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Hisada Y, Archibald SJ, Bansal K, Chen Y, Dai C, Dwarampudi S, Balas N, Hageman L, Key NS, Bhatia S, Bhatia R, Mackman N, Gangaraju R. Biomarkers of bleeding and venous thromboembolism in patients with acute leukemia. J Thromb Haemost 2024; 22:1984-1996. [PMID: 38574862 PMCID: PMC11214882 DOI: 10.1016/j.jtha.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 03/01/2024] [Accepted: 03/26/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Coagulopathy and associated bleeding and deep vein thrombosis (DVT) are major causes of morbidity and mortality in patients with acute leukemia. The underlying mechanisms of these complications have not been fully elucidated. OBJECTIVES To evaluate the associations between biomarker levels and bleeding and DVT in acute leukemia patients. METHODS We examined plasma levels of activators, inhibitors, and biomarkers of the coagulation and fibrinolytic pathways in patients aged ≥18 years with newly diagnosed acute leukemia compared with those of normal controls. Multivariable regression models were used to examine the association of biomarkers with bleeding and DVT in acute leukemia patients. The study included 358 patients with acute leukemia (29 with acute promyelocytic leukemia [APL], 253 with non-APL acute myeloid leukemia, and 76 with acute lymphoblastic leukemia) and 30 normal controls. RESULTS Patients with acute leukemia had higher levels of extracellular vesicle tissue factor (EVTF) activity, phosphatidylserine-positive extracellular vesicles, plasminogen activator inhibitor-1, plasmin-antiplasmin complexes, and cell-free DNA and lower levels of citrullinated histone H3-DNA complexes compared with normal controls. APL patients had the highest levels of EVTF activity and the lowest levels of tissue plasminogen activator among acute leukemia patients. There were 41 bleeding and 23 DVT events in acute leukemia patients. High EVTF activity was associated with increased risk of bleeding (subdistribution hazard ratio, 2.30; 95% CI, 0.99-5.31), whereas high levels of plasminogen activator inhibitor-1 were associated with increased risk of DVT (subdistribution hazard ratio, 3.00; 95% CI, 0.95-9.47) in these patients. CONCLUSION Our study shows alterations in several biomarkers in acute leukemia and identifies biomarkers associated with risk of bleeding and DVT.
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Affiliation(s)
- Yohei Hisada
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | - Sierra J Archibald
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Karan Bansal
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Yanjun Chen
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Chen Dai
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sindhu Dwarampudi
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nora Balas
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lindsey Hageman
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nigel S Key
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ravi Bhatia
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Radhika Gangaraju
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA; Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
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Sawada J, Katayama T, Kikuchi-Takeguchi S, Kano K, Saito M, Mitsui N, Hiroshima S, Kinoshita M, Nakagawa N. Clinical features and prognostic factors of patients with cancer-associated stroke. Neurol Sci 2024; 45:2747-2757. [PMID: 38267601 DOI: 10.1007/s10072-024-07332-y] [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: 09/22/2023] [Accepted: 01/12/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Cerebrovascular diseases in cancer patients significantly aggravate their condition and prognosis; therefore, prompt and accurate diagnosis and treatment are important. The purpose of this study was to investigate patient demographics, laboratory data, brain magnetic resonance imaging (MRI) findings, and prognosis among patients with stroke and cancer, especially cancer-associated ischemic stroke (CAIS). METHODS We performed a retrospective, single-center study. We enrolled consecutive patients who had acute stroke and were admitted to our hospital between January 2011 and December 2021. We collected general demographic characteristics, cancer histopathological type, laboratory data, brain MRI findings, and prognosis data. RESULTS Among 2040 patients with acute stroke, a total of 160 patients (7.8%) had active cancer. The types of strokes were cerebral infarction, cerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack in 124, 25, 5, and 6 patients, respectively. Among the patients with ischemic stroke, there were 69 cases of CAIS. Pancreas and adenocarcinoma were the most frequent types of primary tumor and histopathology. Patients with adenocarcinoma and those with cerebral infarctions in both bilateral anterior and posterior cerebral circulation areas showed higher D-dimer levels. Pancreatic cancer and high plasma D-dimer levels were associated with poor survival rate. CONCLUSION CAIS was seen more frequently in patients with pancreatic cancer and adenocarcinoma. Pancreatic cancer and high plasma D-dimer levels were potential factors of poor prognosis in patients with CAIS.
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Affiliation(s)
- Jun Sawada
- Division of Cardiology, Nephrology, Pulmonology, and Neurology, Department of Internal Medicine, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan.
| | - Takayuki Katayama
- Department of Neurology, Asahikawa City Hospital, Asahikawa, Hokkaido, Japan
| | - Shiori Kikuchi-Takeguchi
- Division of Cardiology, Nephrology, Pulmonology, and Neurology, Department of Internal Medicine, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| | - Kohei Kano
- Division of Cardiology, Nephrology, Pulmonology, and Neurology, Department of Internal Medicine, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| | - Masato Saito
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Nobuyuki Mitsui
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Satoru Hiroshima
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Manabu Kinoshita
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Naoki Nakagawa
- Division of Cardiology, Nephrology, Pulmonology, and Neurology, Department of Internal Medicine, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
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3
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Pourhassan H, Kareem W, Agrawal V, Aldoss I. Important Considerations in the Intensive Care Management of Acute Leukemias. J Intensive Care Med 2024; 39:291-305. [PMID: 37990559 DOI: 10.1177/08850666231193955] [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] [Indexed: 11/23/2023]
Abstract
In the realm of hematologic disorders, acute leukemia is approached as an emergent disease given the multitude of complications and challenges that present both as a result of inherent disease pathology and adverse events associated with antineoplastic therapies and interventions. The heavy burden of leukemic cells may lead to complications including tumor lysis syndrome, hyperleukocytosis, leukostasis, and differentiation syndrome, and the initiation of treatment can further exacerbate these effects. Capillary leak syndrome is observed as a result of antineoplastic agents used in acute leukemia, and L-asparaginase, a bacterial-derived enzyme, has a unique side effect profile including association with thrombosis. Thrombohemorrhagic syndrome and malignancy-associated thrombosis are also commonly observed complications due to direct disequilibrium in coagulant and anticoagulant factors. Due to inherent effects on the white blood cell milieu, leukemia patients are inherently immunocompromised and vulnerable to life-threatening sepsis. Lastly, the advents of newer therapies such as chimeric antigen receptor (CAR) T-cells have clinicians facing the management of related toxicities on unfamiliar territory. This review aims to discuss these acute leukemia-associated complications, their pathology, and management recommendations.
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Affiliation(s)
- Hoda Pourhassan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Waasil Kareem
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Vaibhav Agrawal
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
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4
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Hisada Y, Archibald SJ, Bansal K, Chen Y, Dai C, Dwarampudi S, Balas N, Hageman L, Key NS, Bhatia S, Bhatia R, Mackman N, Gangaraju R. Biomarkers of bleeding and venous thromboembolism in patients with acute leukemia. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.18.23297216. [PMID: 37905148 PMCID: PMC10615001 DOI: 10.1101/2023.10.18.23297216] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Background Coagulopathy and associated bleeding and venous thromboembolism (VTE) are major causes of morbidity and mortality in patients with acute leukemia. The underlying mechanisms of these complications have not been fully elucidated. Objectives To evaluate the associations between biomarker levels and bleeding and VTE in acute leukemia patients. Patients/Method We examined plasma levels of activators, inhibitors and biomarkers of the coagulation and fibrinolytic pathways in patients ≥18 years with newly diagnosed acute leukemia compared to healthy controls. Multivariable regression models were used to examine the association of biomarkers with bleeding and VTE in acute leukemia patients. The study included 358 patients with acute leukemia (29 acute promyelocytic leukemia [APL], 253 non-APL acute myeloid leukemia [AML] and 76 acute lymphoblastic leukemia [ALL]), and 30 healthy controls. Results Patients with acute leukemia had higher levels of extracellular vesicle (EV) tissue factor (TF) activity, phosphatidylserine-positive EVs, plasminogen activator inhibitor-1 (PAI-1), plasmin-antiplasmin complexes, cell-free DNA and lower levels of citrullinated histone H3-DNA complexes compared to healthy controls. APL patients had the highest levels of EVTF activity and the lowest levels of tissue plasminogen activator among the acute leukemia patients. There were 41 bleeding and 37 VTE events in acute leukemia patients. High EVTF activity was associated with increased risk of bleeding (sHR 2.30, 95%CI 0.99-5.31) whereas high PAI-1 was associated with increased risk of VTE (sHR 3.79, 95%CI 1.40-10.28) in these patients. Conclusions Our study shows alterations in several biomarkers in acute leukemia and identifies biomarkers associated with risk of bleeding and VTE.
