D-Dimer and Risk for Thrombosis in Adults with Newly Diagnosed Acute Lymphoblastic Leukemia

Analysis of retinal and choroidal microvascular changes using optical coherence tomography and optical coherence tomography angiography in patients with acute leukemia

PURPOSE

Although leukemic retinopathy accounts for 80% of ocular complications in acute leukemia, its pathogenesis remains unclear. To evaluate changes in retinal and choroicapillaris and structural parameters in patients with acute leukemia, we analyzed the correlation between vascular perfusion metrics and laboratory parameters and assessed the changes after hematopoietic stem cell transplantation (HSCT).

METHODS

Herein, 104 eyes of 52 patients aged 18 and above with acute leukemia were enrolled. 80 eyes of 40 healthy patients were recruited as control participants. All participants underwent optical coherence tomography (OCT) and OCT angiography (OCTA) at baseline.

RESULTS

Patients with acute leukemia had a significantly thicker ganglion cell-inner plexiform layer (GCIPL) and lower circularity index than the control participants. Post-HSCT perfusion metrics did not differ significantly, but parafoveal thickness decreased significantly. During the active phase of acute leukemia, lower platelet levels were associated with significant GCIPL thickening and increased foveal avascular zone and perimeter. D-dimer levels positively correlated with GCIPL thickness.

CONCLUSION

Patients with acute leukemia had subclinical retinal microvascular deficits on OCTA and GCIPL thickening on OCT, possibly associated with bone marrow function. GCIPL thickness may indicate acute ischemia in such patients. Further studies must elucidate their clinical and prognostic significance.

Cancer-associated thrombosis in hematologic malignancies

Patients with hematologic malignancies are often complicated not only by severe bleeding due to thrombocytopenia and disseminated intravascular coagulation but also by thromboembolic events, just like in patients with solid cancers, and these events can negatively impact patient outcomes. Nevertheless, the prevention and treatment of cancer-associated thrombosis (CAT) in hematologic malignancies has not been adequately investigated due to the limited size, heterogeneity, and unique pathophysiology of the patient population. This article summarizes the current understanding, risk factors, prediction models, and optimal prevention and treatment strategies of CAT in hematologic malignancies on a disease-by-disease basis, including acute leukemia, lymphoma, myeloma, and myeloproliferative neoplasms. Specific considerations of novel molecular targeted therapeutics introduced in recent years, such as immunomodulatory drugs and tyrosine kinase inhibitors, are also discussed based on the latest clinical trials.

A nomogram model to predict the portal vein thrombosis risk after surgery in patients with pancreatic cancer

Background

Portal vein thrombosis (PVT) is a common postoperative complication in patients with pancreatic cancer (PC), significantly affecting their quality of life and long-term prognosis. Our aim is to establish a new nomogram to predict the risk of PVT after PC surgery.

Method

We collected data from 416 patients who underwent PC surgery at our hospital between January 2011 and June 2022. This includes 87 patients with PVT and 329 patients without PVT. The patients were randomly divided into a training group and a validation group at a ratio of 7:3. We constructed a nomogram model using the outcomes from both univariate and multivariate logistic regression analyses conducted on the training group. The nomogram's predictive capacity was assessed using calibration curve, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA).

Results

In the study, the prevalence of PVT was 20.9%. Age, albumin, vein reconstruction and preoperative D-dimer were independent related factors. The model achieved a C-index of 0.810 (95% confidence interval: 0.752-0.867), demonstrating excellent discrimination and calibration performance. The area under the ROC curve of the nomogram was 0.829 (95% CI: 0.750-0.909) in the validation group. DCA confirmed that the nomogram model was clinically useful when the incidence of PVT in patients was 5%-60%.

Conclusion

We have established a high-performance nomogram for predicting the risk of PVT in patients undergoing PC surgery. This will assist clinical doctors in identifying individuals at high risk of PVT and taking appropriate preventive measures.

Superior sagittal sinus thrombosis in the course of mixed phenotype acute leukaemia treated with acute lymphoblastic leukaemia-like therapy-a case report

Mixed phenotype acute leukaemia (MPAL) is associated with worse overall survival, compared with other acute leukaemias in adults. Lack of clear treatment guidelines makes the therapy challenging. ALL-like induction and consolidation treatment followed by allo-HSCT is the preferred first-line treatment. We present a case of a 36-year-old woman diagnosed with MPAL (EGIL Myelo/B) with KMT2A rearrangement, treated with the PALG-ALL-7 (including PEG-asparaginase) protocol. On day 25 after the induction therapy initiation, numbness of limbs and dizziness were observed. Therefore, the imaging studies (CT and MRI) were performed and a diagnosis of thrombosis of superior sagittal sinus of the brain was established. Routinely performed blood coagulation tests showed prolonged APTT and PT, decreased antithrombin III activity and decreased free protein S concentration. LMWH treatment and substitutional therapy with antithrombin III were started, which resulted in a significant reduction in the thrombosis associated symptoms and improvement of the neurological status after 3 days. After induction and consolidation therapy, the patient obtained complete haematological remission and negative measurable residual disease. Six months after the diagnosis, allo-HSCT was successfully performed. During the 4 months follow-up, the patient remained MRD negative and thrombotic symptoms free. To the best of our knowledge, our communication has been the first report of such complication in an MPAL patient treated with PEG-asparaginase containing protocol in adults. We recommend increased vigilance in patients manifesting any mild neurological symptoms and early decision about the MRI study performance.

