Incidence and risk factors of VTE in lung cancer: a meta-analysis

BACKGROUND

Lung cancer has maintained a high prevalence and mortality. Besides, venous thromboembolism (VTE) is the third most common disease of cardiovascular disease. Lung cancer with VTE usually influenced the overall survival in the follow-up. In the development of lung cancer, vigilance against and early diagnosis of VTE is of significance.

METHODS

We searched the databases of PubMed, Web of Science, Embase and Cochrane for related research up to 30 November 2023 and extracted information of incidence, odds ratio (OR), hazard ratio (HR) and their 95% confidence intervals (CIs), for evaluating the incidence of VTE and its risk factors.

RESULTS

A total of 54 articles and 873,292 records were included in our study. The pooled incidences of VTE and PE were 6% and 3%, respectively. Subgroup analysis revealed that the tumour, node and metastasis (TNM) stage (HR= 5.43, 95% CI: 2.42, 12.22), metastasis (HR= 2.67, 95% CI: 1.35, 5.29) and chemotherapy (HR= 2.27, 95% CI: 1.11, 4.65) had major influence on VTE occurrence.

CONCLUSIONS

Lung cancer complicated with VTE is unignorable, and its occurrence varies widely by tumour staging, tissue type and treatment. The results may aid in clinical decision-making about lung cancer in higher risk with VTE and weather receiving anticoagulant prophylaxis.

Venous thromboembolism in adrenocortical carcinoma: a retrospective analysis

BACKGROUND

Venous thromboembolism (VTE) is a leading cause of death in patients with cancer. Limited data exist about VTE in patients with adrenocortical carcinoma (ACC). The primary objective of this study was to identify the prevalence of VTE in a cohort of patients with ACC. Secondary objectives were to determine the impact of VTE events on overall survival (OS) and to describe the characteristics of VTE in patients with ACC.

PATIENTS AND METHODS

We retrospectively reviewed data from 289 patients with ACC cared for at a major referral center from February 2010 to June 2022.

RESULTS

VTE prevalence was 18.7% (54 events). Thirty patients (55.6%) had pulmonary embolism (PE); 12 patients (22.2%) had deep vein thrombosis (DVT); and 12 patients (22.2%) had both PE and DVT. VTE occurred after ACC diagnosis in 50 patients (92.6%) including 44 patients (88%) with stage 3 or 4 ACC. VTEs were CTCAE grade ≤2 in 32 cases (59.3%), grade 3 in 17 (31.5%), and grade 4 in 2 (3.7%). Thirteen patients (24%) died within 6 months after VTE diagnosis, although there was no statistically significant association between VTE and overall survival.

CONCLUSION

Despite the potential to underestimate the prevalence of VTEs, we found a high frequency of VTE events in patients with ACC. A majority of VTEs occurred in the context of advanced ACC and we observed high short-term mortality. Further studies are needed to validate our findings and investigate mechanisms associated with VTE in ACC.

Outcomes among patients with cancer and incidental or symptomatic venous thromboembolism: A systematic review and meta-analysis

BACKGROUND

Patients with cancer have an increased risk of venous thromboembolism (VTE) and it is commonly detected incidentally. The outcomes and optimal management for patients with cancer and incidental VTE remain debated.

OBJECTIVES

We conducted a systematic review and meta-analysis to evaluate the outcomes in patients with cancer and incidentally detected VTE compared to those with symptomatic events.

PATIENTS/METHODS

We searched the electronic databases and included randomized controlled trials (RCTs) and observational studies reporting recurrent VTE, major bleeding events, and mortality in patients with cancer and incidental VTE compared to symptomatic VTE.

RESULTS

We included 23 studies for the systematic review: 3 RCTs and 20 observational studies. The meta-analysis of the 3 RCTs showed a significantly lower rate of VTE recurrence at 6 months in patients with incidental VTE compared to those with symptomatic VTE (relative risk [RR] 0.62, 95% confidence interval [CI] 0.44-0.87). The risk of major bleeding events at 6 months was numerically higher with incidental VTE compared to symptomatic VTE (RR 1.47, 95% CI 0.99-2.20). There was no difference in overall mortality.