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Affiliation(s)
- Yohei Hisada
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Sierra J. Archibald
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Karan Bansal
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Yanjun Chen
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Chen Dai
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Sindhu Dwarampudi
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Nora Balas
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Lindsey Hageman
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Nigel S. Key
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Ravi Bhatia
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Radhika Gangaraju
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
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Hisada Y, Kawano T, Archibald SJ, Welch JS, Reeves BN, Mackman N. Tissue factor activates the coagulation cascade in mouse models of acute promyelocytic leukemia. Blood Adv 2023; 7:5458-5469. [PMID: 37450381 PMCID: PMC10515313 DOI: 10.1182/bloodadvances.2023010466] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/03/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023] Open
Abstract
Acute promyelocytic leukemia (APL) is associated with a high risk of bleeding and thrombosis. APL patients have an activated coagulation system, hyperfibrinolysis, and thrombocytopenia. APL cells express tissue factor (TF), a receptor and cofactor for factor VII/VIIa. This study had 2 goals. Firstly, we measured biomarkers of coagulation and fibrinolysis activation as well as platelet counts and bleeding in both mouse xenograft and allograft models of APL. Secondly, we determined the effect of inhibiting TF on the activation of coagulation in these models. We observed increased levels of plasma thrombin-antithrombin complexes (TAT), D-dimer, and plasmin-antiplasmin complexes, reduced platelet counts, and increased tail bleeding in both mouse models of APL. Fibrinogen levels decreased in the xenograft model but not in the allograft model. In contrast, the red blood cell count decreased in the allograft model but not in the xenograft model. Inhibition of APL-derived human TF with an anti-human TF monoclonal antibody reduced the level of TAT, increased platelet count, and normalized tail bleeding in a xenograft model. Inhibition of all sources of TF (APL cells and host cells) in the allograft model with a rat anti-mouse TF monoclonal antibody decreased the levels of TAT but did not affect the platelet count. Our study demonstrates that TF plays a central role in the activation of coagulation in both the xenograft and allograft mouse models of APL. These APL mouse models can be used to investigate the mechanisms of coagulopathy and thrombocytopenia in APL.
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Affiliation(s)
- Yohei Hisada
- University of North Carolina Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Tomohiro Kawano
- University of North Carolina Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sierra J. Archibald
- University of North Carolina Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - John S. Welch
- Division of Oncology, Department of Internal Medicine, Washington University in St. Louis, St. Louis, MO
| | - Brandi N. Reeves
- University of North Carolina Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Nigel Mackman
- University of North Carolina Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Zeineddine L, Gomez-Manjarres D. Examining the differential of digital ischaemia and review of paraneoplastic ischaemia. BMJ Case Rep 2023; 16:e255165. [PMID: 37055076 PMCID: PMC10106003 DOI: 10.1136/bcr-2023-255165] [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] [Indexed: 04/15/2023] Open
Abstract
There is a broad differential diagnosis of digital ischaemia that includes commonly encountered conditions of vascular or thromboembolic nature as well as less commonly seen such as those of vasculitic or rheumatological origin. A less frequently encountered pathology is digital ischaemia associated with malignancy. This paraneoplastic process is rare and infrequently described in the literature, though it has been observed in various solid and haematological malignancies. Here, we describe a patient case with an atypical presentation of digital ischaemia and present a brief review on prior reports of digital ischaemia related to cancer.
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Affiliation(s)
| | - Diana Gomez-Manjarres
- Pulmonary and Critical Care Medicine, University of Florida, Gainesville, Florida, USA
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7
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Akinbo DB, Ajayi OI. Thrombotic Pathogenesis and Laboratory Diagnosis in Cancer Patients, An Update. Int J Gen Med 2023; 16:259-272. [PMID: 36711430 PMCID: PMC9879027 DOI: 10.2147/ijgm.s385772] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/04/2023] [Indexed: 01/23/2023] Open
Abstract
Cancer-associated thrombosis (CAT) is a leading cause of mortality in cancer patients and its incidence varies in different parts of the world. Venous thromboembolism (VTE) is a prominent manifestation of CAT, and significantly impacts morbidity and survival compared to arterial thrombosis in cancer patients. Several risk factors for developing VTE such as chemotherapy and immobilization have also been found co-existing with cancer patients and contributing to the increased risk of VTE in cancer patients than in non-cancer patients. This review highlights recent mechanisms in the pathogenesis of hypercoagulable syndromes associated with cancer, multiple mechanisms implicated in promoting cancer-associated thrombosis and their diagnostic approaches. Cancer cells interact with every part of the hemostatic system; generating their own procoagulant factors, through stimulation of the prothrombotic properties of other blood cell components or the initiation of clotting by cancer therapies which can all directly activate the coagulation cascade and contribute to the VTE experienced in CAT. It is our hope that the multiple interconnections between the hemostatic system and cancer biology and the improved biomarkers reported in this study can be relevant in establishing a predictive model for VTE, optimize early detection of asymptomatic microthrombosis for more personalized prophylactic strategies and incorporate effective therapeutic options and patient management to reduce mortality and morbidity, and improve the quality of life of affected cancer patients.
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Affiliation(s)
- David Bolaji Akinbo
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Afe Babalola University, Ado – Ekiti, Ekiti State, Nigeria,Department of Food, Nutrition, Dietetics and Health, College of Health and Human Sciences, Kansas State University, Manhattan, KS, USA,Correspondence: David Bolaji Akinbo, Email
| | - Olutayo Ifedayo Ajayi
- Department of Physiology, School of Basic Medical Sciences, College of Medical Sciences, University of Benin, Benin City, Edo State, Nigeria
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8
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Huang RZ, Chen N, Hu Y, Hu WM, Wang FH, Chen DL. Case report: PD-1 inhibitor-based treatment strategies in gastric cancer complicated by bone marrow metastasis and disseminated intravascular coagulation: A report of two cases. Front Oncol 2023; 13:1019702. [PMID: 36910633 PMCID: PMC9992714 DOI: 10.3389/fonc.2023.1019702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 02/06/2023] [Indexed: 02/24/2023] Open
Abstract
Introduction Gastric cancer (GC) complicated by bone marrow metastasis (BMM) and disseminated intravascular coagulation (DIC) represents poor prognosis and most of these patients would die in a few months. Active treatment strategies such as chemotherapy are effective in restoring coagulation function and prolonging patients' survival time. Immunotherapy including programmed death protein 1 (PD-1) or programmed death protein ligand 1 (PD-L1) inhibitors has emerged as a first-line treatment of gastric cancer. However, the efficacy of PD-1 inhibitor-based treatment strategies in these patients remains unknown. Case description Herein, we presented two cases of advanced gastric cancer (AGC) complicated by BMM and DIC, in which two patients received chemotherapy and PD-1 inhibitor as the first-line treatment. Both of them achieved a partial response after treatment, and the coagulation function was restored. The patient who discontinued the PD-1 inhibitor after 6 months experienced DIC relapse, whereas the other patient who maintained the PD-1 inhibitor treatment cycle remained responsive after 10 months. Conclusions We speculate that PD-1 inhibitor-based treatment strategies are effective and safe in prolonging survival against gastric cancer with BMM and DIC, and the coagulation function is well controlled by the treatment with a combination of immunotherapy and chemotherapy.
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Affiliation(s)
- Ren-Ze Huang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Nuo Chen
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yan Hu
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Wan-Ming Hu
- Department of Pathology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Feng-Hua Wang
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Dong-Liang Chen
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
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Woock M, Martinez-Majander N, Seiffge DJ, Selvik HA, Nordanstig A, Redfors P, Lindgren E, Sanchez van Kammen M, Rentzos A, Coutinho JM, Doyle K, Naess H, Putaala J, Jood K, Tatlisumak T. Cancer and stroke: commonly encountered by clinicians, but little evidence to guide clinical approach. Ther Adv Neurol Disord 2022; 15:17562864221106362. [PMID: 35785404 PMCID: PMC9243376 DOI: 10.1177/17562864221106362] [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: 02/04/2022] [Accepted: 05/24/2022] [Indexed: 12/03/2022] Open
Abstract
The association between stroke and cancer is well-established. Because of an aging population and longer survival rates, the frequency of synchronous stroke and cancer will become even more common. Different pathophysiologic mechanisms have been proposed how cancer or cancer treatment directly or via coagulation disturbances can mediate stroke. Increased serum levels of D-dimer, fibrin degradation products, and CRP are more often seen in stroke with concomitant cancer, and the clot retrieved during thrombectomy has a more fibrin- and platelet-rich constitution compared with that of atherosclerotic etiology. Multiple infarctions are more common in patients with active cancer compared with those without a cancer diagnosis. New MRI techniques may help in detecting typical patterns seen in the presence of a concomitant cancer. In ischemic stroke patients, a newly published cancer probability score can help clinicians in their decision-making when to suspect an underlying malignancy in a stroke patient and to start cancer-screening studies. Treating stroke patients with synchronous cancer can be a delicate matter. Limited evidence suggests that administration of intravenous thrombolysis appears safe in non-axial intracranial and non-metastatic cancer patients. Endovascular thrombectomy is probably rather safe in these patients, but probably futile in most patients placed on palliative care due to their advanced disease. In this topical review, we discuss the epidemiology, pathophysiology, and prognosis of ischemic and hemorrhagic strokes as well as cerebral venous thrombosis and concomitant cancer. We further summarize the current evidence on acute management and secondary preventive therapy.
