Incidence of hemorrhagic complications in patients with cancer

Disseminated intravascular coagulation and melanoma: a novel case occurring in metastatic melanoma with BRAF and NRAS mutations and systematic review

Disseminated intravascular coagulation is a complex and potentially lethal complication of malignancy, in which the fundamental abnormality is excessive activation of the coagulation system. It is a rare complication of melanoma which can be difficult to diagnose in some circumstances, leading to delay in treatment. Herein, we describe the first case of disseminated intravascular coagulation occurring in BRAF and NRAS-mutant metastatic melanoma, and systematically review the literature regarding disseminated intravascular coagulation in melanoma. This review summarizes the reported cases of disseminated intravascular coagulation in melanoma and those secondary to the novel treatment of melanoma, and explores the pathophysiology of disseminated intravascular coagulation in melanoma, highlighting the key role of expression of markers of coagulation and fibrinolysis in disseminated intravascular coagulation, as well as more widely in melanoma. Current limitations in the literature are also identified and discussed, particularly with respect to improving the management of this lethal complication. Disseminated intravascular coagulation is a rare complication of melanoma that typically portends poor prognosis.

Pulmonary thromboembolism secondary to pelvic thrombosis related to giant ovarian tumor

Pulmonary thromboembolism (PTE) is one of the major complications in oncologic patients. The incidence of PTE in these cases is 4 to 7 times higher than in non-oncologic patients. Ovarian tumors, specifically those of large sizes, may impair the blood flow through the pelvic veins as tumor pressure over the pelvic vessels increases the incidence of thrombosis. The authors report the case of the unexpected death of a 74-year-old female due to massive pulmonary thromboembolism, associated with an ovarian tumor almost of 15 kg of weight that filled the abdominal and pelvic cavities. The compressive effect on the walls of the pudendal and periuterine veins somehow facilitated the local thrombosis. According to the histological characterization on post-mortem samples, the mass was identified as an “atypical proliferative (borderline) mucinous tumor.” The case emphasizes the important association between pulmonary thromboembolism and ovarian tumors

How low can you go: What is the safe threshold for platelet transfusions in patients with hematologic malignancy in sub-Saharan Africa

Background

Despite the importance of platelet transfusions in treatment of hematologic cancer patients, the optimal platelet count threshold for prophylactic transfusion is unknown in sub-Saharan Africa.

Methods

We followed patients admitted to the Uganda Cancer Institute with a hematological malignancy in 3 sequential 4-month time-periods using incrementally lower thresholds for prophylactic platelet transfusion: platelet counts ≤ 30 x 10⁹/L in period 1, ≤ 20 x 10⁹/L in period 2, and ≤ 10 x 10⁹/L in period 3. Clinically significant bleeding was defined as WHO grade ≥ 2 bleeding. We used generalized estimating equations (GEE) to compare the frequency of clinically significant bleeding and platelet transfusions by study period, adjusting for age, sex, cancer type, chemotherapy, baseline platelet count, and baseline hemoglobin.

Results

Overall, 188 patients were enrolled. The median age was 22 years (range 1–80). Platelet transfusions were given to 42% of patients in period 1, 55% in period 2, and 45% in period 3. These transfusions occurred on 8% of days in period 1, 12% in period 2, and 8% in period 3. In adjusted models, period 3 had significantly fewer transfusions than period 1 (RR = 0.6, 95% CI 0.4–0.9; p = 0.01) and period 2 (RR = 0.5, 95% CI 0.4–0.7; p<0.001). Eighteen patients (30%) had clinically significant bleeding on at least one day in period 1, 23 (30%) in period 2, and 15 (23%) in period 3. Clinically significant bleeding occurred on 8% of patient-days in period 1, 9% in period 2, and 5% in period 3 (adjusted p = 0.41). Thirteen (21%) patients died in period 1, 15 (22%) in period 2, and 11 (19%) in period 3 (adjusted p = 0.96).

Conclusion

Lowering the threshold for platelet transfusion led to fewer transfusions and did not change the incidence of clinically significant bleeding or mortality, suggesting that a threshold of 10 x 10⁹/L platelets, used in resource-rich countries, may be implemented as a safe level for transfusions in sub-Saharan Africa.

Creation and evaluation of a cancer chemotherapy order review guide for use at a community hospital

The proper evaluation of cancer chemotherapy orders is necessary for patients to receive safe and effective treatment. The chemotherapy treatment setting is evolving resulting in hospital pharmacists without extensive oncology training or experience now being responsible for evaluation of chemotherapy orders. The primary objective was to create a step-by-step chemotherapy order evaluation guide with a detailed explanation for each step. The secondary objective was to evaluate non-oncology trained pharmacists' ability to accurately review simulated chemotherapy orders post-education using the guide. A two-page chemotherapy order evaluation guide was created based on an accepted method of chemotherapy order review consisting of the following eight steps: regimen verification, clinical trial protocol verification, body surface area calculation, dose calculation, laboratory values, emesis prophylaxis, adjunctive or supportive care measures, and pharmacy labels. A literature search was performed for each step. A detailed explanation for each step was written as a separate component from the guide to encompass the literature search information and current guidelines in a more comprehensive manner. Non-oncology trained community hospital pharmacists were educated on use of the guide for approximately 30 min. The guide was evaluated using timed simulated chemotherapy orders pre- and post-education consisting of a general chemotherapy order and a carboplatin dosing order. Nineteen pharmacists were tested with simulated chemotherapy orders. A significant difference was detected between the pre- and post-education for both the general chemotherapy (p = 0.00032) order and carboplatin dosing order (p = 0.031).

