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Parmentier S, Koschmieder S, Henze L, Griesshammer M, Matzdorff A, Bakchoul T, Langer F, Alesci RS, Duerschmied D, Thomalla G, Riess H. Antithrombotic Therapy in Cancer Patients with Cardiovascular Diseases: Daily Practice Recommendations by the Hemostasis Working Party of the German Society of Hematology and Medical Oncology (DGHO) and the Society for Thrombosis and Hemostasis Research (GTH e.V.). Hamostaseologie 2024. [PMID: 39009011 DOI: 10.1055/a-2337-4025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024] Open
Abstract
Active cancer by itself but also chemotherapy is associated with an increased risk of cardiovascular disease (CVD) and especially coronary artery disease (CAD) and atrial fibrillation (AF). The frequency of CVD, CAD, and AF varies depending on comorbidities (particularly in older patients), cancer type, and stage, as well as the anticancer therapeutic being taken. Many reports exist for anticancer drugs being associated with CVD, CAD, and AF, but robust data are often lacking. Because of this, each patient needs an individual structured approach concerning thromboembolic and bleeding risk, drug-drug interactions, as well as patient preferences to evaluate the need for anticoagulation therapy and targeting optimal symptom control. Interruption of specific cancer therapy should be avoided to reduce the potential risk of cancer progression. Nevertheless, additional factors like thrombocytopenia and anticoagulation in the elderly and frail patient with cancer cause additional challenges which need to be addressed in daily clinical management. Therefore, the aim of these recommendations is to summarize the available scientific data on antithrombotic therapy (both antiplatelet and anticoagulant therapy) in cancer patients with CVD and in cases of missing data providing guidance for optimal careful decision-making in daily routine.
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Affiliation(s)
- Stefani Parmentier
- Tumorzentrum, St. Claraspital Tumorzentrum, St. Claraspital, Basel, Basel-Stadt, Switzerland
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Larissa Henze
- Department of Medicine, Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, Rostock, Germany
- Department of Internal Medicine II, Hematology, Oncology and Palliative Medicine, Asklepios Hospital Harz, Goslar, Germany
| | - Martin Griesshammer
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Minden, Germany
| | - Axel Matzdorff
- Department of Internal Medicine II, Asklepios Clinic Uckermark, Schwedt, Germany
| | - Tamam Bakchoul
- Department of Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Florian Langer
- Center for Oncology, University Cancer Center Hamburg (UCCH), II Medical Clinic and Polyclinic, University Medical Center Eppendorf, Hamburg, Germany
| | - Rosa Sonja Alesci
- IMD Blood Coagulation Center, Hochtaunus/Frankfurt, Bad Homburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Hemostaseology, Angiology and Medical Intensive Care, Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanno Riess
- Division of Hematology, Oncology and Tumorimmunology, Department of Medical, Campus Charité Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
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2
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Petit B, Soudet S, Poenou G, Zarrat E, Accassat S, Plaisance L, Helfer H, Mismetti V, Hello CL, Sevestre MA, Mahé I, Bertoletti L. Cancer-associated thrombosis: How many patients seen in clinical practice would be eligible for a direct oral anticoagulant randomized controlled trial? Respir Med Res 2024; 85:101069. [PMID: 38141577 DOI: 10.1016/j.resmer.2023.101069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/06/2023] [Accepted: 11/17/2023] [Indexed: 12/25/2023]
Abstract
Based on the results of randomized clinical trials (RCT) assessing direct oral anticoagulants (DOACs) for the treatment of patients with cancer-associated thrombosis (CAT), DOACs have been proposed as alternative to low molecular weight heparin by several international guidelines. However, the proportion of CAT patients who would have not been eligible for such trials is currently unknown. Our primary aim was to assess the proportion of patients seen in clinical practice for acute CAT who would not have been eligible for CARAVAGGIO or HOKUSAI-VTE RCT. Secondary aim was to describe patients outcomes according to eligibility. In a multicenter, observational study, all patients consecutively admitted from January 2017 to December 2019 for an acute CAT event were retrospectively analyzed. Patients were classified according to the presence or absence of non-inclusion criteria for CARAVAGGIO or HOKUSAI-VTE RCT. Event free survival during a 6-month follow-up were analyzed as secondary endpoints. Among the 302 patients (women: 53 %, mean age: 67.9 ± 13.2) analyzed, 138 (46 %) for HOKUSAI-VTE cancer and 161 (53 %) for CARAVAGGIO met one or more non-inclusion criteria. Main criteria were upper limb and unsual site thrombosis (n = 63, 18.5 %), anemia/thrombopenia (n = 43, 14.2 %), brain tumors (n = 33, 10.9 %), ECOG PS >2 (n = 28, 9.3 %), severe renal failure (n = 16, 5.3 %). At 6 months, the event-free survival rate was not statistically different between the two groups. Almost half of CAT patients would have not been able to participate to a modern DOAC RCT. Evaluation of DOACs safety and efficacy in this subset of patients deserves further research.
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Affiliation(s)
- Bastien Petit
- Vascular Medicine and Therapeutic Department, CHU-Saint-Etienne, Saint-Etienne, France
| | - Simon Soudet
- Vascular Medicine Department, CHU-Amiens-Picardie, France; EA7516 CHIMERE, University of Picardie Jules Verne, Amiens, France
| | - Géraldine Poenou
- Vascular Medicine and Therapeutic Department, CHU-Saint-Etienne, Saint-Etienne, France; Internal Medicine Department, Louis-Mourier Hospital, Assistance publique-Hôpitaux de Paris (AP-HP), Colombes, France; Paris Cité University, Paris, France; Université Jean Monnet Saint-Étienne, CHU Saint-Étienne, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, all in F-42055, Saint-Etienne, France
| | - Emma Zarrat
- Vascular Medicine Department, CHU-Amiens-Picardie, France
| | - Sandrine Accassat
- Vascular Medicine and Therapeutic Department, CHU-Saint-Etienne, Saint-Etienne, France
| | - Ludovic Plaisance
- Internal Medicine Department, Louis-Mourier Hospital, Assistance publique-Hôpitaux de Paris (AP-HP), Colombes, France
| | - Hélène Helfer
- Internal Medicine Department, Louis-Mourier Hospital, Assistance publique-Hôpitaux de Paris (AP-HP), Colombes, France; INSERM, UMR_ S1140 Innovative Therapies in Haemostasis, 75006 Paris, France
| | - Valentine Mismetti
- Vascular Medicine and Therapeutic Department, CHU-Saint-Etienne, Saint-Etienne, France; Université Jean Monnet Saint-Étienne, CHU Saint-Étienne, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, all in F-42055, Saint-Etienne, France
| | - Claire Le Hello
- Vascular Medicine and Therapeutic Department, CHU-Saint-Etienne, Saint-Etienne, France; Université Jean Monnet Saint-Étienne, CHU Saint-Étienne, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, all in F-42055, Saint-Etienne, France
| | - Marie-Antoinette Sevestre
- Vascular Medicine Department, CHU-Amiens-Picardie, France; EA7516 CHIMERE, University of Picardie Jules Verne, Amiens, France
| | - Isabelle Mahé
- Internal Medicine Department, Louis-Mourier Hospital, Assistance publique-Hôpitaux de Paris (AP-HP), Colombes, France; Paris Cité University, Paris, France; INSERM, UMR_ S1140 Innovative Therapies in Haemostasis, 75006 Paris, France
| | - Laurent Bertoletti
- Vascular Medicine and Therapeutic Department, CHU-Saint-Etienne, Saint-Etienne, France; Université Jean Monnet Saint-Étienne, CHU Saint-Étienne, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, all in F-42055, Saint-Etienne, France; INSERM, CIC 1408, F-42055, Saint-Etienne, France.
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3
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Garcia JJB, Pascual JLV. Cancer-associated stroke from progressive acinic cell carcinoma. BMJ Case Rep 2024; 17:e260385. [PMID: 38789271 DOI: 10.1136/bcr-2024-260385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024] Open
Abstract
Cancer-associated stroke is an evolving subgroup of embolic strokes of undetermined source. A man in his mid-20s with progressive follicular variant acinic cell carcinoma of the parotid was admitted because of new onset left-sided weakness. Neuroimaging confirmed a right middle cerebral artery infarction. After extensive diagnostics, stroke aetiology was deemed from cancer-induced hypercoagulability. Questions which arose regarding his management included (1) What was the best antithrombotic for secondary stroke prevention? (2) What was his risk for intracranial or tumorous bleeding once antithrombotics had been started? (3) How many days post-stroke could the antithrombotic be initiated? and (4) When could he be cleared for palliative chemotherapy and whole brain irradiation? The approach to address the abovementioned questions in the management of a rare cancer complicated by stroke is presented. Although treatments are guided by known pathomechanisms, additional studies are needed to further support current treatment strategies for this subgroup of patients.
