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Chen J, Liu S, Ruan Z, Wang K, Xi X, Mao J. Thrombotic events associated with immune checkpoint inhibitors and novel antithrombotic strategies to mitigate bleeding risk. Blood Rev 2024; 67:101220. [PMID: 38876840 DOI: 10.1016/j.blre.2024.101220] [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: 04/26/2024] [Revised: 05/23/2024] [Accepted: 06/05/2024] [Indexed: 06/16/2024]
Abstract
Although immunotherapy is expanding treatment options for cancer patients, the prognosis of advanced cancer remains poor, and these patients must contend with both cancers and cancer-related thrombotic events. In particular, immune checkpoint inhibitors are associated with an increased risk of atherosclerotic thrombotic events. Given the fundamental role of platelets in atherothrombosis, co-administration of antiplatelet agents is always indicated. Platelets are also involved in all steps of cancer progression. Classical antithrombotic drugs can cause inevitable hemorrhagic side effects due to blocking integrin β3 bidirectional signaling, which regulates simultaneously thrombosis and hemostasis. Meanwhile, many promising new targets are emerging with minimal bleeding risk and desirable anti-tumor effects. This review will focus on the issue of thrombosis during immune checkpoint inhibitor treatment and the role of platelet activation in cancer progression as well as explore the mechanisms by which novel antiplatelet therapies may exert both antithrombotic and antitumor effects without excessive bleeding risk.
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Affiliation(s)
- Jiayi Chen
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Shuang Liu
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zheng Ruan
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Kankan Wang
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; Sino-French Research Center for Life Sciences and Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Xiaodong Xi
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Jianhua Mao
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
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2
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Zhang J, Zhao Q, Du Y, Wang W, Liu C. Pan-cancer analysis identifies venous thromboembolism-related genes F3, PLAT, and C1S as potential prognostic biomarkers for glioblastoma and lower grade glioma. MOLECULAR BIOMEDICINE 2024; 5:34. [PMID: 39179711 PMCID: PMC11343955 DOI: 10.1186/s43556-024-00197-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 07/16/2024] [Indexed: 08/26/2024] Open
Abstract
Venous thromboembolism (VTE) is a prevalent complication among patients with cancer, contributing significantly to morbidity and mortality. However, the relationship between VTE-related genes (VRGs) and their potential impact on prognosis, immune response, and therapeutic targets in various cancer types remains unclear. Based on the coagulation and complement pathways, we identified hub VRGs that play a role in regulating the immune response in cancer. Specifically, coagulation factor III (F3), plasminogen activator (PLAT) and complement C1s (C1S) were identified as genes that exhibit high expression levels, positively correlating with tumor stemness and copy number variations, while inversely correlating with methylation levels, in particular cancer types. Pan-cancer survival analysis revealed detrimental effects of these VRGs in several cancer types, notably in glioblastoma and lower grade glioma (GMBLGG). Further analysis using receiver operating characteristic (ROC) curves demonstrated a high accuracy of F3, PLAT and C1S in predicting outcomes in GBMLGG, with area under the curve (AUC) values ranging from 0.78 to 0.9. Validation of the prognostic value of these three genes in GMBLGG was conducted using an independent Gene Expression Omnibus (GEO) dataset. Additionally, gene-drug association analysis identified ciclosporin, ouabain and 6- mercaptopurine, which all exhibit immunosuppressive properties, as potential therapeutic options for tumor patients exhibiting high F3, PLAT or C1S expression, respectively. In summary, our findings provide a bioinformatics perspective on VRGs in pan-cancer, highlighting the pivotal roles of F3, PLAT and C1S, which could potentially be therapeutically exploited and targeted in several cancers, especially in GBMLGG.
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Affiliation(s)
- Jing Zhang
- Department of Radiology, The First Affiliated Hospital of Jinan University, 510630, Guangzhou, China.
- MOE Key Laboratory of Tumor Molecular Biology and Key Laboratory of Functional Protein Research of Guangdong Higher Education Institutes, College of Life Science and Technology, Institute of Life and Health Engineering, Jinan University, 510632, Guangzhou, China.
| | - Qian Zhao
- MOE Key Laboratory of Tumor Molecular Biology and Key Laboratory of Functional Protein Research of Guangdong Higher Education Institutes, College of Life Science and Technology, Institute of Life and Health Engineering, Jinan University, 510632, Guangzhou, China
| | - Yun Du
- Department of Nursing, The First Affiliated Hospital of Jinan University, 510630, Guangzhou, China
| | - Wannan Wang
- Department of Radiology, The First Affiliated Hospital of Jinan University, 510630, Guangzhou, China
- MOE Key Laboratory of Tumor Molecular Biology and Key Laboratory of Functional Protein Research of Guangdong Higher Education Institutes, College of Life Science and Technology, Institute of Life and Health Engineering, Jinan University, 510632, Guangzhou, China
| | - Cuiqing Liu
- Department of Surgery, The First Affiliated Hospital of Jinan University, 510630, Guangzhou, China.
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Zhang Y, Zeng J, Bao S, Zhang B, Li X, Wang H, Cheng Y, Zhang H, Zu L, Xu X, Xu S, Song Z. Cancer progression and tumor hypercoagulability: a platelet perspective. J Thromb Thrombolysis 2024; 57:959-972. [PMID: 38760535 DOI: 10.1007/s11239-024-02993-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2024] [Indexed: 05/19/2024]
Abstract
Venous thromboembolism, which is common in cancer patients and accompanies or even precedes malignant tumors, is known as cancer-related thrombosis and is an important cause of cancer- associated death. At present, the exact etiology of the elevated incidence of venous thrombosis in cancer patients remains elusive. Platelets play a crucial role in blood coagulation, which is intimately linked to the development of arterial thrombosis. Additionally, platelets contribute to tumor progression and facilitate immune evasion by tumors. Tumor cells can interact with the coagulation system through various mechanisms, such as producing hemostatic proteins, activating platelets, and directly adhering to normal cells. The relationship between platelets and malignant tumors is also significant. In this review article, we will explore these connections.
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Affiliation(s)
- Yifan Zhang
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Jingtong Zeng
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Shihao Bao
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Bo Zhang
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Xianjie Li
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Hanqing Wang
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Yuan Cheng
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Hao Zhang
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Lingling Zu
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaohong Xu
- Colleges of Nursing, Tianjin Medical University, Tianjin, China
| | - Song Xu
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China.
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China.
| | - Zuoqing Song
- Department of Lung Cancer Surgery, Tianjin Medical University General Hospital, Tianjin, China.
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China.
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4
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Mann JA, Bhatt D, Tso MK. Primary Malignant Meningeal Melanoma Complicated by Cerebral Venous Sinus Thrombosis: An Illustrative Case With a Systematic Review of the Literature. Cureus 2024; 16:e66710. [PMID: 39262554 PMCID: PMC11389971 DOI: 10.7759/cureus.66710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2024] [Indexed: 09/13/2024] Open
Abstract
Melanocytic tumors of the central nervous system (CNS) such as meningeal melanoma are exceedingly rare tumours derived from leptomeningeal melanocytes. We report an illustrative case of a previously healthy 47-year-old male who presented with tonic-clonic seizure. Magnetic resonance imaging (MRI) with contrast demonstrated a homogenously enhancing right temporal extra-axial lesion. The patient was stabilized on anti-epileptic medications and dexamethasone prior to proceeding with complete surgical resection of the lesion. Intraoperatively, the lesion was heavily pigmented with invasion of the surrounding dura and skull. Histopathology revealed a poorly differentiated neoplasm with nuclear atypia and melanin-containing cells with strong SOX10 and variable S100 positivity. Computed tomography (CT) of the chest, abdomen, and pelvis showed no metastatic disease, and molecular profiling was negative including absent BRAF mutation. He began checkpoint inhibitor therapy and subsequently developed cerebral venous sinus thrombosis managed with anticoagulation. Sixteen months post-operatively, he was neurologically intact, working full-time, and had resumed immunotherapy. We systematically reviewed the literature on primary intracranial malignant melanoma (PIMM) with the goal of understanding the prognosis and best treatment options for this disease. Our systematic review produced 82 articles (118 unique cases) of PIMM. The average age at diagnosis was 45.9 years (95% CI:42.9-48.9), and headache (54.2%) was the most common initial presentation. Eighty-nine percent of patients had primary surgical resection, and 41.0% of these individuals experienced a recurrence with a mean time to recurrence of 19.6 months (95% CI:6.95-32.23). Adjuvant therapy was administered in 65.7% of surgically resected patients; including radiotherapy, chemotherapy, immunotherapy, or a combination. In summary, PIMM is a rare tumour that can appear radiographically similar to meningioma. The results of our systematic review demonstrate that surgical resection remains the mainstay of therapy for best long-term prognosis.
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Affiliation(s)
- Jennifer A Mann
- Department of Clinical Neurosciences, University of Calgary, Calgary, CAN
| | - Dhyey Bhatt
- Department of Clinical Neurosciences, University of Calgary, Calgary, CAN
| | - Michael K Tso
- Neurosurgery, Kelowna General Hospital, University of British Columbia, Kelowna, CAN
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Liang G, Hu Z, Xu Q, Wang G, Wang Y, Li X, Zhang W, Lei H. Development and validation of a nomogram model for predicting venous thromboembolism risk in lung cancer patients treated with immune checkpoint inhibitors: A cohort study in China. Cancer Med 2024; 13:e70115. [PMID: 39162396 PMCID: PMC11334300 DOI: 10.1002/cam4.70115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 08/01/2024] [Accepted: 08/06/2024] [Indexed: 08/21/2024] Open
Abstract
OBJECTIVE Venous thromboembolism (VTE) poses a significant threat to lung cancer patients, particularly those receiving treatment with immune checkpoint inhibitors (ICIs). We aimed to develop and validate a nomogram model for predicting the occurrence of VTE in lung cancer patients undergoing ICI therapy. METHODS The data for this retrospective cohort study was collected from cancer patients admitted to Chongqing University Cancer Hospital for ICI treatment between 2019 and 2022. The research data is divided into training and validation sets using a 7:3 ratio. Univariate and multivariate analyses were employed to identify risk factors for VTE. Based on these analyses, along with clinical expertise, a nomogram model was crafted. The model's predictive accuracy was assessed through receiver operating characteristic (ROC) curves, calibration curves, decision curve analysis, clinical impact curve, and other relevant metrics. RESULTS The initial univariate analysis pinpointed 13 potential risk factors for VTE. The subsequent stepwise multivariate regression analysis identified age, Karnofsky performance status, chemotherapy, targeted, platelet count, lactate dehydrogenase, monoamine oxidase, D-dimer, fibrinogen, and white blood cell count as significant predictors of VTE. These 10 variables were the foundation for a predictive model, illustrated by a clear and intuitive nomogram. The model's discriminative ability was demonstrated by the ROC curve, which showed an area under the curve of 0.815 (95% CI 0.772-0.858) for the training set, and 0.753 (95% CI 0.672-0.835) for the validation set. The model's accuracy was further supported by Brier scores of 0.068 and 0.080 for the training and validation sets, respectively, indicating a strong correlation with actual outcomes. CONCLUSION We have successfully established and validated a nomogram model for predicting VTE risk in lung cancer patients treated with ICIs.
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Affiliation(s)
- Guanzhong Liang
- Chongqing Cancer Multi‐omics Big Data Application Engineering Research CenterChongqing University Cancer HospitalChongqingChina
| | - Zuhai Hu
- Department of Health Statistics, School of Public HealthChongqing Medical UniversityChongqingChina
| | - Qianjie Xu
- Department of Health Statistics, School of Public HealthChongqing Medical UniversityChongqingChina
| | - Guixue Wang
- MOE Key Lab for Biorheological Science and Technology, State and Local Joint Engineering Laboratory for Vascular ImplantsCollege of Bioengineering Chongqing UniversityChongqingChina
| | - Ying Wang
- Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized TreatmentChongqing University Cancer HospitalChongqingChina
| | - Xiaosheng Li
- Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized TreatmentChongqing University Cancer HospitalChongqingChina
| | - Wei Zhang
- Chongqing Cancer Multi‐omics Big Data Application Engineering Research CenterChongqing University Cancer HospitalChongqingChina
| | - Haike Lei
- Chongqing Cancer Multi‐omics Big Data Application Engineering Research CenterChongqing University Cancer HospitalChongqingChina
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6
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Palaskas NL, Ali HJ, Koutroumpakis E, Ganatra S, Deswal A. Cardiovascular toxicity of immune therapies for cancer. BMJ 2024; 385:e075859. [PMID: 38749554 DOI: 10.1136/bmj-2023-075859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
In addition to conventional chemoradiation and targeted cancer therapy, the use of immune based therapies, specifically immune checkpoint inhibitors (ICIs) and chimeric antigen receptor T cell therapy (CAR-T), has increased exponentially across a wide spectrum of cancers. This has been paralleled by recognition of off-target immune related adverse events that can affect almost any organ system including the cardiovascular system. The use of ICIs has been associated with myocarditis, a less common but highly fatal adverse effect, pericarditis and pericardial effusions, vasculitis, thromboembolism, and potentially accelerated atherosclerosis. CAR-T resulting in a systemic cytokine release syndrome has been associated with myriad cardiovascular consequences including arrhythmias, myocardial infarction, and heart failure. This review summarizes the current state of knowledge regarding adverse cardiovascular effects associated with ICIs and CAR-T.
