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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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Girardi L, Ciuffini LA, Mai V, Santagata D, Ageno W, Wang TF, Carrier M, Le Gal G. Risk of recurrent venous thromboembolism and bleeding in patients with acute isolated subsegmental pulmonary embolism. Thromb Res 2024; 239:109037. [PMID: 38781706 DOI: 10.1016/j.thromres.2024.109037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/04/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Approximately 10 % of all diagnosed pulmonary embolism are isolated to the subsegmental vessels. The risk of recurrent venous thromboembolism (VTE) in patients with an acute subsegmental pulmonary embolism (SSPE) managed with or without anticoagulant therapy remains poorly understood. METHODS This is an observational cohort study including consecutive adult patients diagnosed with acute isolated SSPE between June 01, 2019, and August 31, 2022. We excluded patients with a concomitant diagnosis of deep vein thrombosis and those who had an indication for long-term anticoagulation. The primary outcome was objectively confirmed recurrent VTE. RESULTS Overall, 118 patients with acute SSPE were included in the analysis. The mean (± standard deviation [SD]) age of the participants was 59 ± 17 years and 44 % of them had active cancer. Mean (±SD) duration of follow-up was 438 ± 426 days. Seventy-seven patients (65 %) were initially treated with anticoagulation, whereas 41 patients (35 %) were not. Of the 77 patients receiving anticoagulant therapy, 23 (30 %) received extended-duration anticoagulation (beyond 3 months) for secondary prevention. Overall, recurrent VTE events occurred in 6/118 (5 %, 95 % CI 2.4 to 10.7) patients. Four events (4/77 = 5.2 %, 95 % CI 2.0 to 12.6) occurred in initially treated patients. Two recurrent VTE occurred in patients initially left untreated (2/41 = 4.9 %, 95 % CI 1.4 to 16.1). Half of the recurrent VTE occurred in patients with active cancer. CONCLUSIONS Most patients diagnosed with an acute SSPE received anticoagulation. The incidence of recurrent VTE detected over time was relatively high, especially in patients with cancer.
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Affiliation(s)
- Laura Girardi
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada; Department of Medicine and Surgery, University of Insubria, Varese, Italy.
| | | | - Vicky Mai
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Davide Santagata
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Tzu-Fei Wang
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
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Welker C, Huang J, Elmadhoun O, Esmaeilzadeh S, Mookadam F, Ramakrishna H. Morbidity Following Pulmonary Embolism Hospitalization- Contributing Factors and Outcomes. J Cardiothorac Vasc Anesth 2024; 38:1239-1243. [PMID: 38402062 DOI: 10.1053/j.jvca.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/26/2024]
Affiliation(s)
- Carson Welker
- Division of Anesthesia and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Jeffrey Huang
- Division of Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Omar Elmadhoun
- Division of Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Sarvie Esmaeilzadeh
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Farouk Mookadam
- Emeritus member, Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Mahé I, Mayeur D, Couturaud F, Scotté F, Benhamou Y, Benmaziane A, Bertoletti L, Laporte S, Girard P, Mismetti P, Sanchez O. [Translation into French and republication of: "Anticoagulant treatment of cancer-associated thromboembolism"]. Rev Med Interne 2024; 45:210-225. [PMID: 38677976 DOI: 10.1016/j.revmed.2024.04.004] [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: 04/29/2024]
Abstract
Venous thromboembolism (VTE) is a frequent and potentially fatal complication in patients with cancer. During the initial period after the thromboembolic event, a patient receiving anticoagulant treatment is exposed both to a risk of VTE recurrence and also to an elevated bleeding risk conferred by the treatment. For this reason, the choice of anticoagulant is critical. The choice should take into account patient-related factors (such as functional status, age, body mass index, platelet count and renal function), VTE-related factors (such as severity or site), cancer-related factors (such as activity and progression) and treatment related factors (such as drug-drug interactions), which all potentially influence bleeding risk, and patient preference. These should be evaluated carefully for each patient during a multidisciplinary team meeting. For most patients, apixaban or a low molecular-weight heparin is the most appropriate initial choice for anticoagulant treatment. Such treatment should be offered to all patients with active cancer for at least 6months. The patient and treatment should be re-evaluated regularly, and anticoagulant treatment changed when necessary. Continued anticoagulant treatment beyond 6months is justified if the cancer remains active or if the patient experienced recurrence of VTE in the first 6months. In other cases, the interest of continued anticoagulant treatment may be considered on an individual patient basis in collaboration with oncologists.
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Affiliation(s)
- I Mahé
- Service de médecine interne, hôpital Louis-Mourier, AP-HP, 92700 Colombes, France; Inserm UMR S1140, Innovations thérapeutiques en hémostase, université Paris Cité, Paris, France; F-CRIN INNOVTE network, Saint-Étienne, France.
| | - D Mayeur
- Département d'oncologie médicale, centre Georges-François-Leclerc, Dijon, France
| | - F Couturaud
- F-CRIN INNOVTE network, Saint-Étienne, France; Département de médecine interne, médecine vasculaire et pneumologie, Inserm U1304-Getbo, université de Brest, CHU de Brest, Brest, France
| | - F Scotté
- Département interdisciplinaire d'organisation des parcours patients (DIOPP), institut Gustave-Roussy, Villejuif, France
| | - Y Benhamou
- F-CRIN INNOVTE network, Saint-Étienne, France; UniRouen, U1096, service de médecine interne, CHU Charles-Nicolle, Normandie université, Rouen, France
| | - A Benmaziane
- Département d'oncologie et de soins de supports, hôpital Foch, Suresnes, France
| | - L Bertoletti
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine vasculaire et thérapeutique, Inserm, UMR1059, équipe dysfonction vasculaire et hémostase, université Jean-Monnet, Inserm CIC-1408, CHU de Saint-Étienne, Saint-Étienne, France
| | - S Laporte
- F-CRIN INNOVTE network, Saint-Étienne, France; Sainbiose Inserm U1059, unité de Recherche clinique, innovation et pharmacologie, hôpital Nord, CHU de Saint-Étienne, université Jean-Monnet, Saint-Étienne, France
| | - P Girard
- F-CRIN INNOVTE network, Saint-Étienne, France; Institut du thorax Curie-Montsouris, Institut mutualiste Montsouris, Paris, France
| | - P Mismetti
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine vasculaire et thérapeutique, hôpital Nord, CHU de Saint-Étienne, Saint-Étienne, France
| | - O Sanchez
- Inserm UMR S1140, Innovations thérapeutiques en hémostase, université Paris Cité, Paris, France; F-CRIN INNOVTE network, Saint-Étienne, France; Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France
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Affiliation(s)
- Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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Charpidou A, Gerotziafas G, Popat S, Araujo A, Scherpereel A, Kopp HG, Bironzo P, Massard G, Jiménez D, Falanga A, Kollias A, Syrigos K. Lung Cancer Related Thrombosis (LCART): Focus on Immune Checkpoint Blockade. Cancers (Basel) 2024; 16:450. [PMID: 38275891 PMCID: PMC10814098 DOI: 10.3390/cancers16020450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/10/2023] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
Cancer-associated thrombosis (CAT) is a common complication in lung cancer patients. Lung cancer confers an increased risk of thrombosis compared to other solid malignancies across all stages of the disease. Newer treatment agents, including checkpoint immunotherapy and targeted agents, may further increase the risk of CAT. Different risk-assessment models, such as the Khorana Risk Score, and newer approaches that incorporate genetic risk factors have been used in lung cancer patients to evaluate the risk of thrombosis. The management of CAT is based on the results of large prospective trials, which show similar benefits to low-molecular-weight heparins (LMWHs) and direct oral anticoagulants (DOACs) in ambulatory patients. The anticoagulation agent and duration of therapy should be personalized according to lung cancer stage and histology, the presence of driver mutations and use of antineoplastic therapy, including recent curative lung surgery, chemotherapy or immunotherapy. Treatment options should be evaluated in the context of the COVID-19 pandemic, which has been shown to impact the thrombotic risk in cancer patients. This review focuses on the epidemiology, pathophysiology, risk factors, novel predictive scores and management of CAT in patients with active lung cancer, with a focus on immune checkpoint inhibitors.
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Affiliation(s)
- Andriani Charpidou
- Third Department of Internal Medicine and Laboratory, Athens Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, 157 72 Athens, Greece; (A.K.)
| | - Grigorios Gerotziafas
- Assistance Publique-Hôpitaux de Paris, Thrombosis Center, Service D’Hématologie Biologique Hôpital Tenon, Sorbonne Université, 75005 Paris, France
| | - Sanjay Popat
- Royal Marsden Hospital, Institute of Cancer Research, London SW3 6JJ, UK
| | - Antonio Araujo
- Department of Medical Oncology, Centro Hospitalar Universitário do Porto, 4099-001 Porto, Portugal;
| | - Arnaud Scherpereel
- Department of Pulmonary and Thoracic Oncology, University of Lille, University Hospital (CHU), 59000 Lille, France;
| | - Hans-Georg Kopp
- Departments of Molecular Oncology and Thoracic Oncology, Robert-Bosch-Hospital Stuttgart, 70376 Stuttgart, Germany
| | - Paolo Bironzo
- Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, 10124 Turin, Italy
| | - Gilbert Massard
- Department of Thoracic Surgery, Hôpitaux Robert Schuman, 2540 Luxembourg, Luxembourg
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, 28034 Madrid, Spain;
| | - Anna Falanga
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, University of Milan Bicocca, 24129 Bergamo, Italy
| | - Anastasios Kollias
- Third Department of Internal Medicine and Laboratory, Athens Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, 157 72 Athens, Greece; (A.K.)
| | - Konstantinos Syrigos
- Third Department of Internal Medicine and Laboratory, Athens Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, 157 72 Athens, Greece; (A.K.)
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Mahé I, Mayeur D, Couturaud F, Scotté F, Benhamou Y, Benmaziane A, Bertoletti L, Laporte S, Girard P, Mismetti P, Sanchez O. Anticoagulant treatment of cancer-associated thromboembolism. Arch Cardiovasc Dis 2024; 117:29-44. [PMID: 38092578 DOI: 10.1016/j.acvd.2023.11.010] [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] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 12/27/2023]
Abstract
Venous thromboembolism (VTE) is a frequent and potentially fatal complication in patients with cancer. During the initial period after the thromboembolic event, a patient receiving anticoagulant treatment is exposed both to a risk of VTE recurrence and also to an elevated bleeding risk conferred by the treatment. For this reason, the choice of anticoagulant is critical. The choice should take into account patient-related factors (such as functional status, age, body mass index, platelet count and renal function), VTE-related factors (such as severity or site), cancer-related factors (such as activity and progression) and treatment-related factors (such as drug-drug interactions), which all potentially influence bleeding risk, and patient preference. These should be evaluated carefully for each patient during a multidisciplinary team meeting. For most patients, apixaban or a low molecular-weight heparin is the most appropriate initial choice for anticoagulant treatment. Such treatment should be offered to all patients with active cancer for at least six months. The patient and treatment should be re-evaluated regularly and anticoagulant treatment changed when necessary. Continued anticoagulant treatment beyond six months is justified if the cancer remains active or if the patient experienced recurrence of VTE in the first six months. In other cases, the interest of continued anticoagulant treatment may be considered on an individual patient basis in collaboration with oncologists.