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Affiliation(s)
- Malin Woock
- Department of Neurology, Sahlgrenska University Hospital, Blå stråket 7, 413 46 Gothenburg, Sweden
| | | | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Annika Nordanstig
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Petra Redfors
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Lindgren
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mayte Sanchez van Kammen
- Department of Neurology, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Alexandros Rentzos
- Department of Radiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Karen Doyle
- Department of Physiology, Centre for Research in Medical Devices (CÚRAM), National University of Ireland, Galway, Galway, Ireland
| | - Halvor Naess
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Katarina Jood
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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10
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Maiorano S, Gulden-Sala W, Gerber B, Ghilardi G. Anti-PD-L1 monoclonal antibody for the management of chronic disseminated intravascular coagulation secondary to a urothelial carcinoma: a case report. J Med Case Rep 2022; 16:113. [PMID: 35307010 PMCID: PMC8935767 DOI: 10.1186/s13256-022-03338-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/18/2022] [Indexed: 01/23/2023] Open
Abstract
Background Thrombocytopenia is often considered a risk factor for bleeding, but conversely may be associated with an increased thrombotic risk in several clinical situations. Here we present a patient with arterial thrombosis and chronic disseminated intravascular coagulation caused by metastatic urothelial carcinoma. As the treatment for a disseminated intravascular coagulation caused by a neoplasia is the treatment of the underlying disease itself, our case highlights a new therapeutic approach—immunotherapy—in a patient prone to hematological complications due to conventional chemotherapy. Clinical case A 74-year-old Caucasian male patient with a history of urothelial carcinoma of the bladder and moderate thrombocytopenia had multiple arterial thrombotic events despite antiplatelet therapy and anticoagulation. A diagnosis of chronic disseminated intravascular coagulation in the setting of a metastatic bladder urothelial carcinoma was made. The patient was treated with an anti-PD-L1 monoclonal antibody, and achieved a rapid response with subsequent reversal of the disseminated intravascular coagulation. Conclusion Unexplained arterial or venous thrombosis despite adequate thromboprophylaxis should be investigated, especially in the setting of thrombocytopenia. Chronic disseminated intravascular coagulation is a possible, life-threatening reason for this clinical picture, and should prompt rapid identification of the underlying disease. To the best of our knowledge, this is the second case of chronic disseminated intravascular coagulation due to neoplastic disease treated with immunotherapy.
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11
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Immunotherapy in Metastatic Mucosal Melanoma with Disseminated Intravascular Coagulation: A Case of Success. Case Reports Immunol 2021; 2021:5516004. [PMID: 34659846 PMCID: PMC8519692 DOI: 10.1155/2021/5516004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 09/22/2021] [Indexed: 11/28/2022] Open
Abstract
Mucosal melanoma accounts for 1% of all melanomas. It is more aggressive than cutaneous melanoma, and local excision provides the best disease-free survival. The vast majority of patients eventually develop metastases, with a metastatic pattern independent of the primary tumor site. While studies show that BRAF and KIT inhibitors have a role in the management of these patients, the actual treatment focus is on immunotherapy. Herein is described the case of a 79-year-old woman with metastatic mucosal melanoma and bone marrow infiltration causing disseminated intravascular coagulation, who was treated with an immunotherapy combination (anti-CTLA-4 and anti-PD-1 antibodies), achieving complete disease remission. This is the third case of melanoma with disseminated intravascular coagulation at presentation and the second case treated with immunotherapy in the literature, but the only one achieving disease remission.
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12
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Kamposioras K, Geraghty J, Appleyard J, Dawod M, Papadimitriou K, Lamarca A, Anthoney A. Pancreaticobiliary Malignancies in the Emergency Room: Management of Acute Complications and Oncological Emergencies. J Gastrointest Cancer 2021; 53:1050-1065. [PMID: 34648136 PMCID: PMC9630225 DOI: 10.1007/s12029-021-00718-7] [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] [Accepted: 09/22/2021] [Indexed: 11/29/2022]
Abstract
Background Management of pancreaticobiliary (PB) malignancies remains a clinical challenge. In this review, we focus on the management of oncological emergencies in PB malignancies and the potential complication of associated therapeutic interventions. Methods Biobliographic review of current evidence on the management of oncological emergencies, their potential complications, as well as synthesis of recommendations was performed. The pathogenesis, frequency, related symptoms as well as appropriate investigations are presented. Results The oncologic emergencies in PB patients were summarised in six categories: (1) hematological (including febrile neutropaenia, thrombocytopenia, coagulopathies), (2) gastrointestinal (gastric outlet and biliary obstruction, gastrointestinal bleeding), (3) thromboembolic events, (4) ascites, (5) metabolic disorders and (6) neurologic complications. The pathogenesis, frequency, related symptoms as well as appropriate investigations are also presented. Conclusion Patients with PB malignancies are at increased risk of a wide variation of medical emergencies. Clinical knowledge, early recognition and collaboration with the relevant specialties are critical to manage these complications effectively, tailoring overall management around the actual prognosis and individuals’ expectations.
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Affiliation(s)
| | - Joe Geraghty
- Department of Gastroenterology, Manchester Royal Infirmary, Manchester, UK
| | | | - Mohammed Dawod
- The Christie NHS Foundation Trust, Manchester, Greater Manchester, UK
| | | | - Angela Lamarca
- The Christie NHS Foundation Trust, Manchester, Greater Manchester, UK.,Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Alan Anthoney
- Leeds Institute of Medical Research, St James' Institute of Oncology, St James' University Hospital, University of Leeds, Leeds, LS9 7TF, UK.
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13
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Leung KKY, Hon KL, Hui WF, Leung AK, Li CK. Therapeutics for paediatric oncological emergencies. Drugs Context 2021; 10:dic-2020-11-5. [PMID: 34234831 PMCID: PMC8232653 DOI: 10.7573/dic.2020-11-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/20/2021] [Indexed: 12/19/2022] Open
Abstract
Background With advancements in the field of oncology, cancer survival rates have improved dramatically but modern cancer treatments also come with an increasing number of disease and treatment-associated complications. This article provides an updated narrative review on the pathophysiology, clinical presentations and latest management strategies for common paediatric oncological emergencies. Methods An extensive PubMed® search of all human studies in the English literature was performed in Clinical Queries for different oncology syndromes and conditions using the following Medical Subject Headings: “tumour lysis syndrome”, “hyperleukocytosis”, “disseminated intravascular coagulation”, “superior mediastinal syndrome”, “superior vena cava syndrome”, “sepsis”, “severe inflammatory response syndrome”, “acute respiratory distress syndrome”, “posterior reversible encephalopathy syndrome” and “reversible posterior leukoencephalopathy syndrome”. Categories were limited to clinical trials and reviews for ages from birth to 18 years. Results The general description, presentation and management of these oncologic emergencies are systematically described. Early recognition along with prompt and proactive treatment can reduce the chances of potential complications and improve the clinical outcomes, thereby improving not only survival rates in oncology patients but also their clinical outcomes and quality of life. Conclusions Oncologic emergencies are associated with significant mortality and morbidity. Healthcare professionals involved with the care of oncology patients must be vigilant of these emergencies.
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Affiliation(s)
- Karen Ka Yan Leung
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Kam Lun Hon
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Wun Fung Hui
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Alexander Kc Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Chi Kong Li
- Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong.,Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong
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14
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Desikan SP, Mclaughlin N, McClain C, Desikan R. Recurrent Colon Cancer: Presentation With Disseminated Intravascular Coagulation From Disseminated Carcinomatosis of the Bone Marrow. J Investig Med High Impact Case Rep 2021; 9:23247096211012224. [PMID: 33966469 PMCID: PMC8114248 DOI: 10.1177/23247096211012224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Diffuse carcinomatosis of the bone marrow (DCBM) is a rare clinical condition characterized by diffuse bone marrow involvement with hematological changes. This case study concerns a patient who presented with DCBM secondary to colon cancer with diffuse intravascular coagulation. This is a rare presentation of DCBM in colon cancer. The case study also elaborates on clinical features, pathogenesis, and therapy of this unique presentation.