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Affiliation(s)
| | - Hyeon-Ju Ali
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Sarju Ganatra
- Lahey Hospital and Medical Center, Burlington, MA 01805
| | - Anita Deswal
- University of Texas MD Anderson Cancer Center, Houston, TX, USA 01805
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Patel RM, Pal K, Ahmed SH, Kuban JD, Patel M, Shah K, Habibollahi P, Metwalli Z, Gurusamy V, Gupta S, Rojas-Hernandez CM, Afshar-Kharghan V, Kroll MH, Sheth RA. Mechanical Venous Thrombectomy for Deep Venous Thrombosis in Cancer Patients: A Single-Center Retrospective Study. Cardiovasc Intervent Radiol 2024; 47:556-566. [PMID: 38548981 DOI: 10.1007/s00270-024-03691-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/20/2024] [Indexed: 04/01/2024]
Abstract
PURPOSE Venous thromboembolism (VTE) is a major contributor to the mortality of cancer patients. Mechanical thrombectomy (MT) is an endovascular technique that physically removes a thrombus without thrombolytics. The purpose of this study was to evaluate safety, efficacy, and clinical outcomes following MT for lower extremity DVT in cancer patients. METHODS This single-center, retrospective study evaluated outcomes following MT of lower extremity DVT in cancer patients from November 2019 to May 2023. The primary outcome measure was clinical success, defined as a decrease in Villalta score by at least 2 points following the intervention. Secondary outcomes included repeat intervention-free survival and overall survival. Technical success was defined as restoring venous flow with mild (< 10%) or no residual filling defect. RESULTS In total, 90 patients and 113 procedures were included. Technical and clinical success was achieved in 81% and 87% of procedures performed. Repeat intervention-free survival at 1 month, 3 months, and 6 months post-procedure was 92%, 82%, and 77%, respectively. The complication rate was 2.7%. Pathologic analysis of the extracted thrombus revealed tumor thrombus in 18.4% (18/98) samples. Overall survival for the study cohort was 87% at 1 month, 74% at 3 months, and 62% at 6 months. Patients who were found to have tumor thrombi were noted to have a decreased overall survival compared to patients with non-tumor thrombi (P = 0.012). CONCLUSION MT is safe and efficacious in reducing cancer patients' VTE-related symptoms. The high rate of tumor thrombus in thrombectomy specimens suggests this phenomenon is more common than suspected.
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Affiliation(s)
- Riya M Patel
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1471, Houston, TX, 77030-4009, USA
| | - Koustav Pal
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1471, Houston, TX, 77030-4009, USA
| | - Syed Hadi Ahmed
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1471, Houston, TX, 77030-4009, USA
| | - Joshua D Kuban
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1471, Houston, TX, 77030-4009, USA
| | - Milan Patel
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1471, Houston, TX, 77030-4009, USA
| | - Ketan Shah
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1471, Houston, TX, 77030-4009, USA
| | - Peiman Habibollahi
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1471, Houston, TX, 77030-4009, USA
| | - Zeyad Metwalli
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1471, Houston, TX, 77030-4009, USA
| | - Varshana Gurusamy
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1471, Houston, TX, 77030-4009, USA
| | - Sanjay Gupta
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1471, Houston, TX, 77030-4009, USA
| | | | - Vahid Afshar-Kharghan
- Section of Benign Hematology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael H Kroll
- Section of Benign Hematology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rahul A Sheth
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1471, Houston, TX, 77030-4009, USA.
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Costamagna G, Navi BB, Beyeler M, Hottinger AF, Alberio L, Michel P. Ischemic Stroke in Cancer: Mechanisms, Biomarkers, and Implications for Treatment. Semin Thromb Hemost 2024; 50:342-359. [PMID: 37506734 DOI: 10.1055/s-0043-1771270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Ischemic stroke is an important cause of morbidity and mortality in cancer patients. The underlying mechanisms linking cancer and stroke are not completely understood. Long-standing and more recent evidence suggests that cancer-associated prothrombotic states, along with treatment-related vascular toxicity, such as with chemotherapy and immunotherapy, contribute to an increased risk of ischemic stroke in cancer patients. Novel biomarkers, including coagulation, platelet and endothelial markers, cell-free DNA, and extracellular vesicles are being investigated for their potential to improve risk stratification and patient selection for clinical trials and to help guide personalized antithrombotic strategies. Treatment of cancer-related stroke poses unique challenges, including the need to balance the risk of recurrent stroke and other thromboembolic events with that of bleeding associated with antithrombotic therapy. In addition, how and when to restart cancer treatment after stroke remains unclear. In this review, we summarize current knowledge on the mechanisms underlying ischemic stroke in cancer, propose an etiological classification system unique to cancer-related stroke to help guide patient characterization, provide an overview of promising biomarkers and their clinical utility, and discuss the current state of evidence-based management strategies for cancer-related stroke. Ultimately, a personalized approach to stroke prevention and treatment is required in cancer patients, considering both the underlying cancer biology and the individual patient's risk profile.
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Affiliation(s)
- Gianluca Costamagna
- Stroke Unit, Neurology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas F Hottinger
- Services of Neurology and Oncology, Lundin Family Brain Tumor Research Center, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Hematology Central Laboratory, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Stroke Center, Neurology Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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9
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Moik F, Riedl JM, Englisch C, Ay C. Update on Thrombosis Risk in Patients with Cancer: Focus on Novel Anticancer Immunotherapies. Hamostaseologie 2024; 44:40-48. [PMID: 38190985 DOI: 10.1055/a-2215-9909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024] Open
Abstract
Thromboembolic complications, including venous thromboembolism (VTE) and arterial thromboembolism (ATE), increase mortality and morbidity, and delay treatment in patients with cancer. Therefore, an increased understanding of underlying risk profiles, the identification of risk factors and predictive biomarkers, and ultimately the development of specific cardiovascular prevention strategies in patients with cancer is needed. Medical anticancer therapies have undergone a remarkable development in recent years with the advent of targeted and immunotherapeutic treatment options, including immune checkpoint inhibitors (ICI), chimeric antigen receptor (CAR) T-cell therapies and bispecific T-cell engagers (BiTEs). These developments have important implications for the accompanied risk of thromboembolic events in patients with cancer. First, the increased use of these highly effective therapies renders a growing proportion of patients with cancer at risk of thromboembolic events for a prolonged risk period due to an increase in patient survival despite advanced cancer stages. Second, potential direct cardiovascular toxicity and prothrombotic effect of novel anticancer immunotherapies are a matter of ongoing debate, with emerging reports suggesting a relevant risk of VTE and ATE associated with ICI, and relevant dysregulations of hemostasis in the frequently observed cytokine-release syndrome associated with BiTEs and CAR T-cell therapy. The aim of the present narrative review is to summarize the implications of the emerging use of anticancer immunotherapy for thromboembolic events in patients with cancer, and to provide an overview of available data on the rates and risk factors for VTE and ATE associated with ICI, CAR T-cell therapy, and BiTEs.
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Affiliation(s)
- Florian Moik
- Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jakob M Riedl
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Cornelia Englisch
- Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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10
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Trivanović D, Mojsilović S, Bogosavljević N, Jurišić V, Jauković A. Revealing profile of cancer-educated platelets and their factors to foster immunotherapy development. Transl Oncol 2024; 40:101871. [PMID: 38134841 PMCID: PMC10776659 DOI: 10.1016/j.tranon.2023.101871] [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: 09/30/2023] [Revised: 12/03/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023] Open
Abstract
Among multiple hemostasis components, platelets hyperactivity plays major roles in cancer progression by providing surface and internal components for intercellular crosstalk as well as by behaving like immune cells. Since platelets participate and regulate immunity in homeostatic and disease states, we assumed that revealing platelets profile might help in conceiving novel anti-cancer immune-based strategies. The goal of this review is to compile and discuss the most recent reports on the nature of cancer-associated platelets and their interference with immunotherapy. An increasing number of studies have emphasized active communication between cancer cells and platelets, with platelets promoting cancer cell survival, growth, and metastasis. The anti-cancer potential of platelet-directed therapy has been intensively investigated, and anti-platelet agents may prevent cancer progression and improve the survival of cancer patients. Platelets can (i) reduce antitumor activity; (ii) support immunoregulatory cells and factors generation; (iii) underpin metastasis and, (iv) interfere with immunotherapy by expressing ligands of immune checkpoint receptors. Mediators produced by tumor cell-induced platelet activation support vein thrombosis, constrain anti-tumor T- and natural killer cell response, while contributing to extravasation of tumor cells, metastatic potential, and neovascularization within the tumor. Recent studies showed that attenuation of immunothrombosis, modulation of platelets and their factors have a good perspective in immunotherapy optimization. Particularly, blockade of intra-tumoral platelet-associated programmed death-ligand 1 might promote anti-tumor T cell-induced cytotoxicity. Collectively, these findings suggest that platelets might represent the source of relevant cancer staging biomarkers, as well as promising targets and carriers in immunotherapeutic approaches for combating cancer.
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Affiliation(s)
- Drenka Trivanović
- Group for Hematology and Stem Cells, Institute for Medical Research, National Institute of Republic of Serbia, University of Belgrade, Dr. Subotica 4, PBOX 102, 11129, Belgrade 11000, Serbia.
| | - Slavko Mojsilović
- Group for Hematology and Stem Cells, Institute for Medical Research, National Institute of Republic of Serbia, University of Belgrade, Dr. Subotica 4, PBOX 102, 11129, Belgrade 11000, Serbia
| | | | - Vladimir Jurišić
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac 34000, Serbia
| | - Aleksandra Jauković
- Group for Hematology and Stem Cells, Institute for Medical Research, National Institute of Republic of Serbia, University of Belgrade, Dr. Subotica 4, PBOX 102, 11129, Belgrade 11000, Serbia
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Green CE, Chacon J, Godinich BM, Hock R, Kiesewetter M, Raynor M, Marwaha K, Maharaj S, Holland N. The Heart of the Matter: Immune Checkpoint Inhibitors and Immune-Related Adverse Events on the Cardiovascular System. Cancers (Basel) 2023; 15:5707. [PMID: 38136253 PMCID: PMC10742007 DOI: 10.3390/cancers15245707] [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: 11/07/2023] [Revised: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
Cancer remains a prominent global cause of mortality, second only to cardiovascular disease. The past decades have witnessed substantial advancements in anti-cancer therapies, resulting in improved outcomes. Among these advancements, immunotherapy has emerged as a promising breakthrough, leveraging the immune system to target and eliminate cancer cells. Despite the remarkable potential of immunotherapy, concerns have arisen regarding associations with adverse cardiovascular events. This review examines the complex interplay between immunotherapy and cardiovascular toxicity and provides an overview of immunotherapy mechanisms, clinical perspectives, and potential biomarkers for adverse events, while delving into the intricate immune responses and evasion mechanisms displayed by cancer cells. The focus extends to the role of immune checkpoint inhibitors in cancer therapy, including CTLA-4, PD-1, and PD-L1 targeting antibodies. This review underscores the multifaceted challenges of managing immunotherapy-related cardiovascular toxicity. Risk factors for immune-related adverse events and major adverse cardiac events are explored, encompassing pharmacological, treatment-related, autoimmune, cardiovascular, tumor-related, social, genetic, and immune-related factors. The review also advocates for enhanced medical education and risk assessment tools to identify high-risk patients for preventive measures. Baseline cardiovascular evaluations, potential prophylactic strategies, and monitoring of emerging toxicity symptoms are discussed, along with the potential of adjunct anti-inflammatory therapies.
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Affiliation(s)
- Chase E. Green
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
| | - Jessica Chacon
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
| | - Brandon M. Godinich
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
| | - Rivers Hock
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
| | - Maria Kiesewetter
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
| | - Mark Raynor
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
| | - Komal Marwaha
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
| | - Satish Maharaj
- Department of Internal Medicine, Division of Hematology/Oncology, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 4800 Alberta Ave., El Paso, TX 79905, USA
| | - Nathan Holland
- Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, 5001 El Paso Ave., El Paso, TX 79905, USA
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12
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le Sève JD, Guédon AF, Bordenave S, Agard C, Connault J, Pistorius MA, Quéreux G, Espitia O. Risk Factors of Venous Thromboembolic Disease in Cancer Patients Treated with Immune Checkpoint Inhibitor. Thromb Haemost 2023; 123:1049-1056. [PMID: 37257835 DOI: 10.1055/s-0043-1769609] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have revolutionized the management of cancers. The risk factors and pathophysiological mechanisms of venous thromboembolic events (VTEs) of this new therapeutic class are still to be specified. METHODS The included patients had to have cancer and should be treated with ICI. Data analyzed included demographic data, biological data, and immune-related adverse events (IRAEs). We studied the prevalence of VTEs and the factors associated with VTEs. RESULTS Of 374 patients on ICI, over a median follow-up period of 15.2 months, the number of VTE was 50 (13.4%). The majority of patients were treated for metastatic melanoma or nonsmall cell lung cancer. There was no difference in prevalence or survival between cancer types. Patients with combined therapy composed of nivolumab and ipilimumab had higher 1-year cumulative VTE occurrence (29.3% [95% confidence interval [CI]: 9.7; 44.6]) than patients with pembrolizumab (14.9%, [95%CI: 2.5; 25.8], p = 0.03) or nivolumab (9.1%, [95% CI: 5.0; 12.9], p < 0.01). The presence of IRAE was associated with a higher risk of VTE occurrence compared with patients without any IRAE (1-year VTE cumulative incidence: 17.42% [95% CI: 9.5; 24.65] vs. 9.46% [95% CI: 5.18; 13.55], p = 0.04). There was a higher risk of VTE in patients treated with the combination of nivolumab and ipilimumab (adjusted subdistribution hazard ratio [SHR]: 3.71 [95% CI: 1.74; 7.90], p < 0.001) and in patients with IRAE (adjusted SHR: 2.14 [95% CI: 1.22; 3.75], p < 0.01). CONCLUSION The prevalence of VTE was 14.2% under ICIs. IRAE and combine treatment of nivolumab and ipilimumab were associated with VTE. The pathophysiological mechanisms are multiple and complex with a possible link to aberrant activation of the immune system.