Endovascular approach to acute hemorrhage in locally advanced breast cancer

We report a case of a woman with recurrent axillary fungating breast cancer who developed catastrophic hemorrhage from tumor erosion of her axillary artery. This was treated successfully with endovascular placement of a covered arterial stent. We discuss the suitability of endovascular therapy for patients with advanced malignancy given its lower morbidity in this population with decreased life expectancy.

Pharmacokinetic/Pharmacodynamic modeling of abexinostat-induced thrombocytopenia across different patient populations: application for the determination of the maximum tolerated doses in both lymphoma and solid tumour patients

BACKGROUND

In the clinical development of oncology drugs, the recommended dose is usually determined using a 3 + 3 dose-escalation study design. However, this phase I design does not always adequately describe dose-toxicity relationships.

METHODS

125 patients, with either solid tumours or lymphoma, were included in the study and 1217 platelet counts were available over three treatment cycles. The data was used to build a population pharmacokinetic/pharmacodynamic (PKPD) model using a sequential modeling approach. Model-derived Recommended Doses (MDRD) of abexinostat (a Histone Deacetylase Inhibitor) were determined from simulations of different administration schedules, and the higher bound for the probability of reaching these MDRD with a 3 + 3 design were obtained.

RESULTS

The PKPD model developed adequately described platelet kinetics in both patient populations with the inclusion of two platelet baseline counts and a disease progression component for patients with lymphoma. Simulation results demonstrated that abexinostat administration during the first 4 days of each week in a 3-week cycle led to a higher MDRD compared to the other administration schedules tested, with a maximum probability of 40 % of reaching these MDRDs using a 3 + 3 design.

CONCLUSIONS

The PKPD model was able to predict thrombocytopenia following abexinostat administration in both patient populations. A model-based approach to determine the recommended dose in phase I trials is preferable due to the imprecision of the 3 + 3 design.

Flipping the wound that doesn't heal: the upside of coagulation in cancer

Two mechanisms for targeting tumor vasculature are well recognized: antiangiogenesis and vascular disruption. In this issue of Blood, Bieker and colleagues take therapeutic advantage of coagulation and add a third mechanism, vascular infarction, to this group by demonstrating the effect through first-in-man administration of tTF-NGR.

Postoperative disseminated intravascular coagulation in a patient with ureteral metastasis from gastric cancer

A 66-year-old man, with a history of gastric signet ring cell carcinoma, was admitted due to intermittent dull pain in the left lower abdomen for 3 months. Left ureteral obstruction with suspicious tumor encasement and hydronephrosis was found on imaging studies. Endoscopic ureteral biopsy revealed infiltrating high-grade urothelial carcinoma. As a result, he underwent left nephroureterectomy and bladder cuff excision. Unexpectedly, metastatic carcinoma of the left ureter from the stomach was the final diagnosis after comparison of the permanent sections of the two specimens. Unfortunately, acute disseminated intravascular coagulation developed and the patient died of disease complications 16 days after the operation, even with intensive care. The details of this rare condition are reported herein with a review of the medical literature.

Platelet Transfusion Therapy

This article provides guidelines for the appropriate use of platelet transfusions to reduce unnecessary transfusions, thereby avoiding transfusion-related risks to the patients and the costs of platelet therapy. Platelet products available for transfusion are whole blood derived platelet concentrates and apheresis platelets. Leukoreduced platelets can be used to reduce platelet alloimmunization, cytomegalovirus transmission, and febrile transfusion reactions, while gamma irradiation prevents transfusion-associated graftversus-host disease. Other topics discussed are the expected response to transfused platelets and reasons for poor responses related to alloimmunization, underlying disease state, clinical conditions, and drugs. Appropriate transfusion guidelines based on pretransfusion platelet count, platelet dose, and whether the transfusion is prophylactic or therapeutic are outlined. Identification, prevention, and management of adverse consequences of platelet transfusions and platelet refractoriness are discussed.

Phase I/II dose escalation study of angiotensin 1-7 [A(1-7)] administered before and after chemotherapy in patients with newly diagnosed breast cancer

PURPOSE

Multilineage cytopenias occur following myelosuppressive chemotherapy. Most hematopoietic agents differentiate along a single lineage and fail to prevent progressive cytopenias. Angiotensin 1-7 [A(1-7)] is a hematopoietic agent that stimulates the proliferation of multipotential and differentiated progenitor cells in cultured bone marrow and human cord blood. The purpose of this study was to determine the optimal biologic dose and the maximum tolerated dose of A(1-7).

EXPERIMENTAL DESIGN

This study determined the safety and activity of A(1-7) following chemotherapy in patients with breast cancer. Toxicity was assessed by administering A(1-7) daily for 7 days followed by a 7-day washout prior to the first cycle of chemotherapy. Beginning 2 days after chemotherapy and continuing daily for at least 10 days, fifteen patients received five different A(1-7) doses and five patients received filgrastim as a comparator group over three cycles of chemotherapy.

RESULTS

No dose-limiting toxicity was observed following A(1-7). The frequency of adverse events was slightly lower in A(1-7) than in filgrastim patients. No patient required a chemotherapy modification due to hematologic toxicity. There was an apparent differential dose-response sensitivity of the various lineages to A(1-7). At a dose of 100 microg/kg, A(1-7) reduced the frequency of grade 2-4 thrombocytopenia, anemia, and grade 3-4 lymphopenia as compared to filgrastim.

