, Paz LH, Stocker S, Talamonti M. Pancreatic cancer thromboembolic outcomes: rate of thrombosis after adenocarcinoma and non-adenocarcinoma pancreatic cancer surgery. INT ANGIOL 2019; 38:194-200. [PMID: 31112026 DOI: 10.23736/s0392-9590.19.04127-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study was to define the association of non-adenocarcinoma pancreatic cancer (NACPC) as a risk factor for postoperative cancer-associated thrombosis (CAT). METHODS We conducted analysis of prospectively collected data of pancreatic cancer surgery. Randomly collected NACPC cases were matched 1:3 to adenocarcinoma cases (ACPC). Variables included comorbidities, demographics, cancer extension, and preoperative Khorana score (KRS). Primary outcome was CAT, which included deep vein thrombosis and pulmonary embolism confirmed by imaging. Categorical variables are presented as percentages, continuous variables as median and range. SPSS, χ2, Cochran-Armitage, and logistic regression were use for analysis. RESULTS The study included 441 patients. Age 65.9±11.5, male 57% (N.=252), 8% (N.=36) had metastasis. IPMN and neuroendocrine were the most common NACPC. Median follow-up was 449 days in which 90 (20%) patients developed CAT. The odds (Odds Ratio [OR] 1.1, 95% Confidence Interval [CI] 0.6- 1.9, P=0.7) and time to venous thromboembolism were not different between NACPC and ACPC. We analyzed for trends of prophylactic strategies by year of surgery; there was no trend for NACPC (P=0.4) or ACPC (P=0.06). KRS was not associated with CAT. In the multivariate analysis, peripheral artery disease (Adjusted Odds Ratio [ORadj] 5.4, 95% CI: 1.7-17.3), ASA class ≥4 (ORadj 3.6; 95% CI: 1.3-10.4), length of stay >9 days (ORadj: 1.9; 1.2-3.2), and cancer vascular invasion (ORadj: 2.9; 95% CI: 1.6-5.3) were associated with CAT. CONCLUSIONS The rate of VTE in NACPC after surgery was high and not different than ACPC. Histology type should not govern discrimination in thromboprophylaxis selection or extension.
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Affiliation(s)
- Luis A Diaz Quintero
- Division of Internal Medicine, Department of Medicine, NorthShore University HealthSystem, Evanston, IL, USA -
| | - Harry E Fuentes
- Division of Hematology and Oncology, Department of Medicine, Mayo Clinic Rochester, Rochester, MN, USA
| | - Alfonso J Tafur
- Division of Vascular Medicine, Department of Medicine, NorthShore University HealthSystem, Skokie, IL, USA.,Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Kaushal Majmudar
- Division of Internal Medicine, Department of Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Juan P Salazar Adum
- Division of Internal Medicine, Department of Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Iva Golemi
- Division of Internal Medicine, Department of Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Luis H Paz
- Division of Cardiology, Department of Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Susan Stocker
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Mark Talamonti
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA.,Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
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17
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Kim JS, Kang EJ, Kim DS, Choi YJ, Lee SY, Kim HJ, Seo HY, Kim JS. Early venous thromboembolism at the beginning of palliative chemotherapy is a poor prognostic factor in patients with metastatic pancreatic cancer: a retrospective study. BMC Cancer 2018; 18:1260. [PMID: 30558603 PMCID: PMC6296039 DOI: 10.1186/s12885-018-5154-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 11/29/2018] [Indexed: 02/07/2023] Open
Abstract
Background This study investigated the prognostic effects of venous thromboembolism (VTE)-related factors in patients with metastatic pancreatic cancer receiving palliative chemotherapy. Predictive factors for VTE were also investigated. Methods A total of 216 patients diagnosed with metastatic pancreatic cancer who received gemcitabine-based palliative chemotherapy at our institution were retrospectively evaluated. Results VTE occurred in 51 (23.6%) patients during treatment and did not affect survival. However, patients who were diagnosed with VTE at the beginning of chemotherapy showed poor prognosis compared with patients diagnosed with VTE during chemotherapy: all patients (hazard ratio [HR] 1.897, p = 0.008); patients diagnosed with VTE (HR = 3.768, p = 0.001). Low serum sodium (Na) (< 135 mmol/L) and high Khorana score (≥3) were strong predictive factors of early VTE (odds ratio [OR] 5.109; 95% confidence interval [95% CI] = 1.010–25.845; p = 0.049 for Khorana score, OR 10.304; 95% CI = 1.036–102.466; p = 0.047) for hyponatremia). Conclusions Our study demonstrated that occurrence and detection of VTE in the early period of chemotherapy was the most significant VTE-related prognostic factor in patients with metastatic pancreatic cancer receiving chemotherapy. Prediction using the Khorana score and serum Na levels would be helpful in early diagnosis of VTE.