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15
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Greenberg DJ. Disseminated Intravascular Coagulation as the Initial Presentation of Metastatic Prostate Adenocarcinoma. Cureus 2021; 13:e14845. [PMID: 34104590 PMCID: PMC8175095 DOI: 10.7759/cureus.14845] [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] [Indexed: 11/15/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) can be caused by cancer. However, it is rare to be the presenting sign of malignancy. The manifestations of bleeding or thrombosis in DIC depend on the balance of the fibrinolytic system. This case centers on a 52-year-old male who presented with DIC and spontaneous bruising, and no obvious cause for DIC. He was found to have metastatic prostate adenocarcinoma. DIC related to solid tumors typically have an indolent course and is only apparent on laboratory analysis. Further, DIC with excessive fibrinolysis in prostate cancer is associated with lower median survival. Treatment involves treating prostate cancer, and supportive treatment with blood products. Epsilon-aminocaproic acid may have a role in life-threatening bleeds, while prophylactic heparin treatment can be given for DIC associated with thrombosis.
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16
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Adelborg K, Larsen JB, Hvas AM. Disseminated intravascular coagulation: epidemiology, biomarkers, and management. Br J Haematol 2021; 192:803-818. [PMID: 33555051 DOI: 10.1111/bjh.17172] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Disseminated intravascular coagulation (DIC) is a systemic activation of the coagulation system, which results in microvascular thrombosis and, simultaneously, potentially life-threatening haemorrhage attributed to consumption of platelets and coagulation factors. Underlying conditions, e.g. infection, cancer, or obstetrical complications are responsible for the initiation and propagation of the DIC process. This review provides insights into the epidemiology of DIC and the current understanding of its pathophysiology. It details the use of diagnostic biomarkers, current diagnostic recommendations from international medical societies, and it provides an overview of emerging diagnostic and prognostic biomarkers. Last, it provides guidance on management. It is concluded that timely and accurate diagnosis of DIC and its underlying condition is essential for the prognosis. Treatment should primarily focus on the underlying cause of DIC and supportive treatment should be individualised according to the underlying aetiology, patient's symptoms and laboratory records.
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Affiliation(s)
- Kasper Adelborg
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark
| | - Julie B Larsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark
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17
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Xiao M, Sun A, Yu F, Xiao Y, Li L, Shen D, Xiang C, Dong J. Intraductal papillary neoplasm of intrahepatic bile ducts complicated by chronic disseminated intravascular coagulation and thrombosis: A case report. Medicine (Baltimore) 2021; 100:e24454. [PMID: 33592896 PMCID: PMC7870212 DOI: 10.1097/md.0000000000024454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/06/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Intraductal papillary neoplasm of the bile ducts (IPNB) is a relatively rare tumor that is clinically characterized by digestive symptoms. The concurrent occurrence of chronic disseminated intravascular coagulation (DIC) with thrombosis is an extremely rare combination, reported in patients with IPNB. The clinical features of chronic DIC include microangiopathic hemolytic anemia, thrombocytopenia, and hypofibrinogenemia. Here, we report the case of a mucin-producing IPNB patient with hematological abnormalities. PATIENT CONCERNS A 58-year-old male patient suffered from abdominal distension for more than 2 months with obstructive jaundice appearance. Abdominal contrast-enhanced computed tomography and magnetic resonance cholangiopancreatography showed a neoplasm in the right hepatic lobe. Multiple intravascular fillings were found in the inferior vena cava, pulmonary artery, and right atrium. Anemia and hypofibrinogenemia were discovered through routine laboratory tests. The count of platelets began to decline 25 days after admission, while 1 month after hospitalization, the patient developed abdominal pain, fever, and shock. DIAGNOSIS Pathological examination demonstrated IPNB with a part of high-grade intraepithelial neoplasia. Cardiac and inferior vena cava emboli were diagnosed as thrombi without neoplastic cells. Immunohistochemically, tumor cells were positive for Vimentin (mesenchyme), CK7, CK19, MUC-1, MUC-5AC, MUC-6, S-100p (focal), Ki-67 (12%), and negative for Inhibin-α, ER, CK20, CEA, and MUC-2. Additionally, immunohistochemistry indicated that IPNB was a mucus-secretion gastric type. The laboratory tests confirmed the presence of chronic DIC. INTERVENTIONS The patient was given anticoagulant therapy before hepatectomy and right atrium thrombectomy was performed under cardiopulmonary bypass. OUTCOMES After anticoagulant therapy, the levels of hemoglobin, platelet, and fibrinogen of the patient returned to normal. Hepatectomy and thrombus removal was successfully performed. Then, the patient was discharged 12 days after the operation. After 12 months of follow-up, the patient recovered well without any hematologic abnormalities and no signs of tumor recurrence were observed. LESSONS IPNB may cause hematological complications, which can be easily misdiagnosed. It is essential to pay particular attention to the hematological abnormalities of patients with IPNB. Early detection and differential diagnosis of chronic DIC and thrombosis are necessary. We note that anticoagulant therapy coupled with surgery is an effective strategy to treat these complications.
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Affiliation(s)
- Ming Xiao
- Center of Hepatopancreatobiliary Diseases
| | - Aijun Sun
- Department of Hepatobiliary Surgery, Zhucheng People's Hospital, Zhucheng, China
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18
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Alhenc-Gelas M, Cabel L, Berger F, Delaloge S, Frenel JS, Levy C, Firmin N, Ladoire S, Desmoulins I, Heudel PE, Dalenc F, Loirat D, Dubot C, Vuagnat P, Deluche E, Mokdad-Adi M, Patsouris A, Annic J, Djerroudi L, Lavigne M, Pierga JY, Coppo P, Bidard FC. Characteristics and outcome of breast cancer-related microangiopathic haemolytic anaemia: a multicentre study. Breast Cancer Res 2021; 23:9. [PMID: 33468209 PMCID: PMC7814553 DOI: 10.1186/s13058-021-01386-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 01/01/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Cancer-related microangiopathic haemolytic anaemia (MAHA) is a rare but life-threatening paraneoplastic syndrome. Only single cases or small series have been reported to date. We set up a retrospective multicentre study focusing on breast cancer-related MAHA. METHODS Main inclusion criteria were known diagnosis of breast cancer, presence of schistocytes and either low haptoglobin or cytopenia and absence of any causes of MAHA other than breast cancer, including gemcitabine- or bevacizumab-based treatment. Patient characteristics, treatments and outcome were retrieved from digital medical records. RESULTS Individual data from 54 patients with breast cancer-related MAHA were obtained from 7 centres. Twenty-three (44%) patients had a breast tumour with lobular features, and most primary tumours were low grade (grade I/II, N = 39, 75%). ER+/HER2-, HER2+ and triple-negative phenotypes accounted for N = 33 (69%), N = 7 (15%) and N = 8 (17%) cases, respectively. All patients had stage IV cancer at the time of MAHA diagnosis. Median overall survival (OS) was 28 days (range 0-1035; Q1:10, Q3:186). Independent prognostic factors for early death (≤ 28 days) were PS > 2 (OR = 7.0 [1.6; 31.8]), elevated bilirubin (OR = 6.9 [1.1; 42.6]), haemoglobin < 8.0 g/dL (OR = 3.7 [0.9; 16.7]) and prothrombin time < 50% (OR = 9.1 [1.2; 50.0]). A score to predict early death displayed a sensitivity of 86% (95% CI [0.67; 0.96]), a specificity of 73% (95% CI [0.52; 0.88]) and an area under the curve of 0.90 (95% CI [0.83; 0.97]). CONCLUSIONS Breast cancer-related MAHA appears to be a new feature of invasive lobular breast carcinoma. Prognostic factors and scores may guide clinical decision-making in this serious but not always fatal condition.