CONCLUSION

These data suggest that A(1-7) may be beneficial in attenuating multilineage cytopenias following chemotherapy at a dose of 100 mug/kg per day.

Phase I/II dose escalation study of recombinant human interleukin-11 following ifosfamide, carboplatin and etoposide in children, adolescents and young adults with solid tumours or lymphoma: a clinical, haematological and biological study

Thrombocytopenia remains the major dose-limiting toxicity of myelosuppressive chemotherapy in children with solid tumours. Recombinant human interleukin-11 (rhIL-11) has been approved by the Food and Drug Administration as treatment for adults with solid tumours and lymphomas with severe chemotherapy-induced thrombocytopenia. We conducted a phase I/II trial of rhIL-11 following ifosfamide, carboplatin and etoposide (ICE) chemotherapy in children with solid tumours or lymphomas. Patients received ifosfamide 1800 mg/m(2)/d for 5 d, carboplatin 400 mg/m(2)/d for 2 d and etoposide 100 mg/m(2)/d for 5 d with rhIL-11 subcutaneous (s.c.) at 25-125 microg/kg/d on days 6-33. Forty-seven patients with median age 10.5 years (range, 0.7-26 years) were studied. Median days to absolute neutrophil count >/=0.5 x 10(9)/l, platelet count >/=50 x 10(9)/l and platelet transfusions were 23, 18, 18, 16.5 and 18.5, 21, 20, 18 and 3, 3, 4, and 2 d at doses 25, 50, 75 and 100 Schulteg/kg respectively. There was a dose-dependent increase in C(max) (7.6-25.5 ng/ml), AUC(0-rho) (57-209 ng.h/ml) and T(1/2) (4-8.2 h) respectively. There was a 4% incidence of anti-IL-11 antibody formation. Clinically important adverse events to rhIL-11 were papilloedema and periosteal bone formation. In summary, rhIL-11 was well tolerated at doses of </=50 microg/kg (maximal tolerated dose) and associated with improved haematological recovery and reduced platelet transfusion requirements compared with historical controls receiving similar ICE chemotherapy without rhIL-11.

Thrombocytopenia and hemorrhagic risk in cancer patients

In patients with malignant diseases, despite a direct relationship between the level of platelet count and bleeding episodes, it is evident that the risk of bleeding depends not only on the platelet count, but also on the underlying disease, the use of drugs interfering with platelet function and complications such as fever and infection or the presence of coagulation defects. As a consequence, it is not only the absolute platelet count, but rather the number of functional platelets that is important for the prevention of bleeding. As for Prophylaxis of hemorrhagic risk in these setting of patients, studies have now convincingly demonstrated that a 10,000/microL threshold for prophylactic platelet transfusion is safe and effective in uncomplicated thrombocytopenic patients. However, a threshold of 20,000/microL must be considered only for patients with high fever, hyperleukocytosis, coagulation abnormalities or who necessitate of invasive procedure. Moreover, as suggested by the clinical practice guidelines of the American Society of Clinical Oncology, a threshold of 20,000/microL must be considered for patients receiving aggressive therapy for bladder tumors and for those with demonstrated necrotic tumors.

Pharmacoeconomic analysis of oprelvekin (recombinant human interleukin-11) for secondary prophylaxis of thrombocytopenia in solid tumor patients receiving chemotherapy

BACKGROUND

Previous research has shown oprelvekin (recombinant human interleukin-11 [rhIL-11]) to be effective in reducing the requirements for platelet transfusions after myelosuppressive chemotherapy in patients who have previously experienced thrombocytopenia. The economic consequences of the routine use of this platelet growth factor and the usual standard of platelet transfusions for prophylaxis of severe chemotherapy-induced thrombocytopenia have not been compared.

METHODS

The authors constructed a decision-analytic model to compare the alternatives of rhIL-11 versus usual care using probability, outcome, and cost data from previously published clinical trials and their own institutional sources. They incorporated the costs of platelet transfusions and adverse events from rhIL-11 into the analysis. Quality-of-life outcomes were not considered. The pharmacoeconomic analysis was based on the criterion of cost minimization from the payer's perspective.

RESULTS

The expected cost of the usual care strategy for prophylaxis of severe thrombocytopenia (transfusion when platelets < 20000 microL(-1)) was US dollars 3495 for a 3-week cycle of chemotherapy. The prophylactic rhIL-11 strategy was more expensive, with an expected cost of US dollars 5328 over the same time period. Nonetheless, it was associated with fewer platelet transfusions, avoiding an average of 6.7 U compared with usual care. The savings from avoidance of platelet transfusion and adverse reactions to transfusion from the use of rhIL-11 were not offset by the substantial cost of the pharmaceutical. The greater expected costs from the rhIL-11 strategy were relatively insensitive to the unit price and efficacy of rhIL-11 and the costs of platelet transfusions and monitoring.

CONCLUSIONS

From the payer's perspective, rhIL-11 cannot be considered a cost-saving clinical strategy compared with routine platelet transfusions for patients with severe chemotherapy-induced thrombocytopenia.

Cost of chemotherapy-induced thrombocytopenia among patients with lymphoma or solid tumors

BACKGROUND

The purpose of this study was to estimate the mean incremental cost of chemotherapy-induced thrombocytopenia and the drivers of cost. Another goal was to estimate the impact of depth and duration of thrombocytopenia on the cost of thrombocytopenia.