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Affiliation(s)
- Julien Denis le Sève
- Nantes Université, CHU Nantes, Department of Internal and Vascular Medicine, Nantes, France
| | - Alexis F Guédon
- Nantes Université, CHU Nantes, Department of Internal and Vascular Medicine, Nantes, France
| | - Stéphanie Bordenave
- Nantes Université, CHU Nantes, Department of Thoracic Oncology, Nantes, France
| | - Christian Agard
- Nantes Université, CHU Nantes, Department of Internal and Vascular Medicine, Nantes, France
| | - Jérôme Connault
- Nantes Université, CHU Nantes, Department of Internal and Vascular Medicine, Nantes, France
| | - Marc-Antoine Pistorius
- Nantes Université, CHU Nantes, Department of Internal and Vascular Medicine, Nantes, France
| | - Gaelle Quéreux
- Nantes Université, CHU Nantes, Department of Dermatology, Nantes, France
| | - Olivier Espitia
- Nantes Université, CHU Nantes, Department of Internal and Vascular Medicine, Nantes, France
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13
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Khorana AA. Immune Checkpoint Inhibitors and Venous Thromboembolism: The More Things Change…. Thromb Haemost 2023; 123:1057-1059. [PMID: 37399843 DOI: 10.1055/a-2121-9679] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Affiliation(s)
- Alok A Khorana
- Department of Hematology Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio, United States
- Case Comprehensive Cancer Center, Cleveland, Ohio, United States
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14
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Yhim HY, Lee J, Kim KH, Kim SA, Lee JY, Hwang HG, Hong J, Lee JO, Bang SM. Increased risk of venous and arterial thromboembolism in patients with colorectal cancer receiving cetuximab-based combination chemotherapy: A population-based study in Korea. Thromb Res 2023; 231:50-57. [PMID: 37804738 DOI: 10.1016/j.thromres.2023.10.005] [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: 05/16/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/09/2023]
Abstract
INTRODUCTION Limited data exist on the risk of venous and arterial thromboembolisms (VTE and ATE) in patients receiving cetuximab plus chemotherapy. We aimed to determine the thromboembolic risk of patients with recurrent/metastatic colorectal cancer (CRC) treated with cetuximab plus chemotherapy compared to chemotherapy alone. METHODS This population-based study used nationwide claims data from the Health Insurance Review and Assessment Service of South Korea from 2013 to 2020. Patients with recurrent/metastatic CRC treated with first-line oxaliplatin- or irinotecan-based doublets with or without cetuximab and no secondary prevention for VTE and ATE were included. Primary outcomes were the occurrence of any thromboembolic events, VTE, and ATE, which were determined using the cumulative incidence method incorporating death as a competing event. RESULTS We identified 19,723 patients (cetuximab plus chemotherapy, N = 7630; chemotherapy alone, N = 12,093). The cumulative incidence of any thromboembolic events in patients with cetuximab plus chemotherapy was significantly higher than in those receiving chemotherapy alone (6-month, 5.62 % vs. 3.58 %, P < 0.0001). The rates of VTE (6-month, 5.11 % vs. 3.28 %, P < 0.0001) and ATE (6-month, 0.53 % vs. 0.32 %, P = 0.0218) were also higher in patients receiving cetuximab plus chemotherapy. In multivariable analysis, cetuximab plus chemotherapy was independently associated with developing any thromboembolic events (hazard ratio [HR], 1.63; 95 % confidence interval [CI], 1.42-1.87), VTE (HR, 1.62; 95 % CI, 1.40-1.87), and ATE (HR, 1.77; 95 % CI, 1.16-2.71). CONCLUSIONS Cetuximab with irinotecan- or oxaliplatin-based doublet chemotherapy was associated with an increased risk of any thromboembolic events, VTE, and ATE; further studies are warranted to examine the underlying mechanisms.
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Affiliation(s)
- Ho-Young Yhim
- Department of Internal Medicine, Jeonbuk National University Medical School, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Juhyun Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Kyoung Ha Kim
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Sang-A Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Ji Yun Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Hun-Gyu Hwang
- Department of Internal Medicine, Soonchunhyang University Gumi Hospital, Soonchunhyang University College of Medicine, Gumi, Republic of Korea
| | - Junshik Hong
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Ok Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.
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Abdel-Razeq H, Sharaf B, Al-Jaghbeer MJ, Abu-Fares H, Bater R, Shaer MA, Abu-Jaish H, Laban DA, Salamah O, Tamimi F, Ashouri K, Salameh T, Zughul R, Alhalaseh Y. COMPASS-CAT versus Khorana risk assessment model for predicting venous thromboembolic events in patients with non-small cell lung cancer on active treatment with chemotherapy and/or immunotherapy, the CK-RAM study. J Thromb Thrombolysis 2023; 56:447-453. [PMID: 37430158 DOI: 10.1007/s11239-023-02860-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 07/12/2023]
Abstract
Cancer patients are at higher risk for venous thromboembolism (VTE). Several risk assessment models (RAM), including the Khorana and COMPASS-CAT, were developed to help predict the occurrence of VTE in cancer patients on active anti-cancer therapy. We aim to study the prevalence and predictors of VTE among patients with non-small cell lung cancer (NSCLC) and compare both RAMs in predicting VTE in patients with NSCLC were retrospectively reviewed. Variables known to increase the risk of VTE were collected and risk of VTE was assessed using both Khorana and COMPASS-CAT RAM. A total of 508 patients (mean age ± SD, 58.4 ± 12.2 years) were enrolled. Most (n = 357, 70.3%) patients had adenocarcinoma, and 333 (65.6%) patients had metastatic disease. VTE were confirmed in 76 (15.0%) patients. Rates were higher among patients with metastatic disease (19.8%, p < 0.001), adenocarcinoma (17.4%, p = 0.01) and those treated with immunotherapy (23.5%, p = 0.014). VTE rates were 21.2%, 14.1% and 13.9% among those with high (n = 66), intermediate (n = 341) and low (n = 101) Khorana risk scores, respectively (p = 0.126). On the other hand, 190 (37.4%) were classified as high risk by the COMPASS-CAT RAM; 52 (27.4%) of them had VTE compared to 24 (7.5%) of the remaining 318 (62.6%) classified as Low/Intermediate risk level, p < 0.001. In conclusion, patients with NSCLC are at high risk for VTE, especially those with adenocarcinoma, metastatic disease and when treated with immunotherapy. Compared to Khorana RAM, COMPASS-CAT RAM was better in identifying more patients in high-risk group, with higher VTE rate.
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Affiliation(s)
- Hikmat Abdel-Razeq
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan.
- School of Medicine, The University of Jordan, Queen Rania Al Abdullah Street, P.O. Box: 1269, Amman, 11941, Jordan.
| | - Baha' Sharaf
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | | | - Hala Abu-Fares
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Rayan Bater
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Moataz Abu Shaer
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Hala Abu-Jaish
- School of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Dima Abu Laban
- Department of Radiology, King Hussein Cancer Center, Amman, Jordan
| | - Osama Salamah
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Faris Tamimi
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Khalid Ashouri
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Tareq Salameh
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Raed Zughul
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Yazan Alhalaseh
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
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Gosangi B, Wang Y, Rubinowitz AN, Kwan J, Traube L, Gange C, Bader AS. Cardiothoracic complications of immune checkpoint inhibitors. Clin Imaging 2023; 102:98-108. [PMID: 37659356 DOI: 10.1016/j.clinimag.2023.08.001] [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: 02/19/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 09/04/2023]
Abstract
A paradigm shift in cancer treatment occurred with the advent of immune checkpoint inhibitors (ICI). ICI therapy has improved tumor response and increased overall survival in patients with solid tumors and hematologic malignancies. While ICI therapy has improved overall patient outcomes in oncology, it has also introduced novel adverse effects called immune-related adverse effects (irAEs). Studies have shown that the development of irAEs is associated with improved overall survival, but certain irAEs like pneumonitis and myocarditis are life threatening, and could result in death if not identified and treated early. Therefore, it is important for radiologists to be aware of complications arising from ICI administration, especially those related to the heart and lungs as they are associated with greater mortality. This paper will review the imaging features of cardiothoracic toxicities, recurrent and chronic irAEs, and atypical tumor responses associated with irAEs.
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Affiliation(s)
- Babina Gosangi
- Yale School of Medicine, New Haven, CT 06510, United States of America.
| | - Yifan Wang
- Yale School of Medicine, New Haven, CT 06510, United States of America
| | - Ami N Rubinowitz
- Yale School of Medicine, New Haven, CT 06510, United States of America
| | - Jennifer Kwan
- Yale School of Medicine, New Haven, CT 06510, United States of America
| | - Leah Traube
- Yale School of Medicine, New Haven, CT 06510, United States of America
| | - Christopher Gange
- Yale School of Medicine, New Haven, CT 06510, United States of America
| | - Anna S Bader
- Yale School of Medicine, New Haven, CT 06510, United States of America
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17
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Wahab R, Hasan MM, Azam Z, Grippo PJ, Al-Hilal TA. The role of coagulome in the tumor immune microenvironment. Adv Drug Deliv Rev 2023; 200:115027. [PMID: 37517779 PMCID: PMC11099942 DOI: 10.1016/j.addr.2023.115027] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/01/2023]
Abstract
The rising incidence and persistent thrombosis in multiple cancers including those that are immunosuppressive highlight the need for understanding the tumor coagulome system and its role beyond hemostatic complications. Immunotherapy has shown significant benefits in solid organ tumors but has been disappointing in the treatment of hypercoagulable cancers, such as glioblastoma and pancreatic ductal adenocarcinomas. Thus, targeting thrombosis to prevent immunosuppression seems a clinically viable approach in cancer treatment. Hypercoagulable tumors often develop fibrin clots within the tumor microenvironment (TME) that dictates the biophysical characteristics of the tumor tissue. The application of systems biology and single-cell approaches highlight the potential role of coagulome or thrombocytosis in shaping the tumor immune microenvironment (TIME). In-depth knowledge of the tumor coagulome would provide unprecedented opportunities to better predict the hemostatic complications, explore how thrombotic stroma modulates tumor immunity, reexamine the significance of clinical biomarkers, and enable steering the stromal versus systemic immune response for boosting the effectiveness of immune checkpoint inhibitors in cancer treatment. We focus on the role of coagulation factors in priming a suppressive TIME and the huge potential of existing anticoagulant drugs in the clinical settings of cancer immunotherapy.
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Affiliation(s)
- Riajul Wahab
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Texas at El Paso, El Paso, TX 79968, USA
| | - Md Mahedi Hasan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Texas at El Paso, El Paso, TX 79968, USA; Department of Environmental Science & Engineering, College of Science, University of Texas at El Paso, El Paso, TX 79968, USA
| | - Zulfikar Azam
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Texas at El Paso, El Paso, TX 79968, USA
| | - Paul J Grippo
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Taslim A Al-Hilal
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Texas at El Paso, El Paso, TX 79968, USA; Department of Environmental Science & Engineering, College of Science, University of Texas at El Paso, El Paso, TX 79968, USA.
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18
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Filderman JN, Luke JJ, Storkus WJ. Platelet STING agonism and venous thrombosis: translational implications for improved disease outcomes. J Leukoc Biol 2023; 114:195-198. [PMID: 37399019 PMCID: PMC10473254 DOI: 10.1093/jleuko/qiad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/08/2023] [Accepted: 06/26/2023] [Indexed: 07/04/2023] Open
Affiliation(s)
- Jessica N Filderman
- Department of Immunology, University of Pittsburgh School of Medicine, W1110 Thomas E. Starzl Biomedical Sciences Tower, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Jason J Luke
- Department of Medicine, University of Pittsburgh School of Medicine, 1.27C Research Pavilion, University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center, 5150 Centre Avenue, Pittsburgh, PA 15213, USA
- Cancer Immunology and Immunotherapy Program, Hillman Cancer Center, 5150 Centre Avenue, Pittsburgh, PA 15213, USA
| | - Walter J Storkus
- Department of Immunology, University of Pittsburgh School of Medicine, W1110 Thomas E. Starzl Biomedical Sciences Tower, 200 Lothrop Street, Pittsburgh, PA 15213, USA
- Cancer Immunology and Immunotherapy Program, Hillman Cancer Center, 5150 Centre Avenue, Pittsburgh, PA 15213, USA
- Department of Dermatology, Pathology and Bioengineering, University of Pittsburgh School of Medicine, W1151 BST, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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19
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Park JH, Ahn SE, Kwon LM, Ko HH, Kim S, Suh YJ, Kim HY, Park KH, Kim D. The Risk of Venous Thromboembolism in Korean Patients with Breast Cancer: A Single-Center Experience. Cancers (Basel) 2023; 15:3124. [PMID: 37370734 DOI: 10.3390/cancers15123124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/04/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
The relationship between cancer and venous thromboembolism (VTE) has long been described. The risk of VTE in Asian patients with breast cancer remains largely unknown. This study described the incidence and risk factors of VTE in Korean patients with breast cancer. Data were collected from a retrospective database of patients who underwent breast cancer surgery between 2011 and 2020 at a single institution. The Cox proportional-hazards model was used to identify factors associated with VTE occurrences. Among the 2246 patients with breast cancer, 48 (2.1%) developed VTE during a median follow-up period of 53 months. The average incidence of VTE was 459 per 100,000 person-years. Age ≥ 60 years, male sex, chronic kidney disease, reconstructive procedures, and stage II or higher were independent predictive factors for VTE. VTE was associated with poor disease-free survival (hazard ratio (HR), 6.140; 95% confidence interval (CI), 3.480-10.835), and overall survival (HR, 8.842; 95% CI 4.386-17.824). Most VTE events were manageable with anticoagulation; three (6.3%) patients died of VTE, despite intensive care. The incidence of VTE was significantly elevated in Korean patients with breast cancer. Since VTE has a negative effect on oncologic outcomes of breast cancer, clinicians should manage its risk throughout their lifetime.