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Affiliation(s)
- Isabelle Mahé
- Service de Médecine Interne, Hôpital Louis-Mourier, AP-HP, Colombes, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France.
| | - Didier Mayeur
- Département d'Oncologie Médicale, Centre Georges-François-Leclerc, Dijon, France
| | - Francis Couturaud
- Département de Médecine Interne, Médecine Vasculaire et Pneumologie, CHU de Brest, Inserm U1304 -GETBO, université de Brest, Brest, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Florian Scotté
- Département Interdisciplinaire d'Organisation des Parcours Patients (DIOPP), Institut Gustave-Roussy, Villejuif, France
| | - Ygal Benhamou
- UNI Rouen U1096, service de médecine interne, Normandie université, CHU Charles-Nicolle, Rouen, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Asmahane Benmaziane
- Département d'Oncologie et de Soins de Supports, Hôpital Foch, Suresnes, France
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de Saint-Étienne, INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Inserm CIC-1408, Saint-Étienne, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Silvy Laporte
- SAINBIOSE INSERM U1059, unité de recherche clinique, innovation et pharmacologie, hôpital Nord, université Jean-Monnet, CHU de Saint-Étienne, Saint-Étienne, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Philippe Girard
- Institut du Thorax Curie-Montsouris, Institut Mutualiste Montsouris, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, CHU Saint-Etienne, Hôpital Nord, Saint-Etienne, 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 de Soins Intensifs, AP-HP, Hôpital Européen Georges-Pompidou, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France
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Su Y, Yi J, Zhang Y, Leng D, Huang X, Shi X, Zhang Y. EML4-ALK fusion protein in Lung cancer cells enhances venous thrombogenicity through the pERK1/2-AP-1-tissue factor axis. J Thromb Thrombolysis 2024; 57:67-81. [PMID: 37940761 PMCID: PMC10830642 DOI: 10.1007/s11239-023-02916-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Accumulating evidence links the echinoderm microtubule-associated protein-like 4 (EML4)-anaplastic lymphoma kinase (ALK) rearrangement to venous thromboembolism (VTE) in non-small cell lung cancer (NSCLC) patients. However, the corresponding mechanisms remain unclear. METHOD High-throughput sequencing analysis of H3122 human ALK-positive NSCLC cells treated with ALK inhibitor/ dimethyl sulfoxide (DMSO) was performed to identify coagulation-associated differential genes between EML4-ALK fusion protein inhibited cells and control cells. Sequentially, we confirmed its expression in NSCLC patients' tissues and in the plasma of a subcutaneous xenograft mouse model. An inferior vena cava (IVC) ligation model was used to assess clot formation potential. Additionally, pathways involved in tissue factor (TF) regulation were explored in ALK-positive cell lines H3122 and H2228. Statistical significance was determined by Student t-test and one-way ANOVA using SPSS. RESULTS Sequencing analysis identified a significant downregulation of TF after inhibiting EML4-ALK fusion protein activity in H3122 cells. In clinical NSCLC cases, TF expression was increased especially in ALK-positive NSCLC tissues. Meanwhile, H3122 and H2228 with high TF expression exhibited shorter plasma clotting time and higher TF activity versus ALK-negative H1299 and A549 in cell culture supernatant. Mice bearing H2228 tumor showed a higher concentration of tumor-derived TF and TF activity in plasma and the highest adjusted IVC clot weights. Limiting EML4-ALK protein phosphorylation downregulated extracellular regulated protein kinases 1/2 (ERK1/2)-activating the protein-1(AP-1) signaling pathway and thus attenuated TF expression. CONCLUSION EML4-ALK fusion protein may enhance venous thrombogenicity by regulating coagulation factor TF expression. There was potential involvement of the pERK1/2-AP-1 pathway in this process.
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Affiliation(s)
- Yanping Su
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Jiawen Yi
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Yuan Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Dong Leng
- Clinical Laboratory, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Xiaoxi Huang
- Basic Medical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Xinyu Shi
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China.
| | - Yuhui Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China.
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Mahé I, Meyer G, Girard P, Bertoletti L, Laporte S, Couturaud F, Mismetti P, Sanchez O. French guidelines for the treatment of cancer-associated venous thromboembolism - 2023 update. Respir Med Res 2023; 84:101056. [PMID: 37922776 DOI: 10.1016/j.resmer.2023.101056] [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: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND In recent years, knowledge about cancer associated thrombosis has evolved considerably. METHODS Practical guidelines were drafted on the initiative of the INNOVTE FCRIN Network, led by the French Speaking Society of Respiratory Diseases (SPLF), by a coordinating group, a writing group, and a review group, with the involvement of different scientific societies practicing in various settings. The method followed the "Clinical Practice Guidelines" process of the French National Authority for Health (HAS). RESULTS After a literature review, guidelines were formulated, improved, and then validated by the working groups. These guidelines addressed multiple aspects of the disease and management from the data of available clinical trials and observational studies : epidemiology, initial treatment, treatment duration, extended treatment, recurrent thrombosis, central venous catheter thrombosis, incidental thrombosis, treatment in case of thrombocytopenia. CONCLUSION These evidence-based guidelines are intended to guide the practical management of patients with cancer associated thrombosis.
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Affiliation(s)
- Isabelle Mahé
- Paris Cité University; Internal Medicine Department - Louis Mourier Hospital, Assistance Publique des Hôpitaux de Paris, Colombes; Inserm UMR_S1140, Paris; F-CRIN INNOVTE, St-Etienne.
| | - Guy Meyer
- Paris Cité University; Pulmonology and Intensive Care Department, Georges Pompidou European Hospital, Assistance Publique des Hôpitaux de Paris; INSERM UMRS 970; INSERM CIC 1418, Paris; F-CRIN INNOVTE, St-Etienne
| | - Philippe Girard
- Curie-Montsouris Thorax Institute, Montsouris Mutualist Institute, Paris; F-CRIN INNOVTE, St-Etienne
| | - Laurent Bertoletti
- Vascular and Therapeutic Medicine Department, St-Etienne University Hospital; INSERM UMR1059, Vascular Dysfunction and Hemostasis Team, Jean-Monnet University, Saint-Etienne; INSERM, CIC-1408, Saint-Etienne; F-CRIN INNOVTE, Saint-Etienne, France
| | - Silvy Laporte
- SAINBOIS U1059 DVH team, Jean Monnet University, Lyon University, INSERM; Clinical Research, Innovation, Pharmacology Unit, Saint-Etienne University Hospital, Hôpital Nord; Saint-Etienne; F-CRIN INNOVTE, St-Etienne
| | - Francis Couturaud
- Internal Medicine and Pulmonology Department, EA3878-GETBO, CIC_INSERM1412, Western Brittany University, Brest University Hospital, F-CRIN INNOVTE, St-Etienne
| | - Patrick Mismetti
- Vascular and Therapeutic Medicine Department, St-Etienne University Hospital; INSERM UMR1059, Vascular Dysfunction and Hemostasis Team, Jean-Monnet University, Saint-Etienne; INSERM, CIC-1408, Saint-Etienne; F-CRIN INNOVTE, Saint-Etienne, France
| | - Olivier Sanchez
- Paris Cité University; Pulmonology and Intensive Care Department, Georges Pompidou European Hospital, Assistance Publique des Hôpitaux de Paris; INSERM UMRS 1140, Paris; F-CRIN INNOVTE, St-Etienne
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Huang Y, Gao S, Li T, Zhang B, Du J, Qian Y, Xing Y, Zhou T, Shi M, Huang J, Lian Y. Characteristics and risk factors for advanced lung cancer with pulmonary embolism: A cross-sectional, case-control study. THE CLINICAL RESPIRATORY JOURNAL 2023; 17:1048-1057. [PMID: 37675831 PMCID: PMC10543065 DOI: 10.1111/crj.13692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/24/2023] [Accepted: 08/18/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVES Pulmonary embolism (PE) is a life-threatening complication that can occur in patients with lung cancer. In this study, we aimed to identify risk factors and examine the clinical characteristics of advanced lung cancer patients with PE. METHODS We conducted a retrospective review of patients admitted to our two hospitals between January 2020 and June 2022. The case group consisted of patients with lung cancer and PE, and a closely matched control group was included to identify risk factors. Statistical analysis was conducted using R language. RESULTS A total of 4957 patients were reviewed, and 162 patients (comprising 54 cases and 108 controls) were included in this study. The prevalence of lung cancer with PE in the study population was 1.08%. The majority of patients were male, and the most common histological subtype was adenocarcinoma (67%), followed by squamous cell carcinoma, small cell carcinoma, and poorly differentiated non-small cell lung cancer. The majority of patients had a high performance status (PS) score, with 50% experiencing respiratory failure (mainly hypoxia) and 33% with deep vein thrombosis (DVT). Forty-eight percent of patients were diagnosed with concurrent PE. Further analysis showed that PE was an independent predictor of poor survival, and a PS score of >1 was an independent risk factor for PE in patients with lung cancer. CONCLUSION Our study provides valuable insights into the epidemiology and prognosis of PE in lung cancer patients and suggests that a poor ECOG PS, which has not been previously reported, is an independent risk factor for PE.
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Affiliation(s)
- Yongkang Huang
- Department of Respiratory and Critical Care MedicineThe Second Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Shiyuan Gao
- Department of Respiratory and Critical Care MedicineThe Second Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Ting Li
- Department of Respiratory and Critical Care MedicineThe Second Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Beilei Zhang
- Department of Respiratory and Critical Care MedicineThe First Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Juan Du
- Department of Respiratory and Critical Care MedicineThe First Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Yajuan Qian
- Department of Respiratory and Critical Care MedicineThe Second Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Yufei Xing
- Department of Respiratory and Critical Care MedicineThe Second Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Tong Zhou
- Department of Respiratory and Critical Care MedicineThe Second Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Minhua Shi
- Department of Respiratory and Critical Care MedicineThe Second Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Jian‐an Huang
- Department of Respiratory and Critical Care MedicineThe First Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Yixin Lian
- Department of Respiratory and Critical Care MedicineThe Second Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
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van Hylckama Vlieg MA, Nasserinejad K, Visser C, Bramer WM, Ashrani AA, Bosson JL, Crusan DJ, D'Alessio A, Fluharty ME, Ģībietis V, Hansson PO, Hara N, Jara-Palomares L, Kraaijpoel N, Mahé I, Marshall A, Ogino Y, Otero R, Versmissen J, Klok FA, Kruip MJ, van der Rijt CC, Geijteman EC. The risk of recurrent venous thromboembolism after discontinuation of anticoagulant therapy in patients with cancer-associated thrombosis: a systematic review and meta-analysis. EClinicalMedicine 2023; 64:102194. [PMID: 37731937 PMCID: PMC10507196 DOI: 10.1016/j.eclinm.2023.102194] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/14/2023] [Accepted: 08/16/2023] [Indexed: 09/22/2023] Open
Abstract
Background The optimal duration of anticoagulation in patients with active cancer and venous thromboembolism (VTE) is unknown. Current clinical guidelines advocate anticoagulant therapy for 3-6 months and to continue anticoagulant therapy for as long as the cancer is active. However, an adequate systematic review on the rate of recurrent VTE after discontinuation of anticoagulant therapy has not been performed. Methods For this systemic review and meta-analysis, we searched Embase.com, Medline (Ovid), Web of Science, Cochrane Library, and Google Scholar, from database inception to February 16, 2023, for studies on anticoagulant therapy in patients with cancer and the recurrence of venous thromboembolism after discontinuation of this therapy. We included randomised controlled trials and cohort studies published in English that reported on patients who met the following: cancer and a first VTE, completed at least 3 months of anticoagulant therapy, were followed after discontinuation of anticoagulant therapy, and with symptomatic recurrent VTE as an outcome during follow-up. Study-level data were requested from study authors. The primary outcome was the rate of recurrent VTE after discontinuation of anticoagulant therapy. A Bayesian random-effects meta-analysis was used to estimate the rate of recurrent VTE per 100 person-years for the pooled studies at different time intervals after discontinuation of anticoagulation therapy. We also calculated the cumulative VTE recurrence rate at different time intervals. Forest plots were mapped and the results were summarized by the median and 95% credible interval (CIs). This study was registered with PROSPERO, CRD42021249060. Findings Of 3856 studies identified in our search, 33 studies were identified for inclusion. After requesting study-level data, 14 studies involving 1922 patients with cancer-associated thrombosis were included. The pooled rate of recurrent VTE per 100 person-years after discontinuation of anticoagulant therapy was 14.6 events (95% credible interval 6.5-22.8) in the first three months, decreasing to 1.1 events (95% CI 0.3-2.1) in year 2-3, and 2.2 events (95% CI 0.0-4.4) in year 3-5 after discontinuation of anticoagulant therapy. The cumulative VTE recurrence rate was 28.3% (95% CI 15.6-39.6%) at 1 year; 31.1% (95% CI 16.5-43.8%) at 2 years; 31.9% (95% CI 16.8-45.0%) at 3 years; and 35.0% (95% CI 16.8-47.4%) at 5 years after discontinuation of anticoagulant therapy. Interpretation This meta-analysis demonstrates a high rate of recurrent VTE over time after discontinuation of anticoagulant therapy in patients with cancer-associated thrombosis. Our results support the current clinical guidelines to continue anticoagulant therapy in patients with active cancer. Funding Erasmus MC.