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Affiliation(s)
- Jung Sun Kim
- Division of Hematology/Oncology, Department of Internal Medicine, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Eun Joo Kang
- Division of Hematology/Oncology, Department of Internal Medicine, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea.
| | - Dae Sik Kim
- Division of Hematology/Oncology, Department of Internal Medicine, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Yoon Ji Choi
- Division of Hematology/Oncology, Department of Internal Medicine, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Suk Young Lee
- Division of Hematology/Oncology, Department of Internal Medicine, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Hong Jun Kim
- Division of Hematology/Oncology, Department of Internal Medicine, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Hee Yeon Seo
- Division of Hematology/Oncology, Department of Internal Medicine, Konkuk University School of Medicine, Chungchungbukdo, Chungju, South Korea
| | - Jun Suk Kim
- Division of Hematology/Oncology, Department of Internal Medicine, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
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Venous Thromboembolism in Asian Patients with Pancreatic Cancer Following Palliative Chemotherapy: Low Incidence but a Negative Prognosticator for Those with Early Onset. Cancers (Basel) 2018; 10:cancers10120501. [PMID: 30544670 PMCID: PMC6315992 DOI: 10.3390/cancers10120501] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 11/30/2018] [Accepted: 12/09/2018] [Indexed: 02/08/2023] Open
Abstract
Background: Few studies have reported the epidemiology and clinical outcome of venous thromboembolism (VTE) in Asian patients with pancreatic cancer. This study investigated the incidence, risk factors, and clinical outcome of VTE in patients with pancreatic cancer following palliative chemotherapy. Methods: The medical records of 838 patients with newly diagnosed locally advanced or metastatic pancreatic cancer who underwent palliative chemotherapy between 2010 and 2016 at four institutes in Taiwan were retrospectively reviewed. The clinical characteristics of all patients were analyzed to identify independent predictors of VTE and their effects on survival outcome. Results: During the median follow-up period of 7.7 months (range, 0.6–55.6), VTE occurred in 67 (8.0%) of the 838 patients. Leukocyte count > 11,000/μL and presence of liver metastases were the independent predictors of VTE. Patients with VTE did not show significantly poorer survival outcomes than those without VTE. However, early-onset VTE that occurred within 1.5 months after chemotherapy initiation was an independent negative prognosticator for overall survival. Conclusion: VTE incidence was found to be lower in Asian patients with pancreatic cancer than in their Western counterparts. Early-onset VTE, but not late-onset VTE, is a negative prognosticator for survival outcomes.
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Wang Y, Attar BM, Hinami K, Fuentes HE, Jaiswal P, Zhang H, Simons-Linares CS, Tafur AJ. Characteristics and Impacts of Venous Thromboembolism in Patients with Hepatocellular Carcinoma. J Gastrointest Cancer 2018; 49:275-282. [PMID: 28374272 DOI: 10.1007/s12029-017-9945-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a common complication in cancer patients, and is associated with worse prognosis in such population. Hepatocellular carcinoma (HCC) poses high risk for VTE; however, data is scarce regarding the characteristics and consequences of VTE in HCC patients. METHOD We retrospectively reviewed the electronic medical records (EMR) of 270 patients diagnosed with HCC from 2000 to 2015 in Cook County Health and Hospitals System. We report the cumulative incidence of VTE in the present cohort, and identified through multivariate logistic regression the independent risk factors of the development of VTE. Overall prognosis of patients with and without VTE were presented and compared. RESULTS Sixteen cases (5.93%) of VTE were documented in the present study. In multivariate analysis, obesity, Child B cirrhosis, intra-hepatic lesions more than 3, and multi-organ extrahepatic metastasis were significantly associated with VTE development (p < 0.05). The presence of VTE was an independent risk factor for mortality in multivariate analysis (HR = 3.62, p = 0.021), together with male gender, Child C cirrhosis, and extrahepatic metastasis. CONCLUSIONS Obesity, Child B cirrhosis, more intra-hepatic lesions, and multi-organ extrahepatic metastasis are associated with cancer-associated VTE. VTE will adversely affect the prognosis of patients with HCC; therefore, primary thromboprophylaxis may be warranted in such population.
