Prevalence and risk of occult cancer in stroke

Malignancy-associated ischemic stroke: Implications for diagnostic and therapeutic workup

BACKGROUND

Patients with malignancies have an increased risk of suffering ischemic stroke via several mechanisms such as coagulation dysfunction and other malignancy-related effects as well as iatrogenic causes. Moreover, stroke can be the first sign of an occult malignancy, termed as malignancy-associated ischemic stroke (MAS). Therefore, timely diagnostic assessment and targeted management of this complex clinical situation are critical.

FINDINGS

Patients with both stroke and malignancy have atypical ages, risk factors, and often exhibit malignancy-related symptoms and multiple lesions on neuroimaging. New biomarkers such as eicosapentaenoic acid and blood mRNA profiles may help in distinguishing MAS from other strokes. In terms of treatment, malignancy should not be considered a contraindication, given comparable rates of recanalization and complications between stroke patients with or without malignancies.

CONCLUSION

In this review, we summarize the latest developments in diagnosing and managing MAS, especially stroke with occult malignancies, and provide new recommendations from recently emerged clinical evidence for diagnostic and therapeutic workup strategies.

Association between coronary artery disease and incident cancer risk: a systematic review and meta-analysis of cohort studies

Objective

Coronary artery disease (CAD) and cancer are the two leading causes of death worldwide. Evidence suggests the existence of shared mechanisms for these two diseases. We aimed to conduct a systematic review and meta-analysis to investigateassociation between CAD and incident cancer risk.

Methods

We searched Cochrane, PubMed, and Embase from inception until October 20, 2021, without language restrictions. Observational cohort studies were used to investigate the association between CAD and incident cancer risk. Using random-effects models, the odds ratio (OR) and 95% confidence interval (CI) were calculated. We utilized subgroup and sensitivity analyses to determine the potential sources of heterogeneity and explore the association between CAD and specific cancers. This study was conducted under a pre-established, registered protocol on PROSPERO (CRD42022302507).

Results

We initially examined 8,533 articles, and included 14 cohort studies in our review, 11 of which were eligible for meta-analysis. Patients with CAD had significantly higher odds of cancer risk than those without CAD (OR = 1.15, 95% CI = [1.08-1.22], I2 = 66%). Subgroup analysis revealed that the incident cancer risk was significantly higher in both sexes and patients with CAD with or without myocardial infarction. Sensitivity analysis revealed that the risk remained higher in patients with CAD even after >1 year of follow-up (OR = 1.23, 95% CI = [1.08-1.39], I2 = 76%). Regarding the specific outcome, the incident risk for colorectal and lung cancers was significantly higher (OR = 1.06, 95% CI = [1.03-1.10], I2 = 10%, and OR = 1.36, 95% CI = [1.15-1.60], I2 = 90%, respectively) and that for breast cancer was lower (OR = 0.86, 95% CI = [0.77-0.97], I2 = 57%) in patients with CAD than in those without CAD.

Conclusion

CAD may be associated with incident cancer risk, particularly for lung and colorectal cancers, in men and women as well as patients with or without myocardial infarction. Early detection of new-onset cancer and detailed cancer surveillance programs should be implemented in patients with CAD to reduce cancer-related morbidity and mortality.

Long-term mortality in young patients with spontaneous intracerebral haemorrhage: Predictors and causes of death

INTRODUCTION

Intracerebral haemorrhage (ICH) in young adults is rare but has devastating consequences. We investigated long-term mortality rates, causes of death and predictors of long-term mortality in young spontaneous ICH survivors.

PATIENTS AND METHODS

We included consecutive patients aged 18-55 years from the Prognosis of Intracerebral Haemorrhage cohort (PITCH), a prospective observational cohort of patients admitted to Lille University Hospital (2004-2009), who survived at least 30 days after spontaneous ICH. We studied long-term mortality with Kaplan-Meier analyses, collected causes of death, performed uni-/multivariable Cox-regression analyses for the association of baseline characteristics with long-term mortality.

RESULTS

Of 560 patients enrolled in the PITCH, 75 patients (75% men) met our inclusion criteria (median age 50 years, interquartile range [IQR] 44-53 years). During a median follow-up of 8.2 years (IQR 5.0-10.1), 26 patients died (35%), with a standardized mortality ratio of 13.0 (95% confidence interval [95% CI] 8.5-18.0) compared to peers from the general population. Causes of death were vascular in 7 (27%) patients, non-vascular in 13 (50%) and unknown in 6 (23%). Global cerebral atrophy (hazard ratio [HR] 3.0, 95% CI 1.1-8.6), modified Rankin Score >2 before ICH (HR 3.4, 95% CI 1.0-11.0), and excessive alcohol consumption (HR 3.3, 95% CI 1.1-10.2) were independently associated with long-term mortality.

DISCUSSION

We found a 13-fold higher mortality risk for young ICH survivors compared to the general French population. Predictors of long-term mortality were pre-existing conditions, not ICH-characteristics.

CONCLUSION

Young ICH survivors remain at increased mortality risk of vascular and non-vascular death for years after ICH.

Types of occult cancer in stroke and the relation to smoking

OBJECTIVES

Stroke is associated with a higher risk of occult cancer. We studied the types of occult cancer most often associated with stroke.

MATERIALS AND METHODS

All patients with incident stroke in Denmark 2003-2015 were identified through the Danish Stroke Registry (n = 85 893) and matched 1:10 on age and sex to the Danish background population without history of stroke (n = 858 740). Linking data to the Danish Cancer Registry, we determined the prevalence of occult cancer in stroke defined as the event of previously unknown cancer during a one-year follow-up in the stroke and the background population. We stratified cancers into the 15 most common cancers and into cancers related to and not related to smoking.

RESULTS

Prevalence (per 1000 person-years; stroke/background population) of smoking-related occult cancers (lung, colon, bladder rectum, pancreas, kidney, stomach, and head and neck) was 13.3/8.1 (P < .01) and of cancers not related to smoking (prostate, breast, melanoma, non-Hodgkin lymphoma, ovary, endometrial) it was 6.6/6.2 (P > .05). Among men with stroke prostate (5.8), lung (5.7), and colon cancers (2.9) were most frequent; among women, it was lung (4.7), breast(3.5), and colon cancer(2.8). Among men in the background population, prostate(5.4), lung (3.0), and colon cancers (2.1) were most frequent. Among women, it was breast (3.7), lung(2.1), and colon cancers (1.9).

CONCLUSION

Stroke patients' increased risk of occult cancer was predominantly for smoking-related cancers while there was no higher risk for the most frequent cancers unrelated to smoking, that is, prostate and breast cancers. Lung cancer is the dominant type of occult cancer in stroke.