METHODS

A retrospective cohort, consisting of a random sample of 75 solid tumor or lymphoma patients who developed chemotherapy-induced thrombocytopenia (</= 50,000 platelets per microl), was chosen. The number of each type of resource used during 217 cycles with and 300 cycles without thrombocytopenia were multiplied by the cost of each resource and summed to yield the total cost of care (in 1999 dollars from the provider's perspective).

RESULTS

Compared with cycles without thrombocytopenia, the mean incremental cost of thrombocytopenia was $1037 per cycle. However, 60% of cycles were usual cost, with a mean cost of thrombocytopenia of $43 per cycle less than control cycles. Twelve percent of cycles were high cost (mean incremental cost = $612 per cycle); 28% were very high cost (mean incremental cost = $3519). The excess cost during high-cost cycles was due to high consumption of prophylactic platelet transfusions and during very high-cost cycles to both higher platelet transfusion consumption and to a high incidence of major bleeding episodes.

CONCLUSIONS

Although thrombocytopenia is a common complication of chemotherapy, only 40% of cycles with thrombocytopenia would be considered high or very high cost. Interventions targeted at this subset of cycles could significantly reduce the cost of thrombocytopenia provided they are initiated early enough in the chemotherapy experience to be effective.

The Bleeding Risk Index: a clinical prediction rule to guide the prophylactic use of platelet transfusions in patients with lymphoma or solid tumors

BACKGROUND

The correlation between platelet count and bleeding has been well described, although no formal methods for applying this information to clinical decisions are available. The authors developed a clinical prediction rule to guide the prophylactic use of platelet transfusions among patients with lymphoma or solid tumors.

METHODS

The Bleeding Risk Index (BRI) was developed from logistic regression analysis of a randomly selected 750-chemotherapy cycle derivation set using data from Day 1 of cycles. The sensitivity and specificity of a BRI-based prophylaxis strategy were compared in a 512-cycle validation set with two strategies based on initiation of prophylaxis when platelet counts fell below thresholds of 20,000 per microL or 10,000 per microL.

RESULTS

Factors that were predictive of bleeding included any prior episode of bleeding (odds ratio [OR], 5.6; 95% confidence interval [95% CI], 2.2-14.0), treatment with a drug affecting platelet function (OR, 5.1; 95% CI, 2.0-12.6), bone marrow metastases (OR, 4.3; 95% CI, 1.7-10.8), a baseline platelet count < 75,000 per microL (OR, 3.5; 95% CI, 1.4-8.9), genitourinary or gynecologic malignancy (OR, 3.3; 95% CI, 1.3-8.2), a Zubrod performance status score > 2 (OR, 3.4; 95% CI, 1.4-8.5), and treatment with agents that were highly toxic to the bone marrow (OR, 2.2; 95% CI, 1.0-5.4). Compared with 20,000 and 10,000 platelet threshold strategies, the BRI-based strategy provided the best trade-off between sensitivity for major bleeding episodes (80%) and specificity for any bleeding (84%).

CONCLUSIONS

Patients with lymphoma or solid tumors who are at high risk of bleeding can be identified reliably on Day 1 of a chemotherapy cycle. An individualized, BRI-based approach to bleeding prophylaxis provides a highly sensitive and specific alternative to traditional, nonindividualized platelet threshold strategies.

What is the proper threshold for platelet transfusion in patients with chemotherapy-induced thrombocytopenia?

Platelet transfusion therapy is an integral part of modern oncological practice and is used to treat hemorrhage associated with thrombocytopenia. More commonly, platelets are transfused to prevent hemorrhage in thrombocytopenic patients. Conventional wisdom has suggested a threshold for prophylactic transfusion of <20x10(9)/l. Many studies now support the safety of more conservative transfusion regimes that reduce patient exposure to donors and conserve precious resources, without an increase in risk of hemorrhage. This review presents the data to support the use of a prophylactic transfusion threshold of <10x10(9)/l in patients without risk factors for hemorrhage and who have ready access to emergent medical care.

Platelet transfusion for patients with cancer: clinical practice guidelines of the American Society of Clinical Oncology

OBJECTIVE

To determine the most effective, evidence-based approach to the use of platelet transfusions in patients with cancer.

OUTCOMES

Outcomes of interest included prevention of morbidity and mortality from hemorrhage, effects on survival, quality of life, toxicity reduction, and cost-effectiveness.

EVIDENCE

A complete MedLine search was performed of the past 20 years of the medical literature. Keywords included platelet transfusion, alloimmunization, hemorrhage, threshold and thrombocytopenia. The search was broadened by articles from the bibliographies of selected articles.

VALUES

Levels of evidence and guideline grades were rated by a standard process. More weight was given to studies that tested a hypothesis directly related to one of the primary outcomes in a randomized design. BENEFITS/HARMS/COST: The possible consequences of different approaches to the use of platelet transfusion were considered in evaluating a preference for one or another technique producing similar outcomes. Cost alone was not a determining factor.

RECOMMENDATIONS

Appendix A summarizes the recommendations concerning the choice of particular platelet preparations, the use of prophylactic platelet transfusions, indications for transfusion in selected clinical situations, and the diagnosis, prevention, and management of refractoriness to platelet transfusion.

VALIDATION

Five outside reviewers, the ASCO Health Services Research Committee, and the ASCO Board reviewed this document.