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Affiliation(s)
| | - Kazem Nasserinejad
- Department of Haematology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Innovative Statistical Consulting, Therapeutics Development Team, Cytel Inc., Massachusetts, USA
| | - Chantal Visser
- Department of Haematology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Wichor M. Bramer
- Medical Library, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Aneel A. Ashrani
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jean-Luc Bosson
- Department of Public Health, Grenoble-Alpes University Hospital and TIMC-IMAG, Grenoble, France
| | - Daniel J. Crusan
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Andrea D'Alessio
- Department of Medical Oncology and Internal Medicine, Policlinico San Marco, Istituti Ospedalieri Bergamaschi, Bergamo, Italy
| | | | - Valdis Ģībietis
- Department of Internal Diseases, Riga Stradiņš University, Riga, Latvia
| | - Per-Olof Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Region Västra Götaland, Sweden
| | - Nobuhiro Hara
- Department of Cardiology, IMS Katsushika Heart Center, Tokyo, Japan
| | - Luis Jara-Palomares
- Medical Surgical Unit of Respiratory Diseases, Hospital Universitario Virgen del Rocío, Seville, Spain
- CIBERES, ISCIII, Madrid, Spain
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam UMC/University of Amsterdam, Amsterdam, the Netherlands
| | - Isabelle Mahé
- Université Paris Cité, Hôpital Louis Mourier, Assistance Publique des Hôpitaux de Paris, INSERM, UMR_ S1140 Innovative Therapies in Haemostasis, Paris, France
| | - Andrea Marshall
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Yutaka Ogino
- Department of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Remedios Otero
- Medical Surgical Unit of Respiratory Diseases, Hospital Universitario Virgen del Rocío, Seville, Spain
- CIBERES, ISCIII, Madrid, Spain
| | - Jorie Versmissen
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine and Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Frederikus A. Klok
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke J.H.A. Kruip
- Department of Haematology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | | | - Eric C.T. Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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12
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Giustozzi M, Franco L, Agnelli G, Verso M. Unmet clinical needs in the prevention and treatment of cancer-associated venous thromboembolism. Trends Cardiovasc Med 2023; 33:336-343. [PMID: 35150850 DOI: 10.1016/j.tcm.2022.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/31/2022] [Accepted: 02/06/2022] [Indexed: 12/11/2022]
Abstract
Venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis, is a leading cause of morbidity and mortality in patients with cancer. Based on accumulating evidence, the prophylaxis and treatment of cancer-associated VTE have been changed over the years. Recently, the introduction in clinical practice of the direct oral anticoagulants has radically changed the management of cancer-associated VTE for their easier use and non-inferior efficacy-safety profile compared to low-molecular-weight heparins. However, the heterogeneity of the cancer population in terms of site, type and stage of the malignancy, the presence of comorbidities, and the variability in cancer treatment and prognosis represent major challenges in the management of VTE in patients with cancer. In the present review, we will discuss clinical questions that represent unsolved issues in the setting of cancer-associated VTE and provide an overview on recent evidence on this topic: primary prophylaxis in ambulatory cancer patients treated with chemotherapy and in cancer surgical patients, need of long-term anticoagulation in cancer patients, treatment of VTE in cancer patients at increased bleeding risk and in special categories such as incidental VTE, splanchnic vein thrombosis or catheter-related thrombosis.
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Affiliation(s)
- Michela Giustozzi
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Menghini 1, Perugia 06129, Italy.
| | - Laura Franco
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Menghini 1, Perugia 06129, Italy
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Menghini 1, Perugia 06129, Italy
| | - Melina Verso
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Menghini 1, Perugia 06129, Italy
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13
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Barca-Hernando M, Lopez-Ruz S, Marin-Romero S, Elias-Hernandez T, Otero-Candelera R, Jara-Palomares L. Comparison of long-term complications in cancer patients with incidental and acute symptomatic venous thromboembolism. Front Cardiovasc Med 2023; 10:1118385. [PMID: 37273873 PMCID: PMC10237269 DOI: 10.3389/fcvm.2023.1118385] [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: 12/07/2022] [Accepted: 04/28/2023] [Indexed: 06/06/2023] Open
Abstract
Background Clinical practice guidelines recommend that patients with incidental venous thromboembolism (VTE) receive the same anticoagulant therapy as those with symptomatic VTE. We aimed to compare the rate of complications between cancer patients with incidental and symptomatic VTE through a long-term follow-up cohort. Methods We performed a post hoc analysis of prospective studies of cancer patients with VTE between 2008 and 2019, with the primary outcome of rates of recurrent VTE and clinically relevant bleeding (CRB) in incidental and symptomatic VTE groups. Results In total, 796 patients were included, of which 42.8% had incidental VTE. No significant differences were noted in the rate of recurrent VTE (0.4 per 100 patients/month vs. 0.5 per 100 patients/month; p = 0.313) and in the rate of CRB (0.6 per 100 patients/month vs. 0.5 per 100 patients/month; p = 0.128) between patients with incidental VTE and symptomatic VTE, respectively. At six-month follow-ups, the cumulative incidence of CRB was significantly higher in patients with incidental VTE than that in those with symptomatic VTE (7.9% vs. 4.4%, respectively; OR: 1.8; 95% CI: 1.01-3.2). Conclusion Cancer patients with incidental VTE had similar rates of CRB and VTE recurrence in long-term follow-up compared with patients with symptomatic VTE. At six-month follow-ups, patients with incidental VTE had a higher cumulative incidence of CRB than those with symptomatic VTE.
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Affiliation(s)
- María Barca-Hernando
- Respiratory Department, Medical Surgical Unit of Respiratory Diseases, Hospital Virgen del Rocio, Sevilla, Spain
| | - Sergio Lopez-Ruz
- Respiratory Department, Medical Surgical Unit of Respiratory Diseases, Hospital Virgen del Rocio, Sevilla, Spain
| | - Samira Marin-Romero
- Respiratory Department, Medical Surgical Unit of Respiratory Diseases, Hospital Virgen del Rocio, Sevilla, Spain
| | - Teresa Elias-Hernandez
- Respiratory Department, Medical Surgical Unit of Respiratory Diseases, Hospital Virgen del Rocio, Sevilla, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Remedios Otero-Candelera
- Respiratory Department, Medical Surgical Unit of Respiratory Diseases, Hospital Virgen del Rocio, Sevilla, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Luis Jara-Palomares
- Respiratory Department, Medical Surgical Unit of Respiratory Diseases, Hospital Virgen del Rocio, Sevilla, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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14
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Gounant V, Brosseau S, Lorut C, Guezour N, Vauchier C, Mohammad W, Khalil A, Zalcman G. [Non-infectious respiratory emergencies in patients with cancer]. Rev Mal Respir 2023; 40:416-427. [PMID: 37085441 DOI: 10.1016/j.rmr.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/13/2023] [Indexed: 04/23/2023]
Abstract
Patients with a solid tumor or hematologic malignancy are often addressed to emergency units for an acute respiratory complication associated with the underlying cancer or secondary to treatments. The current article is part of a thematic series: "Intensive care and emergencies in solid tumours and blood cancer patients" and will develop the following points: (1) malignant proximal airway obstruction and, more specifically, the role of therapeutic bronchoscopy; (2) superior vena cava syndrome by tumor compression and/or secondary to thrombosis (diagnosis, local and systemic treatments); (3) cancer-related pulmonary embolism (incidence, indications for low-molecular weight heparins and direct oral anticoagulants). Other respiratory emergencies will be dealt in the other articles of this series.
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Affiliation(s)
- V Gounant
- Université Paris-Cité, France; CIC Inserm 1425, service d'oncologie thoracique, hôpital Bichat-Claude-Bernard, GHU de Paris-Nord, Institut du cancer Paris-Nord, Assistance publique-Hôpitaux de Paris, France.
| | - S Brosseau
- Université Paris-Cité, France; CIC Inserm 1425, service d'oncologie thoracique, hôpital Bichat-Claude-Bernard, GHU de Paris-Nord, Institut du cancer Paris-Nord, Assistance publique-Hôpitaux de Paris, France
| | - C Lorut
- Université Paris-Cité, France; Service de pneumologie, hôpital Cochin, GHU Paris-Centre, Institut Cochin (UMR 1016), Assistance publique-Hôpitaux de Paris, France
| | - N Guezour
- Université Paris-Cité, France; CIC Inserm 1425, service d'oncologie thoracique, hôpital Bichat-Claude-Bernard, GHU de Paris-Nord, Institut du cancer Paris-Nord, Assistance publique-Hôpitaux de Paris, France
| | - C Vauchier
- Université Paris-Cité, France; CIC Inserm 1425, service d'oncologie thoracique, hôpital Bichat-Claude-Bernard, GHU de Paris-Nord, Institut du cancer Paris-Nord, Assistance publique-Hôpitaux de Paris, France
| | - W Mohammad
- Université Paris-Cité, France; Service de radiologie, hôpital Bichat-Claude-Bernard, GHU de Paris-Nord, Institut du cancer Paris-Nord, Assistance publique-Hôpitaux de Paris, France
| | - A Khalil
- Université Paris-Cité, France; Service de radiologie, hôpital Bichat-Claude-Bernard, GHU de Paris-Nord, Institut du cancer Paris-Nord, Assistance publique-Hôpitaux de Paris, France
| | - G Zalcman
- Université Paris-Cité, France; CIC Inserm 1425, service d'oncologie thoracique, hôpital Bichat-Claude-Bernard, GHU de Paris-Nord, Institut du cancer Paris-Nord, Assistance publique-Hôpitaux de Paris, France
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15
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Topff L, Ranschaert ER, Bartels-Rutten A, Negoita A, Menezes R, Beets-Tan RGH, Visser JJ. Artificial Intelligence Tool for Detection and Worklist Prioritization Reduces Time to Diagnosis of Incidental Pulmonary Embolism at CT. Radiol Cardiothorac Imaging 2023; 5:e220163. [PMID: 37124638 PMCID: PMC10141443 DOI: 10.1148/ryct.220163] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 01/13/2023] [Accepted: 02/20/2023] [Indexed: 05/02/2023]
Abstract
Purpose To evaluate the diagnostic efficacy of artificial intelligence (AI) software in detecting incidental pulmonary embolism (IPE) at CT and shorten the time to diagnosis with use of radiologist reading worklist prioritization. Materials and Methods In this study with historical controls and prospective evaluation, regulatory-cleared AI software was evaluated to prioritize IPE on routine chest CT scans with intravenous contrast agent in adult oncology patients. Diagnostic accuracy metrics were calculated, and temporal end points, including detection and notification times (DNTs), were assessed during three time periods (April 2019 to September 2020): routine workflow without AI, human triage without AI, and worklist prioritization with AI. Results In total, 11 736 CT scans in 6447 oncology patients (mean age, 63 years ± 12 [SD]; 3367 men) were included. Prevalence of IPE was 1.3% (51 of 3837 scans), 1.4% (54 of 3920 scans), and 1.0% (38 of 3979 scans) for the respective time periods. The AI software detected 131 true-positive, 12 false-negative, 31 false-positive, and 11 559 true-negative results, achieving 91.6% sensitivity, 99.7% specificity, 99.9% negative predictive value, and 80.9% positive predictive value. During prospective evaluation, AI-based worklist prioritization reduced the median DNT for IPE-positive examinations to 87 minutes (vs routine workflow of 7714 minutes and human triage of 4973 minutes). Radiologists' missed rate of IPE was significantly reduced from 44.8% (47 of 105 scans) without AI to 2.6% (one of 38 scans) when assisted by the AI tool (P < .001). Conclusion AI-assisted workflow prioritization of IPE on routine CT scans in oncology patients showed high diagnostic accuracy and significantly shortened the time to diagnosis in a setting with a backlog of examinations.Keywords: CT, Computer Applications, Detection, Diagnosis, Embolism, Thorax, ThrombosisSupplemental material is available for this article.© RSNA, 2023See also the commentary by Elicker in this issue.
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16
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Wiklund P, Medson K, Elf J. Unreported incidental pulmonary embolism in patients with cancer: Radiologic natural history and risk of recurrent venous thromboembolism and death. Thromb Res 2023; 224:65-72. [PMID: 36867992 DOI: 10.1016/j.thromres.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE To assess the risk of recurrent venous thromboembolism (VTE) and death in patients with unreported cancer-associated incidental pulmonary embolism (iPE). MATERIALS AND METHODS Matched cohort study on cancer patients with a CT study including the chest between 2014-01-01 and 2019-06-30. Studies were reviewed for unreported iPE, and cases were matched with controls without iPE. Cases and controls were followed for one year, with recurrent VTE and death as outcome events. RESULTS Of the included 2960 patients, 171 patients had unreported and untreated iPE. While controls had a one-year VTE risk of 8.2 events per 100 person-years, cases with a single subsegmental iPE had a recurrent VTE risk of 20.9 events, and between 52.0 and 72.0 events per 100 person-years for multiple subsegmental iPE and more proximal iPE. In multivariable analysis, multiple subsegmental and more proximal iPE were significantly associated with the risk of recurrent VTE, while single subsegmental iPE was not associated with the risk of recurrent VTE (p = 0.13). In the subgroup of patients (n = 47) with cancer not in the highest Khorana VTE risk category, no metastases and up to three involved vessels, recurrent VTE occurred in two patients (4.7 cases per 100 person-years). There were no significant associations between iPE burden and risk of death. CONCLUSION In cancer patients with unreported iPE, iPE burden was associated with the risk of recurrent VTE. However, having a single subsegmental iPE was not associated with the risk of recurrent VTE. There were no significant associations between iPE burden and risk of death.