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Affiliation(s)
- Jung Ho Park
- Division of Breast and Endocrine Surgery, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - So Eun Ahn
- Division of Breast and Endocrine Surgery, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Lyo Min Kwon
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Ho Hyun Ko
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Sanghwa Kim
- Division of Breast and Endocrine Surgery, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Yong Joon Suh
- Division of Breast and Endocrine Surgery, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Ho Young Kim
- Division of Hematology-Oncology, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Kyoung-Ha Park
- Division of Cardiovascular Disease, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Doyil Kim
- Division of Breast and Endocrine Surgery, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
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20
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Stadler JC, Keller L, Mess C, Bauer AT, Koett J, Geidel G, Heidrich I, Vidal-Y-Sy S, Andreas A, Stramaglia C, Sementsov M, Haberstroh W, Deitert B, Hoehne IL, Reschke R, Haalck T, Pantel K, Gebhardt C, Schneider SW. Prognostic value of von Willebrand factor levels in patients with metastatic melanoma treated by immune checkpoint inhibitors. J Immunother Cancer 2023; 11:jitc-2022-006456. [PMID: 37258039 DOI: 10.1136/jitc-2022-006456] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND An increased incidence of thrombotic complications associated with an increased mortality rate has been observed under immune checkpoint inhibition (ICI). Recent investigations on the coagulation pathways have highlighted the direct role of key coagulatory proteins and platelets in cancer initiation, angiogenesis and progression. The aim of this study was to evaluate the prognostic value of von Willebrand factor (vWF) and its regulatory enzyme a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), D-dimers and platelets in a cohort of patients with metastatic melanoma receiving ICI. METHODS In a prospective cohort of 83 patients with metastatic melanoma, we measured the systemic levels of vWF-antigen (vWF:Ag), ADAMTS13 activity, D-dimers and platelets, before the beginning of the treatment (baseline), and 6, 12 and 24 weeks after. In parallel, we collected standard biological parameters used in clinical routine to monitor melanoma response (lactate deshydrogenase (LDH), S100). The impact of neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) on overall survival (OS) in patients receiving ICI was assessed. Univariable and multivariable Cox proportional models were then used to investigate any potential association of these parameters to clinical progression (progression-free survival (PFS) and OS). Baseline values and variations over therapy course were compared between primary responders and resistant patients. RESULTS Patients with melanoma present with dysregulated levels of vWF:Ag, ADAMTS13 activity, D-dimers, LDH, S100 and CRP at the beginning of treatment. With a median clinical follow-up of 26 months, vWF:Ag interrogated as a continuous variable was significantly associated with PFS in univariate and multivariate analysis (HR=1.04; p=0.007). Lower values of vWF:Ag at baseline were observed in the primary responders group (median: 29.4 µg/mL vs 32.9 µg/mL; p=0.048) when compared with primary resistant patients. As for OS, we found an association with D-dimers and ADAMTS13 activity in univariate analysis and vWF:Ag in univariate and multivariate analysis including v-raf murine sarcoma viral oncogene homolog B1 (BRAF) mutation and Eastern Cooperative Oncology Group (ECOG) performance status. Follow-up over the course of treatment depicts different evolution profiles for vWF:Ag between the primary response and resistance groups. CONCLUSIONS In this prospective cohort, coagulatory parameters such as ADAMTS13 activity and D-dimers are associated with OS but baseline vWF:Ag levels appeared as the only parameter associated with response and OS to ICI. This highlights a potential role of vWF as a biomarker to monitor ICI response of patients with malignant melanoma.
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Affiliation(s)
- Julia-Christina Stadler
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Fleur Hiege Center for Skin Cancer Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laura Keller
- Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Centre de Recherche en Cancerologie de Toulouse, Toulouse, France
| | - Christian Mess
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander T Bauer
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Koett
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Fleur Hiege Center for Skin Cancer Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Glenn Geidel
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Isabel Heidrich
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sabine Vidal-Y-Sy
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Antje Andreas
- Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carlotta Stramaglia
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark Sementsov
- Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wiebcke Haberstroh
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Deitert
- Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Inka Lilott Hoehne
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Robin Reschke
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Fleur Hiege Center for Skin Cancer Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Haalck
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Klaus Pantel
- Department of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Fleur Hiege Center for Skin Cancer Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoffer Gebhardt
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Fleur Hiege Center for Skin Cancer Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan W Schneider
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Fleur Hiege Center for Skin Cancer Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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21
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Wang TF, Carrier M. Immune Checkpoint Inhibitors-Associated Thrombosis: Incidence, Risk Factors and Management. Curr Oncol 2023; 30:3032-3046. [PMID: 36975443 PMCID: PMC10047296 DOI: 10.3390/curroncol30030230] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/26/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) target programmed cell death (PD) 1 receptor and its ligand PD-L1, and have become an integral part of treatment regimens in many cancers including lung cancer, renal cell carcinoma, melanoma, and more. Cancer is associated with a significantly increased risk of venous thromboembolism compared to non-cancer patients, and the risks increase further with anticancer therapies including ICIs. Cancer-associated thrombosis can lead to hospitalizations, delayed cancer treatment, and mortality. While thrombosis was not reported as a major complication in initial clinical trials leading to the approval of ICIs, emerging evidence from post-marketing studies revealed concerning risks of thrombosis in patients receiving ICIs. However, results remained heterogenous given differences in study designs and populations. Recent studies also showed that C-reactive protein dynamics might be an easily accessible biomarker for thrombosis and disease response in this population. In addition, early findings indicated that a commonly used anticoagulant for cancer-associated thrombosis, factor Xa inhibitors, might have potential synergistic antitumor effects when combined with ICIs. Herein we will review the current literature on the incidence, risk factors, and management of thrombosis in patients with cancer receiving ICIs. We aim to provide valuable information for clinicians in managing these patients.
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22
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Khorana AA, Palaia J, Rosenblatt L, Pisupati R, Huang N, Nguyen C, Barron J, Gallagher K, Bond TC. Venous thromboembolism incidence and risk factors associated with immune checkpoint inhibitors among patients with advanced non-small cell lung cancer. J Immunother Cancer 2023; 11:jitc-2022-006072. [PMID: 36657815 PMCID: PMC9853260 DOI: 10.1136/jitc-2022-006072] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in patients with lung cancer. Systemic therapies, such as chemotherapy (chemo), are associated with increased risk of VTE. Immune checkpoint inhibitors (ICIs) are a new standard of care for the treatment of lung cancer, but their association with VTE is not fully understood. We evaluated the incidence of VTE and risk factors for patients with advanced non-small cell lung cancer (aNSCLC) treated with first-line ICI-based, chemo-based, or ICI+chemo regimens. METHODS This retrospective cohort study used HealthCore Integrated Research Environment - Oncology data, an integrated database of administrative claims, coupled with clinical data from a cancer-care quality program. Patients with first-line treatment of stage IV non-small cell lung cancer from July 2014 to August 2020 were grouped based on three treatment types: ICI-based, chemo-based, or ICI+chemo. Patients with VTE before initiation of systemic treatment were excluded. Newly diagnosed VTE events were identified via inpatient and outpatient diagnosis codes. Cox proportional hazards models were used to investigate the factors associated with VTE risk. RESULTS Among 2299 eligible patients (ICI-based, n=605; chemo-based, n=1092; ICI+chemo, n=602) with a median follow-up of 9.1 months, the VTE incidence rates (95% CI) per 100 person-years were 17.8 (95% CI 16.0 to 19.5) overall, 13.5 (95% CI 10.6 to 16.5) for ICI-based, 18.0 (95% CI 15.5 to 20.5) for chemo-based, and 22.4 (95% CI 20.2 to 24.5) for ICI+chemo. The 6-month cumulative incidence of VTE was 8.1% for ICI-based, 10.9% for chemo-based, and 12.8% for ICI+chemo. Pulmonary embolism was most common, accounting for 63% of the VTE events. After controlling for baseline patient characteristics, the risk of VTE was 26% lower for ICI-based regimens than for chemo-based regimens (HR 0.74, p=0.03). There was no meaningful difference in the risk between ICI+chemo and chemo-based regimens (HR 1.12, p=0.36). Previous radiation and severe obesity (body mass index ≥40) were associated with VTE. CONCLUSIONS VTE incidence rate per 100 person-years was common across regimens in patients with aNSCLC, but numerically lower for patients receiving ICI-based regimens compared with those receiving chemo-based and ICI+chemo regimens. VTE is a common complication of lung cancer, and there is a continued need for awareness of VTE as a comorbidity in this population.
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Affiliation(s)
- Alok A Khorana
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jennell Palaia
- Worldwide Health Economics and Outcomes Research, Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Lisa Rosenblatt
- Worldwide Health Economics and Outcomes Research, Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Radhika Pisupati
- US Medical Oncology, Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Ning Huang
- Worldwide Patient Safety: Medical Safety Assessment, Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Chi Nguyen
- Health Economics and Outcomes Research, HealthCore Inc, Wilmington, Delaware, USA
| | - John Barron
- Health Economics and Outcomes Research, HealthCore Inc, Wilmington, Delaware, USA
| | - Kerrin Gallagher
- Health Economics and Outcomes Research, HealthCore Inc, Wilmington, Delaware, USA
| | - T Christopher Bond
- Worldwide Patient Safety: Epidemiology, Bristol Myers Squibb, Princeton, New Jersey, USA
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23
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Luo Z, Xu N, Ma G, Lu Y, Yao J, Ying K. Incidentally Diagnosed With Pulmonary Embolism in Lung Cancer Patients: Comparison of Clinical Characteristics and Mortality With Symptomatic Pulmonary Embolism. Clin Appl Thromb Hemost 2023; 29:10760296231212482. [PMID: 37981734 PMCID: PMC10664439 DOI: 10.1177/10760296231212482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/08/2023] [Accepted: 10/20/2023] [Indexed: 11/21/2023] Open
Abstract
The purpose of this work was to compare the clinical characteristics, rate of recurrent venous thromboembolism (VTE), bleeding complications and mortality of incidental and symptomatic pulmonary embolism (PE) detected on computed tomography in patients with lung cancer. Clinical data of lung cancer patients with PE were obtained from the Department of Respiratory and Critical Care Medicine of Ningbo First affiliated hospital of Ningbo University during January 2016 and June 2021 and were reviewed retrospectively. We compared clinical and radiological characteristics in lung cancer patients with incidental PE (IPE) and symptomatic PE (SPE) and identified variables associated with the 1-year survival on multivariate Cox analysis. All patients were followed up for 1 year to compare the risks of recurrent VTE, bleeding complications, and mortality. Survival analysis was performed by use of Kaplan-Meier. A total of 223 lung cancer patients with PE were enrolled over the period. Of these, 117 (52%) patients had symptomatic whereas 106 (48%) patients had incidental PE. Those with IPE were more likely to have adenocarcinoma, VTE history, chronic respiratory disease and chemotherapy within 30 days prior to PE, while SPE was more frequently observed in patients with squamous cancer, concomitant VTE, performance status 0-1, chronic heart disease and major surgery within 30 days prior to PE. During 1 year of follow-up, recurrent VTE was diagnosed in 10 patients (9.3%) in lung cancer patients with IPE and 13 patients (11.2%) with SPE. The 12-month cumulative recurrent VTE incidence was 9.6% for patients with incidental and 11.4% for patients with symptomatic PE (P = .61). The 12-month cumulative incidences of major bleeding complications were also comparable in the 2 groups (8.1% for incidental patients and 9.8% for symptomatic patients; P = .62). However, the respective 12-month mortality risks were 34.6% and 30.2% in lung cancer patients with IPE and SPE respectively (P = .03). On multivariate Cox analysis, we found that IPE occurrence was an independent risk factor associated with 1-year mortality in lung cancer patients complicated with PE after adjusting for age and sex (HR 1.517; 95% CI: 1.366-1.684; P = .027). Our findings suggest that lung cancer patients diagnosed with and treated for incidental PE had a similar rate of recurrent VTE, and incidence of hemorrhagic complications, but a significantly higher 1-year cumulative mortality rate after PE compared to those with symptomatic PE. IPE may be a marker of poor prognosis.
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Affiliation(s)
- Zhuanbo Luo
- Department of Respiratory and Critical Care Medicine, Key Laboratory of Respiratory Disease of Ningbo, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Ning Xu
- Department of Respiratory and Critical Care Medicine, Key Laboratory of Respiratory Disease of Ningbo, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Guofeng Ma
- Department of Respiratory Disease, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yangfei Lu
- Department of Respiratory Disease, Hangzhou Fuyang District First People's Hospital, Hangzhou, Zhejiang, China
| | - Jianchang Yao
- Department of Respiratory Disease, Deqing People's Hospital, Deqing, Zhejiang, China
| | - Kejing Ying
- Department of Respiratory Disease, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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24
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Li H, Li H, Tang L, Niu H, He L, Luo Q. Associations Between Immune-Related Venous Thromboembolism and Efficacy of Immune Checkpoint Inhibitors: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2023; 29:10760296231206799. [PMID: 37844585 PMCID: PMC10586005 DOI: 10.1177/10760296231206799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/10/2023] [Accepted: 09/25/2023] [Indexed: 10/18/2023] Open
Abstract
This study aims to summarize the available data and determine if the presence of venous thromboembolism (VTE) immune-related adverse event (irAE) in patients with immune checkpoint inhibitor (ICI) therapy is associated with improved treatment efficacy and clinical outcomes, which in turn was used to help optimize patient selection for anticoagulation therapy and inform rational treatment strategies for overcoming the mechanisms of ICI resistance. PubMed, Embase, Web of Science, and Cochrane Library were searched up to March 18, 2023, for studies assessing the relationship between VTE irAE development during ICI therapy and cancer outcomes. Seven primary articles with a total of 4437 patients were included in the overall survival (OS) meta-analysis. Patients with VTE had a significant increase in overall mortality compared to patients without VTE in adjusted hazard ratios (HRs 1.36, 95% confidence interval [CI] 1.06-1.75, P = .02). In the studies where immortal time bias (ITB) was accounted for, patients with VTE irAE also had poor OS than those without. HR and the corresponding 95% CI values in the non-ITB group were 2.53 (1.75-3.66, P < .00001) with low heterogeneity (P = .17, I2 = 48%) and 1.21 (1.06-1.37, P = .004) in the ITB group with no heterogeneity (P = .95, I2 = 0%), respectively. Despite the heterogeneity identified, the evidence does suggest that VTE irAE occurrence could be served as a prognostic indicator, with higher frequencies of occurrence associated with poorer OS. However, the fundamental role of this association with clinical consequences should be further investigated in large cohorts and clinical trials.