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Affiliation(s)
- Jao Jarro Borromeo Garcia
- Department of Neurosciences, University of the Philippines, Philippine General Hospital, Manila, Metro Manila, Philippines
| | - Jose Leonard Vr Pascual
- Department of Neurosciences, University of the Philippines, Philippine General Hospital, Manila, Metro Manila, Philippines
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4
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Ranjan S, Leung D, Ghiaseddin AP, Taylor JW, Lobbous M, Dhawan A, Budhu JA, Coffee E, Melnick K, Chowdhary SA, Lu-Emerson C, Kurz SC, Burke JE, Lam K, Patel MP, Dunbar EM, Mohile NA, Peters KB. Practical guidance for direct oral anticoagulant use in the treatment of venous thromboembolism in primary and metastatic brain tumor patients. Cancer 2024; 130:1577-1589. [PMID: 38288941 DOI: 10.1002/cncr.35220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/17/2023] [Accepted: 11/27/2023] [Indexed: 04/13/2024]
Abstract
Management of venous thromboembolism (VTE) in patients with primary and metastatic brain tumors (BT) is challenging because of the risk of intracranial hemorrhage (ICH). There are no prospective clinical trials evaluating safety and efficacy of direct oral anticoagulants (DOACs), specifically in patients with BT, but they are widely used for VTE in this population. A group of neuro-oncology experts convened to provide practical clinical guidance for the off-label use of DOACs in treating VTE in patients with BT. We searched PubMed for the following terms: BTs, glioma, glioblastoma (GBM), brain metastasis, VTE, heparin, low-molecular-weight heparin (LWMH), DOACs, and ICH. Although prospective clinical trials are needed, the recommendations presented aim to assist clinicians in making informed decisions regarding DOACs for VTE in patients with BT.
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Affiliation(s)
- Surabhi Ranjan
- Department of Neurology, Cleveland Clinic Florida, Weston, Florida, USA
| | - Denise Leung
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ashley P Ghiaseddin
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Jennie W Taylor
- Department of Neurology, University of California, San Francisco, California, USA
| | - Mina Lobbous
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Andrew Dhawan
- Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Joshua A Budhu
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elizabeth Coffee
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kaitlyn Melnick
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Sajeel A Chowdhary
- Tampa General Hospital Cancer Institute, Tampa General Hospital, Tampa, Florida, USA
| | - Christine Lu-Emerson
- Department of Neurology, Maine Medical Center and Maine Health Cancer Care, Portland, Maine, USA
| | - Sylvia C Kurz
- Department of Neurology & Interdisciplinary Neuro-Oncology, Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Joy E Burke
- Department of Neurology, Beth Israel Lahey Health, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Keng Lam
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mallika P Patel
- Preston Robert Tisch Brain Tumor Center, Duke University, Durham, North Carolina, USA
| | | | - Nimish A Mohile
- Department of Neurology, University of Rochester, Rochester, New York, USA
| | - Katherine B Peters
- Preston Robert Tisch Brain Tumor Center, Duke University, Durham, North Carolina, USA
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5
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Mahé I, Frère C, Pernod G, Sanchez O, Baih AI. [Translation into French and republication of: "Management of venous thromboembolic disease in patients with malignant brain tumours"]. Rev Med Interne 2024; 45:300-311. [PMID: 38763817 DOI: 10.1016/j.revmed.2024.05.016] [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: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 05/21/2024]
Abstract
This article addresses the management of venous thromboembolism in patients with malignant brain tumours, including both primary and secondary (metastatic) tumours. The available data on patients on venous thromboembolism recurrence and bleeding risks in patients with brain tumours is limited, since these patients have been excluded from most randomised, interventional, head-to-head, clinical trials comparing low molecular weight heparins to vitamin K antagonists or to direct oral factor Xa inhibitors. More information is available from retrospective observational studies, which however were generally small, and carried a high risk of confounding. Their findings suggest that direct factor Xa inhibitor use is associated with lower rates of intracranial haemorrhage compared with low molecular weight heparins. Overall, the safety profile of direct oral factor Xa inhibitors when used to prevent venous thromboembolism recurrence in patients with either primary or secondary brain tumours appears to be favourable. The available data are in favour of using an anticoagulant at a full therapeutic dose in patients with primary and secondary brain tumours experiencing a venous thromboembolism, although they are not yet sufficiently robust to permit recommending a direct factor Xa inhibitor over low-molecular weight heparin.
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Affiliation(s)
- I Mahé
- Service de médecine interne, hôpital Louis-Mourier, Assistance publique-Hôpitaux de Paris, 92700 Colombes, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE Network, Saint-Étienne, France.
| | - C Frère
- Hôpital de la Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, Sorbonne université, Inserm UMRS 1166, GRC 27 Greco, DMU BioGeMH, Paris, France
| | - G Pernod
- F-CRIN INNOVTE Network, Saint-Étienne, France; Service de médecine vasculaire, université Grenoble-Alpes, Grenoble, France
| | - O Sanchez
- Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE Network, Saint-Étienne, France; Service de pneumologie et soins intensifs, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, Paris, France
| | - A Id Baih
- Service de neuro-oncologie, Institut du cerveau - Paris Brain Institute, ICM, hôpitaux universitaires La Pitié-Salpêtrière - Charles-Foix, DMU Neurosciences, Sorbonne université, Assistance publique-Hôpitaux de Paris, Inserm, CNRS, Paris, France
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6
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Abdelmessih E, Ahuja T, Wo S, Sango A, Papadopoulos J, Green D, Xiang E. Anticoagulant prescribing patterns in patients with primary central nervous system malignancies and secondary metastases. J Thromb Thrombolysis 2024; 57:418-427. [PMID: 38281232 DOI: 10.1007/s11239-023-02936-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2023] [Indexed: 01/30/2024]
Abstract
To evaluate the safety of direct oral anticoagulants (DOACs) versus low-molecular weight heparin (LMWH) in patients with central nervous system (CNS) malignancies and secondary metastases. All adult patients with CNS malignancies and secondary metastases who were treated with a DOAC or LMWH for any indication from 2018 to 2022 were included. The primary outcome was the incidence of any intracranial hemorrhage (ICH) after anticoagulation initiation. Secondary outcomes included non-ICH bleeding events and thromboembolic events. Tolerability was assessed by any changes in anticoagulant therapy during study period. 153 patients were included; 48 patients received enoxaparin and 105 received DOACs, of which apixaban was used most commonly. The population was predominantly White (74%) and male (59%) with a median age of 65. Data was censored for immortal time bias for outcomes evaluated beyond 3 months. ICH occurred in 7.7% of the population, more frequently in the enoxaparin group (DOACs 4, 4% vs. enoxaparin 7, 16%, p = 0.037). Non-ICH bleeds were predominantly minor and more common in the DOAC group (DOACs 13, 13% vs. enoxaparin 1, 2%, p = 0.037). Thromboembolic events were not different between groups (DOACs 9. 9% vs, enoxaparin 2, 4%, p = 0.503). Anticoagulant switches occurred more in the enoxaparin group (DOACs 12, 12.4% vs. enoxaparin, 37.8%, p < 0.001), primarily due to patient or provider preference. Our data supports DOACs to be preferred over LMWH for the treatment of VTE or for stroke prevention with AF to prevent ICH in patients with brain tumors or metastases.
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Affiliation(s)
- Emily Abdelmessih
- Department of Pharmacy, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA
| | - Tania Ahuja
- Department of Pharmacy, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA.
