Hypercoagulability After Resection of Thoracic Malignancy: A Prospective Evaluation

Fibrin Clot Properties in Cancer: Impact on Cancer-Associated Thrombosis

Cancer is associated with a high risk of venous thromboembolism (VTE) and its recurrence. There is evidence that the prothrombotic fibrin clot phenotype, involving the formation of denser and stiffer clots relatively resistant to lysis, occurs in cancer patients, which is in part related to enhanced inflammation, oxidative stress, and coagulation activation, along with the release of neutrophil extracellular traps, indicating that fibrin-related mechanisms might contribute to cancer-associated thrombosis (CAT). Multiple myeloma and its therapy have been most widely explored in terms of altered fibrin characteristics, but prothrombotic fibrin clot features have also been reported in patients with active solid cancer, including lung cancer and gastrointestinal cancer. Patient-related factors such as advanced age, smoking, and comorbidities might also affect fibrin clot characteristics and the risk of CAT. Prothrombotic fibrin clot features have been shown to predict the detection of cancer in patients following VTE during follow-up. Cancer-specific therapies and anticoagulation can favorably modify the phenotype of a fibrin clot, which may alter the course of CAT. It is unclear whether the fibrin clot phenotype might help identify patients with CAT who are more likely to experience recurrent events. This narrative review summarizes the current knowledge on the role of fibrin clot structure and function in cancer patients in the context of CAT.

Changes in Coagulation in Cancer Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Treatment (HIPEC)-A Systematic Review

Venous thromboembolism and postoperative bleeding are complications of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this systematic review was to summarize current knowledge on the effect of cytoreductive surgery with HIPEC on coagulation and fibrinolysis within 10 days after surgery. Studies were identified in PubMed, Embase, and Web of Science on December 12, 2022. Data on biomarkers of coagulation and fibrinolysis measured preoperatively up to the 10th postoperative day were extracted. Among 15 included studies, 13 studies reported markers of primary hemostasis. Eleven studies found reduced platelet count following cytoreductive surgery with HIPEC and two studies reported reduced platelet function. Twelve studies reported impaired secondary hemostasis until postoperative day 10 indicated by prolonged international normalized ratio, prothrombin time, and activated partial thromboplastin time. Fibrinogen was decreased in three studies from preoperative to postoperative day 3 switching to increased levels until postoperative day 10. In accordance, three studies found reduced maximum amplitude and maximum clot firmness by thromboelastography/thromboelastometry (ROTEM/TEG) on the first postoperative day indicating impaired clot strength. Four studies demonstrated increased d-dimer, factor (F) VIII, and thrombin generation during the 10 postoperative days. Four studies investigated fibrinolysis by ROTEM/TEG and plasminogen activator inhibitor-1 (PAI-1) after cytoreductive surgery with HIPEC reporting contradictive results. In conclusion, a decrease in platelet count and subtle changes in secondary hemostasis were found following cytoreductive surgery with HIPEC. Data on the effect of cytoreductive surgery with HIPEC on fibrinolysis are sparse and this needs to be further investigated.

Evaluation of Haemostasis in Dogs Affected by Resectable Malignancy

Dogs with neoplasm are at risk of thrombosis, yet there is no information on the haemostatic alterations that may result from the surgeries performed to remove neoplastic masses. The aim of this study was to observe the characteristics of haemostasis in dogs undergoing surgery to remove a malignancy by means of rotational thromboelastometry and thrombin generation. Haemostasis was assessed immediately before surgery (T0), 24 h after surgery (T1), and two weeks after surgery (T2). Statistically significant differences were found between the thromboelastometric parameters at T0 vs. T1, with increases observed in MCF, the α angle, and G parameters in the ex-TEM and in-TEM profiles. In the thromboelastometric analysis performed after surgery differences were identified between T1 and T2, with a decrease observed in parameters such as CFT, MCF, the α angle, and G. Between T0 and T2, only a significant decrease in CT was detected in the fib-TEM profile. No differences were found in the comparison among the results obtained via thrombin generation. In dogs with resectable malignancies, the surgeries performed to remove cancer affected coagulation, causing a tendency towards hypercoagulability. The interference with coagulation was transient, and 2 weeks after surgery, the thromboelatometric results returned to those obtained before surgery (T0).

Development and verification of a novel blood viscoelastic monitoring method based on reciprocating motion of magnetic bead

Blood coagulation function is an essential index in clinical examination, and it is of great significance to evaluate blood coagulation function comprehensively. Based on the blood viscoelasticity theory and hydrodynamics, we proposed a method to monitor the whole blood coagulation process based on the reciprocating motion of the magnetic bead (magnetic bead method for short). We have established a mathematical model between the moment acting on the magnetic bead and the viscoelasticity of blood in the process of blood coagulation. The change of blood viscoelasticity acks on the magnetic bead in the form of moment changes, which shows that the amplitude of the motion of the magnetic bead varies with the change of blood viscoelasticity. Designed and verified a blood coagulation monitoring device based on the reciprocating movement of the magnetic bead and discussed the device's parameters through the orthogonal experiment. Lastly, the TEG5000 was used as the control group to test the thromboelasticity of four groups of thromboelastography quality control products in the same batch and 10 groups of human whole blood. It verified that our device has good repeatability, and has good consistency with TEG5000, it has particular application potential as a new blood coagulation monitoring method.