SPONSOR

American Society of Clinical Oncology

FDA licensure of NEUMEGA to prevent severe chemotherapy-induced thrombocytopenia

This paper discusses background information and the body of clinical data that has been accumulated to demonstrate the efficacy and safety of NEUMEGA (recombinant human interleukin 11) when used to prevent severe chemotherapy-induced thrombocytopenia and reduce the need for platelet transfusions in patients with nonmyeloid malignancies. NEUMEGA is recommended to be used at a dose of 50 microg/kg s.c. once daily starting the day after chemotherapy ends until a platelet count of 50,000 cells/microl is achieved after the expected nadir.

Incidence, cost, and outcomes of bleeding and chemotherapy dose modification among solid tumor patients with chemotherapy-induced thrombocytopenia

PURPOSE

To describe the incidence and outcomes of bleeding and chemotherapy dose modifications associated with chemotherapy-induced thrombocytopenia (platelets < 50,000/microL).

PATIENTS AND METHODS

Six hundred nine patients with solid tumors or lymphoma were followed-up during 1,262 chemotherapy cycles complicated by thrombocytopenia for development of bleeding, delay or dose reduction of the subsequent cycle, survival, and resource utilization. The association between survival and bleeding or dose modification was examined using the Cox proportional hazards model. Predisposing factors were identified by logistic regression.

RESULTS

Bleeding occurred during 9% of cycles among patients with previous bleeding episodes (P <.0001), baseline platelets less than 75,000/microL (P <.0001), bone marrow metastases (P =.001), poor performance status (P =.03), and cisplatin, carboplatin, carmustine or lomustine administration (P =.0002). Major bleeding episodes resulted in shorter survival and higher resource utilization (P <.0001). Chemotherapy delays occurred during 6% of cycles among patients with more than five previous cycles (P =.003), radiotherapy (P =.03), and disseminated disease (P =.04). They experienced similar clinical outcomes but used significantly more resources. Dose reductions occurred during 15% of cycles but were not associated with poor clinical outcomes or excess resource utilization. Significantly shorter survival and higher resource utilization were observed among the 20% of patients who failed to achieve an adequate response to platelet transfusion.

CONCLUSION

The incidence of bleeding is low among solid tumor patients overall but exceeds 20% in some subgroups. These subgroups are easily identifiable using routinely available clinical information. A clinical prediction rule is being developed. Poor response to platelet transfusion is a clinically and financially significant downstream effect of thrombocytopenia and warrants further investigation.

Current issues with platelet transfusion in patients with cancer

For the past 30 years, platelet transfusions have been used in the treatment of thrombocytopenia caused by decreased production, inadequate function, or increased destruction of platelets. The number of platelet transfusions has increased more than transfusions of other blood components, shifting from whole blood use for the platelet source to plateletpheresis. Hematology/oncology patients are among the largest group receiving platelet transfusions, primarily because the more aggressive chemotherapies produce more acute and prolonged thrombocytopenia. While platelet transfusions often rescue patients with very low platelet levels, they are associated with the risk of viral and bacterial infections, as well as alloimmunization. Platelet donor recruitment can also be difficult, and platelet transfusion can be very expensive depending on the source of platelets. As a result, prophylactic transfusions are less likely to be administered at higher platelet counts, reducing platelet use and cost of platelet transfusions. However, cancer patients receiving intensive chemotherapy or myeloablative regimens require multiple platelet transfusions. For these patients, alternate strategies are needed so that platelet transfusions can be significantly reduced or eliminated.

Correlation of haemostatic abnormalities with tumour stage and characteristics in dogs with mammary carcinoma

Sixty female dogs with untreated mammary carcinoma, comprising equal numbers of dogs in tumour stages I to IV, were evaluated for haemostatic abnormalities using the following tests: platelet count, prothrombin time, activated partial thromboplastin time, thrombin time, plasma activity of factor V, VIII and X, plasma concentration of fibrinogen, fibrin monomers and fibrinogen degradation products, and plasma antithrombin III activity. Two-thirds of all dogs had one or more haemostatic test abnormality of which the likelihood and frequency was increased in those with stage III and IV neoplasia. Haemostatic abnormalities were more frequently observed in dogs which had mammary tumours with distant metastases, extended tumour necrosis, inflammatory carcinomas, tumours fixed to underlying structures, or tumours in which there was penetration of the tumour capsule by tumour cells. As in humans with mammary carcinoma, these haemostatic abnormalities might be used as prognostic indicators, but their clinical importance remains unknown.

Cancer-related thromboembolic disease in patients with solid tumours: a retrospective analysis

BACKGROUND

Cancer patients frequently suffer thromboembolic events. This study assessed the incidence and resource implications of cancer-related thromboembolic disease (CTD) in a single, large cancer centre.

PATIENTS AND METHODS

A retrospective analysis of patients admitted with CTD and/or the complications of treatment of CTD over a two-year period has been conducted. Forty-eight patients (23 male, 25 female, median age 60 years) with a variety of solid tumours were identified.

RESULTS

The initial presentations were venous thromboses (28 patients) and pulmonary embolism (20 patients). The median interval from cancer diagnosis to the initial episode of CTD was eight (range 0-112) months. Twenty-two patients suffered additional thromboses, despite maintenance warfarin anticoagulation in 18 patients. Six patients experienced anticoagulation-induced haemorrhage. Forty-one (85.4%) patients have died. The median survival from the first thromboembolic event was 8.5 months. The median inpatient stay for management of the first event was 10 (range 4-75) days, accounting for 729 inpatient days during the study period. Recurrent episodes of CTD or complications of anticoagulation resulted in 28 readmissions, accounting for 295 inpatient days. During the two-year period 1024 inpatient days were directly caused by CTD and its complications, representing 6.1% bed occupancy on our unit.