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Affiliation(s)
- Marion Alhenc-Gelas
- Department of Medical Oncology, Institut Curie, Paris and Saint Cloud, France
| | - Luc Cabel
- Department of Medical Oncology, Institut Curie, Paris and Saint Cloud, France.,UVSQ, Université Paris-Saclay, 35 rue Dailly, Saint Cloud, 92210, France
| | | | - Suzette Delaloge
- Department of Cancer Medicine, Institut Gustave Roussy, Villejuif, France
| | - Jean-Sebastien Frenel
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | - Christelle Levy
- Department of Medical Oncology, Centre François Baclesse, Caen, France
| | - Nelly Firmin
- Department of Medical Oncology, Institut du Cancer de Montpellier, Institut de cancérologie de Montpellier INSERM U1194, Montpellier, France
| | - Sylvain Ladoire
- Department of Medical Oncology, Centre Georges-François Leclerc, Dijon, France
| | | | | | - Florence Dalenc
- Department of Medical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse-Oncopole (IUCT-Oncopole), Toulouse, France
| | - Delphine Loirat
- Department of Medical Oncology, Institut Curie, Paris and Saint Cloud, France
| | - Coraline Dubot
- Department of Medical Oncology, Institut Curie, Paris and Saint Cloud, France
| | - Perrine Vuagnat
- Department of Medical Oncology, Institut Curie, Paris and Saint Cloud, France
| | - Elise Deluche
- Department of Cancer Medicine, Institut Gustave Roussy, Villejuif, France
| | - Meriem Mokdad-Adi
- Department of Cancer Medicine, Institut Gustave Roussy, Villejuif, France
| | - Anne Patsouris
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | - Josselin Annic
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest, Saint-Herblain, France
| | | | | | - Jean-Yves Pierga
- Department of Medical Oncology, Institut Curie, Paris and Saint Cloud, France.,Université de Paris, Paris, France
| | - Paul Coppo
- Reference Center for Thrombotic Microangiopathies (CNR-MAT), AP-HP.SU, INSERM UMRS, 1138, Paris, France.,Sorbonne University, Paris, France
| | - Francois-Clement Bidard
- Department of Medical Oncology, Institut Curie, Paris and Saint Cloud, France. .,UVSQ, Université Paris-Saclay, 35 rue Dailly, Saint Cloud, 92210, France.
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19
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Brown SA, Zaharova S, Mason P, Thompson J, Thapa B, Ishizawar D, Wilkes E, Ahmed G, Rubenstein J, Sanchez J, Joyce D, Kalyanaraman B, Widlansky M. Pandemic Perspective: Commonalities Between COVID-19 and Cardio-Oncology. Front Cardiovasc Med 2020; 7:568720. [PMID: 33344513 PMCID: PMC7746643 DOI: 10.3389/fcvm.2020.568720] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 11/06/2020] [Indexed: 12/15/2022] Open
Abstract
Overlapping commonalities between coronavirus disease of 2019 (COVID-19) and cardio-oncology regarding cardiovascular toxicities (CVT), pathophysiology, and pharmacology are special topics emerging during the pandemic. In this perspective, we consider an array of CVT common to both COVID-19 and cardio-oncology, including cardiomyopathy, ischemia, conduction abnormalities, myopericarditis, and right ventricular (RV) failure. We also emphasize the higher risk of severe COVID-19 illness in patients with cardiovascular disease (CVD) or its risk factors or cancer. We explore commonalities in the underlying pathophysiology observed in COVID-19 and cardio-oncology, including inflammation, cytokine release, the renin-angiotensin-aldosterone-system, coagulopathy, microthrombosis, and endothelial dysfunction. In addition, we examine common pharmacologic management strategies that have been elucidated for CVT from COVID-19 and various cancer therapies. The use of corticosteroids, as well as antibodies and inhibitors of various molecules mediating inflammation and cytokine release syndrome, are discussed. The impact of angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) is also addressed, since these drugs are used in cardio-oncology and have received considerable attention during the COVID-19 pandemic, since the culprit virus enters human cells via the angiotensin converting enzyme 2 (ACE2) receptor. There are therefore several areas of overlap, similarity, and interaction in the toxicity, pathophysiology, and pharmacology profiles in COVID-19 and cardio-oncology syndromes. Learning more about either will likely provide some level of insight into both. We discuss each of these topics in this viewpoint, as well as what we foresee as evolving future directions to consider in cardio-oncology during the pandemic and beyond. Finally, we highlight commonalities in health disparities in COVID-19 and cardio-oncology and encourage continued development and implementation of innovative solutions to improve equity in health and healing.
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Affiliation(s)
- Sherry-Ann Brown
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Svetlana Zaharova
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Peter Mason
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jonathan Thompson
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Bicky Thapa
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - David Ishizawar
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Erin Wilkes
- Department of Pharmacy, Froedtert Health and Medical College of Wisconsin, Milwaukee, WI, United States
| | - Gulrayz Ahmed
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jason Rubenstein
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Joyce Sanchez
- Division of Infectious Diseases, Medical College of Wisconsin, Milwaukee, WI, United States
| | - David Joyce
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - Michael Widlansky
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
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20
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Dass J, Mittal S, Gupta N, Kotwal J. Myeloma co-existing with prostatic carcinoma: Clues from a "non-coagulable" prothrombin time. INDIAN J PATHOL MICR 2020; 63:151-153. [PMID: 32031153 DOI: 10.4103/ijpm.ijpm_320_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jasmita Dass
- Department of Hematology, Sir Ganga Ram Hospital, New Delhi, India
| | - Suchi Mittal
- Department of Hematology, Sir Ganga Ram Hospital, New Delhi, India
| | - Nitin Gupta
- Department of 1Clinical Hematology, Sir Ganga Ram Hospital, New Delhi, India
| | - Jyoti Kotwal
- Department of 1Clinical Hematology, Sir Ganga Ram Hospital, New Delhi, India
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21
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Ito T, Maruyama I, Shimazaki S, Yamamoto Y, Aikawa N, Hirayama A, Honda G, Saito H. Effects of thrombomodulin alfa on hemostatic parameters in disseminated intravascular coagulation: Post hoc analysis of a phase 3 randomized controlled trial. Res Pract Thromb Haemost 2020; 4:1141-1149. [PMID: 33134780 PMCID: PMC7590306 DOI: 10.1002/rth2.12419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 06/15/2020] [Accepted: 06/20/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The efficacy and safety of thrombomodulin alfa (TM-α), a cofactor protein promoting thrombin-mediated protein C activation, have been examined in a phase 3 randomized, double-blinded, parallel-group trial in Japan. We have previously reported that TM-α is noninferior to heparin for the resolution of disseminated intravascular coagulation (DIC). OBJECTIVE To investigate the basis for the efficacy of TM-α in the phase 3 clinical trial in Japan through post hoc analysis of coagulation and fibrinolysis parameters. PATIENTS/METHODS The 227 patients of the full analysis set population described in the original phase 3 trial in Japan were included in this analysis. Changes in parameters between before and after TM-α or heparin administration in each of the two patient groups, with underlying diseases of either hematologic malignancy or infection, were studied separately and results were compared between TM-α and heparin treatment groups in a post hoc manner. RESULTS TM-α administration did not prolong activated partial thromboplastin time but significantly decreased thrombin-antithrombin complex levels compared with heparin treatment. TM-α administration reduced consumption of endogenous anticoagulants such as antithrombin and protein C by DIC, compared with the heparin group. DIC scores were decreased in both TM-α and heparin groups during the 6-day treatment. CONCLUSION TM-α can alleviate intravascular coagulation and consumption of anticoagulants without extending coagulation times. This may be associated with the relatively low risk of bleeding during TM-α treatment.
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Affiliation(s)
- Takashi Ito
- Department of Systems Biology in ThromboregulationKagoshima University Graduates School of Medical and Dental SciencesKagoshimaJapan
| | - Ikuro Maruyama
- Department of Systems Biology in ThromboregulationKagoshima University Graduates School of Medical and Dental SciencesKagoshimaJapan
| | - Shuji Shimazaki
- Department of Emergency Medical SystemDisaster and EMS Rescue InstituteKokushikan UniversityTokyoJapan
| | | | | | | | | | - Hidehiko Saito
- National Hospital Organization Nagoya Medical CenterAichiJapan
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22
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Squizzato A, Gallo A, Levi M, Iba T, Levy JH, Erez O, Ten Cate H, Solh Z, Gando S, Vicente V, Di Nisio M. Underlying disorders of disseminated intravascular coagulation: Communication from the ISTH SSC Subcommittees on Disseminated Intravascular Coagulation and Perioperative and Critical Care Thrombosis and Hemostasis. J Thromb Haemost 2020; 18:2400-2407. [PMID: 32881338 DOI: 10.1111/jth.14946] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/01/2020] [Accepted: 05/28/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC), a systemic activation of coagulation, presents with multiple clinical and laboratory manifestations. In this International Society on Thrombosis and Haemostasis (ISTH) communication, we examined the importance of identifying the underlying disorder causing DIC to help physicians in the diagnosis and management of this common and severe condition. METHODS Eight DIC experts participated in a three-step consensus process that searched for published guidelines and diagnostic scores on DIC to create a preliminary list of DIC underlying disorders from those reported in the literature Overall, 13 papers were identified, including three guidelines, one harmonization paper by the ISTH, one ISTH recommendation paper on cancer-associated DIC, five general diagnostic scores, two scores specific for pregnancy, and one specific for children. We then assessed the strength of the evidence on the association between the disease and DIC as many postulated DIC-associated disorders are rare. KEY RESULTS Eight main subgroups - 'severe infection', 'solid tumour', 'haematological neoplasia', 'pregnancy complication', 'vascular disease', 'newborn-complication', 'tissue damage due to internal or external insult', and 'chemical and biological agent' - and a detailed list of specific causes of DIC were provided. CONCLUSIONS & INFERENCES Our results suggest more data are needed to determine the association between DIC and specific diseases such as malignant lymphoma, colorectal cancer, or vasculitis, for which the evidence remains limited. When a patient develops a coagulopathy consistent with DIC, the first step is to immediately search for an underlying disorder, including specific causes that are rarely associated with DIC and to consider that patients may have more than one cause of DIC to identify the principal precipitating disorder to prioritize treatment.