CONCLUSIONS

Among patients with cancer, incidental VTE was associated with a lower rate of VTE recurrence compared to symptomatic VTE, with a trend in increased major bleeding events. The risk-benefit ratio of anticoagulation may differ between incidental and symptomatic events and should be considered in patient management.

Modified model for end-stage liver disease score predicts 30-day mortality in high-risk patients with acute pulmonary embolism admitted to intensive care units

OBJECTIVES

The Model for End-stage Liver Disease excluding the international normalised ratio that is derived from prothrombin time which is calculated as a ratio of the patient's prothrombin time to a control prothrombin time standardized (MELD-XI) and modified MELD, which uses albumin in place of the international normalised ratio (MELD-Albumin) scores reflect liver and renal function and are predictors of mortality. However, their prognostic value in acute pulmonary embolism (APE) has not been studied.

DESIGN

We assessed the predictive value of the MELD scores in patients diagnosed with high-risk APE admitted to the intensive care unit. The primary outcome was 30-day mortality.

RESULTS

Of the 273 patients included in the study, 231 were survivors and 42 were non-survivors. The mortality rate was 15.3%. The mean MELD-XI and MELD-Albumin scores were significantly higher in the non-survivors than in the survivors (MELD XI, 11.8 ± 1.8 and 10.6 ± 1.43, respectively; p = .002; MELD-Albumin, 10.5 ± 1.6 and 8.7 ± 1.1, respectively; p = .001). The multiple logistic regression analysis identified the MELD-XI (hazard ratio: 3.029, confidence interval: 1.06-1.21, p = .007) and MELD-Albumin (hazard ratio: 1.13, confidence interval: 1.06-1.21, p = .002) scores as independent predictors of mortality. Receiver operating characteristic analysis revealed that the predictive power of the MELD-Albumin score (0.871 ± 0.014; p < .001) was higher than those of the MELD-XI (0.726 ± 0.022, p < .001), APACHE III (0.682 ± 0.024, p < .001), and PESI (0.624 ± 0.023, p < .001) scores.

CONCLUSIONS

The MELD-Albumin score is an easily calculable, reliable, and practical risk assessment tool and independent predictor of 30-day mortality in patients with high-risk APE.

How I treat cancer-associated venous thromboembolism

Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is a common complication of cancer and is associated with significant morbidity and mortality. Several cancer-related risk factors contribute to the development of VTE including cancer type and stage, chemotherapy, surgery, and patient-related factors such as advanced age and immobilization. Patients with cancer frequently undergo diagnostic imaging scans for cancer staging and treatment response evaluation, which is increasing the underlying risk of VTE detection. The management of cancer-associated VTE is challenging. Over the years, important advances have been made and, recently, randomized controlled trials have been published helping clinicians' management of this patient population. In this review, we will discuss common cancer-associated VTE scenarios and critically review available evidence to guide treatment decisions.

Imaging of urgencies and emergencies in the lung cancer patient

Lung cancer patients often experience potentially life-threatening medical urgencies and emergencies, which may be a direct or indirect result of the underlying malignancy. This pictorial review addresses the most common thoracic, neurological and musculoskeletal medical emergencies in lung cancer patients, including superior vena cava syndrome, pulmonary embolism, spontaneous pneumothorax, cardiac tamponade, massive haemoptysis, central airway obstruction, oesophagorespiratory fistula, malignant spinal cord compression, carcinomatous meningitis, cerebral herniation and pathological fracture. Emphasis is placed on imaging findings, the role of different imaging techniques and a brief discussion of epidemiology, pathophysiology and therapeutic options. Since early diagnosis is important for adequate patient management and prognosis, radiologists have a crucial role in recognising and communicating these urgencies and emergencies.