Development and validation of a nomogram for predicting the risk of immediate postoperative deep vein thrombosis after open wedge high tibial osteotomy

PURPOSE

This study aimed to identify independent risk factors for immediate postoperative deep vein thrombosis (DVT) in patients with open wedge high tibial osteotomy (OWHTO) and to develop and validate a predictive nomogram.

METHODS

Patients who underwent OWHTO for knee osteoarthritis (KOA) from June 2017 to December 2021 were retrospectively analyzed. Baseline data and laboratory test results were collected, and the occurrence of DVT in the immediate postoperative period was regarded as the study outcome event. Multivariable logistic regression identified independent risk factors associated with a higher incidence of immediate postoperative DVT. The predictive nomogram was constructed based on the analysis results. The stability of the model was further assessed in this study using patients from January to September 2022 as an external validation set.

RESULTS

741 patients were enrolled in the study, of which 547 were used in the training cohort and the other 194 for the validation cohort. Multivariate analysis revealed a higher Kellgren-Lawrence (K-L) grade (III vs. I-II OR 3.09, 95% CI 0.93-10.23. IV vs. I-II OR 5.23, 95% CI 1.27-21.48.), platelet to hemoglobin ratio (PHR) > 2.25 (OR 6.10, 95% CI 2.43-15.33), Low levels of albumin (ALB) (OR 0.79, 95% CI 0.70-0.90), LDL-C > 3.40 (OR 3.06, 95% CI 1.22-7.65), D-dimer > 1.26 (OR 2.83, 95% CI 1.16-6.87) and BMI ≥ 28 (OR 2.57, 95% CI 1.02-6.50) were the independent risk factors of immediate postoperative DVT. The concordance index (C-index) and Brier score of the nomogram were 0.832 and 0.036 in the training set, and the corrected values after internal validation were 0.795 and 0.038, respectively. The receiver-operating characteristic (ROC) curve, the calibration curve, the Hosmer-Lemeshow test, and the decision curve analysis (DCA) performed well in both the training and validation cohorts.

CONCLUSION

This study developed a personalized predictive nomogram with six predictors, which allows surgeons to stratify risk and recommended immediate ultrasound scans for patients with any of these factors.

LEVEL OF EVIDENCE

III.

Simplified predictive scores for thrombosis and bleeding complications in newly diagnosed acute leukemia patients

BACKGROUND

Bleeding and thrombotic complications are the leading causes of death in acute leukemia patients. The Conventional International Society of Thrombosis and Haemostasis Disseminated Intravascular Coagulation (ISTH DIC) scoring system is utilized to assess DIC diagnoses in various conditions. Nevertheless, limited studies have tested the system's accuracy in predicting thrombo-hemorrhagic events in individuals with acute leukemia. This study aimed to (1) validate the ISTH DIC scoring system and (2) propose a new Siriraj Acute Myeloid/Lymphoblastic Leukemia (SiAML) bleeding and thrombosis scoring system for thrombohemorrhagic risk assessment in acute leukemia.

METHODS

We conducted a retro-prospective observational study of newly diagnosed acute leukemia patients between March 2014 and December 2019. We recorded thrombohemorrhagic episodes within 30 days postdiagnosis and DIC profiles, including prothrombin time, platelet level, D-dimer, and fibrinogen. The sensitivities, specificities, positive and negative predictive values, and areas under receiver operating characteristic curves for the ISTH DIC and SiAML scoring systems were calculated.

RESULTS

In all, 261 acute leukemia patients were identified: 64% with acute myeloid leukemia, 27% with acute lymphoblastic leukemia, and 9% with acute promyelocytic leukemia. Overall bleeding and thrombotic events were 16.8% and 6.1%, respectively. With a cutoff of 5 for the ISTH DIC score, the sensitivity and specificity for bleeding prediction were 43.5% and 74.4%, respectively, while the corresponding values for thrombotic prediction were 37.5% and 71.8%, respectively. D-dimer > 5000 µg FEU/L and fibrinogen ≤ 150 mg/dL were significantly associated with bleeding. A SiAML-bleeding score was calculated using these factors, with a sensitivity and specificity of 65.2% and 65.6%, respectively. Conversely, D-dimer > 7000 µg FEU/L, platelet > 40 × 10⁹/L, and white blood cell level > 15 × 10⁹/L were significant variables related to thrombosis. Using these variables, we established a SiAML-thrombosis score with a sensitivity and specificity of 93.8% and 66.1%, respectively.

CONCLUSIONS

The proposed SiAML scoring system might be valuable for prognosticating individuals at risk for bleeding and thrombotic complications. Prospective validation studies are needed to verify its usefulness.

SOHO State of the Art Updates and Next Questions | Asparaginase-Understanding and Overcoming Toxicities in Adults with ALL

The adoption of pediatric-inspired regimens in young adults with newly diagnosed acute lymphoblastic leukemia (ALL) has significantly improved their survival outcomes. Pediatric-inspired regimens in ALL rely profoundly on delivering adequate dosing of non-myelosuppressive drugs of which asparaginase, a bacterial derived agent, is a key component. Asparaginase therapy is associated with a spectrum of unique toxicities that are observed more frequently in adult patients compared to children with ALL, and this observation has contributed to the reluctance of adult oncologists to administer the drug to their patients. Understanding the breadth of asparaginase toxicity and the associated risk factors may help in preventing severe manifestations and allow safer treatment for adults with ALL. In this review, we will discuss the different formulations of asparaginase and the appropriate dosing in adults with ALL. We will further discuss the frequency and risk factors for individual toxicities of asparaginase along with strategies for their prevention and management.