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Affiliation(s)
- Alessandro Squizzato
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Andrea Gallo
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Marcel Levi
- Department of Medicine, University College London Hospitals NHS Foundation Trust and Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, UK
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Offer Erez
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Internal Medicine, Cardiovascular Research Institute, Maastricht University Medical Center, Maastricht, Netherlands
| | - Ziad Solh
- Transfusion Medicine Section, Department of Pathology & Laboratory Medicine (PaLM), Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Satoshi Gando
- Acute and Critical Care Center, Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Vicente Vicente
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria, University of Murcia, Murcia, Spain
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G. D'Annunzio, Chieti-Pescara, Italy
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23
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Bouzidi S, Daiki M, Nasr AA, Nsiri K, Layouni S, Hajjej Z, Fekih-Mrissa N, Ferjani M, Nsiri B. [Disseminated intravascular coagulation: role of the International Society on Thrombosis and Haemostasis (ISTH) diagnostic scoring system]. Pan Afr Med J 2020; 36:154. [PMID: 32874418 PMCID: PMC7436632 DOI: 10.11604/pamj.2020.36.154.20368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 05/25/2020] [Indexed: 11/11/2022] Open
Abstract
La coagulation intravasculaire disséminée (CIVD) est une cause de mortalité redoutable en milieu de réanimation. L´utilisation du système de score de la société internationale sur la thrombose et l´hémostase (ISTH) permet de faciliter le diagnostic précoce de la CIVD. Nous présentons trois observations cliniques de CIVD d´étiologies différentes: un adénocarcinome prostatique, un choc septique et un hématome rétro-placentaire. Les tests d´hémostase nécessaires au calcul du score de la Société Internationale sur la Thrombose et l´Hémostase (ISTH) (numération plaquettaire, taux de prothrombine, fibrinogène et D-dimères) ont été régulièrement réalisés. D´autres tests complémentaires (recherche de complexes solubles, test de lyse des euglobulines, dosage des taux d´antithrombine, de protéine C activée et du facteur V) ont été également réalisés. L´utilisation du score ISTH permet de faciliter le diagnostic précoce de la CIVD.
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Affiliation(s)
- Sawsen Bouzidi
- Laboratoire d´Hématologie, Hôpital Militaire Principal d´Instruction de Tunis, Tunis, Tunisie
| | - Mayssa Daiki
- Service d´Anesthésie Réanimation, Hôpital Militaire Principal d´Instruction de Tunis, Tunis, Tunisie
| | - Amen Allah Nasr
- Laboratoire d´Hématologie, Hôpital Militaire Principal d´Instruction de Tunis, Tunis, Tunisie
| | - Kaouther Nsiri
- Laboratoire d´Hématologie, Hôpital Militaire Principal d´Instruction de Tunis, Tunis, Tunisie
| | - Samy Layouni
- Unité de Recherche de Biologie Moléculaire (UR17DN06), Laboratoire d´Hématologie, Hôpital Militaire Principal d´Instruction de Tunis, Tunis, Tunisie
| | - Zied Hajjej
- Service d´Anesthésie Réanimation, Hôpital Militaire Principal d´Instruction de Tunis, Tunis, Tunisie
| | - Najiba Fekih-Mrissa
- Unité de Recherche de Biologie Moléculaire (UR17DN06), Laboratoire d´Hématologie, Hôpital Militaire Principal d´Instruction de Tunis, Tunis, Tunisie
| | - Mustapha Ferjani
- Service d´Anesthésie Réanimation, Hôpital Militaire Principal d´Instruction de Tunis, Tunis, Tunisie
| | - Brahim Nsiri
- Laboratoire d´Hématologie, Hôpital Militaire Principal d´Instruction de Tunis, Tunis, Tunisie
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Kosir JA, Salihovic M, Sever P, Klen J. An unexpected death after low anterior resection due to disseminated intravascular coagulation: A case report. Int J Surg Case Rep 2020; 71:367-370. [PMID: 32506007 PMCID: PMC7283093 DOI: 10.1016/j.ijscr.2020.05.045] [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: 03/22/2020] [Revised: 05/02/2020] [Accepted: 05/21/2020] [Indexed: 11/24/2022] Open
Abstract
Disseminated intravascular coagulation can develop due to unrecognized sepsis. It can have a life-threatening course even in young, previously healthy patients. Rotational thromboelastometry may aid in guiding the treatment.
Introduction Disseminated intravascular coagulation (DIC) is a blood clotting disorder that is characterized by intravascular thrombi formation and exhaustion of platelets and coagulation factors resulting in diffuse hemorrhage and multiple organ dysfunction. Presentation of case We present a case report of a previously healthy middle-aged patient who was treated by low anterior resection for rectal carcinoma and suddenly went into unexpected circulatory shock on the 7th postoperative day. Despite our resuscitation efforts, he succumbed to the disease. The postmortem examination showed findings consistent with DIC. Discussion The cause for DIC in this patient may be multifactorial. Sepsis, tumor-related factors and hereditary predisposition may have played a role. The role of blood components in treatment is not fully understood as they may worsen the inflammatory response. Conclusion DIC can be the presenting sign of unrecognized sepsis and it can occur in all surgical patients. Even with prompt treatment, the disease can have a fatal course.
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Affiliation(s)
- Jurij Ales Kosir
- Department of Abdominal Surgery, UMC Ljubljana, Zaloška Cesta 7, 1000, Ljubljana, Europe, Slovenia.
| | - Mensur Salihovic
- Department of Anesthesiology and Surgical Intensive Therapy, UMC Ljubljana, Zaloška Cesta 7, 1000, Ljubljana, Europe, Slovenia.
| | - Primoz Sever
- Department of Abdominal Surgery, UMC Ljubljana, Zaloška Cesta 7, 1000, Ljubljana, Europe, Slovenia.
| | - Jasna Klen
- Department of Abdominal Surgery, UMC Ljubljana, Zaloška Cesta 7, 1000, Ljubljana, Europe, Slovenia.
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Disseminated Intravascular Coagulation and Malignancy: A Case Report and Literature Review. Case Rep Oncol Med 2020; 2020:9147105. [PMID: 31976103 PMCID: PMC6959140 DOI: 10.1155/2020/9147105] [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: 07/06/2019] [Accepted: 12/18/2019] [Indexed: 11/21/2022] Open
Abstract
Disseminated Intravascular Coagulation (DIC) is a disorder of coagulation which is commonly seen as a complication of infections, traumas, obstetric diseases, and cancers especially hematological and rarely solid cancers. DIC may rarely be the presenting feature of an undiagnosed malignancy. It may present in the form of different phenotypes which makes its diagnosis difficult and leads to high mortality. The treatment comprises supportive, symptomatic treatment and removal of the underlying source. Here, we present a patient with history of being on warfarin for atrial fibrillation and other comorbidities who presented with elevated INR of 6.3 and increasing dyspnea on exertion. Over the course of her stay, her platelet counts started dropping with a concurrent decrease in fibrinogen levels. She eventually developed pulmonary embolism, followed by stroke and limb ischemia, which was indicative of the thrombotic phenotype of DIC. Her pleural fluid analysis showed huge burden of malignant cells in glandular pattern suggestive of adenocarcinoma and was started on heparin drip. However, the patient had cardiac arrest and expired on the same day of diagnosis.
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Zhi L, Yang S, Chen J, Lu Y, Chen J, Qin Z, Tang XM. Tetrahydropalmatine has a therapeutic effect in a lipopolysaccharide-induced disseminated intravascular coagulation model. J Int Med Res 2019; 48:300060519889430. [PMID: 31830839 PMCID: PMC7327433 DOI: 10.1177/0300060519889430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objectives The aim of this study was to determine the therapeutic effects of
tetrahydropalmatine (Tet) on disseminated intravascular coagulation (DIC) by
exploring the role of Tet using a lipopolysaccharide (LPS)-induced DIC
model. Methods/Materials: We established a mouse DIC model by injecting
LPS. Hematoxylin-eosin (HE) staining was performed to detect liver and
kidney damage. Blood samples were obtained to determine liver and kidney
injury indexes, coagulation indexes, and inflammatory cytokines. An
in vitro cell inflammation model was also established.