TEACHING POINTS

• Multiplanar multidetector computed tomography is the imaging examination of choice for thoracic urgencies and emergencies. • Magnetic resonance imaging is the imaging modality of choice for investigating central nervous system emergencies. • Urgencies and emergencies can be the initial manifestation of lung cancer. • Radiologists have a crucial role in recognising and in communicating these urgencies/emergencies.

Incidental venous thromboembolism: is anticoagulation indicated?

Patients with cancer have a high risk of venous thromboembolism (VTE) and about one-half of these events are incidentally detected. The prognosis of incidental VTE appears to be similar to symptomatic events, with comparably high rates of recurrent VTE in this patient population. In the absence of major contraindications, anticoagulant treatment with low-molecular-weight heparin for 3 to 6 months is generally recommended for incidental proximal deep vein thrombosis as well as for incidental pulmonary embolism that involves multiple subsegmental or more proximal pulmonary arteries. The decision of whether to extend treatment beyond 3 to 6 months should be evaluated on a case-by-case basis after periodic reassessment of the risks factors for bleeding and recurrent VTE while also taking into account patient preferences. The clinical relevance of a single incidental subsegmental pulmonary embolism without concomitant deep vein thrombosis is uncertain and either a watchful approach or a shorter course of anticoagulation to minimize the bleeding risk may also be considered. Preliminary evidence suggests that anticoagulation treatment may be beneficial for cancer patients with incidental distal deep vein thrombosis or incidental splanchnic vein thrombosis.

Lung Cancer Complicated With Asymptomatic Pulmonary Embolism: Clinical Analysis of 84 Patients

Background and Objective:

Pulmonary embolism is potentially life-threatening in patients with lung cancer, but the clinical studies on patients with lung cancer having asymptomatic pulmonary embolism were barely reported.

Methods:

Clinical data of patients with lung cancer were obtained from the Department of Respiratory and Critical Care Medicine of Tianjin Chest Hospital during July 2012 and June 2015 and were reviewed retrospectively. A total of 28 patients with lung cancer having pulmonary embolism (LP group) were enrolled, and another 56 cases with lung cancer alone (LC group) were enrolled as controls.

Results:

Seventeen (60.7%) of 28 patients in the LP group developed adenocarcinoma, which was more frequent than that in the LC group (P < .01); the LP group displayed lower counts of hemoglobin and albumin than the LC group (P < .05); the counts of leukocyte (white blood cell) and d-dimer of patients in the LP group were also higher than those in the LC group (P < .05). The high-incidence period of pulmonary embolism among 17 asymptomatic cases in the LP group was 3.6 months postdiagnosis (95% confidence interval, 3.2-4.0), showing a significant difference with that of other 11 patients with symptomatic pulmonary embolism, which was 10.5 months (95% confidence interval, 8.88-12.12; P < .01). Survival analysis displayed that median survival time of patients with asymptomatic pulmonary embolism was 7.2 months (95% confidence interval, 5.86-8.56), while that of symptomatic pulmonary embolism was 2.8 months (95% confidence interval, 2.48-3.12). Log-rank examination showed that survival time of asymptomatic pulmonary embolism group was statistically longer than that of symptomatic pulmonary embolism group.

Conclusion:

Lung adenocarcinoma, chemotherapy, hyperleukocytosis, and d-dimer increment were the risk factors for lung cancer combined with asymptomatic pulmonary embolism.

Incidence and Fate of "Symptomatic" Venous Thromboembolism After Knee Arthroplasty Without Pharmacologic Prophylaxis in an Asian Population

BACKGROUND

As the possibility of developing complications after an "asymptomatic" venous thromboembolism (VTE) after total knee arthroplasty (TKA) has been reported very low, "symptomatic" VTEs seem to be the real concern among orthopedic surgeons. Therefore, the purpose of this study was to determine the incidence of "symptomatic" VTEs and the fate of "symptomatic" VTEs after anticoagulation therapy and assess whether routine pharmacologic prophylaxis is necessary in TKA patients.