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Affiliation(s)
| | - Koshiar Medson
- Department of Radiology and Functional Imaging, Karolinska University Hospital, Sweden; Department of Physiology and Pharmacology, Karolinska Institutet, Sweden
| | - Johan Elf
- Department of Haematology, Oncology and Radiation Physics, Lund University, Skåne University Hospital, Sweden
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17
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Li J, Rolfe-Vyson V, Rowland V, Woulfe T, Merriman E. Management of single subsegmental pulmonary embolism: a prospective observational study at North Shore and Waitakere Hospitals, Auckland. Intern Med J 2023; 53:216-220. [PMID: 34523216 DOI: 10.1111/imj.15531] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/09/2021] [Accepted: 09/12/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Single subsegmental pulmonary embolism is increasingly diagnosed but the benefit to anticoagulate in the absence of concurrent deep vein thrombosis is not consistently established. AIMS To investigate the safety of an observational approach in patients with isolated subsegmental pulmonary embolism and the utility of the second lower limb ultrasound after 7 days. METHODS Prospective observational study of patients diagnosed with isolated subsegmental pulmonary embolism between July 2016 and July 2020 at North Shore and Waitakere Hospitals, Auckland. The primary outcome was the venous thromboembolism recurrence rate within 3 months of single subsegmental pulmonary embolism diagnosis. Secondary outcomes included all-cause mortality, bleeding complications and the percentage of deep vein thrombosis diagnosed at serial compressive ultrasounds (CUS) of lower limbs. RESULTS Among the 48 patients studied (two excluded due to revised diagnosis), no statistically significant differences were found in the baseline characteristics between the anticoagulated (n = 17) and observed (n = 31) groups. After patients with deep vein thrombosis were excluded, comparisons did not reveal significant differences in the primary outcome (0 vs 1 recurrent venous thromboembolism in the anticoagulated vs. observational groups respectively) and the secondary outcomes. In the observational cohort, 77.4% (n = 24) patients had repeat bilateral lower limb CUS after 7 days, and none had deep vein thrombosis diagnosed on the second CUS. CONCLUSIONS Withholding anticoagulation was a feasible management option for this cohort of patients with single subsegmental pulmonary embolisms with an absence of deep vein thrombosis. The utility of a second lower limb ultrasound is questionable and would warrant further assessment in a prospective study.
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Affiliation(s)
- Jian Li
- Department of Haematology, North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand
| | - Vicki Rolfe-Vyson
- Department of Haematology, North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand
| | - Valerie Rowland
- Department of Haematology, North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand
| | - Tracey Woulfe
- Department of Haematology, North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand
| | - Eileen Merriman
- Department of Haematology, North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand
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18
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Bjørnhart B, Kristiansen C, Asmussen J, Hansen KH, Wedervang K, Jørgensen TL, Herrstedt J, Schytte T. Clinical impact of venous thromboembolism in non-small cell lung cancer patients receiving immunotherapy. Thromb Res 2023; 221:164-172. [PMID: 36396518 DOI: 10.1016/j.thromres.2022.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/13/2022] [Accepted: 10/28/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Prospective investigation on cancer-associated venous thromboembolism (VTE) in non-small cell lung cancer (NSCLC) during treatment with immune checkpoint inhibitors (ICIs) is lacking. PATIENTS AND METHODS A prospective real-world study using combined computed tomography venography and pulmonary angiography (CTVPA) to screen patients with NSCLC for VTE (cohort A). A retrospective multicenter cohort without additional screening with CTVPA was included as control (cohort B). A model with VTE as a time-dependent event using competing risk analysis model with death as a competing event was used to evaluate outcomes and differences in cumulative VTE incidences. RESULTS Cohort A (n = 146) and cohort B (n = 426) had median follow-up for VTE of 16.5 months (IQR 6.7-35.6). Cumulative VTE events at 1, 3, 6, and 12 months were 7.5 %, 9.6 %, 13.0 %, 14.4 % for cohort A and 1.9 %, 3.8 %, 4.9 %, 5.6 % for cohort B with SHR 2.42 (CI 95 % 1.37-4.27) p = 0.0024. Recurrent VTE comprised 52 % and 37 %, respectively. In multivariate overall survival analysis, VTE was significantly associated with impaired OS (HR 2.12 CI 95 % [1.49-3.03], p < 0.0001). Risk factors for VTE comprised prior VTE and ICI administered in first line. CONCLUSION Cumulative VTE incidence in NSCLC patients following palliative ICI may be significantly higher than reported in randomised clinical trials and retrospective real-world reports. VTE development during ICI impair OS significantly. Thus, more focus on VTE during ICI is warranted to optimise both prevention and management of VTE. Whether there is a causal relationship between VTE and ICI remains to be explored.
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Affiliation(s)
- Birgitte Bjørnhart
- Department of Oncology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000 Odense, Denmark; OPEN, Odense Patient Data Explorative Network, Odense University Hospital, J.B.Winsløws Vej 9a, 5000 Odense, Denmark; Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Sdr. Boulevard 29, 5000 Odense, Denmark.
| | | | - Jon Asmussen
- Department of Radiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Karin Holmskov Hansen
- Department of Oncology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense, Denmark; OPEN, Odense Patient Data Explorative Network, Odense University Hospital, J.B.Winsløws Vej 9a, 5000 Odense, Denmark
| | - Kim Wedervang
- Department of Oncology, Hospital Soenderjylland, Sydvang 1, 6400 Soenderborg, Denmark
| | - Trine Lembrecht Jørgensen
- Department of Oncology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000 Odense, Denmark; Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Sdr. Boulevard 29, 5000 Odense, Denmark
| | - Jørn Herrstedt
- Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Sdr. Boulevard 29, 5000 Odense, Denmark; Department of Clinical Oncology and Palliative Care, Zealand University Hospital Roskilde, Sygehusvej 10, 4000 Roskilde, Denmark
| | - Tine Schytte
- Department of Oncology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000 Odense, Denmark; Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Sdr. Boulevard 29, 5000 Odense, Denmark
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19
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Incidental pulmonary embolism in patients with cancer: prevalence, underdiagnosis and evaluation of an AI algorithm for automatic detection of pulmonary embolism. Eur Radiol 2023; 33:1185-1193. [PMID: 36002759 PMCID: PMC9889421 DOI: 10.1007/s00330-022-09071-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/23/2022] [Accepted: 07/26/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To assess the prevalence of reported and unreported incidental pulmonary embolism (iPE) in patients with cancer, and to evaluate an artificial intelligence (AI) algorithm for automatic detection of iPE. METHODS Retrospective cohort study on patients with cancer with an elective CT study including the chest between 2018-07-01 and 2019-06-30. All study reports and images were reviewed to identify reported and unreported iPE and were processed by the AI algorithm. RESULTS One thousand sixty-nine patients (1892 studies) were included. Per study, iPE was present in 75 studies (4.0%), of which 16 (21.3%) were reported. Unreported iPE had a significantly lower number of involved vessels compared to reported iPE, with a median of 2 (interquartile range, IQR, 1-4) versus 5 (IQR 3-9.75), p < 0.001. There were no significant differences in age, cancer type, or attenuation of the main pulmonary artery. The AI algorithm correctly identified 68 of 75 iPE, with 3 false positives (sensitivity 90.7%, specificity 99.8%, PPV 95.6%, NPV 99.6%). False negatives occurred in cases with 1-3 involved vessels. Of the unreported iPE, 32/59 (54.2%) were proximal to the subsegmental arteries. CONCLUSION In patients with cancer, the prevalence of iPE was 4.0%, of which only 21% were reported. Greater than 50% of unreported iPE were proximal to the subsegmental arteries. The AI algorithm had a very high sensitivity and specificity with only three false positives, with the potential to increase the detection rate of iPE. KEY POINTS • In a retrospective single-center study on patients with cancer, unreported iPE were common, with the majority lying proximal to the subsegmental arteries. • The evaluated AI algorithm had a very high sensitivity and specificity, so has the potential to increase the detection rate of iPE.
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20
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Lopez-Ruz S, Barca-Hernando M, Marin-Romero S, Elias-Hernandez T, Otero-Candelera R, Jara-Palomares L. Low-molecular-weight heparin beyond 12 months in patients with cancer-associated thrombosis. Br J Cancer 2022; 127:2234-2240. [PMID: 36241715 PMCID: PMC9727131 DOI: 10.1038/s41416-022-02007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Clinical guidelines indicate that in patients with cancer-associated thrombosis (CAT), anticoagulant treatment should be continued beyond 6 months as long as the cancer is active. We aimed to analyse the safety of low-molecular-weight heparin (LMWH) beyond 12 months in patients with CAT. METHODS We performed a post hoc analysis of consecutive CAT patients from October 2008 to December 2019. The primary outcome was the rate of clinically relevant bleeding (CRB), and we compared two periods (1-12 vs. 12-24 months). Hazard ratio (HR), competing risk analysis and sensitivity analyses were performed. RESULTS Of the 588 patients included, 30.1% (n = 177) received LMWH beyond 12 months. The rate of CRB in the first 12 months compared to the 12-24 month period was 3.2 per 100 patients/month (95% CI 2.5-4.1) vs. 0.9 per 100 patients/month (95% CI 0.4-1.5), (P < 0.0001). The competing risk analysis of CRB comparing both periods showed a lower sub-distribution hazard ratio (SHR) during the period 12-24 months (SHR: 0.5, 95% CI: 0.3-0.8, P < 0.001). CONCLUSION In patients with cancer-associated thrombosis under anticoagulant treatment with LMWH, the rate of clinically relevant bleeding and major bleeding were lower beyond 12 months.
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Affiliation(s)
- Sergio Lopez-Ruz
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, 41013, España
| | - Maria Barca-Hernando
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, 41013, España
| | - Samira Marin-Romero
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, 41013, España
| | - Teresa Elias-Hernandez
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, 41013, España
| | - Remedios Otero-Candelera
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, 41013, España
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España
| | - Luis Jara-Palomares
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, 41013, España.
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España.
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Ajmera P, Kharat A, Seth J, Rathi S, Pant R, Gawali M, Kulkarni V, Maramraju R, Kedia I, Botchu R, Khaladkar S. A deep learning approach for automated diagnosis of pulmonary embolism on computed tomographic pulmonary angiography. BMC Med Imaging 2022; 22:195. [DOI: 10.1186/s12880-022-00916-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/20/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Computed tomographic pulmonary angiography (CTPA) is the diagnostic standard for confirming pulmonary embolism (PE). Since PE is a life-threatening condition, early diagnosis and treatment are critical to avoid PE-associated morbidity and mortality. However, PE remains subject to misdiagnosis.
Methods
We retrospectively identified 251 CTPAs performed at a tertiary care hospital between January 2018 to January 2021. The scans were classified as positive (n = 55) and negative (n = 196) for PE based on the annotations made by board-certified radiologists. A fully anonymized CT slice served as input for the detection of PE by the 2D segmentation model comprising U-Net architecture with Xception encoder. The diagnostic performance of the model was calculated at both the scan and the slice levels.
Results
The model correctly identified 44 out of 55 scans as positive for PE and 146 out of 196 scans as negative for PE with a sensitivity of 0.80 [95% CI 0.68, 0.89], a specificity of 0.74 [95% CI 0.68, 0.80], and an accuracy of 0.76 [95% CI 0.70, 0.81]. On slice level, 4817 out of 5183 slices were marked as positive for the presence of emboli with a specificity of 0.89 [95% CI 0.88, 0.89], a sensitivity of 0.93 [95% CI 0.92, 0.94], and an accuracy of 0.89 [95% CI 0.887, 0.890]. The model also achieved an AUROC of 0.85 [0.78, 0.90] and 0.94 [0.936, 0.941] at scan level and slice level, respectively for the detection of PE.
Conclusion
The development of an AI model and its use for the identification of pulmonary embolism will support healthcare workers by reducing the rate of missed findings and minimizing the time required to screen the scans.