- Department of Medicine NYU Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA.
| | - Stephanie Wo
- Department of Pharmacy, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA
| | - Aaron Sango
- Department of Pharmacy, NYU Langone Health, 150 55th Street, Brooklyn, NY, 11220, USA
| | - John Papadopoulos
- Department of Pharmacy, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA
- Department of Medicine NYU Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - David Green
- Department of Medicine NYU Grossman School of Medicine, 550 First Avenue, New York, NY, 10016, USA
| | - Elaine Xiang
- Department of Pharmacy, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA
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Iyengar V, Agrawal S, Chiasakul T, Tehranchi K, Mcnichol M, Carney BJ, Leader A, Zwicker JI, Patell R. Comparison of direct oral anticoagulants versus low-molecular-weight heparin in primary and metastatic brain cancers: a meta-analysis and systematic review. J Thromb Haemost 2024; 22:423-429. [PMID: 37866517 DOI: 10.1016/j.jtha.2023.10.011] [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: 07/31/2023] [Revised: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND The safety and efficacy of direct-acting oral anticoagulants (DOACs) for therapeutic anticoagulation in the setting of primary or metastatic brain cancer is not known. OBJECTIVES To conduct a meta-analysis and systematic review of studies that compare the risk of intracranial hemorrhage (ICH) in patients with brain cancer treated with DOACs vs low-molecular-weight heparin (LMWH). METHODS A literature search was conducted using PubMed, EMBASE, and Cochrane databases. Summary statistics were obtained by calculating the risk ratio (RR), and heterogeneity across studies was estimated using the I2 statistic. A total of 10 retrospective studies (n = 1638) met criteria for inclusion. The primary endpoint was the pooled RR for ICH in patients with brain tumors receiving anticoagulation with DOACs compared with those receiving LMWH. Secondary analyses included the risk of fatal ICH in each subgroup. RESULTS The pooled RR for ICH in patients receiving DOACs vs those receiving LMWH was 0.65 (95% CI, 0.36-1.17; P = .15; I2 = 50%). In studies evaluating primary brain cancer, there was a reduction in risk of ICH with DOACs (RR, 0.35; 95% CI, 0.18-0.69; P = .003; I2 = 0%). In patients with metastatic brain cancer, there was no difference in the risk of ICH with the type of anticoagulation (RR, 1.05; 95% CI, 0.71-1.56; P = .80; I2 = 0%). The overall risk of fatal ICH was not different between anticoagulants. CONCLUSION The risk of ICH in patients with brain cancer receiving therapeutic anticoagulation varies by anticoagulation agent and diagnosis of primary or metastatic disease.
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Affiliation(s)
- Varun Iyengar
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Shubham Agrawal
- Department of Internal Medicine, Mercy Catholic Medical Center, Darby, Pennsylvania, USA
| | - Thita Chiasakul
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand; Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kian Tehranchi
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Megan Mcnichol
- Division of Knowledge Services, Department of Information Services, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Brian J Carney
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Avi Leader
- Institiute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jeffrey I Zwicker
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
| | - Rushad Patell
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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8
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Mahé I, Frère C, Pernod G, Sanchez O, Id Baih A. Management of venous thromboembolic disease in patients with malignant brain tumours. Arch Cardiovasc Dis 2024; 117:60-71. [PMID: 38087664 DOI: 10.1016/j.acvd.2023.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 12/27/2023]
Abstract
This article addresses the management of venous thromboembolism in patients with malignant brain tumours, including both primary and secondary (metastatic) tumours. The available data on patients on venous thromboembolism recurrence and bleeding risks in patients with brain tumours is limited, since these patients have been excluded from most randomised, interventional, head-to-head, clinical trials comparing low molecular weight heparins to vitamin K antagonists or to direct oral Factor Xa inhibitors. More information is available from retrospective observational studies, which however were generally small, and carried a high risk of confounding. Their findings suggest that direct Factor Xa inhibitor use is associated with lower rates of intracranial haemorrhage compared with low molecular weight heparins. Overall, the safety profile of direct oral Factor Xa inhibitors when used to prevent venous thromboembolism recurrence in patients with either primary or secondary brain tumours appears to be favourable. The available data are in favour of using an anticoagulant at a full therapeutic dose in patients with primary and secondary brain tumours experiencing a venous thromboembolism, although they are not yet sufficiently robust to permit recommending a direct Factor Xa inhibitor over low-molecular weight heparin.
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Affiliation(s)
- Isabelle Mahé
- Service de médecine interne, Hôpital Louis-Mourier, AP-HP, 178, rue des Renouillers, 92700 Colombes, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France.
| | - Corinne Frère
- Hôpital de la Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, Sorbonne université, Inserm UMRS 1166, GRC 27 GRECO, DMU BioGeMH, Paris, France
| | - Gilles Pernod
- Service de médecine vasculaire,Université Grenoble-Alpes, Grenoble, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Olivier Sanchez
- Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; Service de Pneumologie et soins intensifs, hôpital européen Georges Pompidou, APHP, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Ahmed Id Baih
- Sorbonne Université, AP-HP, Institut du Cerveau - Paris Brain Institute, ·ICM, Inserm, CNRS, Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, DMU Neurosciences, Service de Neuro-Oncologie, Paris, France
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9
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Wang T, Liu X, Zhu Y, Zhang Y, Zhang Z, Huang G, Xu J. Antithrombotic strategy in cancer patients comorbid with acute coronary syndrome and atrial fibrillation. Front Cardiovasc Med 2023; 10:1325488. [PMID: 38162143 PMCID: PMC10756915 DOI: 10.3389/fcvm.2023.1325488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 11/27/2023] [Indexed: 01/03/2024] Open
Abstract
It has been shown that patients with cancer have a longer expected life duration, benefiting from advanced medical therapy. Meanwhile, the risk of suffering from cardiovascular disease (CVD) has been increasing with ageing. A growing number of studies have elucidated the association between cancer and CVD. Cancer, atrial fibrillation (AF) and coronary artery disease share some common factors and interact with each other, such as obesity, aging, diabetes, and inflammation, but the potential specific mechanism is still unclear. In addition, cancer-specific and therapy-related factors may increase the risk of embolism and bleeding in patients with cancer than in general population. However, current available embolic and bleeding risk scores applied in patients with CVD may not be applicable for risk assessment in cancer patients, which would be difficult for clinicians to select an appropriate antithrombotic regimen and ensure the balance between bleeding and embolism. Moreover, different types of cancer have distinct risks, which may increase the complexity of antithrombotic therapy. In this review, we review the literature related to cancer, AF, and acute coronary syndrome, focusing on the epidemiological status, physiological mechanism, embolism and bleeding risks, and strategies of antithrombotic therapy.
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Affiliation(s)
- Tianbo Wang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Xiaohan Liu
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Yuxin Zhu
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Yue Zhang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
| | - Zhen Zhang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
| | - Gang Huang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
| | - Junbo Xu
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
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10
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Fioretti AM, Leopizzi T, La Forgia D, De Luca R, Oreste D, Inchingolo R, Scicchitano P, Oliva S. Abelacimab in Cancer-Associated Thrombosis: The Right Drug at the Right Time for the Right Purpose. A Comprehensive Review. Rev Cardiovasc Med 2023; 24:295. [PMID: 39077577 PMCID: PMC11262452 DOI: 10.31083/j.rcm2410295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/07/2023] [Accepted: 08/11/2023] [Indexed: 07/31/2024] Open
Abstract
Cancer-associated thrombosis (CAT) is a devastating complication of cancer that can significantly impact a patient's health and life. The incidence of CAT is approximately 20%, and 1 in 5 cancer patients will develop CAT annually. Indeed, CAT can promote pulmonary embolism and deep vein thrombosis, leading to increased morbidity and mortality that dramatically impact survival. CAT can also provoke delay or discontinuation of anticancer treatment, which may result in a lack of treatment efficacy and high costs for patients, institutions, and society. Current guidelines advocate direct oral anticoagulants (DOACs) as the first-line anticoagulant option in CAT. Compared to low-molecular-weight-heparins (LMWHs), DOACs are advantageous in that they typically have an oral route of administration, do not require laboratory monitoring, and have a more predictable anticoagulant effect. However, in patients with thrombocytopenia, renal failure, or those receiving anticancer regimens with potential for drug-drug interactions, LMWH is still the mainstay of care. The main limitation of current anticoagulant agents is related to bleeding risk (BR), both for DOACs and LMWHs. Specifically, DOACs have been associated with high BR in gastrointestinal and genitourinary cancers. In this challenging scenario, abelacimab, an anti-factor XI agent, could represent a viable option in the management of CAT due to its "hemostasis sparing" effect. The safe profile of abelacimab could be useful in patients with active malignancy and CAT, as long-term anticoagulant therapy is often required. Two ongoing international phase III trials (Aster and Magnolia) compare abelacimab with the standard of care (i.e., apixaban in patients with CAT and dalteparin in those with CAT and high BR, respectively). Abelacimab is a new and attractive anticoagulant for the management of CAT, especially in the insidious and critical scenario of active cancer patients with venous thromboembolism and high BR. The aim of this narrative review is to discuss the updated evidence on the performance of DOACs and LMWHs in the treatment of CAT and to focus on the potential role of abelacimab in CAT and its promising associated clinical trials.