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Affiliation(s)
- Huimin Li
- Department of Respiratory and Neurology, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, China
| | - Hong Li
- Department of Respiratory and Neurology, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, China
| | - Le Tang
- Department of Respiratory and Neurology, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, China
| | - Haiwen Niu
- Department of Respiratory and Neurology, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, China
| | - Lili He
- Department of Respiratory and Neurology, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, China
| | - Qin Luo
- Department of Respiratory and Neurology, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, China
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25
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Wang C, Zoungas S, Yan M, Wolfe R, Haydon A, Shackleton M, Voskoboynik M, Moore M, Andrews MC, Nicholls SJ, Mar V. Immune checkpoint inhibitors and the risk of major atherosclerotic cardiovascular events in patients with high-risk or advanced melanoma: a retrospective cohort study. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2022; 8:23. [PMID: 36461057 PMCID: PMC9716700 DOI: 10.1186/s40959-022-00149-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 11/15/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) are associated with immune-mediated adverse effects, potentially involving any organ. ICI has also been associated with an increased risk of cardiovascular disease in cancer populations. OBJECTIVE To characterize the incidence and risk of major atherosclerotic cardiovascular events associated with ICI use in a high-risk and advanced melanoma population. METHODS We conducted a retrospective cohort study of patients with high-risk or advanced melanoma (AJCC stage II, III or IV) presenting to an academic tertiary hospital between 2015-2020. The main outcome was major atherosclerotic cardiovascular events (MACE) including acute myocardial infarction, ischemic stroke, acute limb ischemia and coronary revascularization. RESULTS The study cohort consisted of 646 patients, including 289 who had been treated with ICI. The incidence of MACE was higher in the ICI treated group (3.6 vs. 0.9 events per 100-person years). After adjusting for age, sex, smoking history and prior BRAF and/or MEK inhibitor use, ICI treatment was associated with an increased risk of MACE (HRadj 2.8, 95% CI 1.1-6.9, p = 0.03). Elevated risk was especially pronounced in patients with a past history of MACE (HR 14.4, 95% CI 1.9-112.3, p = 0.01). CONCLUSION Patients with high-risk or advanced melanoma are at an increased risk of atherosclerotic cardiovascular events following ICI treatment, particularly those with a history of cardiovascular disease.
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Affiliation(s)
- Charlie Wang
- grid.1623.60000 0004 0432 511XVictorian Melanoma Service, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004 Australia ,grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria Australia
| | - Sophia Zoungas
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria Australia
| | - Mabel Yan
- grid.1623.60000 0004 0432 511XVictorian Melanoma Service, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004 Australia ,grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria Australia
| | - Rory Wolfe
- grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria Australia
| | - Andrew Haydon
- grid.1623.60000 0004 0432 511XDepartment of Medical Oncology, The Alfred Hospital, Melbourne, Victoria Australia
| | - Mark Shackleton
- grid.1623.60000 0004 0432 511XDepartment of Medical Oncology, The Alfred Hospital, Melbourne, Victoria Australia
| | - Mark Voskoboynik
- grid.1623.60000 0004 0432 511XDepartment of Medical Oncology, The Alfred Hospital, Melbourne, Victoria Australia ,grid.1002.30000 0004 1936 7857Department of Medicine - Alfred, Monash University, Melbourne, Victoria Australia
| | - Maggie Moore
- grid.1623.60000 0004 0432 511XDepartment of Medical Oncology, The Alfred Hospital, Melbourne, Victoria Australia
| | - Miles C. Andrews
- grid.1623.60000 0004 0432 511XDepartment of Medical Oncology, The Alfred Hospital, Melbourne, Victoria Australia ,grid.1002.30000 0004 1936 7857Department of Medicine - Alfred, Monash University, Melbourne, Victoria Australia
| | - Stephen J. Nicholls
- grid.419789.a0000 0000 9295 3933MonashHeart, Monash Health, Clayton, Victoria Australia ,grid.1002.30000 0004 1936 7857Monash Cardiovascular Research Centre, Victorian Heart Institute, Monash University, Clayton, Victoria Australia
| | - Victoria Mar
- grid.1623.60000 0004 0432 511XVictorian Melanoma Service, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004 Australia ,grid.1002.30000 0004 1936 7857School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria Australia
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26
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Chen X, Hong X, Luo S, Cai J, Huang G, Shen R, Lv L, Bai G, Fu W, Yan L, Liu G, Huang K, Chen Q. Causal relationship between 14 site-specific cancers and venous thromboembolism. CANCER INNOVATION 2022; 1:316-327. [PMID: 38089083 PMCID: PMC10686126 DOI: 10.1002/cai2.36] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 10/19/2022] [Accepted: 10/30/2022] [Indexed: 01/06/2024]
Abstract
BACKGROUND It has been observed that cancer and venous thromboembolism (VTE) are associated, but anticancer therapy may violate the causality. Therefore, this study aimed to elucidate the causal relationship of various cancers to VTE using Mendelian randomization (MR). METHODS Three MR methods were used to estimate causal effects: Inverse variance weighted (IVW), MR-Egger and weighted median. Sensitivity analyses included Cochran's Q-test, MR-Egger intercept test and MR-PRESSO. Gene ontology enrichment analysis was performed to elucidate the underlying mechanisms of VTE development in cancer patients. RESULTS The primary IVW approach showed that non-Hodgkin's lymphoma (NHL) might increase the risk of VTE (odds ratio [OR]: 1.20, 95% confidence interval [95% CI]: 1.00-1.44, p = 0.045), while melanoma possibly reduced the risk of VTE (OR: 0.89, 95% CI: 0.82-0.97, p = 0.006), although there was no significance after adjustment for multiple testing. No association was observed between VTE risk and other site-specific cancers. Gene ontology enrichment analysis revealed that vitamin D played an important role in the development of VTE in cancer patients. CONCLUSIONS Our findings suggested that genetically predicted NHL was associated with higher VTE risk, whereas melanoma had lower VTE risk compared with other site-specific cancers. Moreover, this study suggested that anticancer therapy and increased extensive examination might play a more important role in VTE development than the nature of cancer.
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Affiliation(s)
- Xiong Chen
- Department of Paediatric Urology, Guangzhou Women and Children's Medical CenterGuangzhou Medical UniversityGuangzhouChina
- Department of Paediatric Surgery, Guangzhou Institute of PaediatricsGuangzhou Medical UniversityGuangzhouChina
| | - Xiaosi Hong
- Department of Endocrinology, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Shulu Luo
- Department of Prosthodontics, Hospital of Stomatology, Guanghua School of Stomatology, Guangdong Provincial Key Laboratory of StomatologySun Yat‐sen UniversityGuangzhouChina
| | - Jiahao Cai
- Department of Pediatric Neurology, Guangzhou Women and Children's Medical CenterGuangzhou Medical UniversityGuangzhouChina
| | - Guiwu Huang
- Department of OrthopedicsThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
| | - Runnan Shen
- Medical SchoolSun Yat‐sen UniversityGuangzhouChina
| | - Lin Lv
- Medical SchoolSun Yat‐sen UniversityGuangzhouChina
| | - Gaochen Bai
- Department of Paediatric Urology, Guangzhou Women and Children's Medical CenterGuangzhou Medical UniversityGuangzhouChina
- Department of Paediatric Surgery, Guangzhou Institute of PaediatricsGuangzhou Medical UniversityGuangzhouChina
| | - Wen Fu
- Department of Paediatric Urology, Guangzhou Women and Children's Medical CenterGuangzhou Medical UniversityGuangzhouChina
- Department of Paediatric Surgery, Guangzhou Institute of PaediatricsGuangzhou Medical UniversityGuangzhouChina
| | - Li Yan
- Department of Endocrinology, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouChina
| | - Guochang Liu
- Department of Paediatric Urology, Guangzhou Women and Children's Medical CenterGuangzhou Medical UniversityGuangzhouChina
- Department of Paediatric Surgery, Guangzhou Institute of PaediatricsGuangzhou Medical UniversityGuangzhouChina
| | - Kai Huang
- Department of Cardiovascular SurgerySun Yat‐sen Memorial HospitalGuangzhouChina
| | - Qinchang Chen
- Department of Pediatric Cardiology, Guangdong Provincial Key Laboratory of Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangdong Cardiovascular InstituteGuangzhouChina
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27
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Langouo Fontsa M, Aiello MM, Migliori E, Scartozzi M, Lambertini M, Willard-Gallo K, Solinas C. Thromboembolism and Immune Checkpoint Blockade in Cancer Patients: An Old Foe for New Research. Target Oncol 2022; 17:497-505. [DOI: 10.1007/s11523-022-00908-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2022] [Indexed: 12/19/2022]
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28
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Spagnolo P, Chaudhuri N, Bernardinello N, Karampitsakos T, Sampsonas F, Tzouvelekis A. Pulmonary adverse events following immune checkpoint inhibitors. Curr Opin Pulm Med 2022; 28:391-398. [PMID: 35838354 PMCID: PMC10810354 DOI: 10.1097/mcp.0000000000000895] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitors (ICIs) have rapidly become a mainstay of cancer treatment. However, immune modulation resulting from checkpoint inhibition can cause inflammation in any organ system, with pneumonitis being one of the most severe immune-related adverse events (irAEs). Here, we review the most recent literature on pulmonary adverse events following ICIs. RECENT FINDINGS Several systematic reviews and meta-analyses of data from trials of antiprogrammed death-1 (PD-1; nivolumab, pembrolizumab), anti-PD-ligand-1 (PD-L1; atezolizumab, avelumab, durvalumab) and anticytotoxic T lymphocyte antigen-4 (CTLA-4; ipilimumab or tremelimumab) in patients with advanced cancer have explored the relative risk and incidence of lung toxicity among different tumor types and therapeutic regimens. They have showed that the incidence of all-grade (1-4) and high-grade (3-4) pneumonitis is significantly higher in nonsmall cell lung cancer (NSCLC) compared with other tumor types. In addition, they have demonstrated that immunotherapy, especially monoimmunotherapy, has a significantly lower risk of irAEs compared to immune-chemotherapy. Treatment for lung cancer, preexisting interstitial lung disease, smoking history and male sex appear to increase the risk for ICI-related pneumonitis. SUMMARY Lung toxicity is an uncommon but potentially severe and even fatal complication of ICIs. Timely recognition is critically important but challenging, particularly in patients with lung cancer wherein drug toxicity can mimic disease progression or recurrence.
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Affiliation(s)
- Paolo Spagnolo
- Respiratory Disease Unit, Department of Cardiac Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | | | - Nicol Bernardinello
- Respiratory Disease Unit, Department of Cardiac Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | | | - Fotios Sampsonas
- Department of Respiratory Medicine, University Hospital of Patras, Patras, Greece
| | - Argyrios Tzouvelekis
- Department of Respiratory Medicine, University Hospital of Patras, Patras, Greece
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29
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da Costa WL, Guffey D, Oluyomi A, Bandyo R, Rosales O, Wallace CD, Granada C, Riaz N, Fitzgerald M, Garcia DA, Carrier M, Amos CI, Flowers CR, Li A. Patterns of venous thromboembolism risk, treatment, and outcomes among patients with cancer from uninsured and vulnerable populations. Am J Hematol 2022; 97:1044-1054. [PMID: 35638475 DOI: 10.1002/ajh.26623] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/24/2022] [Accepted: 05/26/2022] [Indexed: 01/22/2023]
Abstract
The epidemiology of cancer-associated thrombosis (CAT) among uninsured and vulnerable populations in the US is not well-characterized. We performed a retrospective cohort study for patients with newly diagnosed cancer from 2011 to 2020 at Harris Health System, which cares for uninsured residents in the Houston metropolitan area. Patient demographics, NCI comorbidity index, area of deprivation index (ADI), cancer histology, staging, and systemic therapy data were extracted. CAT included overall venous thromboembolism (VTE) or pulmonary embolism +/- lower extremity deep vein thrombosis (PE/LE-DVT) within 1 year of diagnosis. We used multivariable Fine-Gray models to assess the associations with CAT accounting for death as a competing risk. Among 15 342 patients, 74% were uninsured and 84% lived in socioeconomically disadvantaged neighborhoods. There were 16% Non-Hispanic White (NHW), 28% Non-Hispanic Black (NHB), 50% Hispanic (27% Mexican), and 6% Asian/Pacific Islanders (API). The 1-year CAT incidence rate was 14.6%. Overall VTE was lower for Hispanics versus NHW (SHR 0.87 [0.76-0.99]) and API versus NHW (SHR 0.58 [0.44-0.77]). PE/LE-DVT was higher for NHB versus NHW (SHR 1.18 [1.01-1.39]). CAT was also associated with chemotherapy-based regimens (+/- immunotherapy), age, obesity, cancer type/staging, VTE history, and recent hospitalization. NCI comorbidity and ADI scores were associated with mortality but not CAT. In a large cohort of underserved patients with cancer, we identified an elevated incidence of CAT with known and novel risk predictors. Hispanics had lower adjusted rates of CAT and mortality. Our findings highlight the need to investigate and incorporate vulnerable populations in clinical trials.