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22
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Benelhaj NE, Hutchinson A, Maraveyas A, Johnson MJ. Cancer patients' experiences of the diagnosis and treatment of incidental pulmonary embolism (a qualitative study). PLoS One 2022; 17:e0276754. [PMID: 36282838 PMCID: PMC9595511 DOI: 10.1371/journal.pone.0276754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 10/12/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The diagnosis of symptomatic cancer-associated thrombosis often causes distress and alarm for patients, especially for those unaware of the risk, or the signs and symptoms to look out for. There are few data about cancer patients' experiences of incidentally diagnosed pulmonary embolism (IPE), where lack of warning (recognised signs, symptoms) may cause delayed diagnosis and aggravate distress. OBJECTIVES To explore cancer patients' experience of the diagnosis of and living with incidental pulmonary embolism treated with anticoagulation. METHODS A qualitative study using modified grounded theory approach. Semi-structured interviews were conducted as part of a mixed- methods prospective observational survey study of consenting patients with IPE. Data were subjected to thematic analysis. The qualitative findings are presented. FINDINGS Eleven participants were interviewed (mean age 68.3 years, range 38-82 years; various forms of cancer and stages). Three major themes and one cross-cutting theme were generated. Theme (1): IPE is experienced in the context of cancer and concomitant comorbidities. Issues are understood in the shadow of-and often overshadowed by-current serious illness. Theme (2): Being diagnosed with IPE. Misattribution to cancer or other comorbidities caused delay in help-seeking and diagnosis. Theme (3): Coping with anticoagulation. Participants' incorporated anticoagulation treatment and its effects into their daily routine with acceptance and stoicism. Finally, the cross-cutting theme relates to a lack of information and uncertainty, contributing to distress throughout the experience. CONCLUSION The diagnosis of IPE was upsetting and unexpected. Expert and timely information was valued by those with IPE. Education called for about the increased risk of cancer-associated thrombosis and the signs and symptoms to be aware of.
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Affiliation(s)
- Naima E. Benelhaj
- Hull York Medical School, University of Hull, Hull, United Kingdom
- * E-mail:
| | - Ann Hutchinson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Anthony Maraveyas
- Queen’s Centre for Oncology and Haematology, Hull and East Yorkshire Hospitals NHS Trust, Hull, United Kingdom
| | - Miriam J. Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
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23
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Zalunardo B, Panzavolta C, Bigolin P, Visonà A. Multidisciplinary Care for the Prevention and Treatment of Venous Thromboembolism in Patients with Cancer-Associated Thrombosis (CAT): Impact of Educational Interventions on CAT-Related Events and on Patients' and Clinicians' Awareness. Life (Basel) 2022; 12:life12101594. [PMID: 36295029 PMCID: PMC9605479 DOI: 10.3390/life12101594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/20/2022] [Accepted: 10/05/2022] [Indexed: 05/27/2023] Open
Abstract
Cancer is a leading cause of death. Venous thromboembolism (VTE) is an often-overlooked cause of morbidity and mortality in cancer patients that can be readily prevented and treated. Actions are needed to reduce the morbidity and mortality of patients with cancer-associated thrombosis (CAT). There is a need to increase awareness of the impact of CAT on cancer patients' morbidity and mortality, on their quality of life and to understand the importance of more effective preventions and treatments of VTE in cancer patients. Moreover, it is of great importance to systematically assess the risk of VTE in regard to patients, cancer and treatment-related factors. Unfortunately, there are unmet clinical needs in the prevention and treatment of cancer-associated VTE. In this review, we discuss an action plan to ensure an increased awareness of and education on the issues that need to be addressed in order to improve the provision of appropriate prevention, early diagnosis and effective and safe treatment of VTE to all cancer patients and, ultimately, to reduce morbidity and mortality.
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24
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Wysokinska EM, Houghton DE, Vlazny DT, Ashrani AA, Froehling DA, Meverden R, Hodge DO, Peterson LG, McBane RD, Wysokinski WE, Casanegra AI. Incidental pulmonary embolism in cancer and noncancer patients: Prospective cohort study. Eur J Haematol Suppl 2022; 110:88-98. [PMID: 36210612 DOI: 10.1111/ejh.13877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clinical picture and outcome of incidental pulmonary embolism (iPE) compared to symptomatic pulmonary embolism (sPE) remain unclear. METHODS Demographics, recurrent venous thromboembolism (VTE), mortality, major bleeding, and clinically relevant nonmajor bleeding (CRNMB) were compared between iPE and sPE patients who were followed prospectively at Mayo Thrombophilia Clinic (March 1, 2013 to August 1, 2020). RESULTS Out of 3576 VTE patients, 1417 (39.6%) had PE: 562 (39.7%) iPE and 855 sPE. Patients with cancer were more likely to have iPE (400 iPE vs. 314 sPE) compared to those without cancer (162 iPE vs. 541 sPE). VTE recurrence rate (all per 100 person-years) was similar in all iPE and sPE patients (3.34 vs. 3.68, p = .50), with cancer (4.16 vs. 4.89, p = .370), and without cancer patients (0.89 vs. 2.80, p = .25). Higher mortality observed in all patients with iPE compared to sPE (46.45 vs. 23.47, p < .001) and with cancer (56.41 vs. 45.77, p = .03) became not significant after adjustment for age, antiplatelet therapy, metastases, and cancer location. Noncancer iPE patients had higher mortality (15.95 vs. 7.18, p = .006) even after adjustment (p = .05). The major bleeding rate was also higher in all patients iPE compared to sPE (7.10 vs. 3.68, p = .03), but not after adjustment (p = .974); higher major bleeding rate in noncancer patients (6.49 vs. 1.25, p = .007) remained significant after adjustment (.02). CRNMB rate was similar to iPE and sPE patients. CONCLUSION iPE represents a more serious clinical condition compared to sPE as indicated by the higher mortality and major bleeding but these differences reflect underlying comorbidities rather than the seriousness of the embolic event.
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Affiliation(s)
| | - Damon E Houghton
- Hematology Division, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Danielle T Vlazny
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Aneel A Ashrani
- Hematology Division, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David A Froehling
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan Meverden
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - David O Hodge
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Lisa G Peterson
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert D McBane
- Hematology Division, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Waldemar E Wysokinski
- Hematology Division, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Ana I Casanegra
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
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25
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Pulmonary Embolism in the Cancer Associated Thrombosis Landscape. J Clin Med 2022; 11:jcm11195650. [PMID: 36233519 PMCID: PMC9570910 DOI: 10.3390/jcm11195650] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/11/2022] [Accepted: 09/19/2022] [Indexed: 11/17/2022] Open
Abstract
In cancer patients, pulmonary embolism (PE) is the second leading cause of death after the cancer itself, most likely because of difficulties in diagnosing the disease due to its nonclassical presentation. The risk of PE recurrence and possibly the case-fatality rate depends on whether the patient presents a symptomatic PE, an unsuspected PE, a subsegmental PE, or a catheter-related PE. Choosing the best therapeutic option is challenging and should consider the risk of both the recurrence of thrombosis and the occurrence of bleeding. The purpose of this review is to provide an overview of the clinical characteristics and the treatment of cancer-associated PE, which could benefit clinicians to better manage the deadliest form of thrombosis associated with cancer. After a brief presentation of the epidemiological data, we will present the current attitude towards the diagnosis and the management of cancer patients with PE. Finally, we will discuss the perspectives of how the medical community can improve the management of this severe medical condition.
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26
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Qdaisat A, Wechsler AH, Cruz Carreras MT, Menendez JR, Lipe D, Highsmith EA, Kamal M, Al-Breiki A, Rojas Hernandez CM, Wu CC, Yeung SCJ. Concomitant Deep Vein Thrombosis in Cancer Patients with Unsuspected Pulmonary Embolism. Cancers (Basel) 2022; 14:cancers14184510. [PMID: 36139673 PMCID: PMC9496711 DOI: 10.3390/cancers14184510] [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: 08/13/2022] [Revised: 09/10/2022] [Accepted: 09/13/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Cancer patients have a significantly higher risk of developing venous thromboembolism during their disease course when compared with the general population. During routine staging or follow-up imaging studies, incidental venous thromboemboli, including incidental pulmonary embolisms, can be identified. Identifying factors associated with incidental or unsuspected venous thromboembolism is important and can improve the management plan. In the current study, we found that 20.9% of patients with unsuspected pulmonary embolisms had concomitant deep vein thrombosis, and most of these patients were asymptomatic. In addition, we found that concomitant deep vein thrombosis increases the odds of venous thrombosis recurrence in cancer patients presenting with unsuspected pulmonary emboli. Therefore, for patients with isolated incidental subsegmental pulmonary embolism and concomitant deep vein thrombosis, initiating anticoagulants if no contraindications exist is recommended. In addition, the presence of concomitant deep vein thrombosis among cancer patients with unsuspected pulmonary embolisms is associated with poor short- and long-term outcomes in these patients. Abstract Incidental venous thromboembolism (VTE) is common in cancer patients and identifying factors associated with these events can improve the management plan. We studied the characteristics of concomitant deep vein thrombosis (C-DVT) in cancer patients presenting with unsuspected pulmonary embolism (PE) and the association of C-DVT with VTE recurrence and survival outcomes. Patients presenting to our emergency department with confirmed unsuspected/incidental PE between 1 January 2006 and 1 January 2016, were identified. Radiologic reports were reviewed to confirm the presence or absence of C-DVT. Logistic regression analyses and cox regression modeling were used to determine the effect of C-DVT on VTE recurrence and survival outcomes. Of 904 eligible patients, 189 (20.9%) had C-DVT. Patients with C-DVT had twice the odds of developing VTE recurrence (odds ratio 2.07, 95% confidence interval 1.21–3.48, p = 0.007). The mortality rates among C-DVT were significantly higher than in patients without. C-DVT was associated with reduced overall survival in patients with unsuspected PE (hazard ratio 1.33, 95% confidence interval 1.09–1.63, p = 0.005). In conclusion, C-DVT in cancer patients who present with unsuspected PE is common and is associated with an increased risk of VTE recurrence and poor short- and long-term survival. Identifying other venous thrombi in cancer patients presenting with unsuspected PE is recommended and can guide the management plan. For patients with isolated incidental subsegmental pulmonary embolism and concomitant deep vein thrombosis, initiating anticoagulants if no contraindications exist is recommended.
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Affiliation(s)
- Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Adriana H. Wechsler
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Maria T. Cruz Carreras
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jazmin R. Menendez
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Demis Lipe
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Emily A. Highsmith
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Mona Kamal
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Aisha Al-Breiki
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Emergency Medicine, Sultan Qaboos University Hospital, Al Seeb 121, Oman
| | | | - Carol C. Wu
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sai-Ching J. Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-713-745-9911
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27
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Practical Considerations for the Management of Cancer-Associated Venous Thromboembolism: A Guide for the General Oncology Practitioner. Curr Oncol 2022; 29:6419-6432. [PMID: 36135074 PMCID: PMC9497708 DOI: 10.3390/curroncol29090505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/31/2022] [Accepted: 09/02/2022] [Indexed: 11/16/2022] Open
Abstract
Cancer-associated venous thromboembolism is a devastating complication of cancer and is associated with significant morbidity and mortality. The cornerstone of cancer-associated venous thromboembolism treatment is anticoagulation, and in recent years, there have been notable randomized clinical trials that have revealed insights into the efficacy and safety of direct oral anticoagulants and low-molecular-weight heparin in the treatment of cancer-associated thrombosis. Deciding on the ideal anticoagulation treatment plan for a patient with a cancer-associated thrombosis is a complex task that requires an understanding of clinical trial data, society guidelines, and, most importantly, consideration of many cancer-related, treatment-related, and patient-related factors. This article summarizes important factors to consider when deciding on anticoagulation therapy for a patient with cancer-associated thrombosis.
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Viteri Jusué A, Domínguez Fernández S, Pérez Persona E, Poza de Celis R. Urgent and unexpected findings in oncology and hematology patients: A practical approach to imaging. RADIOLOGIA 2022; 64:464-472. [PMID: 36243446 DOI: 10.1016/j.rxeng.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/09/2021] [Indexed: 06/16/2023]
Abstract
Urgent and unexpected findings are very common in oncology and haematology patients. This article reviews the most important points included in the European Society of Radiology's guidelines and proposes a practical approach to reporting and communicating these findings more efficiently. This approach is explained with illustrative examples. Radiologists can provide added value in the management of these findings by helping referring clinicians reach the best decisions. To this end, it is essential to know the imaging manifestations of the most common findings that must be reported urgently, such as the specific toxicity of different treatments, the complications of tumours and catheters, infections, and thrombosis. Moreover, it is crucial to consider the individual patient's treatment, risk factors, clinical situation, and immune status.