Tumor necrosis factor-α (TNF-α) levels and nuclear factor kappa B (NF-κB)
signaling pathway activation were determined by western blot. Result Tet ameliorated the damage to organ tissues, improved coagulation indexes,
and reduced the inflammatory cytokine production in LPS-induced mouse DIC.
Tet also inhibited TNF-α expression by suppressing NF-κB signaling pathway
activation in an in vitro LPS model using RAW 264.7
macrophages. Conclusions Tet has a mitigating and therapeutic effect on the LPS-induced DIC model via
anticoagulant and anti-inflammatory effects, showing its potential as an
adjunct to DIC treatment.
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Affiliation(s)
- Lin Zhi
- Department of Pharmacology, Medical College, Jinan University, Guangzhou, China
| | - Shangqi Yang
- Department of Pharmacology, Medical College, Jinan University, Guangzhou, China
| | - Jiekun Chen
- Department of Pharmacology, Medical College, Jinan University, Guangzhou, China
| | - Yuli Lu
- Department of Pharmacology, Medical College, Jinan University, Guangzhou, China
| | - Jiahong Chen
- Department of Pharmacology, Medical College, Jinan University, Guangzhou, China
| | - Zixi Qin
- Department of Pharmacology, Medical College, Jinan University, Guangzhou, China
| | - Xiao-Mei Tang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Jinan University, Guangzhou, China
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Abstract
Cancer can be associated with several distinct coagulation defects which can lead to bleeding complications. The primary hyperfibrinolytic syndrome associated with acute promyelocytic leukemia has been well recognized and is one of the most severe bleeding disorders. Acquired hemophilia, while rare and not only seen in the oncology setting, can be triggered by a malignancy and must be promptly recognized in order to prevent catastrophic hemorrhage. Other, less serious coagulopathic states have been linked to cancer, including acquired von Willebrand disease. Finally, several anti-neoplastic drugs can alter hemostasis and increase the risk of bleeding. A good understanding of this field can help mitigate the risk of complications in the cancer patient.
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Affiliation(s)
- Simon Mantha
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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28
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Considerations for Medications Commonly Utilized in the Oncology Population in the Intensive Care Unit. ONCOLOGIC CRITICAL CARE 2019. [PMCID: PMC7189427 DOI: 10.1007/978-3-319-74588-6_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
An increasing number of oncologic patients are presenting to the intensive care unit with complications from both their chronic disease states and cancer therapies due to improved survival rates. The management of these patients is complex due to immunosuppression (from the malignancy and/or treatment), metabolic complications, and diverse medication regimens with the potential for significant drug-drug interactions and overlapping adverse effects. This chapter will provide clinicians with an overview of non-chemotherapy medications frequently encountered in the critically ill oncologic patient, with a focus on practical considerations.
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Disseminated intravascular coagulation and melanoma: a novel case occurring in metastatic melanoma with BRAF and NRAS mutations and systematic review. Melanoma Res 2019; 29:533-538. [PMID: 31095038 DOI: 10.1097/cmr.0000000000000622] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Disseminated intravascular coagulation is a complex and potentially lethal complication of malignancy, in which the fundamental abnormality is excessive activation of the coagulation system. It is a rare complication of melanoma which can be difficult to diagnose in some circumstances, leading to delay in treatment. Herein, we describe the first case of disseminated intravascular coagulation occurring in BRAF and NRAS-mutant metastatic melanoma, and systematically review the literature regarding disseminated intravascular coagulation in melanoma. This review summarizes the reported cases of disseminated intravascular coagulation in melanoma and those secondary to the novel treatment of melanoma, and explores the pathophysiology of disseminated intravascular coagulation in melanoma, highlighting the key role of expression of markers of coagulation and fibrinolysis in disseminated intravascular coagulation, as well as more widely in melanoma. Current limitations in the literature are also identified and discussed, particularly with respect to improving the management of this lethal complication. Disseminated intravascular coagulation is a rare complication of melanoma that typically portends poor prognosis.
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30
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Dardiotis E, Aloizou AM, Markoula S, Siokas V, Tsarouhas K, Tzanakakis G, Libra M, Kyritsis AP, Brotis AG, Aschner M, Gozes I, Bogdanos DP, Spandidos DA, Mitsias PD, Tsatsakis A. Cancer-associated stroke: Pathophysiology, detection and management (Review). Int J Oncol 2019; 54:779-796. [PMID: 30628661 PMCID: PMC6365034 DOI: 10.3892/ijo.2019.4669] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 12/28/2018] [Indexed: 12/15/2022] Open
Abstract
Numerous types of cancer have been shown to be associated with either ischemic or hemorrhagic stroke. In this review, the epidemiology and pathophysiology of stroke in cancer patients is discussed, while providing vital information on the diagnosis and management of patients with cancer and stroke. Cancer may mediate stroke pathophysiology either directly or via coagulation disorders that establish a state of hypercoagulation, as well as via infections. Cancer treatment options, such as chemotherapy, radiotherapy and surgery have all been shown to aggravate the risk of stroke as well. The clinical manifestation varies greatly depending upon the underlying cause; however, in general, cancer‑associated strokes tend to appear as multifocal in neuroimaging. Furthermore, several serum markers have been identified, such as high D‑Dimer levels and fibrin degradation products. Managing cancer patients with stroke is a delicate matter. The cancer should not be considered a contraindication in applying thrombolysis and recombinant tissue plasminogen activator (rTPA) administration, since the risk of hemorrhage in cancer patients has not been reported to be higher than that in the general population. Anticoagulation, on the contrary, should be carefully examined. Clinicians should weigh the benefits and risks of anticoagulation treatment for each patient individually; the new oral anticoagulants appear promising; however, low‑molecular‑weight heparin remains the first choice. On the whole, stroke is a serious and not a rare complication of malignancy. Clinicians should be adequately trained to handle these patients efficiently.
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Affiliation(s)
- Efthimios Dardiotis
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, 41100 Larissa
| | - Athina-Maria Aloizou
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, 41100 Larissa
| | - Sofia Markoula
- Department of Neurology, University Hospital of Ioannina, 45110 Ioannina
| | - Vasileios Siokas
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, 41100 Larissa
| | | | - Georgios Tzanakakis
- Laboratory of Anatomy-Histology-Embryology, Medical School, University of Crete, 71003 Heraklion, Greece
| | - Massimo Libra
- Department of Biomedical and Biotechnological Sciences, Pathology and Oncology Section, University of Catania, 95124 Catania, Italy
| | | | - Alexandros G. Brotis
- Department of Neurosurgery, University of Thessaly, University Hospital of Larissa, 41100 Larissa, Greece
| | - Michael Aschner
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Illana Gozes
- The Lily and Avraham Gildor Chair for the Investigation of Growth Factors, The Elton Laboratory for Molecular Neuroendocrinology, Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Sagol School of Neuroscience and Adams Super Center for Brain Studies, Tel Aviv University, Tel Aviv 69978, Israel
| | - Dimitrios P. Bogdanos
- Department of Rheumatology and Clinical Immunology, University General Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 40500 Larissa
- Cellular Immunotherapy and Molecular Immunodiagnostics, Biomedical Section, Centre for Research and Technology-Hellas (CERTH) - Institute for Research and Technology-Thessaly (IRETETH), 41222 Larissa
| | | | - Panayiotis D. Mitsias
- Department of Neurology, School of Medicine, University of Crete, 71003 Heraklion, Greece
- Comprehensive Stroke Center and Department of Neurology, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Aristidis Tsatsakis
- Laboratory of Toxicology, School of Medicine, University of Crete, 71003 Heraklion, Greece
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Smeekens M, Wouters M, de Jong P, van der Spek E. Disseminated Intravascular Coagulation in a Patient with Advanced Lung Adenocarcinoma. J Thorac Oncol 2018; 13:e224-e225. [PMID: 30368413 DOI: 10.1016/j.jtho.2018.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/06/2018] [Accepted: 06/07/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Maarten Smeekens
- Department of Pulmonary Medicine, Rijnstate Hospital, Arnhem, The Netherlands.
| | - Moniek Wouters
- Department of Pulmonary Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Peter de Jong
- Department of Pulmonary Medicine, Rijnstate Hospital, Arnhem, The Netherlands
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Cancer-Associated Thrombosis: An Overview of Mechanisms, Risk Factors, and Treatment. Cancers (Basel) 2018; 10:cancers10100380. [PMID: 30314362 PMCID: PMC6209883 DOI: 10.3390/cancers10100380] [Citation(s) in RCA: 322] [Impact Index Per Article: 53.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/04/2018] [Accepted: 10/07/2018] [Indexed: 12/15/2022] Open
Abstract
Cancer-associated thrombosis is a major cause of mortality in cancer patients, the most common type being venous thromboembolism (VTE). Several risk factors for developing VTE also coexist with cancer patients, such as chemotherapy and immobilisation, contributing to the increased risk cancer patients have of developing VTE compared with non-cancer patients. Cancer cells are capable of activating the coagulation cascade and other prothrombotic properties of host cells, and many anticancer treatments themselves are being described as additional mechanisms for promoting VTE. This review will give an overview of the main thrombotic complications in cancer patients and outline the risk factors for cancer patients developing cancer-associated thrombosis, focusing on VTE as it is the most common complication observed in cancer patients. The multiple mechanisms involved in cancer-associated thrombosis, including the role of anticancer drugs, and a brief outline of the current treatment for cancer-associated thrombosis will also be discussed.
