Clinical significance of glycemic parameters on venous thromboembolism risk prediction in gastrointestinal cancer

Circulating Blood Biomarkers and Risk of Venous Thromboembolism in Cancer Patients: A Systematic Review and Meta-Analysis

BACKGROUND

 Cancer patients have an increased risk of venous thromboembolism (VTE). Currently, the availability of highly discriminatory prediction models for VTE in cancer patients is limited. The implementation of biomarkers in prediction models might lead to refined VTE risk prediction. In this systematic review and meta-analysis, we aimed to evaluate candidate biomarkers and their association with cancer-associated VTE.

METHODS

 We searched Medline, EMBASE, and Cochrane Central for studies that evaluated biomarkers in adult cancer patients from inception to September 2022. We included studies reporting on VTE after a cancer diagnosis with biomarker measurements performed at a defined time point. Median/mean differences (for continuous measures) and odds ratios (for dichotomous measures) with 95% confidence intervals were estimated and pooled using random-effects models.

RESULTS

 We included 113 studies in the systematic review. Of these, 50 studies were included in the meta-analysis. We identified two biomarkers at cancer diagnosis (factor VIII and time to peak thrombin), three biomarkers pre-chemotherapy (D-dimer, fibrinogen, and mean platelet volume), and one biomarker preoperatively (platelet count) that had significant median or mean differences. Additionally, we found that hemoglobin <100 g/L and white blood count >11 × 109/L were significantly associated with future VTE risk only when measured at cancer diagnosis. Pre-chemotherapy neutrophil-to-lymphocyte ratio ≥3 and preoperative platelet count ≥400 × 109/L were also found to be associated with future VTE risk.

CONCLUSION

 In conclusion, this study identified nine candidate blood biomarkers that may help in optimizing VTE prediction in cancer patients that should be further explored in future studies.

The genetic causal relationship between type 2 diabetes, glycemic traits and venous thromboembolism, deep vein thrombosis, pulmonary embolism: a two-sample Mendelian randomization study

OBJECTIVE

To investigate the genetic underpinnings of the association between type 2 diabetes (T2D), glycemic indicators such as fasting glucose (FG), fasting insulin (FI), and glycated hemoglobin (GH), and venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), thereby contributing novel insights to the scholarly discourse within this domain.

METHODS

Genome-wide association study (GWAS) summary data pertaining to exposures (T2D, FG, FI, GH) and outcomes (VTE, DVT, PE) were acquired from the IEU Open GWAS database, encompassing participants of European descent, including both male and female individuals. Two-sample Mendelian randomization (MR) analyses were conducted utilizing the TwoSampleMR and MRPRESSO packages within the R programming environment. The primary analytical approach employed was the random-effects inverse variance weighted (IVW) method. Heterogeneity was assessed via Cochran's Q statistic for MR-IVW and Rucker's Q statistic for MR-Egger. Horizontal pleiotropy was evaluated using the intercept test of MR Egger and MR pleiotropy residual sum and outlier (MR-PRESSO) analysis, with the latter also employed for outlier detection. Additionally, a "Leave one out" analysis was conducted to ascertain the influence of individual single nucleotide polymorphisms (SNPs) on MR results.

RESULTS

The random-effects IVW analysis revealed a negative genetic causal association between T2D) and VTE (P = 0.008, Odds Ratio [OR] 95% confidence interval [CI] = 0.896 [0.827-0.972]), as well as between FG and VTE (P = 0.002, OR 95% CI = 0.655 [0.503-0.853]), GH and VTE (P = 0.010, OR 95% CI = 0.604 [0.412-0.884]), and GH and DVT (P = 0.002, OR 95% CI = 0.413 [0.235-0.725]). Conversely, the random-effects IVW analysis did not detect a genetic causal relationship between FI and VTE (P > 0.05), nor between T2D, FG, or FI and DVT (P > 0.05), or between T2D, FG, FI, or GH and PE (P > 0.05). Both the Cochran's Q statistic for MR-IVW and Rucker's Q statistic for MR-Egger indicated no significant heterogeneity (P > 0.05). Moreover, the intercept tests of MR Egger and MR-PRESSO suggested the absence of horizontal pleiotropy (P > 0.05). MR-PRESSO analysis identified no outliers, while the "Leave one out" analysis underscored that the MR analysis was not influenced by any single SNP.