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Affiliation(s)
- A Viteri Jusué
- Servicio de Radiodiagnóstico, Hospital Universitario Araba, Vitoria-Gasteiz, Spain.
| | | | - E Pérez Persona
- Servicio de Hematología, Hospital Universitario Araba, Vitoria-Gasteiz, Spain
| | - R Poza de Celis
- Servicio de Oncología Radioterápica, Hospital Universitario Araba, Vitoria-Gasteiz, Spain
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29
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Hillegass E, Lukaszewicz K, Puthoff M. Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline 2022. Phys Ther 2022; 102:6585463. [PMID: 35567347 DOI: 10.1093/ptj/pzac057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/24/2022] [Accepted: 02/22/2022] [Indexed: 11/14/2022]
Abstract
No matter the practice setting, physical therapists work with patients who are at risk for or who have a history of venous thromboembolism (VTE). In 2016, the first clinical practice guideline (CPG) addressing the physical therapist management of VTE was published with support by the American Physical Therapy Association's Academy of Cardiovascular and Pulmonary Physical Therapy and Academy of Acute Care, with a primary focus on lower extremity deep vein thrombosis (DVT). This CPG is an update of the 2016 CPG and contains the most current evidence available for the management of patients with lower extremity DVT and new key action statements (KAS), including guidance on upper extremity DVT, pulmonary embolism, and special populations. This document will guide physical therapist practice in the prevention of and screening for VTE and in the management of patients who are at risk for or who have been diagnosed with VTE. Through a systematic review of published studies and a structured appraisal process, KAS were written to guide the physical therapist. The evidence supporting each action was rated, and the strength of statement was determined. Clinical practice algorithms based on the KAS were developed that can assist with clinical decision-making. Physical therapists, along with other members of the health care team, should implement these KAS to decrease the incidence of VTE, improve the diagnosis and acute management of VTE, and reduce the long-term complications of VTE.
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Affiliation(s)
- Ellen Hillegass
- Department of Physical Therapy, Mercer University, Atlanta, Georgia, USA
| | | | - Michael Puthoff
- Physical Therapy Department, St Ambrose University, Davenport, Iowa, USA
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30
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Azour L, Ko JP, Toussie D, Gomez GV, Moore WH. Current imaging of PE and emerging techniques: is there a role for artificial intelligence? Clin Imaging 2022; 88:24-32. [DOI: 10.1016/j.clinimag.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/23/2022] [Accepted: 05/02/2022] [Indexed: 11/26/2022]
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31
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EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer. Hemasphere 2022; 6:e750. [PMID: 35924068 PMCID: PMC9281983 DOI: 10.1097/hs9.0000000000000750] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/01/2022] [Indexed: 01/19/2023] Open
Abstract
In cancer patients, thrombocytopenia can result from bone marrow infiltration or from anticancer medications and represents an important limitation for the use of antithrombotic treatments, including anticoagulant, antiplatelet, and fibrinolytic agents. These drugs are often required for prevention or treatment of cancer-associated thrombosis or for cardioembolic prevention in atrial fibrillation in an increasingly older cancer population. Data indicate that cancer remains an independent risk factor for thrombosis even in case of thrombocytopenia, since mild-to-moderate thrombocytopenia does not protect against arterial or venous thrombosis. In addition, cancer patients are at increased risk of antithrombotic drug-associated bleeding, further complicated by thrombocytopenia and acquired hemostatic defects. Furthermore, some anticancer treatments are associated with increased thrombotic risk and may generate interactions affecting the effectiveness or safety of antithrombotic drugs. In this complex scenario, the European Hematology Association in collaboration with the European Society of Cardiology has produced this scientific document to provide a clinical practice guideline to help clinicians in the management of patients with cancer and thrombocytopenia. The Guidelines focus on adult patients with active cancer and a clear indication for anticoagulation, single or dual antiplatelet therapy, their combination, or reperfusion therapy, who have concurrent thrombocytopenia because of either malignancy or anticancer medications. The level of evidence and the strength of the recommendations were discussed according to a Delphi procedure and graded according to the Oxford Centre for Evidence-Based Medicine.
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D-Dimer and Risk for Thrombosis in Adults with Newly Diagnosed Acute Lymphoblastic Leukemia. Blood Adv 2022; 6:5146-5151. [PMID: 35728059 PMCID: PMC9631615 DOI: 10.1182/bloodadvances.2022007699] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/13/2022] [Indexed: 01/19/2023] Open
Abstract
D-dimer level at ALL diagnosis is associated with venous or arterial thrombosis during the first 100 days of therapy. Future studies should include D-dimer with other known risk factors to build a risk assessment model for thrombosis in newly diagnosed ALL.
Patients with acute lymphoblastic leukemia (ALL) are at increased risk of thrombotic and/or bleeding events during early chemotherapy, especially when receiving asparaginase. D-dimer is a marker of fibrinolysis that has been associated with thrombotic risk in solid cancers and acute myeloid leukemia; however, to date, no ALL-based study has assessed D-dimer level and risk for thrombosis. We sought to examine D-dimer as a biomarker for risk of thrombosis or bleeding during ALL treatment in a retrospective cohort study at The University of Chicago. We identified 61 consecutive adult patients with ALL, gathering demographic characteristics, treatment regimens, initial biomarkers including D-dimer, and assessing occurrence of venous or arterial thrombosis and bleeding in the first 100 days after diagnosis (index). The 100-day cumulative incidence (95% confidence interval [CI]) of venous or arterial thrombosis in patients with high D-dimer (≥4 µg/mL) was 52.9% (95% CI, 26.4-73.8) compared with 13.8% (95% CI, 5.5-25.7) in patients with low to moderate D-dimer (<4 µg/mL), corresponding with a hazard ratio of 5.04 (95% CI, 1.79-14.22). When testing for potential confounders in a series of bivariate logistic regression models, the association between D-dimer and thrombosis remained after adjusting for body mass index, age, sex, asparaginase treatment, disseminated intravascular coagulation score, initial platelet level, and ALL phenotype. In conclusion, D-dimer levels at ALL diagnosis are associated with venous or arterial thrombosis at 100 days. Future studies should include D-dimer collated with other known risk factors to build a risk assessment model for thrombosis in patients with newly diagnosed ALL.
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Font C, Cooksley T, Ahn S, Rapoport B, Escalante C. Emergency management of incidental pulmonary embolism (IPE). EMERGENCY CANCER CARE 2022; 1:7. [PMID: 35844667 PMCID: PMC9207846 DOI: 10.1186/s44201-022-00004-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/14/2022] [Indexed: 11/14/2022]
Abstract
Venous thrombo-embolic (VTE) disease is a common cause of complications in patients with cancer and is the second most common cause of death in oncology patients other than the malignant disease. Whilst symptomatic VTE comprises the majority of such presentations to an emergency department (ED), incidental pulmonary embolism (IPE) is an increasingly frequent reason for attendance. Many studies report that the consequences of IPE do not differ significantly from those with symptomatic presentations and thus most guidelines recommend using the same approach. The complexity of treatment in cancer patients due to increased prevalence of co-morbidities, higher risk of bleeding, abnormal platelet and renal function, greater risk of VTE recurrence, and medications with the risk of anticoagulant interaction are consistent across patients with symptomatic and IPE. One of the initial challenges of the management of IPE is the design of a pathway that provides both patients and clinicians with a seamless journey from the radiological diagnosis of IPE to their initial clinical workup and management. Increased access to ambulatory care has successfully reduced ED utilisation and improved clinical outcomes in high-risk non-oncological populations, such as those with IPE. In this clinical review, we consider IPE management, its workup, the conundrums it may present for emergency physicians and the need to consider emergency ambulatory care for this growing cohort of patients.
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Muñoz-Guglielmetti D, Cooksley T, Ahn S, Beato C, Aramberri M, Escalante C, Font C. Risk stratification for clinical severity of pulmonary embolism in patients with cancer: a narrative review and MASCC clinical guidance for daily care. Support Care Cancer 2022; 30:8527-8538. [PMID: 35579753 DOI: 10.1007/s00520-022-07131-1] [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: 10/21/2021] [Accepted: 05/09/2022] [Indexed: 11/26/2022]
Abstract
Pulmonary embolism (PE) is a leading cause of morbidity and mortality in patients with cancer. The clinical presentation and outcomes of PE range from an acute life-threatening condition requiring intensive care to a mild symptomatic condition associated with favorable outcomes and potentially candidate for early hospital discharge. The wide clinical spectrum of PE has led to the development of risk stratification models aimed at the triage of patients in emergency care departments and optimizing the utilization of health care resources. Incidental or unsuspected PE (UPE), detected during routine staging computed tomography scans, make up a significant proportion of this cohort among the oncology population. The present narrative review is aimed at examining the currently available PE risk assessment models developed for the general population and for patients with cancer including UPE. We include general recommendations for the daily care of patients with cancer-related PE and hypothesize on the factors that would potentially favor hospitalization with early discharge or ambulatory management in this setting.
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Affiliation(s)
| | - Tim Cooksley
- The Christie Hospital, University of Manchester, Wythenshawe Hospital, Manchester, UK
| | - Shin Ahn
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Carmen Beato
- Medical Oncology Department, Hospital Universitario Macarena, Seville, Spain
| | - Mario Aramberri
- Internal Medicine Department, Hospital Galdakao-Usansolo, Vizcaya, Spain
| | - Carmen Escalante
- Internal Medicine Department, MD Anderson Cancer Center, University of Texas, Houston, USA
| | - Carme Font
- Medical Oncology Department, Hospital Clinic Barcelona, Barcelona, Spain.
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Klemen ND, Feingold PL, Hashimoto B. Reply to R.A. Snyder et al. J Clin Oncol 2022; 40:2512-2513. [PMID: 35580286 PMCID: PMC9467674 DOI: 10.1200/jco.22.00320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Nicholas D Klemen
- Nicholas D. Klemen, MD, Surgery Branch, National Cancer Institute, Bethesda, MD; Paul L. Feingold, MD, Department of Surgery, Brigham and Women's Hospital, Harvard University, Boston, MA; and Barry Hashimoto, PhD, Division of Social Science, New York University Abu Dhabi, Saadiyat Island, United Arab Emirates
| | - Paul L Feingold
- Nicholas D. Klemen, MD, Surgery Branch, National Cancer Institute, Bethesda, MD; Paul L. Feingold, MD, Department of Surgery, Brigham and Women's Hospital, Harvard University, Boston, MA; and Barry Hashimoto, PhD, Division of Social Science, New York University Abu Dhabi, Saadiyat Island, United Arab Emirates
| | - Barry Hashimoto
- Nicholas D. Klemen, MD, Surgery Branch, National Cancer Institute, Bethesda, MD; Paul L. Feingold, MD, Department of Surgery, Brigham and Women's Hospital, Harvard University, Boston, MA; and Barry Hashimoto, PhD, Division of Social Science, New York University Abu Dhabi, Saadiyat Island, United Arab Emirates
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Klemen ND, Feingold PL, Hashimoto B. How Strong Is the Evidence Supporting Thromboprophylaxis in Surgical Oncology? J Clin Oncol 2022; 40:320-323. [PMID: 34871037 PMCID: PMC9851687 DOI: 10.1200/jco.21.01934] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Nicholas D. Klemen
- Surgery Branch, National Cancer Institute, Bethesda, MD,Nicholas D. Klemen, MD, Surgery Branch, National Cancer Institute, National Institutes of Health, 10 Center Dr, CRC, Building 10, Bethesda, MD 20892; e-mail:
| | - Paul L. Feingold
- Department of Surgery, Brigham and Women's Hospital, Harvard University, Boston, MA
| | - Barry Hashimoto
- Division of Social Science, New York University Abu Dhabi, Saadiyat Island, United Arab Emirates
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Shalaby K, Kahn A, Silver ES, Kim MJ, Balakumaran K, Kim AS. Outcomes of acute pulmonary embolism in hospitalized patients with cancer. BMC Pulm Med 2022; 22:11. [PMID: 34986814 PMCID: PMC8734325 DOI: 10.1186/s12890-021-01808-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/16/2021] [Indexed: 01/22/2023] Open
Abstract
Background Cancer-associated pulmonary embolism (PE) places a significant burden on patients and health care systems.
Methods A retrospective cross-sectional analysis of the National Inpatient Sample (NIS) database was performed in patients with acute PE from 2002 to 2014. Among patients hospitalized with PE, we investigated the differences in clinical outcomes and healthcare utilization in patients with and without cancer. A multivariate logistic regression model was applied to calculate adjusted odds ratios (OR) to estimate the impact of cancer on clinical outcomes. Wilcoxon rank sum tests were used to determine the differences in healthcare utilization between the two cohorts. Results Among 3,313,044 patients who were discharged with a diagnosis of acute PE, 84.2% did not have cancer, while 15.8% had cancer as a comorbidity (56% metastatic cancer, 35% solid tumor without metastasis, and 9% lymphoma). Patients with cancer had a higher mean age but lower rates of common comorbidities except for coagulation deficiency than patients without a cancer diagnosis. In patients with cancer, the rate of IVC filter placement was higher (21.7% vs. 13.11%, OR 1.76 (95% CI 1.73–1.79); p < 0.0001) and thrombolytic use lower (1.34% vs. 2.15%, OR 0.68 (95% CI 0.64–0.72); p < 0.0001). Patients with cancer hospitalized for PE had a higher all-cause in-hospital mortality (11.8% vs. 6.6%, OR 1.79 (95% CI 1.75–1.83); p < 0.0001), longer length of stay (6 vs. 5 days; p < 0.0001), higher total charge per hospitalization ($30,885 vs. $27,273; p < 0.0001), and higher rates of home health services upon discharge (35.8% vs. 23.2%; p < 0.0001) compared with those without cancer. Conclusion Concurrent cancer diagnosis in patients hospitalized for acute PE was associated with a 90% increase in all-cause mortality, longer length of stay, higher total charge per hospitalization, and higher rates of home health services upon discharge. The majority (56%) of patients with cancer had metastatic disease. Furthermore, there were identifiable differences in the intervention for acute PE between the two groups.