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Affiliation(s)
- Wilson L da Costa
- Section of Epidemiology and Population Science, Baylor College of Medicine, Houston, Texas, USA
| | - Danielle Guffey
- Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, Texas, USA
| | - Abiodun Oluyomi
- Section of Epidemiology and Population Science, Baylor College of Medicine, Houston, Texas, USA
| | - Raka Bandyo
- Tegria, Renton, WA, USA.,Harris Health System, Houston, Texas, USA
| | - Omar Rosales
- Section of Epidemiology and Population Science, Baylor College of Medicine, Houston, Texas, USA
| | | | - Carolina Granada
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Nimrah Riaz
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Margaret Fitzgerald
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - David A Garcia
- Division of Hematology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Christopher I Amos
- Section of Epidemiology and Population Science, Baylor College of Medicine, Houston, Texas, USA.,Institute for Clinical & Translational Research, Baylor College of Medicine, Houston, Texas, USA
| | - Christopher R Flowers
- Department of Lymphoma-Myeloma, Division of Cancer Medicine, The University of Texas M D Anderson Cancer Center, Houston, Texas, USA
| | - Ang Li
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
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Maharaj S, Chang S, Kloecker G, Chesney J, Redman R, Rojan A. Venous and arterial thromboembolism with immunotherapy compared to platinum-based therapy. Thromb Res 2022; 217:48-51. [PMID: 35853370 DOI: 10.1016/j.thromres.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/22/2022] [Accepted: 07/11/2022] [Indexed: 11/24/2022]
Affiliation(s)
- Satish Maharaj
- University of Louisville, KY, USA; Texas Tech University Health Sciences Center, Division of Hematology/Oncology, 4800 Alberta-MSC41007, El Paso, Texas 79905, USA.
| | - Simone Chang
- University of Louisville, KY, USA; Texas Tech University Health Sciences Center, Division of Hematology/Oncology, 4800 Alberta-MSC41007, El Paso, Texas 79905, USA
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Allouchery M, Beuvon C, Pérault-Pochat MC, Roblot P, Puyade M, Martin M. Immune Checkpoint Inhibitors and Venous Thromboembolism: An Analysis of the WHO Pharmacovigilance Database. Clin Pharmacol Ther 2022; 112:164-170. [PMID: 35426120 DOI: 10.1002/cpt.2615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/06/2022] [Indexed: 11/07/2022]
Abstract
Data on venous thromboembolic events (VTEs) in patients receiving immune checkpoint inhibitors (ICIs) are scarce and conflicting. This study investigated the risk of reporting VTEs associated with ICIs in comparison with all other anticancer drugs. The World Health Organization pharmacovigilance database (VigiBase), comprising >30 million individual case safety reports, was queried. All reports on patients with cancer, involving at least one anticancer drug as a suspect or interacting drug and registered from January 1, 2008, to May 31, 2021, were included. The association between ICIs and the risk of reporting VTEs was estimated using the reporting odds ratio (ROR) as a measure of disproportionality with all other anticancer drugs as comparators. RORs were estimated as crude and adjusted RORs for age, sex, and other medications (excluding anticancer drugs) associated with risk of VTEs. Among 1,196 patients experiencing VTEs after ICI treatment, the median age was 65 years and 57.6% were men. Anti-PD-1 agents (62.5%) were the most frequently reported. ICIs were not associated with higher reporting of VTEs when compared with other anticancer drugs (crude ROR 0.63, 95% confidence interval (CI) 0.60 to 0.67 and adjusted ROR 0.70, 95% CI 0.65-0.74). No signal of disproportionate reporting was found when considering each class of ICIs. In conclusion, ICIs were not associated with higher reporting of VTEs, in comparison with all other anticancer drugs in a large-scale pharmacovigilance database. Owing to the limitations inherent to pharmacovigilance studies, prospective studies, including an adequate comparison group, are needed to assess the risk of VTEs in ICI-treated patients.
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Affiliation(s)
- Marion Allouchery
- Pharmacologie Clinique et Vigilances, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
| | - Clément Beuvon
- Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
- Médecine Interne et Maladies Infectieuses, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Marie-Christine Pérault-Pochat
- Pharmacologie Clinique et Vigilances, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
- Laboratoire de Neurosciences Expérimentales et Cliniques, INSERM U1084, Université de Poitiers, Poitiers, France
- CIC-1402, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Pascal Roblot
- Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
- Médecine Interne et Maladies Infectieuses, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Mathieu Puyade
- Médecine Interne et Maladies Infectieuses, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- CIC-1402, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Mickaël Martin
- Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
- Médecine Interne et Maladies Infectieuses, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- INSERM U1313, Université de Poitiers, Poitiers, France
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Ma Z, Sun X, Zhang Y, Li H, Sun D, An Z, Zhang Y. Risk of Thromboembolic Events in Cancer Patients Treated with Immune Checkpoint Inhibitors: A Meta-analysis of Randomized Controlled Trials. Thromb Haemost 2022; 122:1757-1766. [PMID: 35772727 DOI: 10.1055/s-0042-1749185] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The association between immune checkpoint inhibitors (ICIs) and thromboembolic events (TEEs) remains controversial. OBJECTIVE The goal of this study was to assess the risk of major TEEs associated with ICIs. METHODS We explored ICI-related TEEs in randomized controlled trials available in ClinicalTrials.gov and electronic databases up to June 30, 2021. Meta-analysis was performed by using Peto odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS A total of 61 studies were included. Patients treated with ICIs had a similar risk of venous thromboembolism (VTE) but a significantly increased risk of arterial thromboembolism (ATE) (Peto OR: 1.58 [95% CI: 1.21-2.06]) compared with non-ICI regimens. Stratified by different regimens, only PD-L1 (programmed cell death ligand 1) inhibitors showed a significant increase in ATE (Peto OR: 2.07 [95% CI: 1.26-3.38]). The incidence of VTE was higher in PD-1/PD-L1 inhibitor and CTLA-4 (cytotoxic T lymphocyte antigen 4) inhibitor combination therapies compared with monotherapies (Peto OR: 2.23 [95% CI: 1.47-3.37]). Stratified by tumor, for pulmonary embolism (PE) and cerebral ATE, the statistically significant results were only seen in lung cancer patients (Peto OR: 1.42 [95% CI: 1.02-1.97]; Peto OR: 2.10 [1.07-4.12]), and for myocardial infarction, the statistically significant result was only seen in other tumor types (Peto OR: 2.66 [95% CI: 1.68-4.20], p < 0.0001). CONCLUSION There was no significant increase in the overall risk of VTE in patients treated with ICIs; however, special attention should be given to the risk of VTE in PD-1/PD-L1 inhibitor and CTLA-4 inhibitor combination therapy and PE in lung cancer patients. PD-L1 inhibitors were associated with a significant increase in ATE.
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Affiliation(s)
- Zhuo Ma
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Ximu Sun
- Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Yi Zhang
- Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Hao Li
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, China
| | - Dan Sun
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, China
| | - Zhuoling An
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yuhui Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, China
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Font C, Cooksley T, Ahn S, Rapoport B, Escalante C. Emergency management of incidental pulmonary embolism (IPE). EMERGENCY CANCER CARE 2022; 1:7. [PMID: 35844667 PMCID: PMC9207846 DOI: 10.1186/s44201-022-00004-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/14/2022] [Indexed: 11/14/2022]
Abstract
Venous thrombo-embolic (VTE) disease is a common cause of complications in patients with cancer and is the second most common cause of death in oncology patients other than the malignant disease. Whilst symptomatic VTE comprises the majority of such presentations to an emergency department (ED), incidental pulmonary embolism (IPE) is an increasingly frequent reason for attendance. Many studies report that the consequences of IPE do not differ significantly from those with symptomatic presentations and thus most guidelines recommend using the same approach. The complexity of treatment in cancer patients due to increased prevalence of co-morbidities, higher risk of bleeding, abnormal platelet and renal function, greater risk of VTE recurrence, and medications with the risk of anticoagulant interaction are consistent across patients with symptomatic and IPE. One of the initial challenges of the management of IPE is the design of a pathway that provides both patients and clinicians with a seamless journey from the radiological diagnosis of IPE to their initial clinical workup and management. Increased access to ambulatory care has successfully reduced ED utilisation and improved clinical outcomes in high-risk non-oncological populations, such as those with IPE. In this clinical review, we consider IPE management, its workup, the conundrums it may present for emergency physicians and the need to consider emergency ambulatory care for this growing cohort of patients.
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Cánovas MS, Garay DF, Moran LO, Pérez JR, Rubio CMG, de Mena ML, Portero BO, Castro JB, Lage Y, Lavin DC, Blanco ABR, de Soignie AMMF, Perejón JZB, Colomo LJ, Boluda NB, Moreno JB, Verduguez TQ, Garrido CR, Huertas RM, Puig CFI, Martín AJM. Immune checkpoint inhibitors-associated thrombosis in patients with lung cancer and melanoma: a study of the Spanish society of medical oncology (SEOM) thrombosis and cancer group. Clin Transl Oncol 2022; 24:2010-2020. [PMID: 35668339 PMCID: PMC9418291 DOI: 10.1007/s12094-022-02860-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/12/2022] [Indexed: 12/03/2022]
Abstract
Purpose Immune Checkpoint Inhibitors (ICI) can be associated with thrombotic events, both venous and arterial (VTE/AT). However, there is a paucity of information regarding patients in routine clinical practice. Methods/patients Retrospective, multicenter study promoted by the Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM). Patients with melanoma and lung cancer who initiated ICI between 01/01/2015 and 31/12/2019 were recruited. Minimum follow-up was 6 months (unless it was not possible because of death). The primary objective was to calculate the incidence of ICI-associated VTE/AT and the secondary objectives included to analyze its impact on survival and to identify predictor variables for VTE/AT. Results 665 patients with lung cancer were enrolled. The incidence of VTE/AT during follow-up was 8.4%. Median overall survival (OS) was lower in the VTE/AT group (12 months 95% CI 4.84–19.16 vs. 19 months 95% CI 16.11–21.9; p = 0.0049). Neutrophil/lymphocyte ratio (NLR) and anemia upon initiation of IT, as well as a history of thrombosis between cancer diagnosis and the start of ICI, were predictive variables for developing of VTE/AT (p < 0.05). 291 patients with melanoma were enrolled. There was a 5.8% incidence rate of VTE/AT during follow-up. Median OS was lower in the VTE/AT group (10 months 95% CI 0.0–20.27 vs. 29 months 95% CI 19.58–36.42; p = 0.034). NLR and lactate dehydrogenase (LDH) at the beginning of ICI were predictor variables for VTE/AT (p < 0.05). Conclusions ICI increases the risk of VTE/AT in patients with lung cancer and melanoma, which impact OS.
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Affiliation(s)
- Manuel Sánchez Cánovas
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain. .,Hematology and Medical Oncology Department, Hospital Universitario José María Morales Meseguer, Murcia, Spain.
| | - David Fernández Garay
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Complejo Hospitalario de Jaén, Jaén, Spain
| | - Laura Ortega Moran
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Jaime Rubio Pérez
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Fundación Jiménez Díaz, Madrid, Spain
| | - Carlos Miguel Guirao Rubio
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Hospital General Universitario de Elche, Elche, Spain
| | - Miriam Lobo de Mena
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Hospital General Universitario de Valencia, Valencia, Spain
| | - Berta Obispo Portero
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Jesús Brenes Castro
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Instituto Catalán de Oncología, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Yolanda Lage
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Diego Cacho Lavin
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Ana Belen Rupérez Blanco
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Ana Manuela Martín Fernández de Soignie
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
| | - Jonatan Zacarías Benoit Perejón
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Complejo Hospitalario de Jaén, Jaén, Spain
| | - Laura Jiménez Colomo
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Instituto Catalán de Oncología, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Noel Blaya Boluda
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Hematology and Medical Oncology Department, Hospital Universitario José María Morales Meseguer, Murcia, Spain
| | - Javier Bosque Moreno
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Hospital General Universitario de Elche, Elche, Spain
| | - Teresa Quintanar Verduguez
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Hospital General Universitario de Elche, Elche, Spain
| | - Carmen Rosa Garrido
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Unidad de Investigación, Hospital Universitario de Jaén, FIBAO, Jaén, Spain
| | - Roberto Martín Huertas
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Carme Font I Puig
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Andrés Jesús Muñoz Martín
- Spanish Society of Medical Oncology (SEOM) Thrombosis and Cancer Group, Madrid, Spain.,Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Wang CY, Zoungas S, Voskoboynik M, Mar V. Cardiovascular disease and malignant melanoma. Melanoma Res 2022; 32:135-141. [PMID: 35377865 DOI: 10.1097/cmr.0000000000000817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In the last decade, systemic therapies such as immune checkpoint inhibitors and BRAF-MEK inhibitors have improved the prognosis of high-risk and advanced melanoma. With improved survival, melanoma survivorship is increasingly important, particularly in patients who have a good prognosis or are diagnosed at a younger age. It is increasingly recognized that cancer and its treatment is associated with increased cardiovascular morbidity and mortality. Indeed, data from observational studies and meta-analyses of randomized controls trials in melanoma show that systemic therapies may be associated with cardiac toxicities, such as myocardial infarction, heart failure, myocarditis and stroke. Our review will discuss cardiovascular disease and risk factors in the context of melanoma and outline the importance of cardiovascular risk modification in this population.