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Sun J, Zhu J, Zhou D, Zhu L, Yang X, Xie M, Li L, Huang X, Zhu M, Zheng Y, Xie W, Ye X. Factors Affecting Early Death and Survival of Patients With Acute Promyelocytic Leukemia Treated With ATRA-Based Therapy Regimens. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 19:e63-e70. [PMID: 30661514 DOI: 10.1016/j.clml.2018.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/27/2018] [Accepted: 08/01/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE To perform a retrospective analysis of the prognostic relevance of clinicopathologic parameters in a well-documented cohort of patients treated with all-trans-retinoic acid (ATRA)-based induction regimens in order to discover which indicators can predict a high risk of early death (ED) and patient survival. PATIENTS AND METHODS We analyzed data of 288 newly diagnosed adult acute promyelocytic leukemia patients in Hangzhou, China. The median follow-up time was 32 months (range, 6-78 months). RESULTS The 3-year disease-free and overall survival rates were 90.83% and 91.69%, respectively. In the multivariable analysis, older age (≥ 60 years) was the only independent risk factor for ED (hazard ratio [HR] = 15.057; P = .004). High white blood cell count was not a risk factor for ED (P = .055), but it was for relapse (HR = 2.7; P = .009). FLT3 mutation (HR = 3.9; 95% confidence interval, 1.4 to 10; P = .007) and older age (≥ 60 years) (HR = 5.3; 95% confidence interval, 2.4 to 11; P < .001) were prognostic factors for poorer disease-free and overall survival. Interestingly, CD15 negativity (HR = 0.23; P = .049) was a prognostic factor for relapse. The ED rate was 5.9% (17/288 patients). CONCLUSION The perceived impact of the identification of these high-risk factors should be described in order to decide whether any modifications to treatment strategy should be entertained.
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Affiliation(s)
- Jianai Sun
- Senior Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Jingjing Zhu
- Senior Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - De Zhou
- Senior Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Lixia Zhu
- Senior Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Xiudi Yang
- Senior Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Mixue Xie
- Senior Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Li Li
- Senior Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Xianbo Huang
- Senior Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Mingyu Zhu
- Senior Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Yanlong Zheng
- Senior Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Wanzhuo Xie
- Senior Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Xiujin Ye
- Senior Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China.
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Levi M. Clinical characteristics of disseminated intravascular coagulation in patients with solid and hematological cancers. Thromb Res 2018; 164 Suppl 1:S77-S81. [DOI: 10.1016/j.thromres.2018.01.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 01/05/2018] [Accepted: 01/08/2018] [Indexed: 01/15/2023]
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Lad D, Jain A, Varma S. Complications and management of coagulation disorders in leukemia patients. BLOOD AND LYMPHATIC CANCER-TARGETS AND THERAPY 2017; 7:61-72. [PMID: 31360085 PMCID: PMC6467343 DOI: 10.2147/blctt.s125121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patients with leukemia are predisposed to various coagulation abnormalities. Thrombosis and bleeding continue to be a major cause of morbidity and mortality in leukemias. The pathophysiology of these disorders is unique, and not only the disease but also the treatment and other factors play a role. There has been an increase in the understanding of these disorders in leukemias. However, it is still difficult to predict when and which patients will have these complications. The evidence for the management of coagulation abnormalities in leukemias is still evolving and not as established as in solid malignancies. The management of these disorders is complex, and making clinical decisions is often challenging. In the era of specialization, where there are different hematologists looking after benign- and malignant-hematology patients, opinions of thrombosis experts are often sought by leukemia specialists. This review aims to bridge the gap in the knowledge of these disorders between these specialists.
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Affiliation(s)
- Deepesh Lad
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
| | - Arihant Jain
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
| | - Subhash Varma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
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36
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Emergencies in Breast Cancer. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
Transfusion of various blood components can provide relief from symptomatic anemia and reduce the bleeding risks associated with low platelet counts or presence of coagulopathy. Blood components are collected from volunteer donors and processed into separate components to maximize efficient utilization of a scarce resource while also providing maximum clinical benefit. Tests including blood type and screening for clinically significant alloantibodies increase the likelihood of successful transfusion. Risks of transfusion include hypersensitivity and hemolytic transfusion reactions, transfusion-related acute lung injury, transfusion-associated circulatory overload, and transmission of infection. Indications for transfusion are reviewed along with various products available for transfusion.
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Affiliation(s)
- Nathan T Connell
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Massive Bleeding as the First Clinical Manifestation of Metastatic Prostate Cancer due to Disseminated Intravascular Coagulation with Enhanced Fibrinolysis. Case Rep Hematol 2016; 2016:7217915. [PMID: 27803823 PMCID: PMC5075599 DOI: 10.1155/2016/7217915] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 09/03/2016] [Accepted: 09/08/2016] [Indexed: 11/29/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) is the most frequent coagulation disorder associated with metastatic prostate adenocarcinoma. However, DIC with enhanced fibrinolysis as an initial presentation of prostate cancer is extremely rare. The appropriate treatment to control bleeding in these situations is challenging, controversial, and based on isolated case reports in the literature. A 66-year-old male presented at the emergency department with acute severe spontaneous ecchymoses localized to the limbs, laterocervical hematoma, and hemothorax. Prostate specific antigen level was 385 μg/L, bone scintigraphy revealed multiple bone metastases, and prostate biopsy confirmed adenocarcinoma (Gleason 9; 4 + 5). Laboratory investigation showed a pattern of enhanced fibrinolysis rather than the more common intravascular coagulation mechanism. Epsilon aminocaproic acid in monotherapy was initiated with a clear and rapid control of bleeding manifestations. This rare case of massive bleeding due to DIC with enhanced fibrinolysis as the first manifestation of prostate cancer suggests that in selected cases where the acute bleeding dyscrasia is clearly associated with a dominant fibrinolysis mechanism it is possible to use an approach of monotherapy with antifibrinolytics.
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Thachil J. Disseminated intravascular coagulation - new pathophysiological concepts and impact on management. Expert Rev Hematol 2016; 9:803-14. [PMID: 27314681 DOI: 10.1080/17474086.2016.1203250] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Disseminated intravascular coagulation (DIC) is an intermediary mechanism of disease which develops secondary to many causes including sepsis, trauma and malignancies. This review attempts to summarise the new pathophysiological developments and the impact they have on the current and future management of DIC. AREAS COVERED Several publications detailing the pathophysiology of DIC and the clinical management were identified using a pubmed search. Expert commentary: In recent years, on the initiatives of the international society of thrombosis and haemostasis, important advances have been made on the diagnostic aspect of DIC. In addition, several researchers have focused on the pathophysiology of the condition which is likely to provide better diagnostic markers and targeted therapy. However, some confusion still exists in the definition and management of DIC since various specialists understands the mechanisms involved in DIC from different perspectives.
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Affiliation(s)
- Jecko Thachil
- a Department of Haematology , Central Manchester University Hospitals NHS Foundation Trust , Manchester , UK
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Wada H, Matsumoto T, Aota T, Yamashita Y, Suzuki K, Katayama N. Management of cancer-associated disseminated intravascular coagulation: guidance from the SSC of the ISTH: comment. J Thromb Haemost 2016; 14:1314-5. [PMID: 26894613 DOI: 10.1111/jth.13297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/12/2016] [Indexed: 12/01/2022]
Affiliation(s)
- H Wada
- Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Tsu, Japan
| | - T Matsumoto
- Department of Hematology and Oncology, Mie University School of Medicine, Mie, Japan
| | - T Aota
- Blood Transfusion, Mie University Hospital, Tsu, Japan
| | - Y Yamashita
- Blood Transfusion, Mie University Hospital, Tsu, Japan
| | - K Suzuki
- Emergency Critical Care Center, Mie University Hospital, Tsu, Japan
| | - N Katayama
- Blood Transfusion, Mie University Hospital, Tsu, Japan
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Oo TH. Management of cancer-associated disseminated intravascular coagulation: guidance from the SSC of the ISTH: comment. J Thromb Haemost 2015; 13:1351-2. [PMID: 25781059 DOI: 10.1111/jth.12904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 03/11/2015] [Indexed: 08/31/2023]
Affiliation(s)
- T H Oo
- The University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA
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