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Affiliation(s)
- Khalid Shalaby
- Department of Internal Medicine, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030-1235, USA
| | - Adriana Kahn
- Department of Internal Medicine, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030-1235, USA
| | - Elizabeth S Silver
- Department of Internal Medicine, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030-1235, USA
| | - Min Jung Kim
- Department of Internal Medicine, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030-1235, USA
| | - Kathir Balakumaran
- Advanced Heart Failure and Transplant Cardiology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Agnes S Kim
- Department of Internal Medicine, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030-1235, USA. .,Department of Medicine, Calhoun Cardiology Center, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, 06030, USA.
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Nahidi SM, Ali U, Duka L, Fuentes-Rosales JC, Bhatt U. Incidental Finding of Saddle Pulmonary Embolism on a CT Scan of the Abdomen and Pelvis in a Patient With Adenocarcinoma of the Colon. Cureus 2021; 13:e20757. [PMID: 34984163 PMCID: PMC8714042 DOI: 10.7759/cureus.20757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2021] [Indexed: 12/29/2022] Open
Abstract
A saddle pulmonary embolism is defined as a large thromboembolus lodged at the bifurcation of the pulmonary artery. It would be expected for a patient with a saddle pulmonary embolism to present with symptoms such as dyspnea or pleuritic pain. However, more often than not, saddle pulmonary embolisms may present asymptomatically and are not associated with the typical symptoms. We present a case of an incidental finding of saddle pulmonary embolism in an 89-year-old patient with a past medical history significant of gastrointestinal adenocarcinoma that was treated with capecitabine. The saddle pulmonary embolism was found incidentally on computer tomography (CT) with the contrast of the abdomen and subsequently confirmed with CT of the chest with contrast. It is crucial to be mindful of a possible pulmonary embolism in a patient with similar past medical history.
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Englisch C, Moik F, Ay C. Risk assessment for recurrent venous thromboembolism in patients with cancer. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
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Maraveyas A, Kraaijpoel N, Bozas G, Huang C, Mahé I, Bertoletti L, Bartels-Rutten A, Beyer-Westendorf J, Constans J, Iosub D, Couturaud F, Muñoz AJ, Biosca M, Lerede T, van Es N, Di Nisio M. The prognostic value of respiratory symptoms and performance status in ambulatory cancer patients and unsuspected pulmonary embolism; analysis of an international, prospective, observational cohort study. J Thromb Haemost 2021; 19:2791-2800. [PMID: 34532927 DOI: 10.1111/jth.15489] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/16/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Optimal risk stratification of unsuspected pulmonary embolism (UPE) in ambulatory cancer patients (ACPs) remains unclear. Existing clinical predictive rules (CPRs) are derived from retrospective databases and have limitations. The UPE registry is a prospective international registry with pre-specified characteristics of ACPs with a recent UPE. The aim of this study was to assess the utility of risk factors captured in the UPE registry in predicting proximate (30-, 90- and 180-day) mortality and how they performed when applied to an existing CPR. OBJECTIVES To evaluate risk factors for proximate mortality, overall survival, recurrent venous thromboembolism and major bleeding, in the patients enrolled in the UPE registry cohort. METHODS Data from the 695 ACPs in this registry were subjected to multivariate logistic regression analyses to identify predictors independently associated with proximate mortality and overall survival. The most consistent predictors were applied to the Hull CPR, an existing 5-point prediction rule. RESULTS The most consistent predictors of mortality were patient-reported respiratory symptoms within 14 days before, and ECOG performance status at the time of UPE. These predictors applied to the Hull-CPR produced a consistent correlation with proximate mortality and overall survival (area under the curve [AUC] = 0.70 [95% CI 0.63, 077], AUC = 0.65 [95% CI 0.60, 070], AUC = 0.64 [95% CI 0.59, 068], and AUC = 0.61, 95% CI 0.57, 0.65, respectively). CONCLUSION In ACPs with UPE, ECOG performance status logged contemporaneously to the UPE diagnosis and respiratory symptoms prior to UPE diagnosis can stratify mortality risk. When applied to the HULL-CPR these risk predictors confirmed the risk stratification clusters of low-intermediate and high-risk for proximate mortality as seen in the original derivation cohort.
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Affiliation(s)
- Anthony Maraveyas
- Faculty of Health Sciences, Joint Centre for Cancer Studies, The Hull York Medical School, Castle Hill Hospital, Hull, UK
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - George Bozas
- Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | | | - Isabelle Mahé
- Service de Médecine Interne, Hôpital Louis Mourier, AP-HP, Colombes, France
- Université de Paris, Paris, France
- Innovative Therapies in Haemostasis, INSERM UMR-_S1140, Paris, France
- INNOVTE-FCRIN, Saint-Etienne, France
| | - Laurent Bertoletti
- CHU de St-Etienne, Service de Médecine Vasculaire et Thérapeutique, INSERM, UMR1059, Université Jean-Monnet, INSERM, CIC-1408, CHU de Saint-Etienne, INNOVTE, CHU de Saint-Etienne, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Annemarieke Bartels-Rutten
- Department of Radiology, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Jan Beyer-Westendorf
- Department of Medicine, Division Hematology, University Hospital "Carl Gustav Carus", Dresden, Germany
| | - Joel Constans
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Diana Iosub
- Thromboembolic Disease Unit, Fondazione Policlinico IRCCS San Matteo, Pavia, Italy
| | - Francis Couturaud
- Department of Internal Medicine and Chest Diseases, Brest University Hospital Centre "La Cavale Blanche", EA 3878, Brest, France
| | - Andres J Muñoz
- Medical Oncology, Hospital General Universitario Gregorio Maranon, Madrid, Spain
| | | | - Teresa Lerede
- Immunohematology and Transfusion Medicine, Azienda Socio Sanitaria Territoriale Bergamo, Seriate, Italy
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G. D'Annunzio, Chieti, Italy
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Giustozzi M, Connors JM, Ruperez Blanco AB, Szmit S, Falvo N, Cohen AT, Huisman M, Bauersachs R, Dentali F, Becattini C, Agnelli G. Clinical characteristics and outcomes of incidental venous thromboembolism in cancer patients: Insights from the Caravaggio study. J Thromb Haemost 2021; 19:2751-2759. [PMID: 34260816 PMCID: PMC9290511 DOI: 10.1111/jth.15461] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/03/2021] [Accepted: 07/12/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Clinical guidelines advise similar anticoagulant treatment for symptomatic and incidental cancer-associated venous thromboembolism (VTE). We investigated clinical features and outcomes of cancer patients with incidental or symptomatic VTE randomized in the Caravaggio study. OBJECTIVES We performed a predefined sub-analysis of the Caravaggio study in order to investigate the clinical features and outcomes of incidental and symptomatic VTE in patients with cancer. The relative efficacy and safety of apixaban and dalteparin in patients with incidental and symptomatic VTE was also assessed. METHODS The Caravaggio study compared apixaban to dalteparin for the 6-month treatment of cancer-associated VTE. The primary efficacy and safety outcomes were recurrent VTE and major bleeding. RESULTS Two hundred thirty patients (20%) had incidental and 925 (80%) symptomatic VTE. Pulmonary embolism with or without deep vein thrombosis as index event, colorectal cancer, Eastern Cooperative Oncology Group (ECOG) score of 0, and locally advanced or metastatic cancer were more frequent in patients with incidental VTE. Deep vein thrombosis as index event, hematological cancer, and ECOG score of 2 were more frequent in patients with symptomatic VTE. Ten patients (4.3%) with incidental and 68 (7.4%) with symptomatic VTE had recurrent VTE (hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.29-1.10). Major bleeding occurred in 12 (5.2%) patients with incidental VTE and in 33 (3.6%) patients with symptomatic VTE (HR 1.43, 95% CI 0.74-2.77). When comparing apixaban to dalteparin in patients with symptomatic and incidental VTE, the HR for recurrence was 0.73 (95% CI 0.45-1.19) and 0.41 (95% CI 0.11-1.56), respectively, and the HR for major bleeding 0.93 (95% CI 0.47-1.83) and 0.96 (95% CI 0.31-2.96), respectively. CONCLUSIONS Compared to cancer patients with symptomatic VTE, those with incidental VTE have different clinical features at presentation, with a numerically lower incidence of recurrent VTE and a numerically higher incidence of major bleeding.
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Affiliation(s)
- Michela Giustozzi
- Internal Vascular and Emergency Medicine – Stroke UnitUniversity of PerugiaPerugiaItaly
| | - Jean M. Connors
- Brigham and Womens’s HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | | | - Sebastian Szmit
- Department of Pulmonary CirculationThromboembolic Diseases and CardiologyCentre of Postgraduate Medical EducationEuropean Health CentreOtwockPoland
| | - Nicolas Falvo
- Service d’Exploration Vasculaire et de Phlébologie InterventionnelleCHU DijonDijonFrance
| | - Alexander T. Cohen
- Guy’s and St Thomas’ NHS Foundation Trust, HospitalKing’s College LondonLondonUK
| | - Menno Huisman
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | | | - Francesco Dentali
- Department of Medicine and SurgeryInsubria UniversityASST SettelaghiVareseItaly
| | - Cecilia Becattini
- Internal Vascular and Emergency Medicine – Stroke UnitUniversity of PerugiaPerugiaItaly
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine – Stroke UnitUniversity of PerugiaPerugiaItaly
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Qiu M, Meng Y, Wang H, Sun L, Liu Z, Kan S, Wang T, Zhang S. Concurrence of Gastric Cancer and Incidental Pulmonary Embolism May Be a Prognostic Factor for Advanced Gastric Cancer Patients with Incidental Pulmonary Embolism. Cancer Manag Res 2021; 13:7637-7644. [PMID: 34675659 PMCID: PMC8500498 DOI: 10.2147/cmar.s329329] [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: 07/21/2021] [Accepted: 09/09/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Cancer is well known as the most important risk factor for the emergence of pulmonary embolism (PE). The incidence of incidental PE (IPE) has increased with widely use of multi-detector-row computed tomography (CT) technology. Simultaneously, more new cancer patients diagnosed concomitantly with IPE are found. No study has examined the presentation and prognosis of incidental pulmonary embolism (IPE) in gastric cancer patients. The aim of this study was to analyse prognostic factors in patients with advanced gastric cancer complicated with IPE. Patients and Methods Ninety patients with histologically confirmed advanced gastric adenocarcinoma diagnosed with IPE were enrolled. Continuous variables were compared using Student’s t-test or the Mann–Whitney U-test if non-normally distributed. The Chi-squared test (or Fisher’s exact test where appropriate) was used to compare categorical variables. The Kaplan–Meier method and the Log rank test were used for survival analysis. Independent prognostic factors for survival were determined using a Cox proportional hazards model. A two-sided P-value < 0.05 was considered statistically significant. Results Nineteen patients were diagnosed with IPE concomitantly with gastric cancer. Concurrence of gastric cancer and IPE, lack of anticoagulation therapy, and location of IPE were associated with survival. After adjusting for age and sex, the concurrence of gastric cancer and IPE, lack of anticoagulation, and central IPE independently influenced the survival of advanced gastric cancer patients with IPE. Subgroup analysis of patients with peripheral pulmonary embolisms confirmed that anticoagulant therapy provided a survival benefit. Conclusion Concurrence of gastric cancer and IPE may be a prognostic factor for advanced gastric cancer patients with IPE.