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Affiliation(s)
| | - Tiziana Leopizzi
- Cardiology-Intensive Care Unit, Ospedale SS. Annunziata, 74121 Taranto, Italy
| | - Daniele La Forgia
- Diagnostic Radiology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy
| | - Raffaele De Luca
- Surgical Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy
| | - Donato Oreste
- Diagnostic Radiology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy
| | - Riccardo Inchingolo
- Interventional Radiology Unit, Ospedale Generale Regionale “F. Miulli”, Acquaviva delle Fonti, 70021 Bari, Italy
| | - Pietro Scicchitano
- Cardiology-Intensive Care Unit, Ospedale della Murgia “Fabio Perinei”, Altamura, 70022 Bari, Italy
| | - Stefano Oliva
- Cardio-Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy
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11
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Masini M, Toma M, Spallarossa P, Porto I, Ameri P. Direct Oral Anticoagulants for Cancer-Associated Venous Thromboembolism. Curr Oncol Rep 2023; 25:979-987. [PMID: 37278934 PMCID: PMC10474987 DOI: 10.1007/s11912-023-01428-y] [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] [Accepted: 05/02/2023] [Indexed: 06/07/2023]
Abstract
PURPOSE OF REVIEW To present the randomized controlled trial (RCT) evidence and highlight the areas of uncertainty regarding direct oral anticoagulants (DOAC) for cancer-associated venous thromboembolism (CAT). RECENT FINDINGS In the last years, four RCTs have shown that rivaroxaban, edoxaban, and apixaban are at least as effective as low-molecular-weight heparin (LMWH) for the treatment of both incidental and symptomatic CAT. On the other hand, these drugs increase the risk of major gastrointestinal bleeding in patients with cancer at this site. Another two RCTs have demonstrated that apixaban and rivaroxaban also prevent CAT in subjects at intermediate-to-high risk commencing chemotherapy, albeit at the price of higher likelihood of bleeding. By contrast, data are limited about the use DOAC in individuals with intracranial tumors or concomitant thrombocytopenia. It is also possible that some anticancer agents heighten the effects of DOAC via pharmacokinetic interactions, up to making their effectiveness-safety profile unfavorable. Leveraging the results of the aforementioned RCTS, current guidelines recommend DOAC as the anticoagulants of choice for CAT treatment and, in selected cases, prevention. However, the benefit of DOAC is less defined in specific patient subgroups, in which the choice of DOAC over LMWH should be carefully pondered.
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Affiliation(s)
- Marta Masini
- Department of Internal Medicine, University of Genova, Viale Benedetto XV, 6 - 16132, Genoa, Italy
| | - Matteo Toma
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Paolo Spallarossa
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Italo Porto
- Department of Internal Medicine, University of Genova, Viale Benedetto XV, 6 - 16132, Genoa, Italy
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Pietro Ameri
- Department of Internal Medicine, University of Genova, Viale Benedetto XV, 6 - 16132, Genoa, Italy.
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
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12
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Yannoutsos A, Cacciatore C, Jaouen S, Farge D, Frere C. Treatment of cancer-associated venous thromboembolism: A focus on special populations. JOURNAL DE MEDECINE VASCULAIRE 2023; 48:124-135. [PMID: 37914457 DOI: 10.1016/j.jdmv.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/02/2023] [Indexed: 11/03/2023]
Abstract
Current evidence-based clinical practice guidelines recommend the use of both low-molecular-weight heparin (LMWH) and direct factor Xa inhibitors (apixapan, edoxaban and rivaroxaban) as first-line options for the treatment of venous thromboembolism (VTE) in patients with cancer. However, most of these guidelines refer to the general cancer patient population and provide limited guidance for specific subgroups of patients at particularly high risk of bleeding, such as those with gastrointestinal cancers, primary or metastatic brain tumors, thrombocytopenia, or renal impairment. In these complex populations, the management of cancer-associated thrombosis (CAT) poses unique challenges and requires a nuanced approach based on the primum non nocere principle. This comprehensive review critically examines the relevant literature and discusses the therapeutic options currently available for the management of CAT in these special situations.
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Affiliation(s)
- Alexandra Yannoutsos
- Department of Vascular Medicine, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Carlotta Cacciatore
- Department of Internal Medicine (UF 04), CRMR MATHEC, Maladies Auto-Immunes et Thérapie Cellulaire, Saint-Louis Hospital, AP-HP Nord, Université de Paris, Paris, France
| | - Simon Jaouen
- Department of Hematology, CHRU de Brest, Brest, France
| | - Dominique Farge
- Department of Internal Medicine (UF 04), CRMR MATHEC, Maladies Auto-Immunes et Thérapie Cellulaire, Saint-Louis Hospital, AP-HP Nord, Université de Paris, Paris, France
| | - Corinne Frere
- Sorbonne Université, INSERM UMRS 1166, GRC 27 GRECO, Paris, France; DMU BioGeMH, AP-HP, Sorbonne Université, Paris, France.
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13
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Yang J, He Z, Li M, Hong T, Ouyang T. Risk of intracranial hemorrhage with direct oral anticoagulation versus low molecular weight heparin in the treatment of brain tumor-associated venous thromboembolism: A meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107243. [PMID: 37413715 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107243] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 06/27/2023] [Accepted: 06/30/2023] [Indexed: 07/08/2023] Open
Abstract
OBJECTIVES Direct oral anticoagulants (DOACs) are effective in treating cancer-related thrombosis and are superior to low molecular weight heparin (LMWH) in terms of efficacy. The effects of DOACs or LMWH on intracranial hemorrhage (ICH) remain uncertain in individuals with brain tumors. We conducted a meta-analysis to compare the frequency of ICH in individuals with brain tumors treated with DOACs or LMWH. METHODS Two independent investigators reviewed all studies that compared the frequency of ICH in patients with brain tumors who received DOACs or LMWH. The primary outcome was the incidence of ICH. We used the Mantel-Haenszel method to estimate the combined effect and calculated 95% confidence intervals (CI). RESULTS This study encompassed six articles. The results indicated that cohorts treated with DOAC experienced much fewer instances of ICH compared to the LMWH cohorts (relative risk [RR] 0.39; 95% CI 0.23-0.65; P = 0.0003; I2 = 0%). The same effect was observed for the prevalence of major ICH (RR 0.34; 95% CI 0.12-0.97; P = 0.04; I2 = 0%), but there was no difference for fatal ICH. Subgroup analysis indicated that DOACs had a substantially reduced incidence of ICH in primary brain tumors (RR 0.18; 95% CI 0.06-0.50; P = 0.001; I2 = 0%), but had no impact on ICH with secondary brain tumors. CONCLUSIONS This meta-analysis showed that DOACs are associated with a lower risk of ICH than LMWH therapy in treating venous thromboembolism associated with brain tumors, especially in patients with primary brain tumors.
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Affiliation(s)
- Jun Yang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Jiangxi Province, China.
| | - Zesong He
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Jiangxi Province, China.
| | - Meihua Li
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Jiangxi Province, China.
| | - Tao Hong
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Jiangxi Province, China.
| | - Taohui Ouyang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Jiangxi Province, China.
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14
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Wu B, Zhou Y, Yang Y, Zhou D. Risk factors and a new nomogram for predicting brain metastasis from lung cancer: a retrospective study. Front Oncol 2023; 13:1092721. [PMID: 37404749 PMCID: PMC10316021 DOI: 10.3389/fonc.2023.1092721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/31/2023] [Indexed: 07/06/2023] Open
Abstract
Objective This study aims to establish and validate a new nomogram for predicting brain metastasis from lung cancer by integrating data. Methods 266 patients diagnosed as lung cancer between 2016 and 2018 were collected from Guangdong Academy of Medical Sciences. The first 70% of patients were designated as the primary cohort and the remaining patients were identified as the internal validation cohort. Univariate and multivariable logistics regression were applied to analyze the risk factors. Independent risk factors were used to construct nomogram. C-index was used to evaluate the prediction effect of nomogram.100 patients diagnosed as lung cancer between 2018 and 2019 were collected for external validation cohorts. The evaluation of nomogram was carried out through the distinction and calibration in the internal validation cohort and external validation cohort. Results 166 patients were diagnosed with brain metastasis among the 266 patients. The gender, pathological type (PAT), leukocyte count (LCC) and Fibrinogen stage (FibS) were independent risk factors of brain metastasis. A novel nomogram has been developed in this study showed an effective discriminative ability to predict the probability of lung cancer patients with brain metastasis, the C-index was 0.811. Conclusion Our research provides a novel model that can be used for predicting brain metastasis of lung cancer patients, thus providing more credible evidence for clinical decision-making.