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Affiliation(s)
- Yuchen Wang
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, 1900 West Polk Street, Chicago, IL, 60612, USA.
| | - B M Attar
- Division of Gastroenterology and Hepatology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA.,Department of Gastroenterology, Rush University Medical Center, Chicago, IL, USA
| | - K Hinami
- Collaborative Research Unit, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - H E Fuentes
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, 1900 West Polk Street, Chicago, IL, 60612, USA
| | - P Jaiswal
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, 1900 West Polk Street, Chicago, IL, 60612, USA
| | - H Zhang
- Collaborative Research Unit, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - C S Simons-Linares
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, 1900 West Polk Street, Chicago, IL, 60612, USA
| | - A J Tafur
- Cardiology-Vascular Medicine, NorthShore University HealthSystem, Evanston, IL, USA
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Frère C, Bournet B, Benzidia I, Jamelot M, Debourdeau P, Hij A, Rafii-Elayoubi H, Buscail L, Farge D. [Venous thromboembolism and pancreatic cancer]. JOURNAL DE MEDECINE VASCULAIRE 2018; 43:246-254. [PMID: 29981733 DOI: 10.1016/j.jdmv.2018.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/22/2018] [Indexed: 06/08/2023]
Abstract
Pancreatic cancer (PC) is a devastating malignancy with an overall 5-year survival of 8% for all stages combined. Most of the PC patients diagnosed have an advanced disease (40%) or metastatic stage (40%), which eliminates surgery as a potentially curative treatment. The disease course is often complicated by venous thromboembolism (VTE) events, which per se account for significant morbidity and mortality, with significantly worsen survival. PC is associated with the highest risk of VTE among all cancer patients. We review the literature data to address the incidence and clinical outcomes of VTE in PC patients. VTE incidence varies from 5 to 41% according to epidemiological studies and is as high as 57% in postmortem series. Since 2013, international clinical practice guidelines recommend primary thromboprophylaxis with a grade 1B level of evidence as an adjuvant therapy in advanced PC. A recent meta-analysis of randomized controlled trials investigating the benefit and risk of low-molecular-weight heparins (LMWH) in ambulatory advanced PC patients under chemotherapy showed that the incidence of VTE was 2.1% in patients treated with LMWH and 11.2% in controls (risk ratio, 0.18; 95% CI, 0.083-0.39; P<0.0001). In conclusion, improved earlier diagnosis and effective management of VTE, a frequent and life-threatening complication in PC, is warranted to improve PC patient outcomes.