METHODS

We retrospectively reviewed 2891 consecutive TKAs in 1933 patients. Graduated compression stockings and intermittent pneumatic calf compression devices were used for VTE prophylaxis. The incidence of symptomatic VTE was investigated until 6 months postoperatively. Patients with VTE underwent anticoagulation therapy and followed up to evaluate range of motion, knee society score, Western Ontario and McMaster Universities index scores, and the presence of any complications (mean follow-up period, 3.6 years).

RESULTS

Fifty-three (1.83%) of the 2891 TKAs had suggestive symptoms and/or sign of VTE. Of these 53 cases, 26 (0.90%) were diagnosed as symptomatic VTE, which comprised 10 (0.35%) symptomatic deep venous thromboses, 11 (0.38%) symptomatic pulmonary embolisms (PEs), 5 (0.17%) symptomatic deep venous thromboses combined with PEs, and no fatal PE. There was no significant difference in range of motion, knee society score, and Western Ontario and McMaster Universities index scores between the groups with or without symptomatic VTE. When treated properly after the diagnosis of symptomatic VTE, no specific complications were identified.

CONCLUSION

Symptomatic VTEs are rare in patients who undergo TKAs with mechanical prophylaxis only. Patients with symptomatic VTEs after TKA can be treated without significant sequelae once they are properly treated with anticoagulation after the diagnosis.

Risk of recurrent venous thromboembolism and major hemorrhage in cancer-associated incidental pulmonary embolism among treated and untreated patients: a pooled analysis of 926 patients

ESSENTIALS: We performed a pooled analysis of 926 patients with cancer-associated incidental pulmonary embolism (IPE). Vitamin K antagonists (VKA) are associated with a higher risk of major hemorrhage. Recurrence risk is comparable after subsegmental and more proximally localized IPE. Our results support low molecular weight heparins over VKA and similar management of subsegmental IPE.

BACKGROUND

Incidental pulmonary embolism (IPE) is defined as pulmonary embolism (PE) diagnosed on computed tomography scanning not performed for suspected PE. IPE has been estimated to occur in 3.1% of all cancer patients and is a growing challenge for clinicians and patients. Nevertheless, knowledge about the treatment and prognosis of cancer-associated IPE is scarce. We aimed to provide the best available evidence on IPE management.

METHODS

Incidence rates of symptomatic recurrent venous thromboembolism (VTE), major hemorrhage, and mortality during 6-month follow-up were pooled using individual patient data from studies identified by a systematic literature search. Subgroup analyses based on cancer stage, thrombus localization, and management were performed.

RESULTS

In 926 cancer patients with IPE from 11 cohorts, weighted pooled 6-month risks of recurrent VTE, major hemorrhage and mortality were 5.8% (95% confidence interval [CI] 3.7-8.3%), 4.7% (95% CI 3.0-6.8%), and 37% (95% CI 28-47%). VTE recurrence risk was comparable under low molecular weight heparins (LMWH) and vitamin K antagonists (VKAs) (6.2% vs. 6.4%; hazard ratio [HR] 0.9; 95% CI 0.3-3.1), while 12% in untreated patients (HR 2.6; 95% CI 0.91-7.3). Risk of major hemorrhage was higher under VKAs than under LMWH (13% vs. 3.9%; HR 3.9; 95% CI 1.6-10). VTE recurrence risk was comparable in patients with an subsegmental IPE and those with a more proximally localized IPE (HR 1.1; 95% CI 0.50-2.4).

CONCLUSION

These results support the current recommendation to anticoagulate cancer-associated IPE with LMWH and argue against different management of subsegmental IPE.