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Affiliation(s)
- Bo Wu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Neurosurgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
| | - Yujun Zhou
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Neurosurgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
| | - Yong Yang
- Department of Neurosurgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
| | - Dong Zhou
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Neurosurgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
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15
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Miyashita K, Nambu K, Kinami S, Nogami K, Nambu I, Tohma Y. Intra-and peritumoral hemorrhage in the meningioma of a nonagenarian due to administration of direct oral anticoagulants after mechanical thrombectomy. Surg Neurol Int 2023; 14:164. [PMID: 37292413 PMCID: PMC10246366 DOI: 10.25259/sni_18_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/20/2023] [Indexed: 06/10/2023] Open
Abstract
Background Spontaneous intratumoral hemorrhage of meningiomas is rare, and their incidence due to anticoagulants is unclear. The incidence of both meningioma and cardioembolic stroke increases with age. We report the very elderly case of intra- and peritumoral hemorrhage in frontal meningioma induced by direct oral anticoagulant (DOAC) following mechanical thrombectomy, in whom, surgical resection was required 10 years after the tumor was first indicated. Case Description A 94-year-old woman with independence in daily living who suffered sudden consciousness disturbance, total aphasia, and right hemiparesis was admitted to our hospital. Magnetic resonance imaging showed an acute cerebral infarction and left middle cerebral artery occlusion. There was also a left frontal meningioma with peritumoral edema, which was discovered 10 years prior, and the size and edema had remarkably increased. The patient underwent urgent mechanical thrombectomy, and recanalization was achieved. Administration of DOAC was initiated for the atrial fibrillation. Computed tomography (CT) revealed an asymptomatic intratumoral hemorrhage at postoperative day 26. The patient's symptoms gradually improved; however, she suffered sudden disturbance of consciousness and right hemiparesis on postoperative day 48. CT revealed intra- and peritumoral hemorrhages with compression of the surrounding brain. Therefore, we decided to perform tumor resection instead of conservative treatment. The patient underwent surgical resection, and the postoperative course was uneventful. It was diagnosed with transitional meningioma with no malignant features. The patient was transferred to another hospital for rehabilitation. Conclusion Peritumoral edema representing a pial blood supply might be a significant factor associated with intracranial hemorrhage due to DOAC administration in patients with meningioma. The evaluation of hemorrhagic risk due to DOACs is important not only for meningioma but also for other brain tumor cases.
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Affiliation(s)
- Katsuyoshi Miyashita
- Corresponding author: Katsuyoshi Miyashita, Department of Neurosurgery, Fukui Prefectural Hospital, Fukui, Japan.
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16
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Cohen AT, Benson G, Bradbury CA, Choudhuri S, Hutchinson Jones N, Maraveyas A, Venugopal B, Young AM, Chapman C, McIntyre S, Burney D, Pollock KG, Morgan AR, Gabb PD, Alikhan R. A consensus viewpoint on the role of direct factor Xa inhibitors in the management of cancer-associated venous thromboembolism in the UK. Curr Med Res Opin 2023; 39:483-495. [PMID: 36629478 DOI: 10.1080/03007995.2023.2167441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Cancer patients are at high risk of venous thromboembolism (VTE), a significant cause of cancer-related death. Historically, low molecular weight heparins (LMWH) were the gold standard therapy for cancer-associated VTE, but recent evidence supports the use of direct factor Xa inhibitors in cancer-associated VTE and this is now reflected in many guidelines. However, uptake of direct factor Xa inhibitors varies and guidance on the use of direct factor Xa inhibitors in specific cancer sub-populations and clinical situations is lacking. This review presents consensus expert opinion alongside evaluation of evidence to support healthcare professionals in the use of direct factor Xa inhibitors in cancer-associated VTE. METHODS Recent guidelines, meta-analyses, reviews and clinical studies on anticoagulation therapy for cancer-associated VTE were used to direct clinically relevant topics and evidence to be systematically discussed using nominal group technique. The consensus manuscript and recommendations were developed based on these discussions. RESULTS Considerations when prescribing anticoagulant therapy for cancer-associated VTE include cancer site and stage, systemic anti-cancer therapy (including vascular access), drug-drug interactions, length of anticoagulation, quality of life and needs during palliative care. Treatment of patients with kidney or liver impairment, gastrointestinal disorders, extremes of bodyweight, elevated bleeding or recurrence risk, VTE recurrence and COVID-19 is discussed. CONCLUSION Anticoagulant therapy for cancer-associated VTE patients should be carefully selected with consideration given to the relative benefits of specific drugs when individualizing care. Direct factor Xa inhibitors are typically the treatment of choice for preventing VTE recurrence in non-cancer patients and should also be considered as such for cancer-associated VTE in most situations.
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Affiliation(s)
- Alexander T Cohen
- Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - Gary Benson
- Northern Ireland Haemophilia Comprehensive Care Centre and Thrombosis Unit, Belfast, UK
| | | | | | | | | | - Balaji Venugopal
- The Beatson West of Scotland Cancer Centre, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Annie M Young
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | | | | | | | | | | | - Peter D Gabb
- Health Economics and Outcomes Research Ltd., Cardiff, UK
| | - Raza Alikhan
- Haemophilia and Thrombosis Centre, University Hospital of Wales, Cardiff, UK
- Cardiff University School of Medicine, Cardiff, UK
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17
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DOACs for VTE in patients with brain cancer and brain metastases: choices, choices, choices. Blood Adv 2022; 7:280-282. [PMID: 36260733 PMCID: PMC9939345 DOI: 10.1182/bloodadvances.2022008846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/21/2022] [Indexed: 01/27/2023] Open
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18
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Escobar A, Salem AM, Dickson K, Johnson TN, Burk KJ, Bashoura L, Faiz SA. Anticoagulation and bleeding in the cancer patient. Support Care Cancer 2022; 30:8547-8557. [PMID: 35579752 PMCID: PMC9529787 DOI: 10.1007/s00520-022-07136-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/09/2022] [Indexed: 11/29/2022]
Abstract
Cancer patients have an increased risk of bleeding compared to non-cancer patients with anticoagulant therapy. A bleeding risk assessment before initiation of anticoagulation is recommended. Currently low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) are the mainstays of treatment for cancer-associated venous thromboembolism (VTE). Since DOACs are administered orally, they offer some convenience and ease of administration; however, LMWH may be preferred in certain cancers. Given the prevalence of anticoagulant therapies in cancer patients, clinical providers must be able to recognize potentially critical bleeding sites and modalities to reverse major hemorrhage. Reversal agents or antidotes to bleeding may be required when bleeding is persistent or life-threatening. These include vitamin K, fresh frozen plasma (FFP), protamine, prothrombin complex concentrate (PCC) or andexanet alfa, and idarucizumab. Inferior vena cava (IVC) filter insertion can be also considered in those with major bleeding. Evidence for timing and need for re-initiation of anticoagulant therapy after a major bleeding remains sparse, but a multi-disciplinary approach and shared decision-making can be implemented in the interim.
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Affiliation(s)
- Andres Escobar
- Divisions of Critical Care, Pulmonary and Sleep Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Ahmed M Salem
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kodwo Dickson
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tami N Johnson
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathyrn J Burk
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lara Bashoura
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, P.O. Box 301402, Houston, TX, 77030-1402, USA
| | - Saadia A Faiz
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, P.O. Box 301402, Houston, TX, 77030-1402, USA.
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19
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Artificial Neural Network Assisted Cancer Risk Prediction of Oral Precancerous Lesions. BIOMED RESEARCH INTERNATIONAL 2022; 2022:7352489. [PMID: 36193309 PMCID: PMC9526607 DOI: 10.1155/2022/7352489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/15/2022] [Accepted: 09/06/2022] [Indexed: 11/18/2022]
Abstract
The incidence of oral cancer is still increasing. It has become very common in patients with malignant tumors, which has forced medical personnel to continuously explore its treatment methods. What kind of method can effectively and correctly diagnose the disease in the early stage and improve the survival rate has become one of the research topics that have attracted much attention. Aiming at this problem, it has great research significance for the field of oral precancerous lesions diagnosis. With the in-depth research on oral precancerous diagnosis, the research on artificial neural network (ANN) in medical diagnosis is gradually carried out. Its performance advantage is of great significance to solve the problem of early and correct disease diagnosis. This paper aimed to investigate the application of ANN-assisted cancer risk prediction method in risk prediction of oral precancerous lesions. Through the analysis and research of ANN and oral cancer, the construction of oral cancer risk prediction model was applied to solve the problem of improving the survival rate of oral cancer patients. In this paper, ANN and oral precancerous lesions were analyzed, the performance of the algorithm was experimentally analyzed, and the relevant theoretical formulas were used to explain. The results showed that the method had higher accuracy than traditional forecasting methods. When
, the output accuracy was above 90%. It can be seen that the algorithm can meet the needs of the diagnosis of high-risk groups of oral cancer lesions, and the diagnosis efficiency and patient survival rate has been greatly improved.