Risk factors for venous thromboembolism and evaluation of the modified Caprini score in patients undergoing lung resection

Background

There is a high incidence of venous thromboembolism (VTE) after lung resection, so it is necessary to identify the risk factors for VTE in these patients. It is also important to evaluate whether the modified Caprini score can accurately assess the risk of VTE in patients after lung resection.

Methods

This retrospective study included 437 patients undergoing lung resection between July 2016 and December 2017. All patients underwent lower extremities ultrasound before and after operation to determine the presence of the newly diagnosed VTE.

Results

Forty-seven (10.8%) of the 437 patients were diagnosed with VTE after lung surgery. Multivariate logistic regression analysis showed that age (OR, 2.04; 95% CI, 1.40-2.99), duration of operation (OR, 1.51; 95% CI, 1.08-2.12), lymphocyte count (OR, 0.28; 95% CI, 0.11-0.69), and D-dimer concentration (OR, 1.55; 95% CI, 1.22-1.97) were significantly associated with VTE in lung resection patients. The cut-off values for lymphocyte count and D-dimer concentration determined using receiver operating characteristic (ROC) curve were 1.15×10⁹/L and 1.37 µg/mL respectively. The modified Caprini score divided the patients into three groups: low risk (0-4 points), moderate risk (5-8 points) and high risk (≥9 points), and the incidence of VTE was 12.3% (37/300), 7.5% (10/133) and 0% (0/4), respectively (P>0.05).

Conclusions

In this study, we identified four independent factors for VTE after lung resection patients: age, duration of operation, lymphocyte count, and D-dimer. According to the modified Caprini score, there were fewer patients in the high-risk group, and the incidence of VTE not increased with the increase of risk. Better evaluation of operation time and D-dimer may help the modified Caprini score to better assess VTE risk in these patients.

Post-operative hypercoagulable whole blood profiles in patients undergoing open thoracotomy vs video-assisted thoracoscopic surgery

BACKGROUND

Patients undergoing video-assisted thoracoscopic surgery (VATS) have a lower risk of thrombosis compared to those undergoing open thoracotomy (OT) which may be due to several post-operative factors such as early mobilisation, shorter hospital stays, lower transfusion rates and lower risk of infections. Whether the higher thrombotic risk after OT is also linked to a peri-operative hypercoagulable state is a matter of debate. We therefore conducted a case-control study to compare peri-operative coagulation profiles in patients with primary lung cancer undergoing VATS vs OT.

MATERIALS AND METHODS

All consecutive patients undergoing VATS or OT for primary lung cancer at the Department of Thoracic Surgery of Padua University Hospital, Italy, between February and June 2018 were enrolled. Each patient provided a venous blood sample at least 30 min prior to surgical incision (T0) and 4±1 days after surgery (T1). Peri-operative coagulation profiles were assessed via traditional, viscoelastic whole blood (ROTEM^® [Instrumentation Laboratory-Werfen]) and impedance aggregometry (Multiplate^® Analyser [Roche Diagnostics]) tests.

RESULTS

We enrolled 65 patients (males 43, females 22; mean age 65±13 years) of whom 35 (54%) underwent VATS and 30 (46%) underwent OT. Compared to healthy controls, the surgical group (VATS and OT patients) had a significantly shorter clot formation time and higher alpha angle and maximum clot firmness values, as well as increased mean platelet function. In the post-operative period, patients who underwent OT had a significantly shorter clot formation time, higher alpha angle and maximum clot firmness values and higher mean platelet function vs VATS patients.

DISCUSSION

Whole blood ROTEM^® profiles and Multiplate^® aggregometry identified a more hypercoagulable post-operative state in patients who underwent OT than in those who underwent VATS. Larger studies are warranted to confirm our results and ascertain whether the observed hypercoagulability might promote post-operative thrombosis.

Preoperative Heparin for Lung Cancer Resection Increases Risk of Reoperation for Bleeding

Lung cancer patients are at risk for venous thromboembolism (VTE). Preoperative heparin administration may increase the risk of bleeding requiring reoperation. The purpose of this study was to evaluate preoperative heparin's effect on reoperation for bleeding. A retrospective review compared outcomes for patients undergoing pulmonary resection for primary lung cancer from January 2006 to April 2018. Preoperative heparin was administered at the discretion of the attending surgeon. Comparisons were performed between preoperative subcutaneous heparin (5000 U) and no heparin groups. A total of 3325 lung resections were reviewed, 1.4% (n = 48) required reoperation for bleeding. VTE occurred in 1.1% (n = 38). Four hundred sixty-four patients (14.0%) did not receive preoperative heparin. The preoperative heparin group had increased rates of prior thoracic surgery (5.1% [n = 146] vs 1.7% [n = 8], P < 0.001), minimally invasive approach (40.2% [n = 1150] vs 10.6% [n = 49], P < 0.001), and sublobar resections (17.7% [n = 506] vs 10.6% [n = 49], P < 0.001). There were no differences in blood loss/transfusions. Reoperation for bleeding was significantly increased in the preoperative heparin group (1.6% [n = 47] vs 0.2% [n = 1], P = 0.017). There were no differences in VTE (1.5% [n = 7] vs 1.1% [n = 31], P = 0.424). On logistic regression, preoperative heparin was independently associated with increased reoperation for bleeding (odds ratio 8.13, P = 0.039); however, preoperative heparin was not independently associated with VTE. Preoperative heparin was associated with increased reoperation for bleeding. VTE rates are low after pulmonary resection for lung cancer and are not decreased by preoperative heparin. Preoperative heparin use should be determined by risk factor stratification for VTE and reoperation for bleeding in patients undergoing lung cancer resection.