CONCLUSION

Our investigation revealed that T2D, FG, and GH exhibit negative genetic causal relationships with VTE at the genetic level, while GH demonstrates a negative genetic causal relationship with DVT at the genetic level. These findings furnish genetic-level evidence warranting further examination of VTE, DVT, and PE, thereby making a contribution to the advancement of related research domains.

Characterization of perioperative glycemic status and dexamethasone use with associated postoperative complications in glioblastoma patients

PURPOSE

Postoperative morbidity in glioblastoma (GBM) patients can be due to the disease course but can also come from postoperative complications. Our objective was to study the association of dexamethasone use and perioperative hyperglycemia with postoperative complications in GBM patients.

METHODS

A single-center, retrospective cohort study was conducted in patients who underwent surgery for primary GBM from 2014-2018. Patients with perioperative fasting blood glucose (FBG) measurements and adequate follow-up to assess for complications were included.

RESULTS

A total of 199 patients were included. More than half (53%) had poor perioperative glycemic control (FBG ≥ 7 mM for ≥ 20% perioperative days). Higher dexamethasone dose (≥ 8 mg) was associated with higher FBG on postoperative days 2-4 and 5 (p = 0.02,0.05,0.004,0.02, respectively). Poor glycemic control was associated with increased odds of 30-day any complication and 30-day infection on univariate analysis (UVA), and 30-day any complication and increased length of stay (LOS) on multivariate analysis (MVA). Higher average perioperative daily dexamethasone dose was associated with increased odds of 30-day any complication and 30-day infection on MVA. Elevated hemoglobin A1c (HgbA1c, ≥ 6.5%) was associated with increased odds of 30-day any complication, 30-day infection, and LOS on UVA. In a multivariate linear regression model, only the diagnosis of diabetes mellitus predicted perioperative hyperglycemia.

CONCLUSIONS

Perioperative hyperglycemia, higher average dexamethasone use and elevated preoperative HgbA1c are associated with increased risk of postoperative complications in GBM patients. Avoiding hyperglycemia and limiting dexamethasone use in postoperative period may decrease the risk of complications. Select HgbA1c screening may allow the identification of a group of patients at higher risk of complications.

Glycemia and venous thromboembolism in patients with primary brain tumors - A speculative review

Venous thromboembolism (VTE) is a significant public health issue causing severe morbidity and mortality. One of the most vulnerable populations for VTE development are cancer patients. And among them, patients with brain tumors have arguably the highest risk of developing this often fatal complication. Hyperglycemia is a well-known factor which leads to a wide variety of pro-thrombotic changes. In this article, we review the current literature on the topic of VTE in brain tumor patients. We also discuss the known correlation between VTE and glycemia, as well as the importance and frequency of glycemia dysregulation in brain tumor patients. Based on the already well-known importance of glucose metabolism in cancer patients, as well as the previous research of our group, we hypothesize that there is a significant number of brain tumor patients who have chronically elevated glycemia, a fact that so-far hasn't been reported. We argue that these patients carry a significantly higher risk of VTE development and would benefit greatly from strict glycemic control. We present our hypothesis, the ways in which to test it, as well as the possible counter-arguments against it. Our hope is that other investigators will be inspired by our article to continue this type of research, since we consider the topic of VTE in brain tumor patients highly important and urgent, primarily due to its prevalence and severity.

The risk of venous thromboembolism in cancer patients receiving chemotherapy: a meta-analysis with systematic review

Background

The Khorana score was developed to predict the risk of venous thromboembolism (VTE) in cancer patients receiving chemotherapy. However, the utility of the Khorana score remains controversial since different studies report varying results. This meta-analysis aims to analyze the incidence of VTE with different risk stratifications using the Khorana score for overall follow-up time, incidence of deep-vein thrombosis (DVT), incidence of pulmonary embolism (PE) and bleeding in cancer patients receiving chemotherapy.

Methods

A systemic search was performed using PubMed, Embase, Cochrane Library and Web of Science for studies describing VTE incidence in cancer patients undergoing chemotherapy. The incidence of VTE was calculated using R computing software.