CONCLUSION

This study demonstrates that CTD represents a significant cause of morbidity in cancer patients with considerable resource implications for cancer centres. Improvements in prevention and management of CTD would reduce morbidity and lead to considerable cost savings.

Transfusion and stem cell support in cancer treatment

Intensification of therapeutic regimens, improved patient survival, and advances in cytokine and cellular therapies have led to increasingly complex requirements for transfusion and stem cell support in cancer treatment. This article focuses on current and evolving issues in red blood cell, platelet, and granulocyte transfusion support, as well as measures to avoid increasingly important complications of transfusion therapy, such as alloimmunization, graft-versus-host disease, cytomegalovirus infection, and immunomodulation. Issues concerning current applications of hematopoietic stem cell transplantation and future prospects also are discussed.

Haemostasis activation markers in plasma of patients with benign and malignant gynaecological tumours: a pilot study

Coagulation and fibrinolysis activation have been investigated in fifty-eight women with recently detected gynaecological tumours. Twenty-six were benign and 32 malignant: of the last group nine patients had metastases. A control group consisted of 31 age-matched healthy women. Prothrombin fragment 1 + 2, thrombin-antithrombin III and D-dimer were measured. The median values of all analytes were significantly higher in the malignant tumour group, but not in the benign tumour group, as compared to the control group. The group of patients with a gynaecological tumour and metastases differed from the non-metastasized tumour group in prothrombin fragment 1 + 2, thrombin-antithrombin III and D-dimer. In the non-metastasized malignant tumour group solely prothrombin fragment 1 + 2 was significantly higher than in the benign tumour group. Coagulation and fibrinolysis predominating as can be derived from the elevated D-dimer/thrombin-antithrombin III and D-dimer/prothrombin fragment 1 + 2 ratios. The studied constituents do not enable a differentiation between the benign and malignant processes. However, as the differences of these values in both malignant tumour groups were significant, this might be used to trace the existence of metastases in gynaecological tumours. Investigation of these analytes in several specific types of gynaecological tumours might be clinically relevant.

Endothelin-1 as an aggravating factor of disseminated intravascular coagulation associated with malignant neoplasms

BACKGROUND

Vascular endothelial damage may play an important role in the pathophysiology of disseminated intravascular coagulation (DIC), a frequent complication of malignant neoplasms. It may mediate a variety of triggering events to initiate DIC and platelet aggregation, which in turn leads to additional endothelial destruction. If so, endothelin-1 (ET-1), the most potent vasoconstrictor of naturally occurring pressor substances known, may leak from injured endothelial cells and aggravate the disease process.

METHODS

The study included 36 patients with various malignant neoplasms in whom DIC developed. The authors measured plasma levels of ET-1 and big ET-1, a precursor peptide of ET-1, in these patients and compared them with other laboratory abnormalities during the course of DIC.

RESULTS

Plasma ET-1 and big ET-1 levels were elevated in most patients with DIC. When compared with the results of other diagnostic tests, elevated plasma big ET-1 was the most frequently found abnormality associated with DIC. Elevation of plasma ET-1 and big ET-1 levels was closely related to the initiation and progression of DIC and provided a higher degree of sensitivity and specificity than did other indicators in assessing patients with cancer and DIC.

CONCLUSIONS

Vascular endothelial damage with the resultant increases in plasma ET-1 and big ET-1 levels is universally associated with DIC caused by malignancy. Excessive secretion or leakage of ET-1 and big ET-1 from injured endothelial cells may cause vasospasm and aggravate the DIC process by facilitating the formation of intravascular microthrombi, ultimately leading to ischemic end-organ dysfunction. Plasma ET-1 and big ET-1 are sensitive and specific markers for vascular endothelial injury in DIC.

The Role of Hemapheresis Technology in Allogeneic Bone Marrow Transplantation

In this paper the impact of hemapheresis technology on 238 allogeneic bone marrow transplants performed in Pescara from 1982 through 1993 is described. Granulocyte transfusions were limited to patients with neutrophil level <0.2x109/L. An average of 4 units of packed red blood cells were required to maintain adequate hemoglobin levels. Patients with major ABO incompatibility showed an increased requirement of red blood cell support as compared to patients ABO-matched and ABO minor mismatched. For platelet support single-donor platelets collected on a blood-cell separator were given. A total of 1548 platelet transfusions were examined. The median number of platelet transfusions for each patient was 5. Platelet refractoriness occurred in 44% of patients. The hemorrhage related mortality was 0.9%.

The advancement made in the field of hemapheresis technology, as well as the improved transplant technique, have contributed to increase the post-transplant survival from 17% in the early experience (1976-1982) to 88% in the recent years (1992-1993).