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20
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ICH in primary or metastatic brain cancer patients with or without anticoagulant treatment: a systematic review and meta-analysis. Blood Adv 2022; 6:4873-4883. [PMID: 35772127 PMCID: PMC9631668 DOI: 10.1182/bloodadvances.2022008086] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 06/22/2022] [Indexed: 11/24/2022] Open
Abstract
Anticoagulant treatment in patients with primary and metastatic brain cancer is a concern due to risk of intracranial hemorrhage (ICH). We performed a systematic review and meta-analysis to evaluate the risk of ICH in patients with primary or metastatic brain cancer treated with or without anticoagulants. Articles on ICH in patients with primary or metastatic brain cancer treated with or without anticoagulants published up to September 2021 were identified by searching PubMed, EMBASE, and Cochrane Library databases. The primary outcome of this analysis was ICH. Thirty studies were included. Rate of ICH was 13.0% in 1009 patients with metastatic brain cancer and 6.4% in 2353 patients with primary brain cancer (relative risk [RR], 3.26; 95% confidence interval [CI], 2.69-3.94; I2 = 92.8%). In patients with primary brain cancer, ICH occurred in 12.5% and 4.4% of patients treated with or without anticoagulants, respectively (11 studies, 659 treated and 1346 not treated patients; RR, 2.63; 95% CI, 1.48-4.67; I2 = 49.6%). In patients with metastatic brain cancer, ICH occurred in 14.7% and 15.4% (5 studies, 265 treated and 301 not treated patients; RR, 0.92; 95% CI, 0.43-1.93; I2 = 0%). ICH occurred in 8.3% of 172 treated with direct oral anticoagulants (DOACs) and in 11.7% of 278 treated with low-molecular weight heparin (LMWH) (5 studies; RR, 0.44; 95% CI, 0.25-0.79; I2 = 0%). Patients with metastatic brain cancer have a particularly high risk of ICH. Patients with primary brain cancer have an increased risk of ICH during anticoagulation. DOACs are associated with a lower risk of ICH than LMWH.
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21
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Iyengar V, Patell R, Zwicker J. Challenges in anticoagulation for patients with brain tumors. Best Pract Res Clin Haematol 2022; 35:101350. [DOI: 10.1016/j.beha.2022.101350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 11/02/2022]
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22
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Sanfilippo KM, Moik F, Candeloro M, Ay C, Di Nisio M, Lee AYY. Unanswered questions in cancer-associated thrombosis. Br J Haematol 2022; 198:812-825. [PMID: 35611985 DOI: 10.1111/bjh.18276] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/02/2022] [Accepted: 05/10/2022] [Indexed: 12/25/2022]
Abstract
Cancer-associated venous thromboembolism (VTE) is a leading cause of morbidity and mortality in patients with cancer. Treatment of cancer-associated VTE comes with a heightened risk of anticoagulant-related bleeding that differs by choice of anticoagulant as well as by patient- and disease-specific risk factors. Available data from randomized controlled trials and observational studies in cancer-associated VTE suggest that direct oral anticoagulants are effective, continuing anticoagulation beyond six months is indicated in those with active cancer and that patients who develop 'breakthrough' thrombotic events can be effectively treated. We review the evidence that addresses these key clinical questions and offer pragmatic approaches in individualizing care. While significant investigative efforts over the past decade have made impactful advances, future research is needed to better define the factors that contribute to anticoagulant-related bleeding and VTE recurrence, in order to aid clinical decision-making that improves the care of patients with cancer-associated VTE.
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Affiliation(s)
- Kristen M Sanfilippo
- Division of Hematology, Washington University School of Medicine St. Louis, St. Louis, MO, USA.,Division of Hematology/Oncology, St. Louis Veterans Administration Medical Center, St. Louis, MO, USA
| | - Florian Moik
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Vienna, Austria.,Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Matteo Candeloro
- Department of Innovative Technologies in Medicine and Dentistry, University 'G. D'Annunzio', Chieti, Italy
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Vienna, Austria
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University 'G D'Annunzio', Chieti-Pescara, Italy
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.,Systemic Therapy, BC Cancer, Vancouver, BC, Canada
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23
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Larsen TL, Garresori H, Brekke J, Enden T, Frøen H, Jacobsen EM, Quist-Paulsen P, Porojnicu AC, Ree AH, Torfoss D, Osvik Velle E, Skuterud Wik H, Ghanima W, Sandset PM, Dahm AEA. Low dose apixaban as secondary prophylaxis of venous thromboembolism in cancer patients - 30 months follow-up. J Thromb Haemost 2022; 20:1166-1181. [PMID: 35114046 DOI: 10.1111/jth.15666] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/20/2022] [Accepted: 01/28/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND There are no data on the effect of low-dose anticoagulation as secondary prophylaxis for venous thromboembolism (VTE) in cancer patients. We assessed the efficacy and safety of low-dose apixaban for 30 months, after initial 6 months of full-dose treatment. METHODS We included 298 patients with cancer and any type of VTE in a single arm interventional clinical trial. All patients were treated with full-dose apixaban (5 mg twice daily) for 6 months. Total 196 patients with active cancer after 6 months treatment continued with apixaban 2.5 mg twice daily for another 30 months. The main endpoints were recurrent VTE, major bleeding and clinically relevant non-major bleeding. RESULTS During the 30 months of treatment with low-dose apixaban 14 (7.6%; 95% confidence interval (CI) 4.0%-11.7%) patients experienced recurrent VTE, six (3.1%; 95% CI 1.1%-6.5%) experienced major bleeding and 16 (8.1%, 95% CI: 4.7%-12.8%) experienced clinically relevant non-major bleeding. The incidence rate per person month of recurrent VTE was 0.8% (95% CI 0.41-1.6) at 2-6 months with full-dose apixaban, and 1.0% (95% CI 0.5-1.9) at 7-12 months with low-dose apixaban. The incidence rate of major bleeding was 1.1% (95% CI 0.6-2.0) at 2-6 months, and 0.3% (95% CI 0.1-1.0) at 7-12 months. Between 12 and 36 months the incidence rate of recurrent VTE and major bleedings remained low. CONCLUSION Dose reduction of apixaban to 2.5 mg twice daily seems safe after 6 months of full-dose treatment. After 12 months the incidence rate of recurrent VTE and major bleeding remained low.
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Affiliation(s)
- Trine-Lise Larsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Hematology, Akershus University Hospital, Lørenskog, Norway
| | - Herish Garresori
- Department of Oncology, Stavanger University Hospital, Stavanger, Norway
| | - Jorunn Brekke
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Tone Enden
- Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Hege Frøen
- Department of Medicine, Baerum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | | | | | | | - Anne Hansen Ree
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
| | - Dag Torfoss
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Elin Osvik Velle
- Department of Medicine, Volda Hospital, Møre and Romsdal Hospital Trust Volda, Ålesund, Norway
| | | | - Waleed Ghanima
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Clinic of Internal Medicine, Østfold Hospital, Grålum, Norway
| | - Per Morten Sandset
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Anders Erik Astrup Dahm
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Hematology, Akershus University Hospital, Lørenskog, Norway
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24
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Anti-platelet medications and risk of intracranial hemorrhage in patients with metastatic brain tumors. Blood Adv 2022; 6:1559-1565. [PMID: 35086145 PMCID: PMC8905695 DOI: 10.1182/bloodadvances.2021006470] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/18/2022] [Indexed: 11/29/2022] Open
Abstract
Antiplatelet medication was not associated with an increased risk of ICH in patients with metastatic brain tumors. Combined antiplatelet agents and anticoagulation was not associated with an increased risk of ICH compared with single-agent use.