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Affiliation(s)
- Charlie Yue Wang
- Victorian Melanoma Service, The Alfred Hospital
- School of Public Health and Preventative Medicine, Monash University
| | - Sophia Zoungas
- School of Public Health and Preventative Medicine, Monash University
| | - Mark Voskoboynik
- Department of Oncology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Victoria Mar
- Victorian Melanoma Service, The Alfred Hospital
- School of Public Health and Preventative Medicine, Monash University
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Alghamdi EA, Aljohani H, Alghamdi W, Alharbi F. Immune checkpoint inhibitors and potential risk of thromboembolic events: Analysis of the WHO global database of individual case safety reports. Saudi Pharm J 2022; 30:1193-1199. [PMID: 36164566 PMCID: PMC9508630 DOI: 10.1016/j.jsps.2022.06.010] [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: 01/26/2022] [Accepted: 06/17/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Thromboembolic events with the use of immune checkpoint inhibitors (ICIs) in patients with cancer have been reported in few studies. However, the detailed profile of these cases remains mostly uncertain. Method A descriptive analysis of Thromboembolic events associated with ICIs retrieved from the VigiBase, between 1967 to November 2020. We extracted the data using the terms of ‘pulmonary embolism’ OR ‘deep vein thrombosis’ OR ‘acute coronary syndrome’ OR ‘myocardial infarction’ OR ‘ischemic stroke’ (preferred term (PT) (MedDRA). Results We included 161 cases from 26 countries in our descriptive analysis. Patients’ ages were reported in 141 (87.6%) cases, with a median of 68 years (interquartile range 61–74), and 63.4% of the patients were male. Indications for ICIs were reported in 151 (93.8%) cases, as follows: lung cancer (n = 85, 52.8%), renal cell carcinoma (n = 24, 14.9%), melanoma (n = 20, 12.4%), urethral carcinoma (n = 12, 7.45%), breast cancer (n = 4, 2.48%), adenocarcinoma of the gastroesophageal junction (n = 3, 1.9%), gastric cancer (n = 2, 1.24%), and skin cancer (n = 1, 0.62%). Nivolumab was reported as a suspected drug in 76 cases (47%), pembrolizumab in 46 cases (28.5%), atezolizumab in 21 cases (13%), durvalumab in 14 cases (8.6%), and avelumab in four cases (2.4%). The time to onset of thromboembolic events was reported in 127 (78.8%) cases. Most of these patients (n = 109, 85.8%) reported thromboembolic events within the first six months. The causality assessment of included cases showed that 50.3% of reported thromboembolic events were possibly related to the suspected reported medication, 13.7% were probably related, 13% were unlikely to be related, and 23% were not assessable due to insufficient information. Conclusion This study demonstrates a possible association between the use of ICIs and thromboembolic events. Further epidemiological studies are needed to assess this association and to elucidate the underlying mechanism.
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Cantrell R, Palumbo JS. Hemostasis and tumor immunity. Res Pract Thromb Haemost 2022; 6:e12728. [PMID: 35647476 PMCID: PMC9130907 DOI: 10.1002/rth2.12728] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/19/2022] [Accepted: 05/01/2022] [Indexed: 12/13/2022] Open
Abstract
Significant data have accumulated demonstrating a reciprocal relationship between cancer and the hemostatic system whereby cancer promotes life‐threatening hemostatic system dysregulation (e.g., thromboembolism, consumptive coagulopathy), and hemostatic system components directly contribute to cancer pathogenesis. The mechanistic underpinnings of this relationship continue to be defined, but it is becoming increasingly clear that many of these mechanisms involve crosstalk between the hemostatic and immune systems. This is perhaps not surprising given that there is ample evidence for bidirectional crosstalk between the hemostatic and immune systems at multiple levels that likely evolved to coordinate the response to injury, host defense, and tissue repair. Much of the data linking hemostasis and immunity in cancer biology focus on innate immune system components. However, the advent of adaptive immunity‐based cancer therapies such as immune checkpoint inhibitors has revealed that the relationship of hemostasis and immunity in cancer extends to the adaptive immune system. Adaptive immunity‐based cancer therapies appear to be associated with an increased risk of thromboembolic complications, and hemostatic system components appear to regulate adaptive immune functions through diverse mechanisms to affect tumor progression. In this review, the evidence for crosstalk between hemostatic and adaptive immune system components is discussed, and the implications of this relationship in the context of cancer therapy are reviewed. A better understanding of these relationships will likely lead to strategies to make existing adaptive immune based therapies safer by decreasing thromboembolic risk and may also lead to novel targets to improve adaptive immune‐based cancer treatments.
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Affiliation(s)
- Rachel Cantrell
- Cancer and Blood Diseases Institute Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine Cincinnati Ohio USA
| | - Joseph S. Palumbo
- Cancer and Blood Diseases Institute Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine Cincinnati Ohio USA
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Zoga E, Wolff R, Ackermann H, Meissner M, Rödel C, Tselis N, Chatzikonstantinou G. Factors Associated with Hemorrhage of Melanoma Brain Metastases after Stereotactic Radiosurgery in the Era of Targeted/Immune Checkpoint Inhibitor Therapies. Cancers (Basel) 2022; 14:cancers14102391. [PMID: 35625996 PMCID: PMC9140160 DOI: 10.3390/cancers14102391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 01/11/2023] Open
Abstract
Simple Summary Melanoma brain metastases (MBM) have a high propensity for hemorrhage (HA) after treatment. Our retrospective analysis evaluated factors associated with HA of MBM after robotic stereotactic radiosurgery (SRS) in the era of modern systemic therapy, and to the best of our knowledge, this is the first study focusing on this side effect. A total of 55 patients with 279 MBM were treated. The use of anticoagulants was the only predictive factor, both for radiologically evident HA and HA causing grade 3 toxicity. The interval between the administration of systemic therapy and SRS was also significant with regard to HA causing grade 1 toxicity, but it appears that the combination was safe, at least concerning grade 3 toxicity. We believe that our study is a useful contribution to the current literature, as it provides insights regarding the factors that correlate with HA. Abstract We aimed to evaluate the factors associated with hemorrhage (HA) of melanoma brain metastases (MBM) after Cyberknife stereotactic radiosurgery (SRS) in the modern era of systemic therapy. A total of 55 patients with 279 MBM were treated in 93 fractions. The median age, SRS dose, radiological follow-up, and time to HA were 60.4 years, 20 Gy, 17.7 months, and 10.7 months, respectively. Radiologically evident HA was documented in 47 (16.8%) metastases. Of the 55 patients, 25 (45.4%) suffered an HA. Among those, HA caused grade 3 toxicity in 10 patients (40%) and grade 1 symptoms in 5 patients (20%). Ten patients (40%) with HA experienced no toxicity. Logistic regression revealed the use of anticoagulants and the administration of systemic therapy within 7/15 days from SRS to be predictive for HA. When considering the HA causing grade 3 symptomatology, only the use of anticoagulants was significant, with the delivery of whole brain radiation therapy (WBRT) before the HA narrowly missing statistical significance. Our retrospective analysis showed that the administration of modern systemic therapy within 7/15 days from SRS may contribute to HA of MBM, though it appears safe, at least concerning grade 3 toxicity. The use of anticoagulants by the time of SRS significantly increased the risk of HA.
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Affiliation(s)
- Eleni Zoga
- Department of Radiotherapy, Sana Hospital Offenbach, 63069 Offenbach am Main, Germany;
| | - Robert Wolff
- Saphir Radiosurgery Center Frankfurt, 60528 Frankfurt am Main, Germany;
| | - Hanns Ackermann
- Institute of Biostatistic and Mathematical Modeling, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany;
| | - Markus Meissner
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany;
| | - Claus Rödel
- Department of Radiotherapy and Oncology, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (C.R.); (N.T.)
| | - Nikolaos Tselis
- Department of Radiotherapy and Oncology, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (C.R.); (N.T.)
| | - Georgios Chatzikonstantinou
- Saphir Radiosurgery Center Frankfurt, 60528 Frankfurt am Main, Germany;
- Department of Radiotherapy and Oncology, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (C.R.); (N.T.)
- Correspondence: ; Tel.: +49-69-6301-5130; Fax: +49-69-6301-5091
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Moik F, Ay C. Venous and arterial thromboembolism in patients with cancer treated with targeted anti-cancer therapies. Thromb Res 2022; 213 Suppl 1:S58-S65. [DOI: 10.1016/j.thromres.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/21/2021] [Accepted: 01/03/2022] [Indexed: 10/18/2022]
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McCrae KR, Swaidani S, Diaz-Montero CM, Khorana AA. Old is new again: emergence of thromboembolic complications in cancer patients on immunotherapy. Thromb Res 2022; 213:S51-S57. [PMID: 36061419 PMCID: PMC9435305 DOI: 10.1016/j.thromres.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cancer immunotherapy has emerged as one of the most important new treatments for cancer in many years, moving rapidly to front-line therapy for several cancers. Cancer immunotherapy is based on treatment with immune checkpoint inhibitors (ICI), which are monoclonal antibodies directed toward immunoregulatory proteins including PD-1, PD-L1 and CTLA-4. ICI inhibit interactions between these proteins and their ligands, disabling physiologic immune regulatory networks and enhancing anti-tumor immunity. However, since the immune response cannot be directed specifically to the tumor, ICI are associated with immune-related adverse events (irAEs) resulting from immune-mediated attack of normal tissues. We and others have reported a high incidence of thrombosis in patients treated with ICI, which may approach 20%. Given the rapidly increasing use of ICIs, it is clear that ICI-Associated Thrombosis (IAT) is a major emerging clinical problem. However, there is a remarkable knowledge gap concerning mechanisms of IAT. IAT may be a composite irAE resulting from activation of blood and vascular cells, leading to thromboinflammation. Cancer itself is an inflammatory disorder, and inducing further inflammation through ICI administration may stimulate procoagulant activity by multiple cell types. Moreover, some blood and vascular cells express ICI target proteins. Here, we review the results of several studies describing the clinical manifestations of IAT, as well as our recent studies demonstrating that elevated levels of myeloid derived suppressor cells and inflammatory cytokines may serve as biomarkers of IAT. It is hoped that the concepts reviewed here may stimulate further research into this important clinical problem.
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Affiliation(s)
- Keith R McCrae
- Department of Hematology & Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Shadi Swaidani
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - C Marcela Diaz-Montero
- Center for Immunotherapy & Precision Immuno-Oncology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Alok A Khorana
- Department of Hematology & Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
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Alma S, Eloi D, Léa V, Julie C, Valérie M, Pierre G, Hilgers W, Philippe G, Christine Z, Philippe D. Incidence of venous thromboembolism and discriminating capacity of Khorana score in lung cancer patients treated with immune checkpoint inhibitors. J Thromb Thrombolysis 2022; 54:287-294. [PMID: 35396660 DOI: 10.1007/s11239-022-02649-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 11/26/2022]
Abstract
Venous-thromboembolism (VTE) is increased in lung cancer patients (LCP) treated with immune-checkpoint inhibitors (ICIs) but risk factors are not identified and the Khorana Score (KS) is not validated. To assess VTE incidence and its clinical impact, to investigate potential clinical risk factors and KS performance in LCP. Retrospective analysis of LCP initiating ICIs treatment between June 2015 and November 2020 in a for-profit cancer center. 481 patients were included: 62% adenocarcinoma, 70% PDL1 + , 86% stage-IV-disease. Over a median follow-up of 9.8 months, 47 VTE were observed: 28 pulmonary embolisms, 15 deep venous thromboses (distal n = 9, proximal n = 6), 3 inferior vena cava thromboses, 1 other VTE, no superficial or digestive vein thrombosis. Median time from ICIs' initiation to VTE was 180 (11-1277) days. Overall survival was significantly lower in patients who experienced VTE (42.5 vs. 86.8 months, p = 0.006). In univariate analysis patients VTE was more frequent in metastatic patients (11.1% vs. 1.5%, p = 0.015) and lower in those treated with durvalumab (1.9% vs. 9.6%, p = 0.046). Logistic regression analysis showed that non-metastatic status (OR 0.13; 0.02-0.95, p = 0.04) and BMI (OR 1.07; 1.01-1.14, p = 0.028) were associated with VTE. The rate of VTE was the same in patients with a KS < or ≥ 2 (10.2% vs. 9.3%, p = 0.87). ICIs-treated LCP are at high risk of thromboembolism. VTE has a negative impact on survival. KS does not perform well in LCP. It is important to identify which VTE prediction models are available to be used in adult ambulatory lung cancer patients.
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Affiliation(s)
- Stancu Alma
- Thoracic Oncology Unit, Institut Sainte Catherine, 250 chemin de baigne pieds, 84918, Avignon Cedex 09, France
| | - Debourdeau Eloi
- Department of Ophthalmology, Gui de Chauliac Hospital, 34000, Montpellier, France
- Institute for Neurosciences of Montpellier INM, Univ. Montpellier, INSERM, 34091, Montpellier, France
| | - Vazquez Léa
- Supportive Care Unit, Institut Sainte Catherine, 250 chemin de baigne pieds, 84918, Avignon Cedex 09, France.
| | - Coussirou Julie
- Pharmacy, Institut Sainte Catherine, 250 chemin de baigne pieds, 84918, Avignon Cedex 09, France
| | - Matagne Valérie
- Pharmacy, Institut Sainte Catherine, 250 chemin de baigne pieds, 84918, Avignon Cedex 09, France
| | - Grassi Pierre
- Thoracic Oncology Unit, Institut Sainte Catherine, 250 chemin de baigne pieds, 84918, Avignon Cedex 09, France
| | - Werner Hilgers
- Thoracic Oncology Unit, Institut Sainte Catherine, 250 chemin de baigne pieds, 84918, Avignon Cedex 09, France
| | - Girard Philippe
- Thoracic Oncology Unit, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, France
| | - Zammit Christine
- Vascular Medicine Department, Hôpital Des Portes de Camargue, route d'Arles, 13150, Tarascon, France
| | - Debourdeau Philippe
- Supportive Care Unit, Institut Sainte Catherine, 250 chemin de baigne pieds, 84918, Avignon Cedex 09, France
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Singh AK, Malviya R. Coagulation and inflammation in cancer: Limitations and prospects for treatment. Biochim Biophys Acta Rev Cancer 2022; 1877:188727. [PMID: 35378243 DOI: 10.1016/j.bbcan.2022.188727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/26/2022] [Accepted: 03/29/2022] [Indexed: 02/08/2023]
Abstract
The development of so-called immune checkpoint inhibitors (ICIs), which target specific molecular processes of tumour growth, has had a transformative effect on cancer treatment. Widespread use of antibody-based medicines to inhibit tumour cell immune evasion by modulating T cell responses is becoming more common. Despite this, response rates are still low, and secondary resistance is an issue that arises often. In addition, a wide range of serious adverse effects is triggered by enhancing the immunological response. As a result of an increased mortality rate, a higher prevalence of thrombotic complications is connected with an increased incidence of immunological reactions, complement activation, and skin toxicity. This suggests that the tumour microenvironment's interaction between coagulation and inflammation is important at every stage of the tumour's life cycle. The coagulation system's function in tumour formation is the topic of this review. By better understanding the molecular mechanisms in which tumour cells circulate, plasmatic coagulation and immune system cells are engaged, new therapy options for cancer sufferers may be discovered.