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Affiliation(s)
- C Frère
- Service d'hématologie biologique, hôpital Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - B Bournet
- Pôle digestif, service de gastro-entérologie et de nutrition, hôpital Rangueil, CHU de Toulouse, 31059 Toulouse cedex 9, France
| | - I Benzidia
- Service de médecine interne, UF04 maladies auto-immunes et pathologie vasculaire, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 75475 Paris cedex 10, France
| | - M Jamelot
- Service d'oncologie médicale, centre Henri-Becquerel, 76038 Rouen, France
| | - P Debourdeau
- Service oncologie, institut Sainte-Catherine, 84918 Avignon, France
| | - A Hij
- Service de médecine interne, UF04 maladies auto-immunes et pathologie vasculaire, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 75475 Paris cedex 10, France
| | - H Rafii-Elayoubi
- Service de médecine interne, UF04 maladies auto-immunes et pathologie vasculaire, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 75475 Paris cedex 10, France
| | - L Buscail
- Pôle digestif, service de gastro-entérologie et de nutrition, hôpital Rangueil, CHU de Toulouse, 31059 Toulouse cedex 9, France
| | - D Farge
- Service de médecine interne, UF04 maladies auto-immunes et pathologie vasculaire, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 75475 Paris cedex 10, France
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Abstract
OBJECTIVES Pancreatic cancer is reported to be highly associated with thromboembolism (TE). The aim of this analysis is to clarify risk factors for TE and its clinical impact in Japanese patients with pancreatic cancer. METHODS Data on consecutive pancreatic cancer patients receiving systemic chemotherapy between August 1999 and July 2015 were retrospectively studied. Both symptomatic and asymptomatic, arterial and venous TEs were included in the analysis. Risk factors for TE development were analyzed using a proportional hazards model with death without TE as a competing risk. The impact of TE on survival was also evaluated using a time-dependent covariate multiple Cox model. RESULTS A total of 475 patients were included in the analysis, and 57 TEs (12%) were identified: 45 venous TEs and 12 arterial TEs. The median time to TE was 169 days and the median survival from TE was 65 days. Liver metastasis was the only significant risk factor for TE (subdistribution hazards ratio, 2.15; P = 0.01), and TE was significantly associated with poor prognosis (hazards ratio, 3.31; P < 0.01). CONCLUSIONS Thromboembolism was not uncommon in Japanese patients receiving chemotherapy for advanced pancreatic cancer and was associated with poor prognosis. Liver metastasis was the risk factor for TE.
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Kok VC. Bidirectional risk between venous thromboembolism and cancer in East Asian patients: synthesis of evidence from recent population-based epidemiological studies. Cancer Manag Res 2017; 9:751-759. [PMID: 29263699 PMCID: PMC5724426 DOI: 10.2147/cmar.s151331] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Unprovoked (idiopathic) venous thromboembolism (VTE) with no obvious antecedent risk factors, is associated with a significant risk of subsequent occult cancer. Conversely, there is a heightened risk of VTE in cancer patients. This bidirectional risk can be estimated from population-based cohort studies conducted in East Asians. METHODS A literature search using medical subject heading terms and Boolean logic in PubMed and MedLine was performed in April 2017. Twenty-two papers reported from East Asia were retrieved for study and data synthesis. Proportional meta-analysis with a random-effects model was used to synthesize data with 95% confidence intervals (CIs) when appropriate. RESULTS Synthesis of data on VTE incidence in the East Asian population (I2 = 76.2%) showed that pooled incidence was 20.3 (95% CI, 11.2-32) per 100,000 person-years. VTE incidence steadily increased with age. Unprovoked VTE accounted for 35% (95% CI, 24%-48%) of all cases of incident VTE (I2 = 99.7%). The overall cancer risk was significantly higher (2.3-fold) in the VTE cohort than in comparators. Among the patients with unprovoked VTE, approximately 7% had a subsequent cancer diagnosis within 2 years of the first episode of idiopathic VTE. The risk of VTE recurrence was increased in cancer patients (adjusted odds ratio, 1.64; 95% CI, 1.26-1.99). VTE incidence was 9.9 per 1,000 person-years in cancer patients, particularly in liver, pancreas, and lung cancer patients. CONCLUSION Newly diagnosed VTE incidence is estimated at approximately 4,400 new cases annually in Taiwan and 7,100 in South Korea. Similar to the trend in VTE incidence among the general population, VTE risk in East Asian cancer patients is markedly lessened.
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Affiliation(s)
- Victor C Kok
- Division of Medical Oncology, Cancer Center, Kuang Tien General Hospital
- Asia University, Taichung, Taiwan
- Correspondence: Victor C Kok, Division of Medical Oncology, Kuang Tien General Hospital, 117 Sha-Tien Road, Shalu, Taichung 43303, Taiwan, Tel +886 4 2662 5111 extension 2263, Fax +886 4 2665 5050, Email
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