Although intracranial hemorrhage (ICH) is frequent in the setting of brain metastases, there are limited data on the influence of antiplatelet agents on the development of brain tumor–associated ICH. To evaluate whether the administration of antiplatelet agents increases the risk of ICH, we performed a matched cohort analysis of patients with metastatic brain tumors with blinded radiology review. The study population included 392 patients with metastatic brain tumors (134 received antiplatelet agents and 258 acted as controls). Non–small cell lung cancer was the most common malignancy in the cohort (74.0%), followed by small cell lung cancer (9.9%), melanoma (4.6%), and renal cell cancer (4.3%). Among those who received an antiplatelet agent, 86.6% received aspirin alone and 23.1% received therapeutic anticoagulation during the study period. The cumulative incidence of any ICH at 1 year was 19.3% (95% CI, 14.1-24.4) in patients not receiving antiplatelet agents compared with 22.5% (95% CI, 15.2-29.8; P = .22, Gray test) in those receiving antiplatelet agents. The cumulative incidence of major ICH was 5.4% (95% CI, 2.6-8.3) among controls compared with 5.5% (95% CI, 1.5-9.5; P = .80) in those exposed to antiplatelet agents. The combination of anticoagulation plus antiplatelet agents did not increase the risk of major ICH. The use of antiplatelet agents was not associated with an increase in the incidence, size, or severity of ICH in the setting of brain metastases.
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25
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Ehret F, Kaul D, Mose L, Budach V, Vajkoczy P, Fürweger C, Haidenberger A, Muacevic A, Mehrhof F, Kufeld M. Intracranial Hemorrhage in Patients with Anticoagulant Therapy Undergoing Stereotactic Radiosurgery for Brain Metastases: A Bi-Institutional Analysis. Cancers (Basel) 2022; 14:cancers14030465. [PMID: 35158734 PMCID: PMC8833468 DOI: 10.3390/cancers14030465] [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: 11/22/2021] [Revised: 01/09/2022] [Accepted: 01/12/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Stereotactic radiosurgery (SRS) is a well-established treatment modality for brain metastases (BM). Given the manifold implications of metastatic cancer on the body, affected patients have an increased risk of comorbidities, such as atrial fibrillation (AF) and venous thromboembolism (VTE), which includes pulmonary embolism (PE) and deep-vein thrombosis (DVT). These may require therapeutic anticoagulant therapy (ACT). Limited data are available on the risk of intracranial hemorrhage (ICH) after SRS for patients with BM who are receiving ACT. This bi-institutional analysis aimed to describe the bleeding risk for this patient subgroup. Methods: Patients with ACT at the time of single-fraction SRS for BM from two institutions were eligible for analysis. The cumulative incidence of ICH with death as a competing event was assessed during follow-up with magnetic resonance imaging or computed tomography. Results: Forty-one patients with 97 BM were included in the analyses. The median follow-up was 8.2 months (range: 1.7–77.5 months). The median and mean BM volumes were 0.47 and 1.19 cubic centimeters, respectively. The most common reasons for ACT were PE (41%), AF (34%), and DVT (7%). The ACT was mostly performed utilizing phenprocoumon (37%), novel oral anticoagulants (32%), or low-molecular-weight heparin (20%). Nine BM from a group of five patients with ICH after SRS were identified: none of them caused neurological or any other deficits. The 6-, 12-, and 18-month cumulative bleeding incidences per metastasis were 2.1%, 12.4%, and 12.4%, respectively. The metastases with previous bleeding events and those originating from malignant melanomas were found to more frequently demonstrate ICH after SRS (p = 0.02, p = 0.01). No surgical or medical intervention was necessary for ICH management, and no observed death was associated with an ICH. Conclusion: Patients receiving an ACT and single-fraction SRS for small- to medium-sized BM did not seem to have a clinically relevant risk of ICH. Previous bleeding and metastases originating from a malignant melanoma may favor bleeding events after SRS. Further studies are needed to validate our reported findings.
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Affiliation(s)
- Felix Ehret
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, 13353 Berlin, Germany; (D.K.); (V.B.); (F.M.)
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
- Correspondence:
| | - David Kaul
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, 13353 Berlin, Germany; (D.K.); (V.B.); (F.M.)
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité CyberKnife Center, 13353 Berlin, Germany;
| | - Lucas Mose
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
| | - Volker Budach
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, 13353 Berlin, Germany; (D.K.); (V.B.); (F.M.)
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité CyberKnife Center, 13353 Berlin, Germany;
| | - Peter Vajkoczy
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité CyberKnife Center, 13353 Berlin, Germany;
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurosurgery, 10117 Berlin, Germany
| | - Christoph Fürweger
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
- Department of Stereotaxy and Functional Neurosurgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Alfred Haidenberger
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
| | - Alexander Muacevic
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
| | - Felix Mehrhof
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, 13353 Berlin, Germany; (D.K.); (V.B.); (F.M.)
| | - Markus Kufeld
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
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26
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Carrier M, Blais N, Crowther M, Kavan P, Le Gal G, Moodley O, Shivakumar S, Suryanarayan D, Tagalakis V, Wu C, Lee AYY. Treatment Algorithm in Cancer-Associated Thrombosis: Updated Canadian Expert Consensus. Curr Oncol 2021; 28:5434-5451. [PMID: 34940092 DOI: 10.3390/curroncol28060453] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/02/2021] [Accepted: 12/13/2021] [Indexed: 12/20/2022] Open
Abstract
Patients with cancer-associated thrombosis (CAT) are at high risk of recurrent venous thromboembolism (VTE) and major bleeding complications. Risks vary significantly between individuals based on cancer status, treatment, and other characteristics. To facilitate the evidence-based management of anticoagulant therapy in this patient population, a committee of 11 Canadian clinical experts updated a consensus-based algorithm for the acute and extended treatment of symptomatic and incidental CAT that was developed in 2018. Following a systematic review of the literature, updates to the algorithm were discussed during an online teleconference, and the algorithm was subsequently refined based on feedback from committee members. Clinicians using this treatment algorithm should consider bleeding risk, type of cancer, and drug-drug interactions, as well as patient and clinician preferences, in tailoring anticoagulation for patients with CAT. Anticoagulant therapy should be adapted as the patient's cancer status and management change over time.
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Affiliation(s)
- Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON K1H 8L6, Canada
| | - Normand Blais
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC H2L 4M1, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON L8N 4A6, Canada
| | - Petr Kavan
- Department of Oncology, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON K1H 8L6, Canada
| | - Otto Moodley
- Department of Hematology, Royal University Hospital, Saskatoon, SK S7N 0W8, Canada
| | - Sudeep Shivakumar
- Department of Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax, NS B3H 3A7, Canada
| | - Deepa Suryanarayan
- Department of Medicine, University of Calgary, Foothills Hospital, Calgary, AB T2N 2T9, Canada
| | - Vicky Tagalakis
- Department of Medicine, Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, QC H3T 1E2, Canada
| | - Cynthia Wu
- Department of Medicine, University of Alberta, Edmonton, AB T5J 2J7, Canada
| | - Agnes Y Y Lee
- Department of Medicine, University of British Columbia, British Columbia Cancer Agency, Vancouver, BC V5Z 4E6, Canada
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27
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Frere C, Font C, Esposito F, Crichi B, Girard P, Janus N. Incidence, risk factors, and management of bleeding in patients receiving anticoagulants for the treatment of cancer-associated thrombosis. Support Care Cancer 2021; 30:2919-2931. [PMID: 34617159 DOI: 10.1007/s00520-021-06598-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/26/2021] [Indexed: 12/19/2022]
Abstract
Updated clinical practice guidelines recommend the long-term use of low-molecular-weight heparins or direct oral anticoagulants as the preferred option for the treatment of cancer-associated thrombosis (CAT), using a personalized approach matching the right drug to the right patient. In most cases, the benefit of anticoagulant therapy outweighs the risk. However, the long-term use of anticoagulants is associated with a non-negligible risk of bleeding, which constitutes a rare but serious adverse effect. Bleeding complications have been reported to be overall 2 to 3 times more frequent in cancer patients with CAT receiving anticoagulation than in non-cancer patients, with a reported incidence of major bleeding ranging from 2.4 to 16.0% in randomized controlled trials (RCT). In the absence of validated risk assessment model to predict the risk of bleeding in these patients, a careful evaluation of each individual profile, with adequate selection of the most appropriate anticoagulant for each individual patient, is warranted for overcoming management challenges, taking in account the numerous factors which may potentiate the overall bleeding risk in these complex patients, such as advanced or metastatic disease, older age, anemia, thrombocytopenia, renal impairment, liver dysfunction, and concomitant anticancer therapies. The purpose of this review is to call for awareness on bleeding complications as a major safety issue of CAT treatment and to summarize data from recent RCT and real-world studies on the incidence and risk factors for bleeding in this unique and challenging population to further help clinicians in decision-making.