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Affiliation(s)
- Arun Kumar Singh
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University, Greater Noida, Uttar Pradesh, India
| | - Rishabha Malviya
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University, Greater Noida, Uttar Pradesh, India.
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43
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Clinical impact of cerebral infarction in patients with non-small cell lung cancer. Int J Clin Oncol 2022; 27:863-870. [PMID: 35192084 DOI: 10.1007/s10147-022-02132-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 01/27/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Lung cancer patients have a high risk of cerebral infarction, but the clinical significance of cerebral infarction in advanced non-small cell lung cancer (NSCLC) remains unclear. This study aimed to comprehensively investigate the incidence, prognostic impact, and risk factors of cerebral infarction in patients with NSCLC. METHODS We retrospectively examined 710 consecutive patients with advanced or post-operative recurrent NSCLC treated between January 2010 and July 2020 at Kumamoto University Hospital. Cerebral infarction was diagnosed according to the detection of high-intensity lesions on diffusion-weighted magnetic resonance imaging regardless of the presence of neurological symptoms during the entire course from 3 months before NSCLC diagnosis. The prognostic impact and risk factors of cerebral infarction were evaluated based on propensity score matching (PSM) and multivariate logistic regression analysis. RESULTS Cerebral infarction occurred in 36 patients (5%). Of them, 21 (58%) and 15 (42%) patients developed asymptomatic and symptomatic cerebral infarction, respectively. PSM analysis for survival showed that cerebral infarction was an independent prognostic factor (hazards ratio: 2.45, 95% confidence interval (CI): 1.24-4.85, P = 0.010). On multivariate logistic regression analysis, D-dimer (odds ratio [OR]: 1.09, 95% CI 1.05-1.14, P < 0.001) and C-reactive protein (OR: 1.10, 95% CI 1.01-1.19, P = 0.023) levels were independent risk factors. CONCLUSION Cerebral infarction occurred in 5% of NSCLC patients, and asymptomatic cerebral infarction was more frequent. Cerebral infarction was a negative prognostic factor and was associated with hyper-coagulation and inflammation. The high frequency of asymptomatic cerebral infarction and its risk in NSCLC patients with these conditions should be recognized.
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Abstract
Cancer-associated thrombosis (including venous thromboembolism (VTE) and arterial events) is highly consequential for patients with cancer and is associated with worsened survival. Despite substantial improvements in cancer treatment, the risk of VTE has increased in recent years; VTE rates additionally depend on the type of cancer (with pancreas, stomach and primary brain tumours having the highest risk) as well as on individual patient's and cancer treatment factors. Multiple cancer-specific mechanisms of VTE have been identified and can be classified as mechanisms in which the tumour expresses proteins that alter host systems, such as levels of platelets and leukocytes, and in which the tumour expresses procoagulant proteins released into the circulation that directly activate the coagulation cascade or platelets, such as tissue factor and podoplanin, respectively. As signs and symptoms of VTE may be non-specific, diagnosis requires clinical assessment, evaluation of pre-test probability, and objective diagnostic testing with ultrasonography or CT. Risk assessment tools have been validated to identify patients at risk of VTE. Primary prevention of VTE (thromboprophylaxis) has long been recommended in the inpatient and post-surgical settings, and is now an option in the outpatient setting for individuals with high-risk cancer. Anticoagulant therapy is the cornerstone of therapy, with low molecular weight heparin or newer options such as direct oral anticoagulants. Personalized treatment incorporating risk of bleeding and patient preferences is essential, especially as a diagnosis of VTE is often considered by patients even more distressing than their cancer diagnosis, and can severely affect the quality of life. Future research should focus on current knowledge gaps including optimizing risk assessment tools, biomarker discovery, next-generation anticoagulant development and implementation science.
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45
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Bauer AT, Gorzelanny C, Gebhardt C, Pantel K, Schneider SW. Interplay between coagulation and inflammation in cancer: Limitations and therapeutic opportunities. Cancer Treat Rev 2022; 102:102322. [DOI: 10.1016/j.ctrv.2021.102322] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 12/12/2022]
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Schlesinger M, Gobec M, Bauer AT. Editorial: The Role of Platelets in Cancer Progression and Malignancy. Front Oncol 2021; 11:814006. [PMID: 34976846 PMCID: PMC8714635 DOI: 10.3389/fonc.2021.814006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/26/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Martina Gobec
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Alexander T. Bauer
- Department of Dermatology and Venereology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- *Correspondence: Alexander T. Bauer,
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47
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Goel A, Khorana A, Kartika T, Gowda S, Tao DL, Thawani R, Shatzel JJ. Assessing the Risk of Thromboembolism in Cancer Patients Receiving Immunotherapy. Eur J Haematol 2021; 108:271-277. [PMID: 34905252 DOI: 10.1111/ejh.13734] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/28/2021] [Accepted: 11/30/2021] [Indexed: 11/28/2022]
Abstract
Malignancy has long been implicated with hypercoagulability, leading to an increased rate of both venous and arterial thromboembolism (VTE and ATE). Immunotherapy has established itself as a cornerstone of modern cancer therapy by promoting antitumor immune responses, though there have been some suggestions that immune-related adverse events could include increased rates of VTE and ATE. In this review, we examine the available evidence regarding the use of immune checkpoint inhibitors (ICIs) and thrombosis. First, we describe the potential mechanisms by which ICIs might lead to thrombophilia given the overlap between the immune system, coagulation cascade, and platelet adhesion and activation. In addition, while there is some preclinical data evaluating immunotherapy associated ATEs in animal models, there is a paucity of evidence exploring potential mechanism of VTEs in ICIs. Second, we review the incidence of ATE and VTE in patients receiving ICIs in the published literature. Finally, we discuss current limitations in understanding, areas of conflicting evidence, and approaches to further investigation.
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Affiliation(s)
- Abhishek Goel
- University of California San Diego, San Diego, California
| | | | - Thomas Kartika
- Division of Hematology and Oncology, Department of Medicine, Oregon Health & Science University, Portland
| | - Sonia Gowda
- Department of Medicine, Oregon Health & Science University, Portland
| | - Derrick L Tao
- Earle A. Chiles Research Institute, Providence Portland Medical Center
| | - Rajat Thawani
- Division of Hematology and Oncology, Department of Medicine, Oregon Health & Science University, Portland
| | - Joseph J Shatzel
- Division of Hematology and Oncology, Department of Medicine, Oregon Health & Science University, Portland.,Department of Biomedical Engineering, Oregon Health & Science University, Portland
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Sun JY, Qu Q, Lou YX, Hua Y, Sun GZ, Sun W, Kong XQ. Cardiotoxicity in cancer immune-checkpoint therapy: Mechanisms, clinical evidence, and management strategies. Int J Cardiol 2021; 344:170-178. [PMID: 34563597 DOI: 10.1016/j.ijcard.2021.09.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 08/30/2021] [Accepted: 09/20/2021] [Indexed: 12/17/2022]
Abstract
Immune-checkpoint inhibitors (ICIs), a unique antibody-based therapeutic strategy, have revolutionized the treatment landscape of solid and hematological cancers. Despite the proven benefits of ICIs, the cardiotoxicity from unspecific immune activation (uncommon but potentially fatal) is a continuing concern. Accumulating preclinical research has demonstrated that ICIs initiate inflammation in the myocardium, while clinically significant cardiotoxicity were reported in few patients receiving ICI therapy, probably due to the low incidence and unspecific symptoms. The subtle signs and symptoms (e.g., chest pain, dizziness, and dyspnea) were likely attributed to cancer and/or non-cardiac events by previous studies, thus limiting the understanding of the incidence, outcomes, risk factors, and management of ICI-related cardiotoxicity. The heterogeneous clinical presentation and complex diagnostic procedure further make it challenging to accurately identify ICI-related cardiac events in clinical trials. Therefore, ICI-related cardiotoxicity, whose incidence is probably underestimated, has not been well recognized. In this article, we provide an overview of potential mechanisms underlying ICI-related cardiotoxicity and review accumulating clinical evidence of ICI-related cardiotoxicity, with a focus on myocarditis. Moreover, we discuss possible strategies to manage ICI-related cardiotoxicity and highlight the importance of developing cardio-oncology.
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Affiliation(s)
- Jin-Yu Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Qiang Qu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Yu-Xuan Lou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Yang Hua
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Guo-Zhen Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China
| | - Wei Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China..
| | - Xiang-Qing Kong
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210000, China..
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Zou XL, Chen WY, Zhang GY, Ke H, Yang QH, Li XB. Risk Factors, Incidence, and Prognosis of Thromboembolism in Cancer Patients Treated With Immune Checkpoint Inhibitors. Front Pharmacol 2021; 12:747075. [PMID: 34819857 PMCID: PMC8606686 DOI: 10.3389/fphar.2021.747075] [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: 07/25/2021] [Accepted: 10/15/2021] [Indexed: 11/16/2022] Open
Abstract
In recent years, immune checkpoint inhibitors (ICIs) have become the standard treatment option for tumors. With the widespread application of ICIs, immune-related adverse events (irAEs) have gradually attracted the attention of researchers. Owing to the characteristics of ICIs, irAEs can affect each organ of the human body. Thromboembolism is uncommon in cancer patients receiving ICIs, but it may affect their survival. Most thromboembolic events do not cause serious effects after early prediction and treatment, but life-threatening toxic reactions are also observed. This condition should not be ignored because of vague and atypical symptoms, which make early diagnosis more challenging. This article focuses on the high-risk factors, underlying mechanisms, incidence, and prognosis of thromboembolism in patients using ICIs and briefly describes the intervention and treatment measures. This information would allow patients to effectively manage the side effects of thromboembolism during Immune checkpoint inhibitors treatment, ensuring the efficacy of ICIs and reducing mortality.
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Affiliation(s)
- Xue-Lin Zou
- Department of Respiratory Medicine, Chengdu Seventh People's Hospital, Chengdu, China
| | - Wei-Yong Chen
- Department of Respiratory Medicine, Chengdu Seventh People's Hospital, Chengdu, China
| | - Guang-Yan Zhang
- Department of Respiratory Medicine, Chengdu Seventh People's Hospital, Chengdu, China
| | - Hua Ke
- Department of Respiratory Medicine, Chengdu Seventh People's Hospital, Chengdu, China
| | - Qiu-Hong Yang
- Department of Respiratory Medicine, Chengdu Seventh People's Hospital, Chengdu, China
| | - Xiao-Bo Li
- Department of Respiratory Medicine, Chengdu Seventh People's Hospital, Chengdu, China
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50
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Sheng IY, Gupta S, Reddy CA, Angelini D, Funchain P, Sussman TA, Sleiman J, Ornstein MC, McCrae K, Khorana AA. Thromboembolism in Patients with Metastatic Renal Cell Carcinoma Treated with Immunotherapy. Target Oncol 2021; 16:813-821. [PMID: 34741719 DOI: 10.1007/s11523-021-00852-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Metastatic renal cell carcinoma (mRCC) is associated with a high risk of thromboembolism (TE). OBJECTIVE We investigated whether immunotherapy (IO) increases the hypercoagulable state in this high-risk population. PATIENTS AND METHODS Patients with mRCC treated with IO between 1 January 2015 and 31 December 2019 at the Cleveland Clinic were identified. Cumulative incidence analysis calculated TE rates over time and Gray's test determined differences in TE rates among groups. The Kaplan-Meier method estimated survival, while Cox proportional hazard regression evaluated the impact of TE on OS. RESULTS Of 351 patients, 75% were men with clear cell mRCC (81%) and International Metastatic Renal Cell Carcinoma (IMDC) intermediate- to poor-risk disease (77%). Patients received single-agent IO (52%), doublet IO (31%), or IO with non-IO therapy (17%). The median number of IO doses was 8 (range 1-81). At a median follow-up of 12.8 months, 12% of patients (n = 43) had a TE event (venous n = 37 [11%], arterial n = 6 [2%]). The cumulative TE incidence at 6 months was 4.4% (95% confidence interval [CI] 2.6-6.9) and 9.8% (95% CI 6.8-13.4) at 12 months. No factors, including IMDC or Khorana score, were identified to predict TE development. Seventy-two percent of TE resulted in hospitalization (9% TE-related mortality and 21% TE-related dose delay). TE (p < 0.0001), poor IMDC score (p < 0.0001), and Khorana score ≥ 2 (p < 0.0001) were associated with worse OS. CONCLUSIONS Patients with mRCC treated with IO had a high incidence of TE. TE was associated with risk of treatment delay, hospitalization, and mortality, while TE, IMDC poor risk, and Khorana score ≥ 2 were associated with worse survival. Further investigations into IO-associated TE are needed to identify benefit from primary thromboprophylaxis.
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Affiliation(s)
- Iris Y Sheng
- Department of Medicine, Beth Israel Lahey Mt. Auburn Hospital, Boston, MA, USA
| | - Shilpa Gupta
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Chandana A Reddy
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Dana Angelini
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Pauline Funchain
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Tamara A Sussman
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Joseph Sleiman
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Moshe C Ornstein
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Keith McCrae
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA
| | - Alok A Khorana
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, 10201 Carnegie Ave/CA 60, Cleveland, OH, 44106, USA.
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