Hemostasis in malignancy

Hemostatic abnormalities are present in a majority of patients with metastatic cancer. These abnormalities can be categorized as 1) increased platelet aggregation and activation, 2) abnormal activation of coagulation cascade, 3) release of plasminogen activator, and 4) decreased hepatic synthesis of anticoagulant proteins like Protein C and antithrombin III. The abnormal activation of coagulation cascade is mediated through release of Tissue Factor, Factor X activators, and other miscellaneous procoagulants from the plasma membrane vesicles of tumor cells. Macrophages of a tumor-bearing host also produce increased amounts of Tissue Factor. Production of Factor X activators and macrophage Tissue Factor is decreased by warfarin. The ability of the tumor cells to produce platelet-aggregating activity and plasminogen activator parallels their metastatic potential in animal and experimental systems. These studies also show that antiplatelet agents and antibodies against plasminogen activator can suppress the metastatic process. One or more laboratory abnormalities of hemostasis can be shown in up to 95% of patients with metastatic cancer. These abnormalities, however, are unable to predict subsequent development of thromboembolic or hemorrhagic complications. Clinical complications occur in 9-15% of the patients in the form of thrombotic or hemorrhagic disorders. The therapy of tumor-related coagulopathy should be guided by its clinical expression. Subclinical DIC should not be treated. Coumadin is generally ineffective for therapy of thrombosis in cancer patients. There is no consensus regarding the use of heparin in acute promyelocytic leukemia (APL). The defibrination in APL may be from disseminated intravascular coagulation as well as systemic fibrinolysis, as shown by decreased alpha 2 antiplasmin levels. In such cases, epsilon aminocaproic acid plus heparin therapy may be of benefit.

Prevalence of pulmonary embolism at necropsy in patients with cancer

The series studied comprised 6197 patients who had died of or who had cancer at death and represents all patients with cancer from 21,530 necropsies performed at this department from 1960-84. Pulmonary embolism was significantly more common among cancer patients than in those with non-neoplastic diseases. Among those palliatively treated, patients with ovarian cancer, cancer of the extrahepatic bile duct system, and cancer of the stomach had the highest prevalence of pulmonary embolism (34.6%, 31.7%, and 15.2%, respectively). Necropsy patients with cancer of the oesophagus and larynx, together with leukaemia, myelomatosis, and malignant lymphoma had the lowest prevalence (0-5.6%). Palliatively treated cancers in organs of the peritoneal cavity had a significantly higher incidence than all other cancers combined. Cancer of the peritoneal cavity may impede venous drainage from the lower limbs and thus be an important factor in the onset of deep calf vein thrombosis and pulmonary embolism. It is concluded that cancer represents an increased risk factor for onset of pulmonary embolism, in particular in patients with ovarian cancer and cancer of the extrahepatic bile duct system.

Coagulation abnormalities associated with neoplasia

Subclinical abnormalities in hemostasis occur commonly in small animal patients with cancer, but the incidence of clinical thrombosis or hemorrhage is unknown. Malignancy can lead to abnormalities in both primary and secondary hemostasis, which in turn can lead to either thrombotic or hemorrhagic tendencies. These coagulation abnormalities can be associated with the tumor itself, with anticancer chemotherapy, or with secondary organ dysfunction. Thrombocytopenia and DIC are probably the most common defects associated with clinical bleeding in small animal patients.

Untreated prostatic carcinoma is not associated with frequent thrombohemorrhagic disorders

We conducted an evaluation of the hemostatic integrity of patients with untreated cancer of the prostate. Of 60 patients analyzed retrospectively, only 1 had a mild case of disseminated intravascular coagulation, possibly associated with concomitant estrogen therapy, and in 1 patient mild deep vein thrombosis developed preoperatively, also possibly associated with multiple medications for concurrent disorders. Of 16 other patients prospectively evaluated on admission, only 1 had frankly abnormal levels of fibrinopeptide A unaccompanied by other coagulation abnormalities. Occasional individuals had minimal, negligible deviations of partial thromboplastin times, thrombin time, or antithrombin III values. In none of these patients did hemostatic complications develop during their hospital stay. These results demonstrate that although an occasional coagulation abnormality may occur in patients with cancer of the prostate (albeit with a lower incidence than in other neoplasms), this malignancy does not require increased precautions with respect to those given to the patient population at large.

In vitro generation of procoagulant activity by leukemic promyelocytes in response to cytotoxic drugs

Disseminated intravascular coagulation (DIC) is a frequent occurrence in acute promyelocytic leukemia (APL), especially after onset of chemotherapy. We have used a human promyelocytic leukemic established cell line (HL-60) and various other human leukemic cells to investigate the effect of cytotoxic drugs on generation of procoagulant activity (PCA). The results indicate that, unlike normal human peripheral blood monocytes and certain other cell types where PCA induction requires active mRNA and protein synthesis, in HL-60 cells, compounds such as actinomycin D, puromycin, and cytosine arabinoside and a variety of other cytotoxic agents, induced generation of a potent PCA. Although different in its mechanism of induction, this HL-60 cell PCA was similar, and may be identical, to mononuclear cell tissue factor. The PCA induction was rapid and preceded the lytic effect of the drugs. It was first detected on the outer cell surface but, following prolonged exposure to the drugs, upon lysis of the cells, it was also found in the extracellular medium. This in vitro effect mimics the development of DIC in patients with APL. The system may, therefore, serve as a model for the study of the cellular and molecular events associated with PCA generation by malignant promyelocytes and DIC occurrence in patients with APL and other malignancies.