Pulmonary embolus diagnosed by endobronchial ultrasound

Endobronchial ultrasound (EBUS) imaging is commonly used to evaluate and aid in biopsy of mediastinal lymph nodes. Pulmonary arteries are readily viewable with this type of imaging modality. We present a case report of a pulmonary embolism (PE) diagnosed by EBUS. Our patient had no smoking history and presented with respiratory and constitutional symptoms, urinary retention, and leg weakness suspicious for malignancy with metastasis to spine. Chest computed tomography (CT) was suggestive of lung carcinoma and specifically showed no PE. EBUS with TBNA was requested for tissue diagnosis. A mobile filling defect consistent with a PE was observed and reported to primary team. Follow-up chest CT showed an acute PE which confirmed the diagnosis originally made by EBUS. Bronchoscopists should be aware of potential to diagnose a PE while performing EBUS. Additionally, there may be a role in using EBUS specifically to diagnose a PE in the right patient population.

Cancer-associated unsuspected pulmonary embolism

Clinically unsuspected pulmonary embolism (UPE) is frequently diagnosed in cancer patients undergoing routine computed tomography scans for staging purposes or treatment response evaluation. The reported incidence of UPE ranges from 1% to 5% which probably represents an underestimation. A significant proportion of cancer patients with UPE actually do have pulmonary embolism (PE) related symptoms. However, these can erroneously be attributed to the cancer itself or to cancer therapy leading to a delayed or missed diagnosis. The incidence of UPE is likely to increase further with the improvements of imaging techniques. Radiologic features of UPE appear similar to symptomatic PE with nearly half of the UPE located in central pulmonary arteries and one third involving both lungs. UPE in cancer patients is not a benign condition with rates of recurrent venous thromboembolic events, bleeding and a mortality rate comparable to cancer patients with symptomatic PE. Current guidelines suggest that UPE should receive similar initial and long-term anticoagulant treatment as for symptomatic PE. However, direct evidence regarding the treatment of UPE is scarce and treatment indications are largely derived from studies performed in cancer patients with symptomatic venous thromboembolism. Selected subgroups of cancer patients with UPE such as those with sub-segmental UPE may be treated conservatively by withholding anticoagulation and avoiding the associated bleeding risk, although this requires further evaluation.

Thromboembolism in lung cancer - an area of urgent unmet need

INTRODUCTION

Thromboembolism is common in lung cancer. Current thromboprophylaxis guidelines lack specific recommendations for appropriate strategies in this high thrombotic risk patient cohort. We profiled lung cancer patients receiving anti-cancer therapy. Thromboembolism incidence and thromboembolism-related mortality rates are reported and we explored patient, disease, and treatment-related risk factors associated with higher thrombotic rates.

METHODS

Retrospective review of lung cancer patients referred to a Comprehensive Cancer Centre between 01/07/2011 and 30/06/2012 for anti-cancer therapy. Data were collected from medical, pharmacy, pathology and diagnostic imaging electronic records.

RESULTS

After a median follow up of 10 months (range: 0.03-32 months), 24/222 patients (10.8%) had developed radiologically confirmed thromboembolism; 131 events per 1000 person-years (95%CI 87-195). Thromboembolism occurred equally in patients with non-small cell and small cell lung cancer (10.8% and 10.5% respectively), and more frequently among patients with adenocarcinoma compared to squamous cell carcinoma (14.7% and 5.3% respectively). Chemotherapy-treated patients experienced thromboembolism more often than patients who did not receive chemotherapy (HR 5.7 95%CI 2.2-14.8). Radiotherapy was also associated with more frequent thromboembolism (HR 5.2 95%CI 2.0-13.2). New lung cancer diagnosis, presence of metastatic disease, second primary malignancy and Charlson Index ≥ 5 were also associated with higher rates of thromboembolism. Importantly, pharmacological thromboprophylaxis (P-TP) was not routinely or systematically prescribed for ambulant lung cancer patients during any treatment phase, at this institution. The majority (83%) of thromboembolic events occurred in the ambulatory care setting.

CONCLUSION

Morbidity and mortality from thromboembolism occurs frequently in lung cancer. Thromboprophylaxis guidelines should be developed for the ambulatory care setting.