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Affiliation(s)
- Corinne Frere
- Institute of Cardiometabolism And Nutrition, GRC 27 GRECO, Sorbonne Université, INSERM UMRS_1166, Paris, France
- Department of Haematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Carme Font
- Department of Internal Medicine, Hospital Clinic, Barcelona, Spain
| | | | - Benjamin Crichi
- Department of Internal Medicine, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, 75010, Paris, France
| | - Philippe Girard
- Département Thoracique, Institut Mutualiste Montsouris, Paris, France
- FCRIN INNOVTE, Paris, France
| | - Nicolas Janus
- Global Thrombosis Strategy, Medical Affairs, Leo Pharma, Voisins-le-Bretonneux, France.
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28
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Falanga A, Gal GL, Carrier M, Abdel-Razeq H, Ay C, Martin AJM, Rocha ATC, Agnelli G, Elalamy I, Brenner B. Management of Cancer-Associated Thrombosis: Unmet Needs and Future Perspectives. TH OPEN 2021; 5:e376-e386. [PMID: 34485812 PMCID: PMC8407937 DOI: 10.1055/s-0041-1736037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/29/2021] [Indexed: 12/28/2022] Open
Abstract
Patients with cancer are at a high risk of symptomatic venous thromboembolism (VTE), which is a common cause of morbidity and mortality in this patient population. Increased risk of recurrent VTE and bleeding complications are two major challenges associated with therapeutic anticoagulation in these patients. Long-term therapy with low-molecular-weight heparins (LMWHs) has been the standard of care for the treatment of cancer-associated VTE given its favorable risk–benefit ratio in comparison with vitamin K antagonists. Direct oral anticoagulants (DOACs), which offer the convenience of oral administration and have a rapid onset of action, have recently emerged as a new treatment option for patients with cancer-associated thrombosis (CT). Randomized clinical trial data with head-to-head comparisons between DOACs and LMWHs showed that overall, DOACs have a similar efficacy profile but a higher risk of bleeding was observed in some of these studies. This review aims to identify unmet needs in the treatment of CT. We discuss important considerations for clinicians tailoring anticoagulation (1) drug–drug interactions, (2) risk of bleeding (e.g., gastrointestinal bleeding), (3) thrombocytopenia, hematological malignancies, (4) metastatic or primary brain tumors, and (5) renal impairment. Additional research is warranted in several clinical scenarios to help clinicians on the best therapeutic approach.
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Affiliation(s)
- Anna Falanga
- Department of Medicine and Surgery, School of Medicine, University of Milano-Bicocca, Monza, Italy.,Department of Immunohematology and Transfusion Medicine, Thrombosis and Hemostasis Center, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Internal Medicine, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria.,Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Andrés J Muñoz Martin
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Ana Thereza Cavalcanti Rocha
- Departamento de Saúde da Família, Faculdade de Medicina da Bahia, Universidade Federal da Bahia - UFBA, Salvador, BA, Brazil
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - Ismail Elalamy
- Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University, Moscow, Russia.,Hematology and Thrombosis Centre, Hôpital Tenon, INSERM U938, Sorbonne Université, AP-HP, Paris, France
| | - Benjamin Brenner
- Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University, Moscow, Russia.,Department of Hematology, Rambam Health Care Campus, Haifa, Israel
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29
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Jo J, Donahue J, Sarai G, Petroni G, Schiff D. Management of Venous Thromboembolism in High-Grade Glioma: Does Low Molecular Weight Heparin Increase Intracranial Bleeding Risk? Neuro Oncol 2021; 24:455-464. [PMID: 34383073 DOI: 10.1093/neuonc/noab198] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) occurs in up to 30% of patients with high-grade glioma (HGG). Concern for increased risk of intracranial hemorrhage (ICH) with therapeutic anticoagulation complicates VTE treatment. Some retrospective studies have reported an increased risk of ICH associated with therapeutic anticoagulation; however, effective alternatives to anticoagulation are lacking. The aim of our study is to assess the risk of ICH in HGG patients with VTE on low molecular weight heparin (LMWH). METHODS We performed a retrospective matched cohort study of HGG patients from 1/2005-8/2016. Blinded review of neuroimaging for ICH was performed. For analysis of the primary endpoint, estimates of cumulative incidence (CI) of ICH were calculated using competing risk analysis with death as competing risk; significance testing was performed using the Gray's test. Median survival was estimated using Kaplan-Meier method. RESULTS 220 patients were included, 88 (40%) with VTE treated with LMWH, 22 (10%) with VTE, not on anticoagulation (AC), and 110 (50%) without VTE. A total of 43 measurable ICH was recorded: 19 (26%) in LMWH, 3 (14%) in VTE not on AC, and 21 (19%) in non-VTE cohort. No significant difference was observed in the 1-year CI of ICH in the LMWH cohort and non-AC with VTE group (17% versus 9%; Gray's test, p=0.36). Among patients without VTE, the 1-year CI of ICH was 13%. Median survival was similar among all three cohorts. CONCLUSIONS Our data suggest that therapeutic LMWH is not associated with substantially increased risk of ICH in HGG patients.
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Affiliation(s)
- Jasmin Jo
- Department of Internal Medicine, Division of Hematology and Oncology, East Carolina University/Vidant Medical Center, Greenville, NC
| | - Joseph Donahue
- Department of Radiology, University of Virginia, Charlottesville, VA
| | - Guneet Sarai
- Department of Primary Care and Population Health, Virginia Commonwealth University, Richmond, VA
| | - Gina Petroni
- Department of Public Health Sciences, Division of Biostatistics, University of Virginia, Charlottesville, VA
| | - David Schiff
- Department of Neurology, Division of Neuro-Oncology, University of Virginia, Charlottesville, VA
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30
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Treatment of venous thromboembolism in cancer patients: The dark side of the moon. Cancer Treat Rev 2021; 96:102190. [PMID: 33812338 DOI: 10.1016/j.ctrv.2021.102190] [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: 01/10/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 02/08/2023]
Abstract
Venous thromboembolism (VTE) is a common complication in patients with cancer. The risk of emergent VTE is four- to seven-fold higher in cancer patients compared to non-cancer patients. Although the therapeutic armamentarium for cancer-associated VTE has been recently implemented, anticoagulant treatment remains challenging because of the increased risk of recurrent VTE and bleeding. Several international societies and expert panels released clinical practice guidelines on VTE treatment which are mostly focused on the general cancer population. Nevertheless, recommendations for the management of VTE in patients with peculiar clinical presentations are inconsistent and remain elusive due to the lack of pertinent evidence. The challenging clinical scenarios include, among others, patients with thrombocytopenia, renal impairment, gastrointestinal cancer, primary or metastatic brain cancer, distal thrombosis of the lower extremities, catheter-related VTE, splanchnic thrombosis, incidental VTE, extreme body weight, recurrent VTE during treatment, as well as the optimal duration of anticoagulant treatment in patients with active disease who have received 3 to 6 months of anticoagulation. Herein, we present a critical overview on VTE management in these challenging clinical settings, discuss potential approaches, and include some calls to action for future clinical research.
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31
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Leader A, Hofstetter L, Spectre G. Challenges and Advances in Managing Thrombocytopenic Cancer Patients. J Clin Med 2021; 10:1169. [PMID: 33799591 PMCID: PMC8000983 DOI: 10.3390/jcm10061169] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/02/2021] [Accepted: 03/08/2021] [Indexed: 12/16/2022] Open
Abstract
Cancer patients have varying incidence, depth and duration of thrombocytopenia. The mainstay of managing severe chemotherapy-induced thrombocytopenia (CIT) in cancer is the use of platelet transfusions. While prophylactic platelet transfusions reduce the bleeding rate, multiple unmet needs remain, such as high residual rates of bleeding, and anticancer treatment dose reductions/delays. Accordingly, the following promising results in other settings, antifibrinolytic drugs have been evaluated for prevention and treatment of bleeding in patients with hematological malignancies and solid tumors. In addition, Thrombopoeitin receptor agonists have been studied for two major implications in cancer: treatment of severe thrombocytopenia associated with myelodysplastic syndrome and acute myeloid leukemia; primary and secondary prevention of CIT in solid tumors in order to maintain dose density and intensity of anti-cancer treatment. Furthermore, thrombocytopenic cancer patients are often prescribed antithrombotic medication for indications arising prior or post cancer diagnosis. Balancing the bleeding and thrombotic risks in such patients represents a unique clinical challenge. This review focuses upon non-transfusion-based approaches to managing thrombocytopenia and the associated bleeding risk in cancer, and also addresses the management of antithrombotic therapy in thrombocytopenic cancer patients.
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Affiliation(s)
- Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 4941492, Israel; (L.H.); (G.S.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Liron Hofstetter
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 4941492, Israel; (L.H.); (G.S.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Galia Spectre
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 4941492, Israel; (L.H.); (G.S.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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