Incidence of thrombocytopenia and serious hemorrhage among patients with solid tumors

To evaluate the incidence of thrombocytopenia and bleeding among patients with solid tumors treated intensively with chemotherapy, the records of 1274 patients treated between 1972 and 1980 on protocols known to produce significant myelosuppression were reviewed. Three hundred one patients with solid tumors (breast, lung, melanoma, sarcoma, primary brain, testicular, hypernephroma and others) experienced 5063 days of thrombocytopenia (platelet count less than 50,000/microliters) and 670 days of severe thrombocytopenia (platelet count less than 20,000/microliters). The median number of days thrombocytopenia was 6 (range, 1-250). There were only 44 episodes of clinically detectable serious bleeding, primarily gastrointestinal (26/44), during thrombocytopenia and all but seven episodes first occurred at platelet counts between 20,000-50,000/microliters. Fifteen of the 44 bleeding episodes were associated with coagulation abnormalities, 24 occurred during serious infection, and 12 occurred at sites of tumors. One hundred forty-seven of the 301 patients (49%) received platelet transfusions. In 86 thrombocytopenic patients with central nervous system (CNS) tumors, there was no evidence of CNS bleeding during thrombocytopenia. Hemorrhagic deaths were uncommon, and of the 12 patients who died of bleeding, 7 had normal counts. There is a very low incidence of significant thrombocytopenia or bleeding among patients with solid tumors treated with combination chemotherapy or experimental agents escalated to maximally tolerated doses. These data suggest that with respect to thrombocytopenic bleeding intensive treatment of patients with solid tumors can be pursued with relative safety utilizing the standard transfusion supportive measures now widely available.

Therapeutic and clinical course of deep vein thrombosis

We have reviewed our experience with the treatment of 250 patients with deep vein thrombosis diagnosed by contrast venography. The level of thrombosis was recorded according to the anatomic level to which it extended. A third of the patients had cancer, and the most common clinical findings were swelling and pain. The risk of the development of pulmonary embolism, based on the anatomic level of initial deep vein thrombosis, revealed the following: 12 of 115 patients (10 percent) with level I (calf) deep vein thrombosis developed pulmonary embolism, as did 2 of 27 patients (7 percent) with level II (popliteal) disease, 5 of 60 (8 percent) with level III (thigh) disease, 1 of 19 patients (5 percent) with level IV (groin) disease, and 2 of 26 patients (8 percent) with level V (iliac) disease. Based on our favorable experience with heparin we believe that heparin is the treatment of choice for deep vein thrombosis regardless of the anatomic level. The incidence of pulmonary embolism does not appear to be influenced significantly by the level of the deep vein thrombosis.

Clinical experience with vena caval filters in high-risk cancer patients

Our experience with the placement of intracaval filter devices in patients with malignancies, is reviewed. Seventy patients had either a Mobin Uddin or Greenfield Umbrella Filter placed since 1971. The indications for caval interruption in our series included contraindications to anticoagulant therapy, bleeding with anticoagulant therapy, and recurrent pulmonary embolism with anticoagulant therapy. Of the 70 patients, 47 had a diagnosis of deep vein thrombosis, 15 had the diagnosis of pulmonary embolus, and eight had the diagnosis of both deep vein thrombosis and pulmonary embolus. The types of malignancies that were present in our patients included breast carcinoma, gynecologic tumors, colon tumors, pancreatic carcinoma, and hematologic malignancies. We report no operative mortality and a low operative morbidity of 7% utilizing this method of caval interruption. The late morbidity of stasis sequelae following caval interruption was present in 14% of the patients. Based on a favorable experience with this method of vena cava interruption in high-risk patients with advanced malignancies, the authors suggest a more liberal indication for caval interruption in this group of patients.

Oncology Grand Rounds. Platelet transfusion--clinical applications in the oncology setting

The increased availability of platelets for transfusion has been a major factor in the improved prognosis noted in patients with acute nonlymphocytic leukemia. This review summarizes our current understanding of the proper use of platelet transfusion for patients with leukemia and cancer, with a particular emphasis on the management of alloimmunized patients. The need for careful and close collaboration between the blood bank and the referring clinicians is emphasized. Cryopreservation of autologous platelets, which can be of considerable assistance in the management of alloimmunized patients, and a summary of the large number of questions that still require further investigation are presented.

Hemostatic function in cancer patients

We performed coagulation profiles including a complete blood count (CBC), prothrombin time (PT), activated partial thromboplastin time (aPTT), and quantitation of fibrinogen, antithrombin III (AT III), plasminogen, and fibrin/fibrinogen degradation products (FDP) on 73 cancer patients. All had solid tumors with clinically documented metastases. Eleven patients had strong clinical and laboratory evidence of disseminated intravascular coagulation (DIC). Fifty-five of the remaining 62 patients had no clinical evidence of serious hemorrhage or thrombosis at the time of testing. Thirty-one (50%) non-DIC patients had no abnormal clotting tests. Our data indicate that a majority of cancer patients, with or without hepatic involvement, are able to maintain normal or near normal hemostatic function in vitro until advanced stage of disease. Deviation from normal for PT, aPTT, or TT, depressed AT III activity, or increased FDP signal the presence of complicating pathophysiologic events such as DIC or cirrhosis. Diminution of fibrinogen level or AT III activity and elevation of FDP are more sensitive indicators of DIC than prolongation of PT, aPTT, or TT.

Coagulation problems in patients with cancer

The cases of 43 cancer patients and nine patients without cancer were reviewed to assess the coagulation mechanism in patients with cancer. Of the 43 patients with cancer, at least one factor known to be associated with coagulation disturbances was present in 26. Hematologic or coagulation studies disclosed one or more abnormalities in 34 of the patients. A subgroup of 17 patients had no clinical or laboratory evidence of ongoing variables that should interfere with coagulation or hemostasis. Of these, 11, or 65%, had one or more abnormal results from coagulation studies. Of the nine members of the control group (patients without cancer), no patient had a positive history for a clinical coagulation disorder except for one incidence of thrombophlebitis in the year preceding the study. During the study, at least one coagulation abnormality was disclosed by hematologic testing. The results support the concept that coagulation problems in cancer patients are attributable to debilitation, multiple organ involvement, and coagulation-interfering variables rather than to a primary effect of the malignant tumor.