Results

We included 13 studies in this meta-analysis, with a total of 5,852 cancer patients and 424 VTE cases. Results revealed that overall incidence of low, intermediate and high-risk groups were 2% (95% CI: 1–6%), 11% (95% CI: 6–18%) and 14% (95% CI: 9–20%), respectively. The overall incidence of DVT and PE were 6% (95% CI: 4–10%) and 4% (95% CI: 2–7%), respectively. Lastly, bleeding rate was 4% (95% CI: 2–8%).

Conclusions

According to this meta-analysis, the Khorana score is suitable for cancer patients receiving chemotherapy in a 3–6-month timeframe rather than “forever”. The incidence of PE in this population was significantly greater than what was observed for non-cancer patients. More than half of VTE events occurred within 6 months of commencing chemotherapy.

From Classical Laboratory Parameters to Novel Biomarkers for the Diagnosis of Venous Thrombosis

Venous thrombosis is a common and potentially fatal disease, because of its high morbidity and mortality, especially in hospitalized patients. To establish the diagnosis of venous thrombosis, in the last years, a multi-modality approach that involves not only imaging modalities but also serology has been evolving. Multiple studies have demonstrated the use of some biomarkers, such as D-dimer, selectins, microparticles or inflammatory cytokines, for the diagnosis and treatment of venous thrombosis, but there is no single biomarker available to exclusively confirm the diagnosis of venous thrombosis. Considering the fact that there are some issues surrounding the management of patients with venous thrombosis and the duration of treatment, recent studies support the idea that these biomarkers may help guide the length of appropriate anticoagulation treatment, by identifying patients at high risk of recurrence. At the same time, biomarkers may help predict thrombus evolution, potentially identifying patients that would benefit from more aggressive therapies. This review focuses on classic and novel biomarkers currently under investigation, discussing their diagnostic performance and potential benefit in guiding the therapy for venous thrombosis.

Predicting VTE in Cancer Patients: Candidate Biomarkers and Risk Assessment Models

Risk prediction of chemotherapy-associated venous thromboembolism (VTE) is a compelling challenge in contemporary oncology, as VTE may result in treatment delays, impaired quality of life, and increased mortality. Current guidelines do not recommend thromboprophylaxis for primary prevention, but assessment of the patient's individual risk of VTE prior to chemotherapy is generally advocated. In recent years, efforts have been devoted to building accurate predictive tools for VTE risk assessment in cancer patients. This review focuses on candidate biomarkers and prediction models currently under investigation, considering their advantages and disadvantages, and discussing their diagnostic performance and potential pitfalls.

The Khorana score for prediction of venous thromboembolism in cancer patients: a systematic review and meta-analysis

We aimed to evaluate the performance of the Khorana score in predicting venous thromboembolic events in ambulatory cancer patients. Embase and MEDLINE were searched from January 2008 to June 2018 for studies which evaluated the Khorana score. Two authors independently screened studies for eligibility, extracted data, and assessed risk of bias. Additional data on the 6-month incidence of venous thromboembolism were sought by contacting corresponding authors. The incidence in each Khorana score risk group was estimated with random effects meta-analysis. A total of 45 articles and eight abstracts were included, comprising 55 cohorts enrolling 34,555 ambulatory cancer patients. For 27,849 patients (81%), 6-month follow-up data were obtained. Overall, 19% of patients had a Khorana score of 0 points, 64% a score of 1 or 2 points, and 17% a score of 3 or more points. The incidence of venous thromboembolism in the first six months was 5.0% (95%CI: 3.9-6.5) in patients with a low-risk Khorana score (0 points), 6.6% (95%CI: 5.6-7.7) in those with an intermediate-risk Khorana score (1 or 2 points), and 11.0% (95%CI: 8.8-13.8) in those with a high-risk Khorana score (3 points or higher). Of the patients with venous thromboembolism in the first six months, 23.4% (95%CI: 18.4-29.4) had been classified as high risk according to the Khorana score. In conclusion, the Khorana score can be used to select ambulatory cancer patients at high risk of venous thromboembolism for thromboprophylaxis; however, most events occur outside this high-risk group.