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Affiliation(s)
- Meiqing Qiu
- Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China.,Department of Oncology, Zaozhuang Municipal Hospital, Zaozhuang, 277100, People's Republic of China.,Department of Gastroenterology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Ying Meng
- Department of Gastroenterology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Huijun Wang
- Department of Gastroenterology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Li Sun
- Department of Gastroenterology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Zhen Liu
- Department of Gastroenterology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Shifeng Kan
- Department of Oncology, Zaozhuang Municipal Hospital, Zaozhuang, 277100, People's Republic of China
| | - Tao Wang
- Department of Oncology, Zaozhuang Municipal Hospital, Zaozhuang, 277100, People's Republic of China
| | - Shu Zhang
- Department of Gastroenterology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
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The Incidence of Cancer Associated Thrombosis is Increasing Over Time. Blood Adv 2021; 6:307-320. [PMID: 34649273 PMCID: PMC8753193 DOI: 10.1182/bloodadvances.2021005590] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/21/2021] [Indexed: 11/20/2022] Open
Abstract
Cancer associated thrombosis (CAT) is an important cause of morbidity and mortality for patients with malignancy and varies by primary cancer type, stage and therapy. We aimed to characterize the incidence, risk factors, temporal trends and the effect on mortality of CAT. The California Cancer Registry was linked to the statewide hospitalization database to identify individuals with the 13 most common malignancies diagnosed 2005 -2017 and determine the 6 and 12-month cumulative incidence of CAT by venous thromboembolism (VTE) location, tumor type and stage after adjusting for competing risk of death. Cox proportional hazard regression models were used to determine risk factors associated with CAT and the effect of CAT on all-cause mortality. 942,019 patients with cancer were identified; 62,003 (6.6%) had an incident diagnosis of CAT. Patients with pancreatic, brain, ovarian, and lung cancer had the highest and patients with breast and prostate cancer had the lowest 12-month cumulative incidence of CAT. For most malignancies, men, those with metastatic disease and more co-morbidities, and African-Americans (vs. non-Hispanic Whites) were at highest risk for CAT. Patients diagnosed with cancer 2014-2017 had higher risk of CAT compared to those diagnosed 2005-2007. CAT was associated with increased overall mortality for all malignancies (HR ranges 1.89 - 4.79). The incidence of CAT increased over time and was driven by an increase in PE±DVT. CAT incidence varies based on tumor type and stage, and on individual risk factors including gender, race/ethnicity, and co-morbidities. For all tumor types CAT is associated with an increased mortality.
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Caiano L, Carrier M, Marshall A, Young AM, Ageno W, Delluc A, Wang TF. Outcomes among patients with cancer and incidental or symptomatic venous thromboembolism: A systematic review and meta-analysis. J Thromb Haemost 2021; 19:2468-2479. [PMID: 34161655 DOI: 10.1111/jth.15435] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients with cancer have an increased risk of venous thromboembolism (VTE) and it is commonly detected incidentally. The outcomes and optimal management for patients with cancer and incidental VTE remain debated. OBJECTIVES We conducted a systematic review and meta-analysis to evaluate the outcomes in patients with cancer and incidentally detected VTE compared to those with symptomatic events. PATIENTS/METHODS We searched the electronic databases and included randomized controlled trials (RCTs) and observational studies reporting recurrent VTE, major bleeding events, and mortality in patients with cancer and incidental VTE compared to symptomatic VTE. RESULTS We included 23 studies for the systematic review: 3 RCTs and 20 observational studies. The meta-analysis of the 3 RCTs showed a significantly lower rate of VTE recurrence at 6 months in patients with incidental VTE compared to those with symptomatic VTE (relative risk [RR] 0.62, 95% confidence interval [CI] 0.44-0.87). The risk of major bleeding events at 6 months was numerically higher with incidental VTE compared to symptomatic VTE (RR 1.47, 95% CI 0.99-2.20). There was no difference in overall mortality. CONCLUSIONS Among patients with cancer, incidental VTE was associated with a lower rate of VTE recurrence compared to symptomatic VTE, with a trend in increased major bleeding events. The risk-benefit ratio of anticoagulation may differ between incidental and symptomatic events and should be considered in patient management.
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Affiliation(s)
- Lucia Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Marc Carrier
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Andrea Marshall
- Warwick Clinical Trials Unit, Warwick Medical School University of Warwick, Coventry, UK
| | - Annie M Young
- Warwick Clinical Trials Unit, Warwick Medical School University of Warwick, Coventry, UK
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Aurélien Delluc
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Verso M, Agnelli G. Treatment of venous thromboembolism in patients with cancer: from clinical trials to real life. Thromb Res 2021; 191 Suppl 1:S123-S127. [PMID: 32736770 DOI: 10.1016/s0049-3848(20)30409-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/20/2019] [Accepted: 01/03/2020] [Indexed: 12/13/2022]
Abstract
Approximately one-fifth of all cases of venous thromboembolism (VTE) are related to cancer. VTE complications may have a substantial impact on prognosis, quality of life and care in patients with cancer. Patients with cancer-related VTE are at increased risk of developing recurrent VTE compared to patients without cancer, but also have a higher risk of major bleeding. In the last years, direct oral anticoagulants (DOACs) have been evaluated in a head-to-head comparison with low molecular weight heparin (LMWH) in two randomized trials for the long-term treatment of VTE in patients with advanced cancer. The results of these trials show that DOACs have a similar efficacy profile, but probably higher risk of bleeding, compared to LMWH dalteparin. Because DOACs offer a simple oral treatment regimen without the need for anticoagulation monitoring, they could be attractive alternatives to LMWHs in these setting. The American Society of Clinical Oncology guidelines, published in August 2019, recommend LMWH, edoxaban and rivaroxaban as first-choice therapies for long-term anticoagulation in cancer patients with VTE. However, several practical issues should be considered concerning the long-term use of DOAC treatment in patients with cancer. Major concerns have been highlighted about the gastrointestinal bleeding risk in patients with gastrointestinal cancers and the potential drug-drug interactions in combination for some specific anticancer therapies. Several studies comparing DOACs with LMWH are currently ongoing to refine our knowledge concerning treatment with DOACs in patients with cancer-associated VTE.
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Affiliation(s)
- Melina Verso
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy.
| | - Giancarlo Agnelli
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
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Dahm AEA. Cancer and Thrombosis: New Treatments, New Challenges. Med Sci (Basel) 2021; 9:medsci9020041. [PMID: 34204957 PMCID: PMC8293316 DOI: 10.3390/medsci9020041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/26/2021] [Accepted: 05/29/2021] [Indexed: 12/21/2022] Open
Abstract
The direct-acting oral anticoagulant (DOAC) has become an alternative to low-molecular-weight heparin (LMWH) for treatment and prophylaxis of venous thromboembolism (VTE) in cancer patients. The clinicians are, however, faced with difficult decisions regarding DOAC treatment: Which patients cannot use DOACs? Should incidental VTE be treated similar to symptomatic VTE? Is it safe to give DOACs to patients with gastrointestinal or urogenital cancers? How about drug–drug interactions? Should all cancer patients receive thromboprophylaxis? Is arterial thrombosis a problem? The current article reviews the available literature regarding these questions and aims to provide practical solutions based on data from the clinical trials and new guidelines.
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Affiliation(s)
- Anders Erik Astrup Dahm
- Department of Hematology, Akershus University Hospital, 1478 Lørenskog, Norway;
- Institute of Clinical Medicine, University of Oslo, 0316 Oslo, Norway
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Clinical factors and outcomes of subsegmental pulmonary embolism in cancer patients. Blood Adv 2021; 5:1050-1058. [PMID: 33599740 DOI: 10.1182/bloodadvances.2020003136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 01/12/2021] [Indexed: 12/20/2022] Open
Abstract
In the cancer population, patients diagnosed with venous thromboembolism (VTE) are considered to have a threefold increased risk of mortality compared with those without VTE. With the advent of modern computed tomography (CT), the rate of diagnosis of subsegmental pulmonary embolism (SSPE) has increased, likely as a result of improved visualization of the peripheral pulmonary arteries. The clinical significance of SSPE remains unclear because of the lack of randomized controlled clinical trials. The aim of this study was to identify the incidence and risk factors of recurrent proximal PE within 12 months of diagnosis of SSPE in cancer. We performed a retrospective analysis of 206 adult cancer patients who were diagnosed with SSPE from 2014 to 2016 at the University of Texas MD Anderson Cancer Center. At the time of SSPE diagnosis, the majority had metastatic cancer, 108 patients (53.2%) were undergoing chemotherapy, and 23 patients (11.2%) had a history of VTE. Most patients had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 2. Sixty-seven percent of SSPE was discovered incidentally on restaging CT scans, with the majority being a single and isolated event (70.9%). Within 12 months of SSPE diagnosis, 18 patients (8.7%) were found to have a recurrent PE. The patients treated with anticoagulation had a lower rate of PE recurrence (8% vs 13% in those not treated with anticoagulation). Treatment with anticoagulation did not appear to have a significant impact on overall survival (P = .48) when adjusted for ECOG performance status and cancer stage.
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Frere C. Burden of venous thromboembolism in patients with pancreatic cancer. World J Gastroenterol 2021; 27:2325-2340. [PMID: 34040325 PMCID: PMC8130043 DOI: 10.3748/wjg.v27.i19.2325] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/28/2021] [Accepted: 04/22/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer (PC) is a devastating malignancy with fewer than 10% of patients being alive at 5 years after diagnosis. Venous thromboembolism (VTE) occurs in approximatively 20% of patients with PC, resulting in increased morbidity, mortality and significant health care costs. The management of VTE is particularly challenging in these frail patients. Adequate selection of the most appropriate anticoagulant for each individual patient according to the current international guidelines is warranted for overcoming treatment challenges. The International Initiative on Thrombosis and Cancer multi-language web-based mobile application (downloadable for free at www.itaccme.com) has been developed to help clinicians in decision making in the most complex situations. In this narrative review, we will discuss the contemporary epidemiology and burden of VTE in PC patients, the performances and limitations of current risk assessment models to predict the risk of VTE, as well as evidence from recent clinical trials for the primary prophylaxis and treatment of cancer-associated VTE that support up-dated clinical practice guidelines.
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Affiliation(s)
- Corinne Frere
- Department of Haematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris F-75013, France
- INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, GRC 27 GRECO, Sorbonne Université, Paris F-75013, France
- Groupe Francophone Thrombose et Cancer, Saint-Louis Hospital, Paris F-75010, France
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Clinical characteristics, management, and outcome of incidental pulmonary embolism in cancer patients. Blood Adv 2021; 4:1606-1614. [PMID: 32311012 DOI: 10.1182/bloodadvances.2020001501] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/12/2020] [Indexed: 12/17/2022] Open
Abstract
Incidental pulmonary embolisms (IPEs) are common in cancer patients. Examining the characteristics and outcomes of IPEs in cancer patients can help to ensure proper management, promoting better outcomes. To determine the clinical characteristics, management, and outcomes of IPEs for cancer patients, we conducted a 1:2 ratio case-control study and identified all consecutive patients with IPE who visited the emergency department at The University of Texas MD Anderson Cancer Center between 1 January 2006 and 1 January 2016. Each IPE case was matched with 2 controls using a propensity score obtained using logistic regression for IPE status with other factors affecting overall survival. A total of 904 confirmed cases were included in the analysis. IPE frequently occurred during the first year after cancer diagnosis (odds ratio [OR], 2.79; 95% confidence interval [95% CI], 2.37-3.29; P < .001). Patients receiving cytotoxic chemotherapy had a nearly threefold greater risk of developing IPE (OR, 2.87; 95% CI, 2.42-3.40; P < .001). In-hospital mortality was 1.9%. The 7- and 30-day mortality rates among the cases were 1.8% and 9.9%, respectively, which was significantly higher than in the control groups: 0.2% and 3.1%, respectively (P < .001). IPE was associated with reduced overall survival (hazard ratio [HR], 1.93; 95% CI, 1.74-2.14; P < .001). Concurrent incidental venous thromboembolism was identified in 189 of the patients (20.9%) and was also associated with reduced overall survival (HR, 1.65; 95% CI, 1.21-2.25; P = .001). Our results show that IPE events are associated with poor outcomes in cancer patients. Proper management plans similar to those of symptomatic pulmonary embolisms are essential.
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Viteri Jusué A, Domínguez Fernández S, Pérez Persona E, Poza de Celis R. Urgent and unexpected findings in oncology and hematology patients: a practical approach to imaging. RADIOLOGIA 2021; 64:S0033-8338(21)00086-2. [PMID: 33985767 DOI: 10.1016/j.rx.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/29/2022]
Abstract
Urgent and unexpected findings are very common in oncology and hematology patients. This article reviews the most important points included in the European Society of Radiology's guidelines and proposes a practical approach to reporting and communicating these findings more efficiently. This approach is explained with illustrative examples. Radiologists can provide added value in the management of these findings by helping referring clinicians reach the best decisions. To this end, it is essential to know the imaging manifestations of the most common findings that must be reported urgently, such as the specific toxicity of different treatments, the complications of tumors and catheters, infections, and thrombosis. Moreover, it is crucial to consider the individual patient's treatment, risk factors, clinical situation, and immune status.
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Affiliation(s)
- A Viteri Jusué
- Servicio de Radiodiagnóstico, Hospital Universitario Araba, Vitoria-Gasteiz, España.
| | | | - E Pérez Persona
- Servicio de Hematología, Hospital Universitario Araba, Vitoria-Gasteiz, España
| | - R Poza de Celis
- Servicio de Oncología Radioterápica, Hospital Universitario Araba, Vitoria-Gasteiz, España
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